Level 1 Publishing

STEPPS Group Treatment Programme: Introduction to Training

Welcome to STEPPS YP

STEPPS YP is a cognitive-behavioural, skills-training approach for young people between the ages of 16 and 18, who have been identified either as already diagnosable with Borderline Personality Disorder, or as having early signs of a possible future diagnosis, should matters deteriorate. It is the aim of this programme to provide an intervention without the need to make the diagnosis formally, to provide a non pathologising approach where one has been made already, or to serve as an early intervention.

Making a diagnosis of BPD in those under the age of 18 has been controversial for many years. However, Chanen and McCutcheon (2013) write that BPD is common and among the most functionally disabling of disorders. It can be identified reliably in its early stages in young people, and can lead to a life of considerable future distress and early death. According to Chanen and McCutcheon, data suggest that these traits in youth can be considerably flexible and malleable, and have already been shown to respond to intervention, which can potentially change the life - course of the individual. To meet the need for early intervention, STEPPS YP has been developed from STEPPS, an evidence-based programme with proven effectiveness in adults.

These Facilitator Guidelines will provide general information about the STEPPS approach, including information about BPD from time-to-time, where relevant. In the STEPPS YP workbook pages, we have made an attempt to change all of these references to Emotional Intensity Difficulties (EID), a term which will be explained in due course. In our experience, some young people have already self-diagnosed and some will recognise this programme and its contents as relevant to BPD. Our approach is not to deny this, but to redirect into what we believe is a more hopeful, recovery-orientated or educative/developmental approach.

WHAT IS STEPPS?

The Iowa programme began in 1995, based on a systems approach to treating individuals with Borderline Personality Disorder (BPD), originally developed by Bartels and Crotty (1992). That programme was subsequently adapted and revised by Blum, Bartels, St. John, and Pfohl (2002, 2012), and has been further revised for this edition. The acronym STEPPS stands for Systems Training for Emotional Predictability and Problem Solving. (Note to Facilitators: throughout this introductory section, we use the terms patient, client, participant, or group member interchangeably).

In this cognitive-behavioural, skills training approach, Borderline Personality Disorder (BPD) is characterized as a disorder of emotion and behaviour regulation. The goal is to provide the person with EID, 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. In the STEPPS YP programme we try consistently to refer to Emotional Intensity Difficulties rather than BPD. STEPPS participants learn specific emotion and behaviour management skills and also identify key professionals, friends, and family members as part of their “reinforcement team;” these individuals 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 about the merits of differing perspectives and behaviours. Splitting, like other behaviours common in BPD, is viewed not as an intentional act of aggression, but as an automatic response to the emotional intensity and dysregulation the group member can learn to anticipate and replace with more effective responses. A specific feature of STEPPS YP is the concurrent group run for parents/ carers, in which this part of the young person's system is brought closer and helped to reinforce the skills learned in a more direct way.

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 biological 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 patients with the diagnosis 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, adult group members often resist the label of BPD, even though they may readily acknowledge the behaviours. Young people may not have had this diagnostic label applied, and our approach is to try to avoid this where possible. Bartels and Crotty suggested the name Emotional Intensity Disorder (EID) as a more accurate description that group participants may find easier to understand and accept so this is what is preferred in the adult programme. For adult groups, the word “disorder” is used instead of “difficulty” (in STEPPS YP.) There may be significant advantages to reframing one’s understanding of BPD as a disorder where this diagnosis has actually been made. Rather than viewing themselves as someone who is attempting to manipulate, is attention-seeking, or is sabotaging treatment, the STEPPS participants learn to view themselves as driven by the symptoms of the disorder to seek relief from a painful disorder through desperate behaviours which are reinforced by negative and distorted thinking. In this manual, where we refer to Emotional Intensity Difficulties (EID), the aim is similarly to focus on how difficult it may be for someone to experience intense emotions that feel out of control. The aim is to acknowledge the painful process participants may go through in trying to cope with these intense emotions without necessarily framing it in illness or disorder terminology.

Training: Step 1 – Awareness of Emotional Intensity Difficulties (EID)

The first step is to replace misconceptions about "wrong" with an awareness of the behaviors and feelings that define emotional intensity difficulties. Behaviors can be changed, and emotions 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 problem and that the individual can learn specific skills to manage it is essential 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 offeelings, thoughts, and behaviors.

Training: Step 2 – Emotion Management Skills Training

We describe the five basic skills that aid the person with EID in managing the cognitive and emotional effects they may experience. Combined with an understanding of how the criteria for EID work, and recognizing the filters that are triggered in a given situation, the skills assist the person in predicting the course of an episode, anticipating stressful situations in which the symptoms are intensified, and building confidence in their ability to manage their intensity.

Training: Step 3 – Behaviour Management Skills Training

There are eight behavioural skills to work at mastering. As the person’s emotional reactivity progresses through the disruptive interplay between the emotionally intense episodes and a
social environment that becomes increasingly less empathic and unresponsive, many functional areas start to break down. Learning or relearning patterns of managing these functional areas helps to keep these areas under control during episodes.

STEPPS Basic Skills Group Programme

The Basic Skills Programme consists of 18 weekly meetings, with breaks as required for conventional school/college holidays. Each lesson 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 Behaviours

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

Outpatient Treatment – Classroom Format

The training format is a weekly two-hour classroom experience with three facilitators and 10– 12 group members. Participants are supplied with a 3-ring binder, or folder (the colour red is suggested for easy visibility) to hold their training materials; they are instructed to bring their binder or folder to each session. They are also strongly urged to share their binder or folder and the lesson materials with others in their support network. By the end of the training, most clients view the red binder or folder as a resource they can turn to during difficult times.

Rather than a traditional group therapy model, sessions have the look and feel of a class. Group members sit at a conference table facing a white board. Besides the use of the white board and the printed materials, the training is facilitated by poetry, audio recordings of songs, art activities, and relaxation exercises. Group members often bring materials, poems, and even artwork they have created to help reinforce the skills and themes of the meetings, and they are strongly encouraged to do so.

A typical class session begins with completing the Quick Evaluation of Severity over Time (QuEST) form, which allows participants to rate the intensity of their thoughts, feelings, and behaviours 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 EID, and to note over time the decrease in the intensity of their emotional episodes and the increased use of the positive behaviours and skills they are learning. The QuEST can be used for data collection to evaluate the effectiveness of training. The data allow monitoring of increases and decreases in self-harm urges and behaviours, as well as emotional intensity, negative behaviours (e.g., substance abuse, self harm, eating-disordered behaviour), and positive behaviours (e.g., choosing a positive activity, keep- ing appointments, etc.). This is followed by a brief relaxation/observation exercise. Scripts for some of the activities are written out and are available in the handouts. Participants are encouraged to record the scripts (e.g., visualisations) to use outside of sessions.

The first half of each session is spent reviewing the Emotional Intensity Continuum, which operationalises 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 asked to fill this out on a daily basis and to summarise 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 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 participants to indicate which skills they used in the previous week. As part of the family/care provider education component, clients are encouraged to give their reinforcers a card with suggestions for reinforcing the participant’s use of the skills. 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. In the participant lessons, the term “homework” has been changed to weekly tasks. Participants are encouraged to read aloud the material being introduced.

With occasional exceptions, our group members respond very well to this structured approach to emotional problem solving. 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 event that the young people/person does not find this approach helpful, then omit and add suitable time to discuss skills used, for example, in the reinforcement session or an additional homework discussion.

During a group session, an individual with EID may try to reframe his or her emotional experi- ence in the context of or as a result of some personal or interpersonal problem. While there is an opportunity for participants 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 having particular difficulties currently or who may even 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 the 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 challenges of excessive emotional intensity and cognitive filters (schemas). 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/EID in a manner that reinforces pathological behaviour. 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 behaviours.

For 18 weeks, the STEPPS group becomes a mini-system in which the participant receives in- struction in new ways of thinking and new behaviours. Participants receive positive reinforcement in the form of support from group leaders and other group members. The new behaviours are designed to influence the individual’s larger support system so it too begins to reinforce healthy behaviour. STEPPS emphasizes that group members can and should take responsibility for taking steps to help key players in their system respond more effectively. The same is true for STEPPS YP in young people’s services. Specifically, STEPPS incorporates the following 5 components to address the participants’ support system:

  • Teaching the participant to challenge cognitive distortions and develop more realistic expectations about what types of support are appropriate from key players in their support system.
  • Teaching strategies (skills) 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 participant to share appropriate sections from the STEPPS binder or folder with close friends and significant others (as well as other care providers) to help these individuals better understand the disorder, the terminology (STEPPS “language”), and ways of responding that help reinforce the skills taught in the STEPPS programme.
  • In the adult programme for STEPPS, offering at least one 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. This manual provides written guidelines that summarise how to respond to the participant on occasions when he or she is feeling desperate and out of control. More detail is provided in STEPPS YP during the weekly sessions for carers/key members, which runs in parallel with the main group.

Integrating STEPPS With Other Treatments

STEPPS is not a comprehensive treatment programme for managing individuals with Border- line Personality Disorder. In adult services, from its inception, STEPPS was designed to be a “value added” or supplemental treatment intervention that augments, rather than replaces, the existing network of mental health providers. The same is true for STEPPS YP in young people’s services.

STEPPS has been implemented in a wide variety of settings and is usually well received by those who continue to provide mental health treatment and other services to individuals enrolled in STEPPS.

Clients in the STEPPS programme are frequently treated with one or more psychopharmacolog- ical agents, most often antidepressants and mood stabilizers. The programme addresses adherence to prescribed medications as an important enabling factor for group therapy. However, it is also important to note that NICE guidelines do not recommend prescribing medication for this problem and hopefully, as clients increase their emotion and behaviour management skills, they will be able to revise the use of these substances with their prescriber.

Substance use is viewed as treatment-disabling and clients are required to seek appropriate treatment and maintain abstinence either before or concurrently with STEPPS YP. Clients with a severe eating disorder are similarly required to be in an appropriate treatment programme.

Implementing a team approach to working with a person with BPD/EID may reduce the fre- quent over-dependence on an individual therapist. The optimal treatment system is one where, in addition to the weekly skills training, the person with BPD/EID receives skill and behaviour pattern reinforcement from all treatment system team members, family, and friends. All professionals involved with the client are encouraged to be part of this team. This approach encourages the person with EID to rely on peers, family, and others for reinforcement and reduces the possibility that the person will focus exclusively on a single therapist, who then runs the risk of being alternately over-idealized and devalued. Those who are receiving individual therapy are eligible for the STEPPS programme, provided the therapist agrees to support the programme by reviewing the STEPPS materials with the client as they add the lessons to their binder or folder each week. We provide several opportunities for professionals, relatives, and significant others to participate in the programme. We offer 18 weekly sessions alongside the young persons’ group for parents/carers to attend and to work through the manual. In some locations, group facilitators have chosen to have monthly reinforcement team meetings to provide additional education and support. Carers weekly group may be open to reinforcers to attend; however, this group quickly becomes quite cohesive and inviting others to attend should be negotiable.