About The Manual
The Second Edition of the STEPPS Manual incorporates a number of additions and changes since the original publication of STEPPS. Many of these changes reflect the experience of facilitators and participants throughout the US and internationally, in diverse populations and a variety of settings, spanning the more than 20 years the program has been in use. In addition to the typical outpatient clinical setting, STEPPS has been implemented in correctional settings (both prisons and community corrections), residential treatment, and inpatient units. Specific suggestions are included for these settings.
Section 1 of the manual is for use by facilitators, and is produced with the Typewriter tool enabled in Adobe Reader®. This tool allows the user to type on the PDF pages and save the edited pages. This feature is specifically included to enable the user to save notes, suggested text, prompts, or other information facilitators may find helpful, together with the Facilitator Guidelines for each lesson.
The Workbook Materials, Sections 2 and 3 of the Manual, may be copied and distributed to participants, and are formatted to facilitate two-sided printing (available on many copy machines.) Each lesson begins with "Page 1" and finishes with an even-numbered page.
On the flash drive, in addition to the STEPPS Manual files, there are several helpful supplements to the manual, including an optional Introductory/Intake session to help screen and/or prepare participants for a group; a section of Frequently Used Forms; a Quick Reference; a file with Small Skills Cards; and a Microsoft® Word file containing a Certificate of Completion.
A file contains three informational brochures (previously offered for sale) that can be customized for a specific agency or institution is also included.
STEPPS training is composed of three parts:
Part 1 - Awareness of EID
The first step is to replace misconceptions about the BPD label with an awareness of the thought patterns, feelings, and behaviors that define the disorder. Thoughts and behaviors can be changed; feelings can be tolerated and 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 disorder and that the individual can learn specific skills to manage it, is an important precursor to developing the capacity for change.
Group members are provided with a list of features of EID, and time is provided to acknowledge examples of the criteria in their behavior ("owning" the problem). A second component is the concept of cognitive filters. Therapists may recognize the similarity to the idea 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 see the relationship between them, features of emotional intensity difficulties, and their subsequent patterns of feelings , thoughts, and behaviors.
Part 2 - Emotion Management Skills Training
We describe the five basic skills that aid the Person with EID in managing the cognitive and emotional effects of EID. Combined with an understanding of how EID works and recognizing the filters that have been triggered in a given situation, the skills assist the Person with EID to predict the course of an episode, anticipate stressful situations in which their difficulties are intensified, and build confidence in their ability to manage it.
Part 3 - Behavior Management Skills Training
There are eight behavioral skills the Person with EID must work at mastering. As EID 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 keep these areas under control during episodes.
Outpatient Treatment - Classroom Format
The training format is a weekly two-hour classroom experience with two facilitators and 6-10 group members. Participants are supplied with a folder(the color red is suggested for easy visibility) to keep their training materials; they are instructed to bring their folder to each session. They are also strongly urged to share their folder and the lesson materials with others in their system. By the end of the training, most clients view the red folder as are source they can turn to during difficult times.
Rather than following a traditional group therapy model, sessions have a look and feel of a class. Clients sit at a conference table facing a whiteboard. Besides using the whiteboard 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 to help reinforce the skills and themes of the meetings, and they are encouraged to do so.
A typical class session begins by asking the group to complete the Quick Evaluation of Severity over Time (QuEST) 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 typical of EID and to note the decrease in the intensity of their emotional episodes and the increased use of the positive behaviors and skills being taught. The QuEST can be used for data collection to evaluate training effectiveness. The data will allow monitoring of increases and decreases in self-destructive urges and behaviors, emotional intensity, negative behaviors (e.g., substance abuse, self-destructive, eating-disordered behavior, etc.), and positive behaviors (e.g., choosing a positive activity, keeping appointments, etc.). A brief relaxation/observation exercise follows this. Scripts for some of the activities are written out and are available in the handouts. Participants are encouraged to record the hands (e.g., 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 feels calm and relaxed, and 5 is feeling out of control, engaging in self-destructive impulses, angry outbursts, etc. Clients are asked to fill this out daily and to summarize the percentage 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 have significant periods when they are not at the highest level of emotional intensity.
Our group members respond very well to this structured approach to emotional problem solving with occasional exceptions. On one occasion, when a group leader was unexpectedly delayed about 20 minutes, she arrived to discover that the group had appointed one of its members to be the leader and was well into reviewing the Emotional Intensity Continuum.
During a group session, an individual with EID 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 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 interaction's scope, so the meeting's primary goal is not lost. The group leaders must be prepared to reframe problems in the context of EID features and cognitive filters (schemas).The rule to use is: focus on EID and filters, not the content.