Vol. 8, No. 10 / October 2009
Borderline personality disorder: STEPPS is practical, evidence-based, easier to use
20-week adjunctive group program improves multiple BPD symptom domainsDonald W. Black, MD
Professor, Department of psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA Nancee Blum, MSW
Adjunct instructor, Department of psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA Don St. John, MA, PA-C
Physician assistant, Department of psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA
Comment on this article
Treatment of borderline personality disorder (BPD) often is viewed as challenging and the results so discouraging that some clinicians avoid referrals of BPD patients.1-3 Psychotherapy has been the treatment mainstay for decades, and supportive approaches are probably the most widely employed.4 Psychodynamic therapy often has been recommended.
This article introduces a new evidence-based group treatment program that we developed for BPD patients. Systems Training for Emotional Predictability and Problem Solving (STEPPS) is founded on the successes of better known psychoeducational models but is easier for practicing psychiatrists to implement.
A different approach to BPD
Linehan5 introduced dialectical behavior therapy (DBT)—a manualized, time-limited, cognitive-behavioral approach in which patients learn to regulate their emotions and behaviors rather than change their personality structure. Other evidence-based BPD treatments include transference-focused psychotherapy,6 schema-focused psychotherapy,7 and Bateman and Fonagy’s mentalization program.8 For a description of the unique challenges presented by BPD patients, see Box.
In the mid-1990s, we set out to create a treatment program for our BPD patients in response to managed care directives to lower the cost of care, decrease length of inpatient treatment, and reduce rehospitalization rates. Despite DBT’s many appealing features, we felt this model was too lengthy and labor-intensive for our treatment setting. We concluded that modifying a program developed by Bartels and Crotty9 would serve our needs. This 12-week psychoeducational program:
employs established cognitive-behavioral techniques in group treatment intended to supplement but not replace patients’ ongoing treatment
incorporates a “systems” component that recognizes the importance of the patient’s family and friends.
We adapted Bartels and Crotty’s manual (with permission), lengthened the program to 20 weeks, and developed specific session agendas with explicit facilitator guidelines.
We eventually renamed the program Systems Training for Emotional Predictability and Problem Solving (STEPPS)10 and created a new manual (see Related Resources) to simplify group leader training and ensure fidelity to the model. Data from 5 studies, including 2 randomized controlled trials (Table 1), show that STEPPS has a robust antidepressant effect and leads to broad-based improvements in the affective, cognitive, impulsive, and disturbed relationship domains of BPD.11-15Box
Why treating borderline personality disorder is so challenging
Borderline personality disorder (BPD) is 1 of the most challenging mental health conditions. BPD is surprisingly common, with prevalence rates of 0.5% to 1% in the community, 10% in outpatient mental health settings, and up to 20% in inpatient psychiatric settings.a-c Patients with BPD experience substantial functional impairment in several areas (eg, difficulty maintaining employment, disturbed interpersonal relationships, and disrupted family relationships).a,d,e
Many borderline patients have childhood histories of abuse and continue to be victims of domestic and other violence through adulthood.f High utilization of medical and psychiatric health care services is common and costly.g BPD also is associated with substantial psychiatric comorbidity, particularly mood and anxiety disorders, substance use disorders, eating disorders, and other Axis II disorders.h,i
Persons with BPD experience intense dysphoria and intrapsychic pain. Characteristic features include affective intensity, reactivity, and lability; a pervasive pattern of unstable interpersonal relationships; marked behavioral impulsivity; unstable self-identity; intense anger; and extreme fear of abandonment.j
The symptom that probably makes the greatest demand on mental health resources is recurrent suicidal threats/attempts or episodes of self-mutilation, many prompted by disappointment in a relationship.k Two-thirds to three-quarters of BPD patients will attempt suicide, with up to 10% eventually completing suicide, often following multiple failed treatments.l
a. Gunderson J. Borderline personality disorder: A clinical guide. 2nd ed. Washington, DC: American Psychiatric Publishing; 2008.
b. Widiger TA, Frances AJ. Epidemiology, diagnosis, and co-morbidity of borderline personality disorder. In: Tasman A, Hales RE, Frances AJ (eds). American Psychiatric Press Review of Psychiatry, vol. 8. Washington, DC: American Psychiatric Press; 1989:8-24.
c. Swartz MS, Blazer D, George L, et al. Estimating the prevalence of borderline personality disorder in the community. J Personal Disord. 1990;4:257-272.
d. Nakao K, Gunderson JG, Phillips KA, et al. Functional impairment in personality disorders. J Personal Disord. 1992;6:24-31.
e. Skodol AE, Gunderson JG, McGlashan TH, et al. Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder. Am J Psychiatry. 2002;159:276-283.
f. Zanarini MC. Childhood experiences associated with the development of borderline personality disorder. Psychiatr Clin North Am. 2000;23:89-101.
g. Bender DS, Dolan RT, Skodol AE, et al. Treatment utilization by patients with personality disorders. Am J Psychiatry. 2001;158:295-302.
h. Zanarini MC, Frankenburg FR, Dubo ED, et al. Axis I co-morbidity of borderline personality disorder. Am J Psychiatry. 1998;155:1733-1739.
i. Zimmerman M, Coryell W. DSM-III personality disorder diagnoses in a non-patient sample: demographic correlates and co-morbidity. Arch Gen Psychiatry. 1989;46:682-689.
j. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 1994.
k. Paris J. Social factors in personality disorders— a biopsychosocial approach to etiology and treatment. New York, NY: Cambridge University Press; 1996.
l. Soloff PH, Lynch KG, Kelly TM. Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. Am J Psychiatry. 2000;157:601-608.
STEPPS: Trials show improvement across BPD domains
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
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.
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.
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.Box 2
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:
Patients learn skills to predict emotional states, anticipate stress, and develop coping strategies
predict the course of emotional states
anticipate stressful situations
develop functional coping strategies.
Behavior management skills include goal-setting, sleep hygiene, diet and nutrition, exercise and physical health, relaxation and leisure, abuse avoidance, and interpersonal relationship management. Participants learn that following a daily routine and managing behaviors such as sleep and diet yields the energy needed to manage the disorder.
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
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:
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.
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.
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:
Trying new things (oriented toward long-term goals, such as obtaining a degree, employment, etc.)
Relationship management (emphasis on conflict management)
Writing a script (identifying and preparing for future stressors)
Your choices (making healthy choices)
Staying on track (relapse prevention).
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.
The STEPPS Model for Borderline Personality Disorder Manual. www.steppsforbpd.com.
van Wel B, Kockmann I, Blum N, et al. STEPPS group treatment for borderline personality disorder in The Netherlands. Ann Clin Psychiatry. 2006;18(1):63-67.
Dr. Black receives research/grant support from AstraZeneca and Forest Laboratories and is a consultant to Jazz Pharmaceuticals.
Ms. Blum and Mr. St. John receive royalties from Blums’ Books LLC, publisher of the Systems Training for Emotional Predictability and Problem Solving (STEPPS) manual.
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- Soloff PH. Psychopharmacology of borderline personality disorder. Psychiatr Clin North Am. 2000;23:169–191.
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- Paris J. Borderline personality disorder—a multidimensional approach.Washington, DC: American Psychiatric Press; 1994.
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- 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.
- 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.
- 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.
- Bartels N, Crotty T. A systems approach to treatment: the borderline personality disorder skill training manual.Winfield, IL: EID Treatment Systems, Inc; 1992.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Young J. Cognitive therapy for personality disorders: a schema-focused approach.Sarasota, FL: Professional Resource Press; 1994.
- 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.
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