Group format
STEPPS consists of 20 consecutive weekly, 2-hour sessions led by 2 therapists (we prefer the term “facilitators”). Sessions take place in a classroom setting and are highly structured, with specific facilitator guidelines for each session.
When they arrive at each session, patients fill out the Borderline Evaluation of Severity Over Time (BEST) scale (Box 2)11,17 and record the results on a graph to measure their progress. Each session has a specific handout, including an agenda, followed by the homework assignment for the next week. Participants read the handout material aloud during the group session and start the homework assignment to be sure they understand it.
Handouts also include poems, essays, drawings, and examples created by previous STEPPS participants; these provide a sense of ownership among participants past, present, and future. Participants are encouraged to share their own writings and drawings, as well as other resources they have found helpful to illustrate the skills being taught.
Skills training. Facilitators introduce a new skill at each session, and each skill builds on previously taught skills. A recurring theme in STEPPS is that “most of the work is done between sessions”—during the week, patients are expected to practice the skill taught at the previous session. Using the STEPPS skills is framed as “change from the outside in.” As patients challenge maladaptive filters and distorted cognitions, they find that negative feelings and dysfunctional behaviors change.
Patients identify their use of specific skills by completing a 5-point Emotional Intensity Continuum (EIC) scale. This abstract concept is made concrete with drawings of pots on a burner. At level 1 (baseline), there is no heat under the burner; at level 5, the pot is boiling over.
BEST: A new tool for assessing severity of BPD behaviors
We developed the Borderline Evaluation of Severity Over Time (BEST) to rate severity and change in patients with borderline personality disorder (BPD).11,17 The self-rated scale has 15 items for which patients rate themselves on a 5-point scale; scores can range from 12 to 72.
The BEST shows evidence for good internal consistency and for both face and content validity because the items were constructed to assess behaviors relevant to BPD. We recently assessed the BEST in subjects who had participated in our randomized controlled trials and concluded that the scale is reliable, valid, and sensitive to clinical change as early as week 4.17 To obtain a copy of this scale, contact the authors.
3 components of STEPPS
Awareness of illness. The first step is for patients to replace misconceptions about BPD with awareness of the behaviors and feelings that define the disorder. They are provided with a printed handout listing DSM-IV criteria for BPD and given time to acknowledge examples in their own behavior. This is called “owning” the illness.
The second step is to introduce the concept of schemas, referred to as cognitive filters. With the author’s permission, we extracted 64 items from Young’s Schema Questionnaire,18 which helps patients identify their early maladaptive schemas. We encourage patients to understand the relationship among these filters, DSM-IV criteria, and their subsequent pattern of feelings, thoughts, and behaviors.
Emotion management skills taught in STEPPS are distancing, communicating, challenging, distracting, and managing problems (Table 2). Using these skills, participants learn to:
- predict the course of emotional states
- anticipate stressful situations
- develop functional coping strategies.
Table 2
Patient skills taught in STEPPS
| Awareness of illness |
| Understand what BPD is |
| Reframe BPD as ‘emotional intensity disorder’ |
| ‘Own’ the illness |
| Identify and challenge dysfunctional schemas |
| Emotion management skills |
| Distancing: Provide distance from emotional intensity |
| Communicating: Describe and define feelings, physical sensations, thoughts, filters, action urges, and behaviors |
| Challenging: Identify distorted thinking and develop alternate ways of thinking |
| Distracting: Identify and engage in behaviors that lower emotional intensity or assist in getting through an episode without resorting to damaging behaviors |
| Managing problems: Identify and define problems, then plan and carry out action steps |
| Behavior management skills |
| Setting goals: Identify specific goals and develop strategies to manage specific problematic behaviors |
| Eating: Balanced diet |
| Sleeping: Good sleep hygiene |
| Exercising: Regular and balanced exercise |
| Leisure: Regular leisure activities |
| Physical health: Manage medical problems |
| Abuse avoidance: Develop strategies to replace abusive behaviors (self-harm, substance abuse, gambling, etc.) |
| Relationship management: Identify and determine strategies to develop healthy relationships. Understand and implement healthy boundaries |
| BPD: borderline personality disorder; STEPPS: Systems Training for Emotional Predictability and Problem Solving |