Please scroll down to read the first few pages of the STEPPS
Second Edition
Treatment Manual
The STEPPS Group Treatment Program for Borderline Personality Disorder

Introduction to Training

The Iowa program began in 1995, based on a systems approach to
treating individuals with Borderline Personality Disorder (BPD),
originally developed by Bartels and Crotty (1992). That program was
subsequently adapted and revised by Blum, St. John, and Pfohl (2002),
and has been further revised for this second edition. The current program
includes two phases – a  20-week basic skills group, and a one-year,
twice monthly advanced group program called STAIRWAYS. The
combined program is identified by the acronym STEPPS, which 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-behavioral, skills training approach, Borderline
Personality Disorder (BPD) is characterized as a disorder of emotion
and behavior regulation. The goal is to provide the person with BPD,
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. STEPPS participants learn
specific emotion and behavior 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 behaviors. Splitting, like other behaviors 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.

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 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, group members often resist the label of BPD,
even though they may readily acknowledge the behaviors. Bartels and
Crotty suggested the name Emotional Intensity Disorder (EID) as a
more accurate description that patients may find easier to understand
and accept.  We use both terms interchangeably.  Regardless of  
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 symptoms of the disorder to seek relief from a painful
illness through desperate behaviors which are reinforced by negative and
distorted thinking.

Training: Step 1 - Awareness Of Illness

The first step is replacing 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 given a printed handout listing the DSM-IV criteria
for BPD and time is provided to acknowledge examples of the criteria in
their own behavior (“owning” the disorder ). A second component is the
concept of cognitive filters. Therapists may recognize 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
behaviors.

Training: 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 disorder. Combined
with an understanding of how the disorder works, and recognizing the
filters that are 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 symptoms are intensified, and building
confidence in their ability to manage their symptoms.

Training: Step 3 - Behavior Management Skills Training

There are eight behavioral 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 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 Program

The Basic Skills Program consists of 20 weekly meetings of two hours
each. This includes a short break between the first and second hour.
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 Behaviors

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

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 3-
ring binder, or folder (the color 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 system. 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 Borderline Evaluation
of Severity over Time (BEST) form, which allows participants 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 that is typical of BPD, and to note over time
the decrease in the intensity of their emotional episodes and the
increased use of the positive behaviors and skills they are learning. The
BEST 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 behaviors, as well as emotional intensity, negative
behaviors (e.g., substance abuse, self-harm, eating-disordered behavior),
and positive behaviors (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., visualizations) to use outside of 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 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
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
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 an abbreviated version of this card (included in the
manual) to members of their reinforcement team. 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. 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.

During a group session, an individual with BPD 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
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 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 symptoms of the disorder and cognitive filters (schemas). The rule
to use is: focus on the disorder, not the content...
                                                                                                                                                                                                                    
©2012
Please click here to read the first few pages of the UK Edition.
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 in a
variety of settings, spanning the more than 15 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 on inpatient units. Specific
suggestions are included for these settings.

Section 1 of the manual is intended for use by facilitators, and has been 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 to a computer. This feature is specifically included to allow completion of
Group Process Notes included with the Facilitator Guidelines for each lesson (for documenting
purposes), but may also be useful for adding notes, suggested text, prompts, or other information
facilitators may find useful.

The Workbook Materials, Sections 2 and 3 of the Manual, may be copied and distributed to
participants, and have been 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 CD in addition to the STEPPS Manual files, there are a number of 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.

There is also a file containing three informational brochures (previously offered for sale) that can be
customized for a specific agency or institution.