Evidence-Based Reviews

Borderline personality disorder: STEPPS is practical, evidence-based, easier to use

Current Psychiatry. 2009 October;8(10):18-35

References

1. American Psychiatric Association. Practice guidelines for the treatment of patients with borderline personality disorder. Am J Psychiatry. 2001;158(suppl 1):1-52.

2. Soloff PH. Psychopharmacology of borderline personality disorder. Psychiatr Clin North Am. 2000;23:169-191.

3. Zanarini MC. Update on pharmacotherapy of borderline personality disorder. Curr Psychiatry Rep. 2004;6:66-70.

4. Paris J. Borderline personality disorder—a multidimensional approach. Washington, DC: American Psychiatric Press; 1994.

5. Linehan MM. Cognitive-behavioral treatment for borderline personality disorder. New York, NY: Guilford Press; 1993.

6. Clarkin JF, Levy KN, Lenzenweger MF, et al. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007;164:922-928.

7. Giesen-Bloo J, van Dyck R, Spinhoven P, et al. Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused therapy. Arch Gen Psychiatry. 2006;63:649-658.

8. Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 1999;156:1563-1569.

9. Bartels N, Crotty T. A systems approach to treatment: the borderline personality disorder skill training manual. Winfield, IL: EID Treatment Systems, Inc; 1992.

10. Blum N, Bartels N, St. John D, et al. STEPPS: Systems Training for Emotional Predictability and Problem Solving—group treatment for borderline personality disorder. Coralville, IA: Blum’s Books; 2002.

11. Blum N, Pfohl B, St. John D, et al. STEPPS: a cognitive behavioral systems based group treatment for outpatients with borderline personality disorder—a preliminary report. Compr Psychiatry. 2002;43:301-310.

12. Black DW, Blum N, Eichinger L, et al. Systems Training for Emotional Predictability and Problem Solving (STEPPS) in women offenders with borderline personality disorder in prison: a pilot study. CNS Spectr. 2008;13(10):881-886.

13. Freije H, Dietz B, Appelo M. Behandling van de borderline persoonlijk heidsstoornis met de VERS: de Vaardigheidstraining emotionele regulatiestoornis. Directive Therapies. 2002;4:367-378.

14. Blum N, Pfohl B, St. John D, 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.

15. van Wel B. VERS: RCT on Dutch STEPPS. Presented at: Annual Meeting of the International Society for the Study of Personality Disorders; September 21, 2007; Den Haag, The Netherlands.

16. Black DW, Blum N, Pfohl B, et al. The STEPPS group treatment program for outpatients with borderline personality disorder. Journal of Contemporary Psychotherapy. 2004;34:193-210.

17. Pfohl B, Blum N, St. John D, et al. Reliability and validity of the Borderline Evaluation of Severity over Time (BEST): a self-rated scale to measure severity and change in persons with borderline personality disorder. J Pers Disord. 2009;23(3):281-293.

18. Young J. Cognitive therapy for personality disorders: a schema-focused approach. Sarasota, FL: Professional Resource Press; 1994.

19. Black DW, Blum N, Pfohl B, et al. Predictors of response to Systems Training to Emotional Predictability and Problem Solving (STEPPS) for borderline personality disorder: an exploratory study. Acta Psychiatr Scand. 2009;120:53-61.

Table 1

STEPPS: Trials show improvement across BPD domains

Study	Patients	Results
Uncontrolled trials
Blum et al, 2002¹¹	52 outpatients; 94% female; mean age 33	Significant improvement in BEST score; significant drop in BDI score and the PANAS negative affect scale
Black et al, 2008¹²	12 incarcerated women; mean age 35	Significant improvement in BEST score; significant drop in BDI score and the PANAS negative affect scale
Freije et al, 2002¹³	85 patients; 91% female; mean age 32	Significant improvement in score on a Dutch version of BEST; significant improvement on SCL-90 subscales, especially those rating anxiety, depression, and interpersonal sensitivity
Randomized controlled trials
Blum et al, 2008¹⁴	165 adults with BPD assigned to STEPPS plus treatment as usual or only treatment as usual	Patients receiving STEPPS plus treatment as usual experienced greater improvements in ZAN-BPD total score, impulsivity, negative affect, mood, and global functioning
van Wel, 2007¹⁵	79 adults with BPD assigned to STEPPS plus treatment as usual or only treatment as usuals	Patients receiving STEPPS plus treatment as usual had greater improvements in global psychiatric symptoms using the SCL-90, BPD symptoms, and quality of life measures at the end of treatment and at 6-month follow-up
BDI: Beck Depression Inventory; BEST: Borderline Evaluation of Severity Over Time; BPD: borderline personality disorder; PANAS: Positive and Negative Affect Scale; SCL-90: Symptoms Checklist-90; STEPPS: Systems Training for Emotional Predictability and Problem Solving; ZAN-BPD: Zanarini Rating Scale for Borderline Personality Disorder

STEPPS’ theoretical foundation

Clinical Point

STEPPS uses general psychotherapy techniques and thus requires little additional training for mental health workers

Because STEPPS employs general psychotherapy principles and techniques commonly taught in graduate-level psychotherapy training programs, it requires little additional training for mental health workers.¹⁶ Further, because it supplements ongoing treatment, STEPPS:

does not disrupt the patient’s present regimen, and
potentially enhances relationship skills by encouraging the patient to remain in longer relationships with professional and non-professional support.

STEPPS also integrates the patient’s ongoing social and professional support system, thereby avoiding the perception of abandonment common among patients with BPD.

Clinical Point

STEPPS has a unique systems component that enlists the help of a patient’s family and friends

STEPPS employs cognitive-behavioral methods, including identifying and challenging distorted thoughts and specific behavioral change, combined with psycho-education and skills training.^11,12 The addition of a systems component that enlists the help of the patient’s family and friends is unique to STEPPS (Box 1).

Emotional intensity disorder. Many clinicians assume that the core deficit in BPD is inability to manage emotional intensity. In STEPPS, therapists reframe BPD as emotional intensity disorder (EID), a term patients find easier to understand and accept. Patients tend to “see themselves as driven by the disorder to seek relief from a painful illness through desperate behaviors that are reinforced by negative and distorted thinking.”¹⁶ Starting with the first session, STEPPS therapists validate the patients’ experience of BPD and provide hope by teaching that patients can acquire skills to manage the disorder.

Box 1

STEPPS’ systems component: Involving family and friends

In the first Systems Training for Emotional Predictability and Problem Solving (STEPPS) session, patients identify and utilize a “reinforcement team” that consists of any person or persons—family members, professionals, friends, coworkers, etc.—who agree to assist the patient in reinforcing STEPPS skills. The systems perspective emphasizes patients’ responsibility for responding to their system more effectively by using their skills and helps patients develop more realistic expectations of—and more helpful interactions with—their support system. Patients are:

expected to become STEPPS experts and to teach their reinforcement team how to respond with the STEPPS “language”
encouraged to share what they are learning in group sessions, including relevant handouts
given “reinforcement team” cards that explain how team members should respond when the patient contacts them.

The cards also list the skills taught in STEPPS and provide questions for team members to ask when contacted by the participant (ie, “Where are you on the Emotional Intensity Continuum?” “Have you used your notebook?” “What skill can you use in this situation?” “How will you use it?”). The cards provide a common language and consistent interaction between patients and their support systems. Patients are instructed to give the cards to their reinforcement team members when they request their assistance.

After the first 4 to 6 STEPPS sessions, a 2-hour meeting is arranged for reinforcement team members, during which the facilitators describe diagnostic criteria and clinical symptoms of borderline personality disorder and discuss the STEPPS language and format. Team members are taught that their role is to reinforce and support the use of skills taught in STEPPS. They are shown how to use the reinforcement team cards.