About STEPPS EI                                   Ordering Information

STEPPS EI is a cognitive-behavioural, skills-training approach developed for
people attending Primary Care Services in the UK who are identified as
struggling with high levels of emotional intensity. Some may already be
diagnosed with Borderline Personality Disorder (BPD), or may be recognised
as falling just below the threshold for such a diagnosis. This programme is
aimed at providing 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. In the STEPPS EI programme we
try consistently to use the term Emotional Intensity Difficulties (EID) rather than
BPD.

During this 12 or (optional) 13 lesson program, EID is characterised as
difficulty with emotion and behaviour management. The goal is to provide the
person attending STEPPS EI, professionals treating them, and closely allied
friends and family members with a common language to communicate clearly
about EID and the skills used to manage it. Clients (service users) learn
specific emotion and behaviour management skills. Clients identify key
professionals, friends, and family members as part of their “reinforcement
team,” and 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 EID may externalise 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 EID, is viewed not as an intentional act of aggression, but as an
automatic response to the emotional intensity and deregulation that the client
can learn to anticipate and replace with more effective behaviour.

The training is composed of three steps:

Step 1 - Awareness of EID

The first step is to replace misconceptions about what is “wrong” with an
awareness of the behaviours and feelings that define emotional intensity
difficulties. Behaviours 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 problem 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 own behaviour
(“owning” the problem). A second component is the concept of cognitive filters.
Therapists may recognise 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, features of emotional intensity difficulties, and their
subsequent patterns of feelings, thoughts, and behaviours.

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 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.

Step 3 - Behaviour Management Skills Training

There are eight behavioural 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
to keep these areas under control during episodes.

NOTE: Although this program was developed specifically for use in
Primary Care Services in the UK, the program may be equally suitable in a
variety of settings outside the UK. For US users, the manual (on CD)
contains a brief glossary of UK terms with their US definition.


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OF THE MANUAL

Outpatient Treatment - Classroom Forma
t

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 colour red is suggested for easy visibility) in which 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 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 class. Clients 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. 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 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 being taught. The
QuEST can be used for data collection
to evaluate the effectiveness of training. The data will allow monitoring of
increases and decreases in self-destructive urges and behaviours, as well as
emotional intensity, negative behaviours (e.g., substance abuse, self-
destructive, eating-disordered behaviour, etc.), and positive behaviours (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 are available in the handouts. Participants are encouraged to
record the scripts (e.g., visualisations) to use outside of the 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.

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 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 his or her
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 focussing 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 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 features of EID and cognitive filters (schemas).
The rule to use is: focus on EID and filters, not the content.

The Systems Component of STEPPS EI

Whether it is cause or effect, the individual coming to the group is usually
enmeshed in a system of relationships in which even concerned and well-
intentioned friends and significant others respond to the individual with EID in a
manner that reinforces problematic 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.

During the treatment programme, the STEPPS EI group becomes a mini-
system in which the participant receives instruction 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 behaviours. STEPPS EI emphasises that group members
can and should take responsibility for taking steps to help key players in their
system respond more effectively. Specifically, STEPPS EI incorporates the
following 4 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 team.

  • 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 their folder
    with close friends and significant others (as well as her/his other care
    providers) so these individuals can better understand EID, the terminology,
    and ways of responding that help reinforce the skills taught in the STEPPS
    EI programme.

  • Offering at least one evening session in which key members of the support
    team are invited to come and learn about EID, how STEPPS EI 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.

Integrating STEPPS EI With Other Treatments

STEPPS EI is not a comprehensive treatment programme for managing
individuals with Borderline Personality Disorder or Emotional Intensity
Difficulties. From its inception, STEPPS EI was designed to be a “value
added” or supplemental treatment intervention that augments, rather than
replaces, the existing network of mental health providers. STEPPS EI 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 the STEPPS EI programme.

Clients in the STEPPS EI programme are often also being treated with one or
more psychopharmacological agents, most often antidepressants and mood
stabilisers. The programme addresses adherence to prescribed medications
as an important enabling factor for the group therapy programme. 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 EI programme. Clients with a severe eating
disorder are similarly required to be in an appropriate treatment programme.

Facilitators should note that in the development of this approach, the need for
traditional individual therapy might be reduced. In fact, a team approach to
working with a person with EID who is familiar with the skills and behaviour
patterns might be preferable to an individual approach. The optimal treatment
system is one in which, in addition to the weekly skills training, the person with
EID receives skill and behaviour pattern reinforcement from all treatment
system team members, family, and friends. This approach encourages the
person with EID to rely on peers, family, and others for reinforcement and
reduces the possibility that the person with EID will focus exclusively on a
single therapist, who then runs the risk of being alternately over-idealised and
devalued by the person with EID.
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