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.

Patient characteristics

Although some patients learn of STEPPS from previous participants, at our facility we usually request a formal professional referral. We then send potential participants a letter inviting them to attend the group, along with a brochure describing STEPPS and a dated syllabus. We generally begin with 12 to 15 patients but typically have 7 to 10 by the fifth session.

Patients with strong narcissistic or antisocial traits may have difficulty in group settings, probably because they prefer to be the center of attention. That said, we have successfully implemented STEPPS in Iowa prisons and have not experienced difficulties.¹² Patients who are abusing substances or have active eating disorders (primarily anorexia nervosa) may not be cognitively able to benefit from STEPPS until these behaviors are better controlled. We recommend that patients seek treatment for these behaviors before—or concurrent with—STEPPS participation.

Persons who deal with conflict by physical threats or intimidation are potential threats to group integrity and are removed immediately. We avoid forming groups with a lone male participant because:

he may come to represent all men to the rest of the group
he may have difficulty identifying with problems unique to women with BPD.

Patients who do well in STEPPS are able to share time with others, limit discussion of their own problems, have some capacity for empathy, and demonstrate an ability to consider that another’s perception may be different from their own. We encourage referring clinicians to discuss with the patient his or her readiness to enter STEPPS, as well as the requirements for and expectations of the program (such as capacity to listen, compliance with homework assignments, etc.). Some patients may need to wait until they are psychologically ready to participate.

Clinical Point

Evidence suggests BPD patients rated as more symptomatic experience greater improvement from STEPPS

In a recent study we found that patients who were rated as more symptomatic at baseline experienced the greatest improvement. Apart from this finding, there were few response predictors, but it was reassuring that both men and women improved.¹⁹ Members are cautiously encouraged to use each other as reinforcement team members between sessions, once they feel safe in the group. They are instructed to follow the reinforcement team guidelines.

The facilitators’ role

STEPPS groups are led by 2 facilitators with graduate level training in social sciences and psychotherapy experience. Therapists may be trained in STEPPS during a 1- to 2-day on-site workshop or by attending a 20-week group. These trainees are identified as professionals and do not participate in the sessions.

Using 1 male and 1 female facilitator for a STEPPS group allows modeling of relationship behaviors between genders, projects a healthy male role, and provides support for male participants, who in most groups are in the minority. Initially the facilitators’ stance is active and directive, although this tends to decrease as patients gradually are given increasing leadership responsibilities (such as leading brief reviews of homework assignments).

The therapists’ main tasks include:

maintaining the psychoeducational format
adhering to the guidelines
avoiding involvement in individual issues and past traumas (providing individual psychotherapy in a group setting)
maintaining focus on skills acquisition
encouraging group cohesion through identification
facilitating participants’ change of perspective from victims of EID to experts on managing EID.

Crises are common among patients with BPD and if not attended to appropriately can easily derail the group process. Crises are acknowledged, then managed in the group by careful attention to the use of skills (such as using a crisis as an example of applying the skill to be learned that session). Facilitators direct patients to deal with long-standing personal issues with their individual therapists. Patients who appear in imminent danger of self-harm or suicide are removed from the group and immediately referred to emergency personnel. On these rare occasions, the referral is done swiftly to avoid disrupting the group and creating a perception of special treatment.

Follow-up: STAIRWAYS

STAIRWAYS is a 1-year follow-up group that meets twice a month after the 20-week STEPPS program and consists of stand-alone modules addressing:

Setting goals
Trying new things (oriented toward long-term goals, such as obtaining a degree, employment, etc.)
Anger management
Impulsivity control
Relationship management (emphasis on conflict management)
Writing a script (identifying and preparing for future stressors)
Assertiveness training
Your choices (making healthy choices)
Staying on track (relapse prevention).

Clinical Point

Patient crises are acknowledged and then used as an example of applying the STEPPS skills

STAIRWAYS follows a format similar to STEPPS, with a classroom-like setting and homework assignments. It maintains participants’ contact with the STEPPS model by emphasizing ongoing use of newly learned skills and reinforcing STEPPS skills.