Acceptability and Feasibility of a DBT Skills Group Intervention for Bipolar Disorder - a Randomized Pilot Trial
Phase: NA
Conditions: Bipolar Disorder
Sponsor: Julieta Azevedo

 
 
 
 
                                                                                       
 
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Full Title  
Bi-REAL - DBT Skills Online Group Intervention for Bipolar 
Disorder: a feasibility study 
Short Title/Acronym  
 
 
Bi-REAL a DBT Skills intervention for BD: feasibility study 
 
Document date:  
 
 
Version 1.4 - 31.12.2020 
 
National Clinical Trial:  
 
NCT04797351 (Date registered: 15/03/2021) 
Unique Protocol ID: 
 
 
UPID: BD/130116/2017_Pilot 
 
Sponsor 
 
 
 
University de Coimbra - Center for Research in  
Neuropsychology and Cognitive and Behavioral  
Intervention (CINEICC) 
Contact: Julieta Azevedo (julietazevedo@gmail.com) 
 
 
Lead Investigator 
Julieta Azevedo (Email: julietazevedo@gmail.com) 
 
CINEICC, Faculty of Psychology and Educational Sciences, 
University of Coimbra, Rua do Colégio Novo, 3000-115 
Coimbra | +351 239 851 450 
 
Supervisors 
PhD Prof. Paula Castilho – University of Coimbra (UC) 
 
PhD Prof Michaela Swales – Bangor University 
 
PhD Prof. António Macedo – University of Coimbra 
 
 
 
Sites/collaborating institutions: 
Centro Hospitalar e Universitário de Coimbra, EPE (CHUC) 
Centro Hospitalar de Leiria, E.P.E (CHL) 
Centro Hospitalar do Oeste, E.P.E. (CHE) 
Associação de Apoio a Doentes Depressivos e Bipolares (ADEB) 
CINEICC - Faculty of Psychology and Education Sciences UC 
Institute of Psychological Medicine - Faculty of Medicine UC 
 
 
 

 
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Contents 
1. GLOSSARY  of Terms and Abbreviations ............................................................................................. 4 
2. SUMMARY/SYNOPSIS .......................................................................................................................... 5 
3. SCIENTIFIC RATIONALE ........................................................................................................................ 6 
4. TRIAL AIMS .......................................................................................................................................... 8 
4.1 General aims ................................................................................................................................. 8 
5. METHOD .............................................................................................................................................. 9 
5.1 Research Design ............................................................................................................................ 9 
5.2 Inclusion Criteria ........................................................................................................................... 9 
5.3 Exclusion Criteria ........................................................................................................................... 9 
5.4 Recruitment Sites ........................................................................................................................ 10 
5.5 Treatment Arms .......................................................................................................................... 10 
5.6 Study Recruitment Plan .............................................................................................................. 11 
5.7 Procedure .................................................................................................................................... 12 
5.8 Randomisation Procedure .......................................................................................................... 13 
5.9 Data collection ............................................................................................................................ 13 
5.9.1 Feasibility and acceptability of study and treatment: ......................................................... 13 
5.10 Measures ................................................................................................................................... 13 
5.10.1 Primary outcomes .............................................................................................................. 14 
5.10.2 Self-report measures of therapy process .......................................................................... 14 
5.10.3 Measures completed session by session by participants in Bi-REAL + TAU condition. ..... 16 
5.10.4 Qualitative process evaluation .......................................................................................... 16 
5.11 Criteria for Discontinuation ...................................................................................................... 17 
5.12 End of Study Definition ............................................................................................................. 17 
6. STATISTICAL CONSIDERATIONS ......................................................................................................... 17 
6.1 Sample Size ................................................................................................................................. 17 
6.2 Method of analysis ...................................................................................................................... 17 

 
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6.3 Qualitative analysis ..................................................................................................................... 18 
7. ETHICS ............................................................................................................................................... 18 
7.1 The intervention.......................................................................................................................... 18 
7.2 Use of randomisation .................................................................................................................. 18 
7.3 Informed consent ........................................................................................................................ 19 
7.4. Participant and researcher Risk ................................................................................................. 19 
8. RESEARCH GOVERNANCE .................................................................................................................. 20 
8.1 Monitoring and adverse events .................................................................................................. 20 
9. FINANCE AND FUNDING.................................................................................................................... 20 
10. CHANGES TO THE INITIAL PROJECT ................................................................................................ 20 
12. REFERENCES .................................................................................................................................... 20 
Appendix 1 - Study Procedure: Application phases, randomised distribution of participants and 
assessment moments ........................................................................................................................... 24 
Appendix 2 : Bi-REAL: 12-Session DBt-ST programme for Bipolar Disorder Layout ............................. 25 
Appendix 3:  Timing of Measures Completed by Participants .............................................................. 26 
Appendix 4:  Diary card  ........................................................................................................................ 27 
 
 
 

 
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1. GLOSSARY  of Terms and Abbreviations 
 
ABED 
 
 
Associação de Apoio aos Doentes Depressivos e Bipolares 
 
 
AR 
 
 
Adverse Reaction 
BD 
 
 
Bipolar Disorders 
BSD 
 
 
Bipolar Spectrum Disorder 
DBT 
 
 
Dialectical Behaviour Therapy 
FPCEUC 
 
Faculty of Psychology and Educational Sciences – University of Coimbra 
FMUC  
 
Faculty of Medicine – University of Coimbra 
HMDS  
 
Hamilton Depression Scale 
ICF 
 
 
Informed Consent Form 
Participant 
 
An individual who takes part in a clinical trial 
RCT 
 
 
Randomised Controlled Trial 
REC 
 
 
Research Ethics Committee 
SAE 
 
 
Serious Adverse Event 
ST 
 
 
Skills Training 
UC 
 
 
University of Coimbra 
YMRS  
 
Young Mania Rating Scale 

 
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2. SUMMARY/SYNOPSIS 
 
Short Title 
BI-REAL: a 12-session DBT Skills Group Intervention adapted for 
Bipolar Disorder – a feasibility Randomized Pilot Trial 
Methodology 
 
Feasibility study with a two-arm randomised parallel controlled trial 
design 
Research Sites 
 
University of Coimbra - Center for Research in Neuropsychology and 
Cognitive and Behavioral Intervention (CINEICC) 
Objectives/Aims 
 
To assess the feasibility and acceptability of a future definitive 
randomised controlled trial (RCT) evaluating the feasibility and 
acceptability of a Dialectical Behaviour Therapy Skills intervention 
for adults with bipolar and related disorders 
Number of 
Participants/Patients 
60 
Main Inclusion Criteria 
 
Client group: individuals with a Diagnosis of Bipolar and Related 
Disorders:  
Inclusion criteria: 
i) 
aged 18 or over 
ii) 
lifetime diagnosis of Bipolar Disorder (I,II, "other 
specified bipolar disorder") or Cyclothymic Disorder, 
according to DSM-V 
iii) 
mood instability (at least one complete mood episode in 
the last 5 years, and reported interference of sub-clinical 
mood symptoms) 
iv) 
Sufficient competency in Portuguese to be able to 
complete study measures without the need for 
translation. 
v) 
Having access to means to participate in the online 
group (i.e. access to a stable internet connection, having 
a functional camera and microphone on their computer, 
and zoom) 
 
Exclusion criteria:  
i) 
current high risk of suicide (measured through clinical 
interview)  
ii) 
Bipolar disorder secondary to an organic cause; 
iii) 
Diagnosis of substance dependence or continuous illicit 
substance misuse resulting in uncertain primary 
diagnosis; 

 
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iv) 
Acute episode of mania, hypomania or major depressive 
episode (at baseline) or not euthymic. 
v) 
Other high-risk pervasive disorders such as Borderline 
Personality Disorder; persistent self-injury; 
vi) 
the person lacks capacity to consent to treatment, low 
insight  
vii) 
Receiving psychological specific treatment for BD  
Statistical Methodology 
and Analysis (if 
applicable) 
Quantitative analysis: descriptive, linear mixed models 
Qualitative analysis: qualitative interview and questionnaire 
assessing programmes utility, acceptability and satisfaction 
Proposed Start Date 
01.02.2020 
 
Proposed End Date 
31.08.2022 
Study Duration 
 
24 months from obtaining approvals to delivery of intervention 
programme to the experimental group, and assessment of all 
participants 6 month after randomisation; plus 6 months post data 
collection for production of a report. 
 
 
 
3. SCIENTIFIC RATIONALE  
Bipolar disorder (BD) is a serious mental disorder characterised by episodes of mania, hypomania, and 
depression, occurring with a typically cyclical course (Johnson, 2004). In addition to mood instability, 
BD has been associated with significant functional impairment, lower quality of life, and higher rates 
of suicide compared to the general population (Pompili et al., 2014). Despite advancements in 
pharmacological and non-pharmacological treatments, BD often involves recurring episodes and 
subclinical symptoms within episodes (Geddes & Miklowitz, 2013). Predicting the course and outcome 
of the disorder remains challenging. BD ranks as the sixth leading cause of disability-adjusted life years 
worldwide, imposing substantial costs on society, patients, and mental health services (Vos et al., 
2020). 
Even though the aetiology of BD is still unclear, it is considered multifactorial, involving a combination 
of genetic and environmental factors. While fewer studies have explored the role of psychosocial 
factors in the development and maintenance of BD, some risk factors have been identified. Negative 

 
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early experiences, family characteristics, and adverse life circumstances have been implicated. 
Research has also found higher levels of childhood abuse and current internalised shame in individuals 
with BD compared to control groups. Stressful life events may act as triggers for affective symptoms, 
and individuals with BD often face stigma, which can negatively impact their social and occupational 
functioning (Fowke et al., 2012). Pharmacological interventions prevail as the primary management 
tool in BD. However, most patients are not fully stabilised on drug therapies alone, and a large number 
of patients experience residual symptoms; thus, full functional recovery is uncommon (Geddes & 
Miklowitz, 2013; Roth & Fonagy, 2005). Hence, growing evidence and international guidelines support 
the need to use psychosocial interventions as adjuvant therapies to improve recovery in BD (C. Henry 
et al., 2011; Slade & Longden, 2015). 
Our research adopts a recovery-based perspective, aiming to foster hope, understanding, and 
empowerment while striving for a meaningful and satisfying life, with less emphasis on clinical 
outcomes. Recovery in mental health encompasses more than the traditional clinical definition 
focused on symptom reduction, hospitalisation rates, and medication adherence. It emphasises 
achieving a better quality of life despite ongoing clinical symptoms (Jones et al., 2013). 
Psychoeducation (PE) and Cognitive-Behavioral Therapy (CBT) are the most extensively studied 
psychosocial interventions for BD, with some evidence supporting their efficacy (Colom et al., 2009; 
NICE, 2014; Salcedo et al., 2016). However, there are also contradictory findings contesting their 
efficacy, and that is why there are still no consensual Gold standard psychosocial interventions in BD  
(Geddes & Miklowitz, 2013). A systematic review regarding empirically supported psychosocial 
interventions for BD suggested Dialectical Behavior Therapy (DBT) as a promising treatment for BD 
needs further research (Salcedo et al., 2016). Nonetheless, standard DBT and the available evidence 
of its efficacy mainly target key psychological and interpersonal processes hypothesised to contribute 
to negative emotion (e.g. anger, sadness) but does not address or help clients to manage 
high/hypomanic mood states present in BD, which demands an adaptation of the standard skills 
training to BD. We took that into consideration and the work of DiRocco et al. (2020), along with the 
DBT skills workbook that Van Djick (2009) developed for people with BD, and developed a 12-session 
skills intervention programme. A couple of studies have examined modified versions of DBT as an 
intervention for Bipolar Disorder for adolescents and adults, with preliminary encouraging results 
(Goldstein et al., 2014; Van Dijk et al., 2013; Wright et al., 2018). Even so, none has been fully powered 
randomised controlled trial or included individuals across the BSD, and there is no evidence, as far as 
we know, that any intervention programme with DBT for BD was conducted in Portugal. Thus, DBT 
seems to be a promising approach, given its components for emotion regulation, and has shown some 

 
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preliminary findings to reduce depressive and manic symptoms as well as to improve emotional 
dysregulation in BD groups (Goldstein et al., 2007; Van Dijk et al., 2013).  
This study aims to investigate if our programme Bi-REAL (Respond Effectively and Live mindfully), a 
12-session online DBT skills intervention for BD, is acceptable and feasible and if it shows preliminary 
improvements in selected variables connected to recovery and emotional regulation and other 
psychological processes, in a randomised controlled pilot trial. 
4. TRIAL AIMS 
1. To inform the recruitment and timeline of a future fully powered trial by establishing the number 
of participants identified, approached, consented, randomised and completed. 
3. To refine future trial procedures by establishing the acceptability and experience of the trial process 
to participants, including randomisation and completion of outcome measures. 
4. To determine the optimal primary outcome measure in a future trial by assessing the performance 
of selected candidate primary outcome measures with respect to the level of acceptability to 
participants (completion rates) and participant-perceived relevance and value, and based on some 
additional secondary measures that are thought to improve with DBT-ST. 
5. To inform estimation of sample size for a future trial by measuring data completeness at follow-up 
(participant attrition). 
7. To further assess the acceptability of the treatment via qualitative interviews and, based on input 
from trial participants and clinicians, to further refine and develop the treatment manual and the 
procedures for training trial therapists. 
 
4.1 General aims 
We will also evaluate whether the following criteria have been met prior to planning a future 
definitive trial: 
1. Trial participation does not lead to serious negative consequences (unexpected adverse reactions) 
for our participants. 
2. Any serious concerns about the acceptability and feasibility of the trial procedures can be rectified 
prior to a full trial. 
3. Follow-up data at 3 months is available from at least 60% of participants. 
4. At least 60% of patients complete treatment (attend at least 50% of possible sessions). 
 

 
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5. METHOD 
5.1 Research Design 
Our feasibility study is a two-arm randomised parallel controlled trial design: where we intend to have 
60 participants that will be randomised on a 1:1 ratio to Treatment as Usual (TAU) [control arm] or Bi-
REAL programme plus TAU (TAU + Bi-REAL) [intervention arm]. Outcome measures will be recorded 
at baseline and at post-intervention (3 months after baseline) and with a follow-up point at 3 months 
after treatment ends (6 months post-randomisation). See appendix 1 for more detail. 
 
5.2 Inclusion Criteria  
i) 
aged 18 or over 
ii) 
lifetime diagnosis of Bipolar Disorder (I,II, "other specified bipolar disorder") or 
Cyclothymic Disorder, according to DSM-V (American Psychiatric Association, 2013) 
iii) 
mood instability (at least one complete mood episode in the last 5 years, and reported 
interference of sub-clinical mood symptoms) 
iv) 
Sufficient competency in Portuguese to be able to complete study measures without the 
need for translation. 
v) 
Having access to means to participate in the online group (i.e. access to a stable internet 
connection, having a functional camera and microphone on their computer, and zoom) 
5.3 Exclusion Criteria  
viii) 
current high risk of suicide (measured through clinical interview)  
ix) 
Bipolar disorder secondary to an organic cause; 
x) 
Diagnosis of substance dependence or continuous illicit substance misuse resulting in 
uncertain primary diagnosis; 
xi) 
Undergoing an acute episode of mania, hypomania or major depression (at baseline) or 
not euthymic (cut off YMRS > 8 and HMDS >8 used); 
xii) 
Other high-risk pervasive disorders such as Borderline Personality Disorder, persistent 
self-injury; 
xiii) 
The person lacks the capacity to consent to treatment, has low insight 
xiv) 
Receiving psychological intervention tailor-made for BD (if the person is receiving 
psychological support, the person assessing them will register the recurrence and type of 
intervention and assess on a case-by-case basis if this treatment is concurrent) 
 
Neither medication status nor the presence of other co-morbid psychiatric conditions (apart from the 
previously mentioned exclusion of BPD) will serve as exclusion criteria but will be recorded. 
Participants will not be denied access to routine care but will have changes to their support and 
treatment recorded.  
The decision to include patients that are receiving some kind of psychological intervention, which is 
not adapted for BD was made in conscience, under the assumption that this skills training can be 
useful for people with BD even if they are undergoing psychological treatment that does not address 
these skills and can thus be useful to deliver parallelly to it. The usual complete DBT treatment also 
has DBT skills training plus individual therapy, with the addition of this being DBT based. Nevertheless, 

 
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it is common to have patients going to the skills groups and receiving parallel individual psychological 
support in other therapy, and it is seen as useful. By not changing the current conditions of the patients 
recruited, we are also respecting the ecological validity of the study. 
 
5.4 Recruitment Sites 
To establish the feasibility of the full RCT, we will deliver the Bi-REAL programme online with the 
collaboration and referral of three hospitals in the centre of Portugal: Centro Hospital e Universitário 
de Coimbra (CHUC), Centro Hospitalar de Leiria (CHL) and Centro Hospitalar do Oeste (CHL) and with 
the additional collaboration of a national association that supports people with bipolar diagnosis 
(ADEB1).  
 
5.5 Treatment Arms 
Bi-REAL was developed in consultation with other researchers and clinicians who delivered DBT to 
people with mood instability. Furthermore, the research team was composed of clinical psychologists 
and psychiatrists with expertise in DBT and dealing with BD patients. The programme was thus 
conceptualised respecting the five key principles of DBT: i) clearly structured treatment; ii) application 
of behavioural therapy; iii) emphasis on validation of emotional response; iv) dialectical stance, 
balancing acceptance and change; v) integration of mindfulness practice. The programme was thus 
organised in a pre-session to contextualise the skills training and its principles, where the bio-social 
model adjusted to BD was presented, and the assumptions and goals of treatments were explained. 
The 12 sessions were then conceptualised to follow the same structure as the treatment proposed in 
the skills training manual (Linehan, 2014); the four skills modules of DBT (i.e. mindfulness, 
interpersonal effectiveness, emotional regulation and distress tolerance), with more sessions being 
dedicated to emotion regulation (6/12), considering it necessary to dedicate more training and time 
to this topic. The sessions seek to include examples that people with BD can relate to and cover skills 
for observing events, thoughts, emotions and bipolar symptoms and skills to down-regulate high 
emotions and upregulate low/depressive symptoms. The component of interpersonal difficulties will 
also be covered in detail to help participants develop their skills in order to decrease possible 
triggering situations of bipolar mood swings. There is an effort to help participants to learn and 
generalise behaviours through teaching and practice. Homework provides opportunities to generalise 
these skills across real-world contexts and continue the use of skills beyond treatment end. Moreover, 
participants can have up to 3 individual sessions (of 30 minutes maximum) delivered online or by 
 
1 For more information https://www.adeb.pt/ 

 
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telephone to help them generalise skills (a register will be kept with the number of sessions taken by 
each participant). 
Real-life generalisation of skills was also supported by the facilitators within sessions via email 
(participants will be allowed to submit support with skills application and homework) or message for 
quick advice on skills use. Additionally, participants will be invited to attend a group booster session 
at 1,5 months post-intervention to help keep the skills present and generalise to their lives (see 
Appendix 2 for programme layout). 
Each Bi-REAL group will be delivered by two clinical psychologists, a leader and a co-leader (as defined 
in the DBT skills training manual, Linehan 2014). Both therapists will have a CBT background, 
experience delivering group interventions, and intensive training (at least 5 days intensive training) in 
DBT. The leader will be the same across groups.  
Our comparison arm will be receiving general psychiatric treatment, which in Portugal is considered 
the treatment as usual (even though it is not clearly described in the literature) and can be receiving  
psychotherapy, as long as it is not a specialized intervention for people with BD. There is no formal 
data to indicate the likely content of TAU for individuals with Bipolar Disorder in Portugal. Thus, we 
will record this in terms of the services received by each participant during the trial in order to 
characterise the TAU across services. The decision to keep people that are receiving other kind of 
individual therapy intends to keep the ecological validity of the study and characterize what is the 
treatment as usual. At the same time, since DBT full programme includes individual therapy and sees 
it as a mean to help generalize what is learned, it is not seen as concurrent but complementary.  Also, 
since there is no gold-standard psychological treatment for this client group against which to 
benchmark a new treatment, we want to know what they are receiving and what can be helpful to 
add.  
 
5.6 Study Recruitment Plan 
Participants will be recruited via i) psychiatric services and specialist appointments for mood disorder 
and bipolar disorder; ii) ADEB (newsletter and sessions online to associates to raise interest); iii) online 
support groups for bipolar disorder vii) self-referral (adds online and distribution of flyers and posters 
in mental health services). 
Researchers will be present at the hospitals and ADEBs facilities to recruit potential participants at 
advised moments (e.g. when they go for their routine appointment, at events for people with BD). 
Additionally, patients identified by their psychiatrists as a potential participant will be approached by 
clinicians at their routine appointments, who will briefly explain what the study consists of, and if 

 
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permission to contact is given, they will be approached by the research team via telephone/email 
(according to their mentioned preference).  
People who self-refer will be contacted by the research team to discuss the study and then, if the 
participant wishes to proceed, they will need to sign a consent form and send it to the research team, 
after which they will the be assessed. For the complete study recruitment and procedure flow chart 
see Appendix 1. 
 
5.7 Procedure 
Participants which reveal interest in the study at the screening process will agree a suitable date and 
time with the researcher (either face-to-face or online) to do the following assessment. The screening 
interview will allow an explanation of the study details, addressing any queries, and address the 
suitability of the participant to the study. Individuals deemed ineligible at this stage will be informed 
accordingly. All participants will be thanked for their collaboration and will be reassured that what 
they choose to do will have no impact in the care they receive. Eligible participants will then coordinate 
a convenient date and time with the researcher for the baseline assessment appointment. 
At baseline assessment (which can take place face to face or through videocall) the researcher will 
discuss the study information sheet and request the patient to read the consent form and sign (after 
asking any additional questions). If the participant needs more time to consider the study, the 
researcher will reschedule a second moment to allow for the appropriate time for them to consider 
their participation. In this baseline assessment the participant will undergo a semi-structured clinical-
interview (Clinical Interview for Bipolar Disorder; Azevedo et al., nd), and the interviewer will also fill 
in two additional scales to monitor depressive and hypo/mania symptoms (Hamilton Depression Scale 
and Young Mania rating Scale, respectively). At this point, the researcher will also ask the necessary 
questions to understand if the person meets inclusion / exclusion criteria. 
If the participant is eligible for the study, they will then complete the baseline self-report measures 
(see Appendix 3): measures assessed by the clinician will take place during the assessment (i.e. CIBD, 
YMRS and HMDS), and the self-report measure will be sent via link to be completed online. 
Participants in the experimental group will additionally fill in an adapted diary card and submit it once 
a week (between sessions), where they are asked to rate their emotions intensity and use of skills (see 
Appendix 4). Additionally, after each session participants will be asked to anonymously fill in the Group 
Session Rating Scale (GSRS; Duncan et al., 2003) which briefly assessed participants experience of the 
group regarding relationships in the group, goals and topics, approach/method, and overall cohesion. 
Following randomisation (more details in that section) participants will be followed up by the research 
team at 3 and 6 months post baseline. At 3 month follow up (post-randomisation) blinding was not 

 
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conducted considering the need to conduct a qualitative interview of the intervention programme. 
Independent clinicians and researchers conducted these interviews, and the qualitative interview was 
anonymised so that participants could share their experience freely about the facilitators, programme 
and group. All the assessment moments are described in Appendix 1 and the assessment measures 
per moment in Appendix 3. 
 
5.8 Randomisation Procedure 
Following completion of the baseline assessment, eligible participants will be randomised on a 1:1 
ratio (minimisation by age and psychological support status [undergoing psychotherapy versus not 
receiving psychological support]) to Treatment as Usual (TAU) [control arm] or Treatment as Usual 
plus Bi-REAL programme (TAU + BI-REAL) [intervention arm]. We will perform a stratified block 
randomization after participant has attended a baseline assessment and has consented to the trial, a 
member of the research team will enter a set of data on the randomisation website 
(www.randomization.com). Participants will receive an email informing them of the arm to which they 
have been allocated. For participants allocated to the intervention arm, they will be informed at the 
group starting date and time. 
 
5.9 Data collection 
5.9.1 Feasibility and acceptability of study and treatment: 
- 
Feasibility will be assessed in terms of numbers of patients identified, approached, consented, 
randomised and completed over the active period of recruitment and treatment, as well as 
participant attrition from the trial and from treatment.  
- 
To assess acceptability all participants will complete a questionnaire about their experience 
in the trial, at the end of the programme, and will be interviewed to express what was more 
and less useful in the programme, suggestions, and skills retention. The participants will also 
be asked at 6 month follow up what was retained and continues to be used in their daily life, 
to assess transferability of what was learned. 
 
5.10 Measures 
The following measures where used, to assess diagnosis, clinical symptoms and self report: 
Diagnosis and mood episode/functionality/empowerment (completed at baseline and 3, 6 months post 
baseline): 
• 
Clinical Interview for Bipolar Disorder (CIBD; Azevedo et al., nd) – Clinical semi-structured 
interview which allows for the diagnosis of Bipolar and Related disorders. It includes an 

 
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assessment of mood symptoms interference and empowerment towards bipolar 
symptomatology by the interviewee – outcomes considered will include empowerment and 
interference of mood symptoms 
• 
Young Mania Rating Scale  - observer rated, measures current mania symptoms  
• 
Hamilton Depression Scale - observer rated, measures current depressive symptoms 
 
5.10.1 Primary outcomes: 
• BIPOLAR DISORDER RECOVERY QUESTIONNAIRE (Jones et al., 2013), a 36 item self-report measure 
that has been developed to measure personal recovery in people with Bipolar Disorder. 
• BRIEF QUALITY OF LIFE IN BIPOLAR DISORDER SCALE(Michalak et al., 2010), a self-report measure of 
quality of life in bipolar disorder that has been specifically designed for and validated with individuals 
with the condition. 
 
The additional measures selected for this study include secondary outcomes we believe might change 
due to the skills developed in the programme, and some hypothesised mechanisms of change, 
providing data on their performance and preliminary analysis of change. Hypothesised treatment 
targets include difficulties in regulating emotions, hyper/hypo activation, emotional acceptance, 
emotional awareness, self-reassurance, self-criticism (hated selfxxx( and shame. 
 
5.10.2 Self-report measures of therapy process (completed at baseline, 3, and 6 months post 
baseline): 
• 
Depression Anxiety and Stress Scale (DASS-21) (Henry & Crawford, 2005) – we will use the 
depression and anxiety subscales to assess the psychological distress. 
• 
Multidimensional assessment of thymic states (MATHYS) (Henry et al., 2008) - is a visual 
analogic scale consisting of 20 items. These items corresponded to five quantitative 
dimensions: emotional reactivity (EM), thought/cognitive processes (CO), psychomotor 
function (MO), motivation (VO) and sensory perception (SE). These are them grouped and 
vary into three continuous: Hypo-reactivity/Hyper-reactivity (EM), Retardation/Acceleration 
(CO, MO), and Decrease/Increase (VO, SE). The range of scores is from 0-200 and it will vary 
between the continuous with zero corresponding to one end and 200 to the other, and values 
around 100 will correspond to stability. 
• 
Distress Tolerance Scale (DTS) (Simons & Gaher, 2005) - is a 15 item self-report measure of 
emotional distress tolerance. Individuals select on a 1-5 likert scale (Strongly Disagree, Mildly 

 
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Disagree, Feel Neutral, Mildly Agree, Strongly Agree) about each of the statements about 
distress tolerance. 
• 
Difficulties in Emotion Regulation Questionnaire (DERS) (Gratz & Roemer, 2004) - is an 
instrument measuring emotion regulation problems. The 36 items self-report scale asks 
respondents how they relate to their emotions in order to produce scores on the following 
subscales: Nonacceptance of emotional responses: tendency to have a negative secondary or 
non-accepting reaction to one’s own distress; Difficulty engaging in goal-directed behaviour: 
difficulty in concentrating and/or accomplishing tasks when experiencing negative emotions; 
Impulse control difficulties: difficulty remaining in control of one’s behaviour when 
experiencing negative emotions; Lack of emotional awareness: reflects a lack of awareness or 
inattention to emotional responses; Limited access to emotion regulation strategies: reflects 
the belief that there is little one can do to regulate oneself once upset; and Lack of emotional 
clarity: reflects the extent to which an individual knows and is clear about his or her emotions. 
This scale measures an integrative conceptualization of emotion regulation as involving not 
just the modulation of emotional arousal, but also the awareness, understanding, and 
acceptance of emotions, and the ability to act in desired ways regardless of emotional state. 
• 
Philadelphia Mindfulness Scale (PHLMS) (Cardaciotto et al., 2008) – this scale has 20 items and 
measures two dimensions of mindfulness: Acceptance and Awareness (having 10 items per 
subscale, and providing separate scoring for the dimensions and not as a total). This self report 
scale asks people to assess how much they have experienced each of the described items over 
the past week, and participants rate from 0-Never, 1-Rarely, 2-Sometimes. 3- Often, to 4-Very 
often. 
• 
External and Internal Shame Scale (EISS) (Ferreira et al., 2022) – assesses global shame 
experience, as well as its external and internal dimensions. This scale consists of eight items, 
generated to measure the four central domains of general feelings of shame, and present in 
both 
external 
and 
internal 
shame: 
inferiority/inadequacy, 
sense 
of 
exclusion, 
uselessness/emptiness and criticism/judgment. Each of the dimensions is composed of four 
items: external (e.g., “I feel that others see me as uninteresting”) and internal dimensions 
(e.g., “I feel that I am different and inferior to the others”), to which the participants must 
answer using a 5-point scale (0 = “Never” to 4 = “Always”). Scores vary between 0 and 32 
points, with higher values indicating higher levels of shame. 
• 
Ruminative Responses Questionnaire (RRQ-10) (Treynor et al., 2003) – a 10-item scale that 
measures the individuals’ tendency to ruminate when in a sad or depressed mood. This scale 
comprises two subscales: brooding (5 items) and reflection (5 items). To the statement “what 

 
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you generally do, not what you think you should do when feel down, sad or depressed” 
respondents are asked to rate each item on a 4 point scale (1 = “almost never” to 4 = “almost 
always”). Thus, scores may range between 10 and 40, with higher scores indicating higher 
levels of ruminative responses styles.  
• 
Forms of Self-Criticising/Attacking & Self-Reassuring Scale (FSCRS) - (Gilbert et al., 2004) is a 
22-item self-report questionnaire in which participants are asked to rate how they typically 
think and react when things go wrong for them. To a first probe statement: “When things go 
wrong for me…” participants respond on a 5-point Likert scale (ranging from 0 = not at all like 
me to 4 = extremely like me). A scale has three factors: Inadequate Self (e.g. ‘I think that I 
deserve my self-criticism’; ‘I remember and dwell on my failings’); Hated Self (e.g. ‘I stop caring 
about myself’; ‘I do not like being me’); Reassured Self (e.g. ‘I still like being me’; ‘I can feel 
lovable and acceptable’). 
 
5.10.3 Measures completed session by session by participants in Bi-REAL + TAU condition. 
• 
Online Version of Diary card submitted before each session (see Appendix 4); 
• 
Group Session Rating Scale (GSRS; Duncan et al., 2003) participants are asked to fill in this 
assessment scale after each session in an anonymous way to decrease social-desirability bias; 
this measure uses a four-item visual analogue scale designed to assess key dimensions from 
0 to 40: Relationship (0 – “I did not feel heard, understood, respected, and/ or accepted by the 
leader and/ or the group” to 40 - “I felt heard understood, respected, and accepted by the 
leader and the group”); Goals and Topics (0 – “We did not work on or talk about what I wanted 
to work on and talk about” to 40 -  “We worked on and talked about what I wanted to work 
on and talk about.”); Approach or Method (0 – “The leader and/ or the group's approach is 
not a good fit for me” to  40 – “The Leader and group's approach is a good fit for me.”); and 
Overall (0 – “There was something missing in group today - I was not engaged” to 40 – “Overall 
today’s group was right for me - I felt engaged”). 
 
5.10.4 Qualitative process evaluation 
This feasibility study will focus upon understanding what might be seen as facilitators and barriers to 
implementation of the intervention to inform implementation of the intervention within a future 
definitive trial. Within these, we will consider seek to understand the context (how external factors 
influence the delivery and functioning of the interventions) and implementation (evaluation of the 
way in which the intervention is delivered, and the quality and quantity of the intervention delivered).  
 

 
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5.11 Criteria for Discontinuation  
We will discontinue the treatment if  the participant manifest they do not wish to continue with the 
intervention or study; the participant or facilitators (or researchers) believe that the intervention or 
trial participation will result in, or is likely to result in, a serious adverse reaction if continued; if the 
participant does not attend four consecutive group therapy sessions (they are made aware of this 
rule before starting). 
 
5.12 End of Study Definition  
The end of the study will be defined as after providing the programme to the control group, after their 
last 6 month follow up assessment which is part of our ethic responsibility. 
 
6. STATISTICAL CONSIDERATIONS 
6.1 Sample Size 
60 participants (30 per group) will allow us to address the stated objectives of this feasibility trial. This 
represents recruitment to Bi-REAL at full capacity (10 per group), with equivalent numbers 
randomised to TAU. Previous studies with this population estimate an attrition rate of 17% ( with 
respect to the primary end point at nine months post-randomisation. Our sample size of 48 will allow 
us to estimate this level of attrition for a future definitive trial with a precision of ±15% with 95% 
certainty. 
 
6.2 Method of analysis 
Given the feasibility objectives of this study, the initial focus of data analysis will be descriptive, 
regarding the enrolment data, attrition rates and treatment and study dropoust. We will also describe 
the acceptability of the programme though the report of the programme assessment questionnaire 
and interview, along with the scores of the GSRS. The number of people completing the intervention 
will be reported and it is defined as attending at least 65% of group sessions, which corresponds to 8 
sessions approximately). We will also report on the number who complete the research outcome 
measures alongside means and standard deviations regarding the number, length and frequency (time 
between) of sessions. All protocol deviations, along with reasons and number of missing items on 
questionnaires will be reported. 
To address the other primary outcome (i.e., recovery and QoL) and informing future sample size 
estimation) levels of completion and mean and standard deviations (or equivalent) for all outcomes 
for both study arms will be reported at baseline, three and six months follow up, as will participant 

 
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rankings of personal value and relevance of clinical outcome measures. Additionally we expect to do 
linear mixed models analysis to explore the time x group interaction in the variables in study. 
 
6.3 Qualitative analysis 
Qualitative interviews will be analysed using a framework approach, whereby data will be coded 
according to both theme and case, and then abstraction of themes and explanatory inferences will 
occur iteratively with codes, themes and inferences being quality checked by a second team members. 
7. ETHICS  
7.1 The intervention 
Particular caution and attention must be taken when administering a new therapeutic intervention to 
monitor any potential negative reactions. Although psychological interventions generally have 
minimal harmful effects, there is still a slight risk involved. The skills training we developed is however 
based on a well-established treatment (DBT), and it has been adapted and used in BD, with no adverse 
reactions reported, and with good acceptability (Eisner et al., 2017; Goldstein et al., 2015; Van Dijk et 
al., 2013). Nevertheless, more robust studies are still needed, since most of these studies were pilots 
as well. Our programme seeks to follow the same principles, with some additional innovations, namely 
with specific skills to help upregulate and down regulate emotions in depressive/hypo/manic periods. 
If at any period a potential ethical issue arises from delivery of the treatment, the participants will be 
approached, and risk protocol will be put into place (according to the place where they are routinely 
followed). Information provided by participants as part of their treatment will be treated in 
confidence. Participants will be informed of the circumstances under which confidentiality may be 
broken and will be consulted with as far as possible if this should become necessary. 
In addition, regarding the group session, a set of "ground rules" will be established at the pre-session, 
together with the facilitators. All group participants will be made aware that they should not divulge 
what is talked in the group, and at the same time they do not have to share any information in the 
group that they do not wish to. Due to the training approach and format of the group, which is not 
the same as a traditional therapeutic group, participants can discuss the material and exercises 
without having to share personal information if they do not wish to. 
 
7.2 Use of randomisation 
Participants will informed of the randomisation procedure and that they have a fifty-fifty chance to 
receive the treatment. Since we are aware of the ethical issue underlying the allocation to a control 
group, and the possible frustration/disappointment of the participants for not being allocated to the 

 
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intervention group, we also make sure they know the importance of the randomisation for a future 
definitive trial, and this ensures the two groups do not differ systematically in their baseline 
characteristics. The participants are also informed they will be offered the possibility to do the 
programme after they finish their 6 month follow up assessment, so they have the same possibility as 
the experimental group. 
 
7.3 Informed consent 
At the initial contact with the research team, the study will be discussed, and patients asked whether 
they wish to move to the next stage (receiving the full information sheet and arranging a telephone 
research screening interview, with specific consent, if appropriate). If the patient indicates at this 
point – or later - that they do not wish to take part they will not be contacted further by the research 
team, other than to invite them to take part in a brief survey to ascertain their reasons for not taking 
part. If at the baseline assessment the patient wishes to consent to participation at that point the 
researcher will take consent and then proceed to the research assessment; if the patient does not 
wish to participate their involvement will finish at this point, and reasons will be noted. If the patient 
wishes to take more time to consider the study, the research assessment appointment will be 
rescheduled to allow sufficient time for them to consider their participation. Participants judged not 
to have capacity due to severe symptom levels will be reassessed at a later point convenient to them 
and directed the necessary care in the meantime. 
 
7.4. Participant and researcher Risk 
Inherent in the nature of the population under scrutiny is the risk of suicide. We will follow good 
clinical practice in monitoring for suicide risk during all research assessments with service-user 
participants. Risk to/from self or others, if detected, will be responded to in accordance with the 
established protocols established in the hospitals or association the participants are followed. 
Participants will be informed of any circumstances under which confidentiality may be broken.  
 
7.5 Data Protection 
Information collected in clinical assessment will be stored according to standard practice and GDPR 
advice, stored in a way that allows them to be easily traced and located if required, while making sure 
the paper documents are stored in locked cabinets and access is restricted to the people in the 
research team that need access. This documents will be stored in the hosting research center – 
CINEICC, in the building 2 facilities of the Faculty of Psychology and Educational Sciences, University 
of Coimbra. Information held on computers will be stored in a password protected location with codes 

 
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replacing personal data when possible. Original research records will be retained for 5 years, after 
which they will be retained in electronic form and original records destroyed. The electronic records 
will be kept for 10 years after the end of the study. 
8. RESEARCH GOVERNANCE 
The study will be conducted in compliance with the principles of the Declaration of Helsinki and in 
accordance with all applicable regulatory requirements for a study with its specifications. The 
University of Coimbra and its scientific committee will monitor its progress, and relevant contacts are 
provided for participants to contact in case they have any concerns regarding the study. The same 
agreement has been made with the hospitals and organisation collaborating with the study.  
 
8.1 Monitoring and adverse events 
All serious adverse events that are trial or treatment related will be recorded and immediately 
reported to the responsible investigator, and measures to be taken will be discussed. Additionally, in 
line with other studies, we will screen for adverse events that are not trial or treatment related and 
active withdrawals from treatment. We will also monitor if the participant changed their medication. 
Participants will be asked at their follow-up assessments if any adverse events happened since the 
beginning of their participation, or since the last assessment (in the 6 month follow up).  
 
9. FINANCE AND FUNDING 
This study is funded by the Portuguese Foundation of Science and Technology (or: Fundação para a 
Ciência e Tecnologia - FCT), with the attribution of an individual doctoral scholarship (funder reference 
number: SFRH/BD/130116/2017). 
 
10. CHANGES TO THE INITIAL PROJECT 
Changes to the assessment procedures were done due to the pandemic Covid-19, which had 
implications in the recruitment strategies and the timings initially projected. This project proposal was 
adjusted and resubmitted to the ethics committee involved in the study and approved. 
 
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Appendix 1 - Study Procedure: Application phases, randomised distribution of participants and 
assessment moments  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
Submission of the planogram and study protocol for approval of the Ethics Commission of the University of 
Coimbra’s faculties ethical commissions (FMUC and FPCE), followed by the hospitals ethical commissions 
and ADEB’s scientific comission 
Explanation of study objectives to 
participants (informed consent) 
Eligibility assessment 
Semi-structured clinical interview  to 
confirm the presence of BD and 
related disorders (CIPD) 
Do not meet inclusion criteria 
Do not want to participate 
Eligible and accepts to participate 
T0 – Baseline Assessment 
 Participants will be re-assessed with CIPD to scan for current mood episodes, and HMDS and YMRS (need to be 
euthymic to be included score <8), and will fill out a battery of self-report baseline questionnaires. 
Randomized distribution (n expected = 60) 
Phase 1 – Presentation and Recruitment 
Phase 2 - Implementation 
Presentation of the programme to the clinical and staff meetings in the hospital involved, to explain 
inclusion/exclusion criteria and procedure to articulate the referral of BP patients for the study. 
Exclude
Participants are assessed with a clinical interview 
(CIBD) and a qualitative interview about Bi-REAL, 
with an independent interviewer Self-report 
measures are completed online 
Phase 3 – Follow up 
T2 –  Follow up at 3 months (6 months after randomisation) 
Participants are assessed with a clinical interview (CIBD) and fill-in self-report questionnaires 
online. 
Experimental Group 
12-session Bi-REAL  
+TAU 
Control Group 
TAU 
Participants are assessed with a clinical interview 
(CIBD) and self-report measures are completed 
online 
T1 –  Post-Treatment Follow-Up (3 Month after randomisation) 
After each session: 
Assessment with Group 
session Rating Scale 

 
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Appendix 2 : Bi-REAL: 12-Session DBt-ST programme for Bipolar Disorder Layout 
 
 
 
MODULE 
SESSION 
CONTENT AND SKILLS 
TARGET PROBLEMS / FOCUS 
Pre-Session 
0 
DBT Assumptions 
General and personal 
Goals, Biosocial Theory for 
Bipolar Disorder 
DBT Assumptions, Group Rules 
and confidentiality 
Mindfulness 
1 
Wise mind 
What Skills: Observe, 
Describe, Participate 
Understand the difference 
between emotion mind, reason 
mind and wise mind. 
Introduction to Mindfulness 
2 
How Skills:  
Non-judgmentally,  
One-Mindfully, Effectively 
Attention Focus, notice 
thoughts. 
Not reacting to urges and 
impulsive behavior 
Emotion Regulation 
3 
Understand, Identify and 
Label emotions 
Perception and processing of 
emotions 
4 
Check the Facts, Opposite 
action 
Behaviour and Cognitive 
Change 
5 
Problem Solving 
Skilfully make an action plan. 
Put emotions into action 
6 
CAMARAS – managing 
highs and lows 
Knowing what to do when a 
mood change arises. 
7 
ABC PLEASE Skills Build 
Mastery 
Cope ahead 
Managing vulnerability to 
emotions 
Anticipate reactions, plan 
Distress Tolerance 
8 
TIPP, Managing Extreme 
emotions 
Managing extreme mood 
states, prevent impulsive 
reactions. Focusing attention 
9 
Distract, Self-Soothe, 
Radical Acceptance 
Capacity to tolerate difficult 
emotions 
Interpersonal 
Effectiveness 
10 
DEAR MAN (Describe, 
Express, Assert, Reinforce; 
Mindful, Appear 
Confident, Negotiate) 
Managing situations that cue 
emotions 
11 
GIVE FAST (Gentle, act 
Interested, Validate, Easy 
manner) 
Relationship and Self-respect 
effectiveness 
12 
Validation 
Review what was learned, 
what to take home. 
Review of the program and 
intention to continue training 
skills. 

 
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Appendix 3:  Timing of Measures Completed by Participants 
Table 1 - Schedule of participants’ assessment 
 
Pre-intervention 
During Intervention2 
Post-intervention 
 
Screening 
Baseline 
Each session 
Post-
treatment 
3 months 
follow-up 
Clinical Interview for Bipolar 
Disorder (CIBD) 
 
 
 
 
 
 
 
 
 
Demographics (e.g. Age, education, 
employment)   
 
 
 
 
 
 
Clinical History (e.g., family history of 
mood disorder, age of onset, number of 
affective episodes, hospitalisation) 
 
 
 
 
 
 
Hamilton Rating Scale for 
Depression (HMDS) 
 
 
 
 
 
 
 
 
Young Mania Rating Scale (YMRS) 
 
 
 
 
 
 
 
 
Quality of Life in Bipolar Disorder 
(QOL-BD) 
 
 
 
 
 
 
 
 
Bipolar Recovery Questionnaire 
(BRQ) 
 
 
 
 
 
 
 
 
Multidimensional assessment of 
thymic states (MATHYS) 
 
 
 
 
 
 
 
 
Distress Tolerance Scale (DTS) 
 
 
 
 
 
 
 
 
Depression Anxiety and Stress 
Scale (DASS-21) 
 
 
 
 
 
 
 
 
Difficulties in Emotion Regulation 
Questionnaire (DERS) 
 
 
 
 
 
 
 
 
Philadelphia Mindfulness Scale 
(PHLMS) 
 
 
 
 
 
 
 
 
External and Internal Shame Scale 
(EISS) 
 
 
 
 
 
 
 
 
Rumination-Reflexion  
Questionnaire (RRQ-10) 
 
 
 
 
 
 
 
 
Forms of Self-Criticising/Attacking 
& Self-Reassuring Scale (FSCRS) 
 
 
 
 
 
 
 
 
The group session rating scale 
(GSRS)2 
 
 
  
 
 
Bi-REAL Diary card2 (Appendix 4) 
 
 
  
 
 
 
 
2 Only for the Experimental Group 

 
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Appendix 4:  Diary card (1/2) 
Diary Card 
Week overall 
assessment 
Mood 
 
Sleep 
Adherence to medication 
Did you take your medication as prescribed? 
 
-5 to +5 
Mean number of 
hours daily: 
Yes 
No 
Only part of it 
Week 1 
 
 
 
 
 
Mood Scale: 
-5 = Extremely depressed/ the more depressed I have ever been | 0 = Stable Mood (neither depressive nor 
hypo/maniac) 5 = Extremely hipo/maniac (the most maniac I have ever been) 
Instructions: Mark the days where you used the following skills 
Mindfulness 
1. 
Wise Mind 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
2. 
Observe 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
3. 
Describe 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
4. 
Participate 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
5. 
Non-judgemental 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
6. 
One mindfully 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
7. 
Effectively 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
Emotional Regulation 
8. 
Identify and name emotions 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
9. 
Check the Facts 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
10. Opposite Action 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
11. Problem Solving 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
12. Accumulate Positives 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
13. Build Mastery 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
14. Cope ahead 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
15. CAMERAS 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
Distress Tolerance 
16. STOP 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
17. TIPP 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
18. ACCEPTS 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
19. Self-Soothing 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
20. Redirect the mind 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
21. Open hand, half smile 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
22. Radical Acceptance 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
Interpersonal 
Effectiveness 
23. DEAR MAN 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
24. GIVE FAST 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
25. Interpersonal Validation 
Monday 
Tuesday 
Wednes. 
Thurs 
Friday 
Sat 
Sun 
 
 

 
 Version 1.4        31.12.20          Bi-REAL DBT Skills programme: a feasibility study  
 28 
Appendix 4:  Diary card (2/2) 
 
Anger 
Fear 
Joy 
Nervous/ 
Anxiety 
Sadness 
Shame/ 
Guilt 
Use of the skill 
and their effect 
0-5 
0-5 
0-5 
0-5 
0-5 
0-5 
0-7 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Connecting with the personal goals stablished: 
Regarding the behaviour you want to decrease, how would you say you manage to do that this week: 
I did not have this 
behaviour at all 
1 
2 
3 
4 
5 
I did it every time 
I felt like doing it 
 
Regarding the behaviour you want to increase, how would you say you manage to do that this week: 
I did not have this 
behaviour at all 
1 
2 
3 
4 
5 
I did it every time 
I planned to do it 
 
Register emotions and skills frequence during the week: 
0 = Not at all 
1 = A little 
bit 
2 = Somehow 
3 = A bit 
strong 
4 = very 
strong 
5 = Extremely 
strong