Two randomized controlled trials have shown the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program to be effective in reducing the intensity of core aspects of borderline personality disorder (BPD), Dr Donald Black and social worker Nancee Blum announced at the annual meeting of the American Psychiatric Association held recently in San Francisco. Black summarized, “Data from several studies show that STEPPS reduced global severity as rated by clinicians and patients, borderline personality disorder symptoms, and depressive symptoms."
STEPPS is a 20-week, manual-based, psychoeducational group treatment that combines skills training with cognitive-behavioral techniques. It includes a systems component to train family members, friends, and significant others.1,2
STEPPS did not appear to reduce hospital utilization or suicidal ideation, although it reduced emergency department visits and showed a trend toward fewer suicide attempts. “The advantages of STEPPS when compared with other programs that currently treat BPD are that it is relatively easy to learn and implement, uses a short time frame, and can be added into existing treatment systems. We consider it a value-added adjunct to therapy and medications,” Black explained. “STEPPS has already been implemented in the prison population.”
STEPPS is usually delivered by 2 leaders in a weekly 2-hour group of 6 to 10 participants. It generally begins with participants filling out the BEST (Borderline Evaluation of Severity over Time) self-report scale of borderline symptom severity, and graphing their BEST score so that they can monitor weekly progress in diminishing their symptom intensity. “We developed the BEST as a way of quantifying the severity of borderline symptomatology, and of tracking utilization of positive coping skills. Studies have shown it to be a reliable and valid measure,” said Black. Participants then enjoy a brief relaxation exercise, such as deep breathing or coloring complex geometric patterns. Next, one participant will share how much time he or she spent in each of 5 domains of escalating “emotional intensity” during the past week, and what new skills she used to de-escalate herself when she was in danger of “boiling over.”
One set of skills pertains to emotion management. These skills include learning to distance or distract oneself from current problems, challenging one’s own negative schemas or “cognitive filters,” and managing daily problems. Another set of skills involve behavioral self-management. Clients learn to set goals, practice self-care, avoid substances, and normalize their eating, sleeping and exercise patterns. Group leaders present a new skill each week, and clients then preview their homework for the upcoming week, which they are supposed to use “in vivo.”
For example, a client might become progressively more upset that her boyfriend is late coming home. She may notice that her body is getting more tense and her mood more irritable. She may notice that she is having behavioral urges—such as wanting to use drugs, drive over and confront him at his workplace, or harm herself. Her thoughts may become more extreme: “He is going to break up with me! I’ll always end up alone.” With the STEPPS program, the client is taught to challenge her negative cognitions: “Not every disappointment ends in abandonment.” She learns to monitor her level of physical and emotional distress, and use soothing techniques to calm herself. She might decide to do some light exercise or distract herself with a good book. She may decide to use a more positive communication strategy—“In the future, I’d appreciate a phone call when you’re running late, because otherwise I worry.”
One unique aspect of STEPPS is that patients identify a “reinforcement team,” which consists of friends, family members, and professionals who are willing to coach the client when she is in crisis. These support people are invited to one of the training group sessions. They learn to ask simple questions that help the person with BPD when she is in crisis: “What is your level of emotional intensity? What skills can you use to reduce your distress? May I remind you of the STEPPS coping skills so you can pick which one you are going to try?” Patients are periodically reminded in the group sessions to expand their reinforcement team. “One of the best things about having a reinforcement team is that everyone speaks a common language,” explained Blum.
Blum and Black have already adapted the STEPPS program for implementation in correctional facilities in Iowa and elsewhere in the Midwest. Blum sometimes leads the prison groups via teleconference from her University of Iowa office. “The groups work well and I can see everyone’s face. We always begin with everyone holding up their emotional intensity graphs so I can see how they’ve done over the week.” Response from the correctional facilities and parole boards has been very positive. “The biggest adaptation we’ve made is to shorten the program duration to 10 sessions and increase the frequency of sessions. Otherwise, people get moved around in prison and may not be able to complete the program. We’ve also had correctional boards that didn’t want to release an inmate until she had completed the STEPPS program. Inmates with literacy challenges are welcome to come to optional weekly STEPPS homework groups. We encourage inmates who can read and write to be a model and mentor for their peers in these groups,” Blum said.
Future directions include development of a yearlong, less intense aftercare program called Stairways, and adaptations of specialized versions for adolescents, people with substance abuse disorders, and people with mental retardation. Black summarized, “We consider STEPPS a viable supplement to current treatment of BPD.”
1. Blum N, St John D, Pfohl B, et al. Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up. Am J Psychiatry. 2008;165:468-478.
2. Van Wel B, Kockmann I, Blum N, et al. STEPPS group treatment for borderline personality disorder in The Netherlands. Ann Clin Psychiatry. 2006;18:63-67.