Please scroll down to read the first few pages of the STEPPS Treatment Manual
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The STEPPS Group Treatment Program for Borderline Personality Disorder
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
which 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 which 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 which 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 Goal
• 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 art work 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 per
cent 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.
The authors gratefully acknowledge the contribution and creativity of Cynthia Claude-Rawson for her artistic
conceptualization of the Emotional Intensity Continuum (please refer to week 1), and her illustrations and poems in the lesson
on Eating Behaviors (week 15).
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 re-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 turns 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.
It helps if everyone uses a consistent approach and language. The group has also proved to be a very successful training
vehicle for other professionals who have then gone on to start their own STEPPS groups in other locations. 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:
1. 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.
2. Teaching the trainee a series of strategies for dealing with anxiety, anger, depression, and self-destructive thoughts
which can be accomplished either independently or with a level of input from others that the support system can
comfortably provide.
3. Encouraging the trainee to share appropriate sections from their red 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.
4. Offering two special evening sessions 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 it’s inception, STEPPS was designed to be a “value added” treatment intervention which augments rather that replaces
the existing network of mental health providers. This approach helps reduce the time and expense needed to set new STEPPS
treatment groups. 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 may 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.
continued...