• Introduction to Training
• 3 Steps of Training
• Basic Program
• Classroom
• Integrating STEPPS With Other Treatment
• STAIRWAYS Program
• Other Treatment Settings, Training & Materials

Introduction to Training

The Iowa program began in 1995, and is based on a systems approach to treatment of individuals with Borderline Personality Disordered(BPD) originally developed by Bartels and Crotty (1992). That program has subsequently been adapted and revised by Blum, St. John, and Pfohl (2002). The current program includes two phases--a 20-week Basic Skills group, and a one-year, twice monthly advanced group program called STAIRWAYS. The combined program is identified by the acronym STEPPS, which stands for Systems Training for Emotional Predictability and Problem Solving.

In this cognitive-behavioral, skills training approach, Borderline Personality Disorder (BPD) is characterized as a disorder of emotion and behavior regulation. The goal is to provide the person with BPD, other professionals treating them, and closely allied friends and family members with a common language to communicate clearly about the disorder and the skills used to manage it. Clients learn specific emotion and behavior management skills. Key professionals, friends, and family members whom clients identify as part of their "reinforcement team," learn to reinforce and support the newly learned skills. This helps avoid the phenomenon of "splitting," a process in which the person with BPD may externalize their internal conflict by appearing to draw others around them into taking sides against each other and arguing out the merits of differing perspectives and behaviors. Splitting, like other behaviors common in BPD, is viewed not as an intentional act of aggression, but as an automatic response to the emotional intensity and dysregulation that the client can learn to anticipate and replace with more effective behavior.

Underlying this training approach is the assumption that at the core of BPD is an actual clinical entity, a disorder that might be characterized as a defect in the individual’s internal ability to regulate emotional intensity. As a result, the person with BPD is periodically overwhelmed by abnormally intense emotional upheavals that drive him or her to seek relief. Family studies suggest an underlying biologic vulnerability. The childhood history of the person with BPD often includes inconsistent emotional support or even abuse by important caregivers. In most cases there is a complex interplay between underlying vulnerability and the social environment. Identifying someone to "blame" for the disorder is usually counterproductive. We believe that individuals with BPD do not consciously choose to have this disorder and, with rare exceptions, parents and other important caregivers do not consciously choose to create an inconsistent and unsupportive childhood environment.

Early in treatment, many of our clients view the term personality disorder as a code for, "it’s all your own fault." The term borderline seems to imply that it is only a matter of time before they fall completely "over the edge." For these reasons, clients often resist the label of BPD, even though they may readily acknowledge the behaviors. Bartels and Crotty have suggested the name Emotional Intensity Disorder as a more accurate description that clients find easier to understand and accept. We use both terms interchangeably. Regardless of the terminology, there are significant advantages to reframing one’s understanding of BPD as a disorder. Rather than viewing themselves as someone who is attempting to manipulate, is attention-seeking, or is sabotaging treatment, the trainees learn to view themselves as driven by the disorder to seek relief from a painful illness through desperate behaviors which are reinforced by negative and distorted thinking.

The training is composed of three steps:

Step 1 - Awareness Of Illness

The first step for the client is to replace misconceptions about the BPD label with an awareness of the behaviors and feelings that define the disorder. Behaviors can be changed and feelings can be managed. Clients often begin with the belief that they are fatally flawed (for which they may alternately blame themselves or others) and that they deserve to suffer. The ability to entertain the notion that this is a legitimate illness and that the individual can learn specific skills to manage it is an important precursor to developing the capacity for change.

Clients are provided with a printed handout listing the DSM-IV criteria for BPD and time is provided for trainees to acknowledge examples of the criteria in their own behavior ("owning" the illness). A second component is the concept of cognitive filters. Therapists may recognize the similarity to the concept of schemas described by Jeffrey Young (1999) in Cognitive Therapy for Personality Disorders — A Schema-Focused Approach. A questionnaire has been developed to allow trainees to identify their early maladaptive filters and to see the relationship between these filters, the DSM-IV criteria, and their subsequent patterns of feelings, thoughts, and behaviors.

Step 2 - Emotion Management Skills Training

We describe the five basic skills that aid the person with BPD in managing the cognitive and emotional effects of the illness. Combined with an understanding of how the illness works and recognizing the filters that have been triggered in a given situation, the skills assist the person with BPD in predicting the course of an episode, anticipating stressful situations in which the illness is aggravated, and building confidence in their ability to manage the illness.

Step 3 - Behavior Management Skills Training

There are eight behavior skills areas the person with BPD must work at mastering. As the BPD syndrome progresses through the disruptive interplay between the emotionally intense episodes and a social environment that becomes increasingly unempathic and unresponsive, many functional areas may begin to break down. Learning or relearning patterns of managing these functional areas helps the person with BPD to keep these areas under control during episodes.

STEPPS Basic Skills Group Program

The Basic Skills Program consists of 20 weekly meetings of two hours each. This includes a short break between the first and second hour. Each week is organized around a skill that is the focus of the session. Some skills require more than one weekly session to teach. The skills include:

• Distancing
• Communicating
• Challenging
• Distracting
• Managing Problems
• Setting Goals
• Eating
• Sleeping
• Exercise
• Leisure
• Physical Health
• Abuse Avoidance
• Relationship Management

For those groups whose meetings occur during the Holiday Season, we have included an optional unit (See Appendix) on managing emotional intensity during this time of the year.

Outpatient Treatment - Classroom "Seminar" Format

The training format is a weekly two-hour classroom experience with two trainers and 6-10 trainees. Trainees are supplied with a red notebook in which to keep their training materials. They are instructed to bring in the notebook to each session. They are strongly urged to share their notebook and the lesson materials with others in their system. By the end of the training, most clients view the red notebook as a resource they can turn to during difficult times.

Rather than following a traditional group therapy model, sessions have the look and feel of a seminar. Clients sit at a conference table facing a board. Besides the use of the board and the printed materials, the training is facilitated by poetry, audio recordings of songs, art activities, and relaxation exercises. It is not unusual for clients to bring in materials, poems, and even artwork they have created that reinforce the skills and themes of the meetings.

A typical class session begins with trainees completing the Borderline Evaluation of Severity over Time (BEST) form, which allows them to rate the intensity of their thoughts, feelings, and behaviors over the past week. They keep track of their weekly score on a graph. This allows them to see the variability that is typical of BPD, and to note over time the decrease in the intensity of their emotional episodes and the increased use of the positive behaviors and skills being taught. The BEST can be used for data collection to evaluate the effectiveness of training. The data will allow monitoring of increases and decreases in self-abuse urges and behaviors, as well as emotional intensity, negative behaviors (e.g.,, substance abuse, eating-disordered behavior), and positive behaviors (e.g., choosing a positive activity, keeping appointments, etc.). This is followed by a brief relaxation/observation exercise. Scripts for some of the activities are written out and available in the handouts. Participants are encouraged to record the scripts (e.g., for progressive muscle relaxation and visualizations) to use outside of the sessions.

The first half of each session is spent reviewing the Emotional Intensity Continuum, which operationalizes the concept of varying degrees of emotional intensity on a 1-5 scale. A 1 is feeling calm and relaxed, and 5 is feeling out of control, engaging in self-destructive impulses, angry outbursts, etc. Clients are expected to fill this out on a daily basis and to summarize the percent of time spent at each level during the previous week. Clients often achieve a more balanced view of themselves through this self-rating. In addition, clients are often surprised to find that they do have significant periods of time when they are not at the highest level of emotional intensity.

A Skills Monitoring Card lists the skills being taught and allows trainees to indicate which skills they used in the previous week. As part of the family/caregiver education component, clients are encouraged to give an abbreviated version of this card to members of their reinforcement team. The previous week’s homework assignment(s) are reviewed and the remainder of the session is devoted to introducing the material for the current lesson. Participants are encouraged to read aloud the material being introduced

With occasional exceptions, our clients take to this structured approach to emotional problem solving very well. On one occasion when a group leader was unexpectedly delayed about 20 minutes, she arrived to discover that the group had appointed one of the members to be the leader and the group was well into reviewing the Emotional Intensity Continuum for the group. In the advanced (STAIRWAYS) group, clients regularly request permission to conduct that portion of the session.

While in a training session, a person with BPD may try to reframe their emotional experience in the context of or as a result of some personal or interpersonal problem. While there is an opportunity for clients to respond and share experiences relevant to the skills being taught, the structure does not allow the group to spend long periods of time focusing on a given group member who may be in crisis. One effect of the structured format is to model how to acknowledge problems and offer support while still imposing reasonable limits and boundaries on the scope of interaction so the main goal of the meeting is not lost. The group leaders must be prepared to reframe problems in the context of the disorder and filters. The rule to use is: focus on the disorder, not the content.

The Systems Component of STEPPS

Whether it is cause or effect, the individual coming to therapy is usually enmeshed in a system of relationships in which even concerned and well-intentioned friends and significant others respond to the individual with BPD in a manner that reinforces pathologic behavior. For example, the individual experiencing a perceptual distortion that others dislike him or her may become irritated and behave in ways that turn the distortion into a reality. This new reality then serves to reinforce the cognitive distortions and maladaptive behavior.

For 20 weeks, the STEPPS group becomes a mini-system in which the trainee receives instruction on new ways of thinking and new behaviors. Trainees receive positive reinforcement in the form of support from group trainers and other group members. The new behaviors are designed to influence the individual’s larger support system so it too begins to reinforce healthy behavior. STEPPS emphasizes that the trainees can and should take responsibility for taking steps to help key players in their system respond more effectively. Specifically, STEPPS incorporates the following 4 components to address the trainees’ support system:

• Teaching the trainee to challenge cognitive distortions and to develop more realistic expectations about what types of support are appropriate from key players in their support team.
• Teaching the trainee a series of strategies for dealing with anxiety, anger, depression, and self-destructive thoughts that can be accomplished either independently or with a level of input from others that the support system can comfortably provide.
• Encouraging the trainee to share appropriate sections from their manual with close friends and significant others (as well as her/his other mental health providers) so that these individuals can better understand the illness, the terminology, and ways of responding to the trainee that reinforce the strategies taught in the STEPPS program.
• Offering a special evening session in which key members of the support team are invited to come and learn about BPD, how STEPPS works, and what they can do to help. We provide written guidelines that summarize how to respond to the trainee on occasions when the trainee is feeling desperate and out of control.

Integrating STEPPS With Other Treatments

Clearly, STEPPS is not a comprehensive treatment program for managing individuals with borderline personality disorder. From its inception, STEPPS was designed to be a "value added" treatment intervention that augments rather than replaces the existing network of mental health providers. STEPPS has been implemented in a wide variety of settings and is usually well received by other providers who continue to provide mental health services to individuals enrolled in STEPPS.

Clients in the STEPPS program are frequently being treated with one or more psychopharmacologic agents, most often antidepressants and mood stabilizers. The program addresses compliance with medications as prescribed by the client’s physician as an important enabling factor for the group therapy program. Substance abuse is viewed as treatment disabling and clients are required to seek appropriate substance abuse treatment and maintain abstinence either before or concurrently with the STEPPS program. Clients with a severe eating disorder are similarly required to be in an appropriate treatment program.

Trainers should note that in the development of this treatment approach, the need for traditional individual therapy might be reduced. In fact, a team approach to working with a person with BPD who is familiar with the skills and behavior patterns has been found by Bartels and Crotty to be preferable to an individual approach. The optimal treatment system is one in which, in addition to the weekly skills training, the person with BPD receives skill and behavior pattern reinforcement from all treatment system personnel, family, and friends. This approach encourages the person with BPD to rely on peers, family, and others for reinforcement and reduces the possibility that the person with BPD will focus exclusively on a single therapist who then runs the risk of being alternately over-idealized and devalued by the person with BPD. Those individuals receiving individual therapy are eligible for the STEPPS program provided the therapist agrees to support the program by reviewing the STEPPS materials with the client as they add the lessons to the red notebook each week. We provide several opportunities for professionals, relatives, and significant others to participate in the program. During the 20 weeks, a special evening session is held that also includes professionals, relatives, and significant others. In addition, we have found that the clients are quite willing to have significant others and even their individual therapist attend a regular group meeting, and group members are given permission to bring them to any two sessions following the evening session.

Life After STEPPS

As expected, trainees are often anxious about finishing the STEPPS program and losing the support they received in the group. STEPPS works to minimize the impact of finishing group by constantly focusing on how the individual is using their larger support system including friends, relatives, significant others, and professionals. Patients are encouraged from the start to view STEPPS as a time-limited program designed to make their existing support system work better, rather than viewing it as a replacement for that support system. Patients who have an established relationship with an individual therapist often continue to use the language and principles of STEPPS as a component of their individual therapy.

Some trainees find it difficult to grasp the principles of STEPPS the first time through and benefit from repeating the basic program with the next group. At Iowa we are developing a manual for an advanced group called STAIRWAYS which is described below. The STAIRWAYS group meets only twice a month and therefore helps provide a smoother transition. The transition can be continued by having trainees attend STAIRWAYS only once a month, and then for occasional "booster sessions."

The STAIRWAYS Program

STAIRWAYS is designed as a one-year program consisting of two meetings each month. As before, a series of themes are covered. The themes reinforce and extend the skills learned during the STEPPS program.

STAIRWAYS is an acronym that stands for:

Setting Goals
Trusting and Taking Risks
Anger Management
Impulsivity Control
Relationship Behavior
Writing a Script
Assertiveness Training
Your Choices
Stepping Out

As with the STEPPS group, handouts are provided each session and these are added to the notebook.

Other Treatment Settings

This training approach is adaptable to a variety of treatment settings such as partial hospital, day treatment programs, residential facilities, and substance abuse treatment. Depending on the available time and intellectual level of trainees, lessons may be broken down into shorter components at more frequent intervals. On inpatient units where typically length of stay is a few days, the awareness component may be used to assess the ability of the client to participate in a more extensive program and to prepare the client to enter such a program.

Training

We recommend that group leaders, at a minimum, have a master’s degree in the social sciences with several years of experience in psychotherapy and counseling. On-site training workshops are available with ongoing consultation. For more information on training workshops, contact Nancee Blum, MSW, (319) 353-4393; E-mail: nancee-blum@uiowa.edu.

Ordering Information for Manual

The STEPPS manual is available on CD-ROM. The price is $49.95 plus $5.95 shipping and handling (Iowa residents add $2.00 sales tax). Order from Blums Books, 685 Breconshire Lane, Coralville, IA 52241.