Alternatives to Self-Harm Program

This chapter describes the Alternatives to Self-Harm (ASH) program and its follow-up program, PHOENIX—programs that complement STEPPS and STAIRWAYS. ASH was developed for those individuals whose self-harm behaviors put them at imminent risk and those whose self-harm is likely to increase if they find therapy too emotionally challenging in the beginning. Data supportive of ASH are presented and show that the program leads to a reduction of self-harm risk for people with emotional dysregulation. ASH can stand alone or be adjunctive to STEPPS. ASH is an approach that reduces the risk of self-harm and increases participants’ confidence in their ability to acquire and maintain more effective coping strategies, as well as progressing to other therapies (e.g., STEPPS) as needed.

STEPPS in a Residential Therapeutic Community in Italy

This chapter describes the implementation of STEPPS in a residential therapeutic community in Rome, Italy. STEPPS is integrated with sociotherapy to provide residents and staff with a common language. STEPPS is adapted on a daily basis as homework for residents, as well as for support training for social rehabilitation workers without a background in cognitive behavioral therapy. There is an emphasis on patient empowerment and providing residents with new skills and strategies to reduce their overly intense emotions. Mutual support has been enhanced, and trust, empathy, and personal awareness have increased. The program has led to a reduced length of stay and to a general improvement in perceived quality of life. The chapter describes challenges associated with its implementation. STEPPS has been translated into Italian.

Overview of STEPPS

This chapter provides an overview of Systems Training for Emotional Predictability and Problem Solving (STEPPS), a manualized, cognitive-behavioral, skills-based group treatment program, originally developed as an adjunctive treatment for outpatients with borderline personality disorder. STEPPS was developed at the University of Iowa in 1995 in response to patient and provider needs. A detailed manual was developed and training workshops are conducted nationally and internationally. The systems component is unique to the program and refers to providing the client’s support system, (i.e., family members, friends, and key professionals) with an understanding of the STEPPS approach, a common language to communicate clearly about BPD, and ways to reinforce the skills that patients are acquiring. The program has been implemented worldwide and is included in SAMSHA’s NREPP list of evidence-based programs. The program is user-friendly and easily learned and delivered by therapists. A follow-up program, STAIRWAYS, is also described.

STEPPS in Correctional Settings

This chapter describes STEPPS in Iowa correctional systems and elsewhere, as well as the US federal prison system. The program was introduced to the Iowa correctional system in 2005; data show that it is effective in reducing symptoms specific to borderline personality disorder. In addition, STEPPS has been shown to boost mood, reduce disciplinary infractions, and reduce self-harm behaviors. The advantages over other BPD treatment programs in prison settings include the relatively short 20-week length of STEPPS, which is very important because offenders have varying sentence lengths and are transferred or released (or receive parole/probation status) without notice. The program is easily learned by therapists strapped for time, since corrections-based therapists have little time for extensive additional training and budgets are tight. The STEPPS manual can be used “as-is” in prisons and community corrections without extensive modifications. Last, the authors describe potential problems of implementing the program in prisons.

STEPPS in The Netherlands

This chapter describes the introduction and implementation of STEPPS (and STAIRWAYS) in The Netherlands, starting in 1998. The program was translated into the Dutch language (VERS I and VERS II) and has been gradually implemented nationwide. Apart from the United States, The Netherlands has the largest number of STEPPS programs. Research conducted in The Netherlands on STEPPS is reviewed, including controlled and uncontrolled studies. Several STEPPS-based training formats have been developed, including those for adolescents, family members of patients, and patients who are parents. The basic VERS I program has also been implemented as a part of assertive community treatment for patients with psychotic disorders and comorbid personality problems, and it is used in community mental health agencies, forensic facilities, and addiction clinics. A brief version of STEPPS has also been developed.

Research Evidence Supportive of STEPPS

This chapter reviews the empirical database for STEPPS, which now consists of eight uncontrolled studies and three randomized controlled studies. This provides one of the world’s largest bodies of data supportive of any group treatment for persons with borderline personality disorder, exceeded only by that for dialectical behavior therapy. The data are remarkably consistent in showing that patients have measureable improvements in mood, impulsiveness, and symptoms specific to BPD such as mood instability, cognitive problems (e.g., overvalued ideas, depersonalization, and nonpsychotic paranoia), identity issues, and disturbed relationships; health care seeking and self-harm behaviors are reduced. In correctional settings, STEPPS decreases disruptive behaviors. Further, data show that STEPPS is well accepted by patients and therapists. On the strength of this research evidence, STEPPS has been designated by the United States Substance Abuse and Mental Health Administration as an evidence-based treatment and is listed on the National Registry for Evidence-Based Practices.

Treatment of Borderline Personality Disorder in Adolescents

The chapter describes how STEPPS has been modified for the adolescent population in The Netherlands. Emotion regulation training (ERT) provides a group therapy experience for adolescents that consists of 17 weekly sessions, one session with family members and “important others” and two booster sessions for the adolescents at 6 and 12 weeks following treatment. The three phases of treatment include psychoeducation and problem solving techniques; helping the group members see the connection between their character/temperament and their emotions and behavior; focusing on improving lifestyle choices (e.g. eating, sleeping, relationships, avoiding substance abuse). The chapter includes an overview of the ERT protocol, briefly reviews the data from recent clinical trials, and discusses future opportunities for this field. The goal was to implement a program that would help prevent long-term consequences of borderline personality disorder.

Introducing STEPPS on an Inpatient Unit in Italy

This chapter describes how STEPPS has been adapted for inpatients with borderline personality disorder and co-occurring mood disorders at San Raffaele Hospital in Milan, Italy. All of the participants had a history of multiple hospitalizations and suicide attempts before entering STEPPS. The chapter describes how the program was modified for the inpatient setting. The patients begin the program during hospital admission to an inpatient unit and continue twice-weekly following discharge. The admission typically lasts one month, and the STEPPS program begins after remission of the acute mood disorder symptoms. Following discharge, the group program meets twice weekly for 45 minutes; the typical 20 session program is increased to 30 sessions. STEPPS was used as a stand-alone treatment for these patients. Data show that STEPPS has contributed to a reduction in self-destructive behaviors and frequency of hospitalization.

STEPPS in the United Kingdom

This chapter describes the implementation and dissemination of STEPPS in the United Kingdom (UK). The program is used in several partnerships within the National Health Service in England and Scotland. A UK version of the program was developed to ensure that the program was linguistically compatible with British culture. Modifications of the program have been developed for adolescents and persons with symptoms of borderline personality disorder who do not meet full criteria, with the goal of providing a non-pathologizing approach or to serve as an early intervention. For these two versions of the program, the reference to “emotional intensity disorder” (EID), has been replaced by “emotional intensity difficulties” (EID), and BPD is not used in the patient workbook materials. The goal of the National Health Service is to ensure that STEPPS is available for those with disorders of emotional regulation and to prevent a lifetime of involvement in mental health services.