STEPPS Group Treatment Programme:  Introduction to Training

Welcome to STEPPS
In this cognitive-behavioural, skills training approach, Borderline
Personality Disorder (BPD) is characterised as a disorder of emotion and
behaviour 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 (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 BPD 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 BPD, 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.

Underlying this training approach is the assumption that at the core of  
BPD is an actual clinical entity, a disorder that might be characterised 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 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 behaviours. Bartels and Crotty suggested the
name Emotional Intensity Disorder as a more accurate description that
clients may 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 STEPPS participants
learn to view themselves as driven by the disorder to seek relief from a
painful illness through desperate behaviours which are reinforced by
negative and distorted thinking.

The training is composed of three steps:

Step 1 - Awareness Of Illness

The first step is to replace misconceptions about the BPD label with an
awareness of the behaviours and feelings that define the disorder.   
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 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 printed handout listing the DSM-IV  
criteria for BPD and time is provided to acknowledge examples of the
criteria in their own behaviour (“owning” the illness). A second com-
ponent 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, the DSM-IV criteria, 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 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 intensified, and building confidence in
their ability to manage the illness.

Step 3 - Behaviour Management Skills Training

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

STEPPS Basic Skills Group Programme

The Basic Skills Programme consists of 20 weekly meetings of two hours
each.  This includes a short break between the first and second hour. Each
lesson is organised around a skill that is the focus of the session.  Some
skills require more than one weekly session to teach. The skills include:

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

  • ·            Distancing
  • ·        Communicating
  • ·        Challenging
  • ·        Distracting
  • ·        Managing Problems
  • ·        Setting Goals
  • ·        Eating
  • ·        Sleeping
  • ·        Exercise
  • ·        Leisure
  • ·        Physical Health
  • ·        Abuse Avoidance
  • ·        Relationship Behaviours