Augmenting Psychotherapy for Borderline Personality Disorder: The STEPPS Program

The diagnosis of borderline personality disorder conjures up thoughts of helplessness and hopelessness. The helplessness and hopelessness reside not only in the patient but often in the treatment providers as well. A widespread belief that continues to exist among mental health professionals is that treatment does very little for borderline personality disorder patients. Yet they are very difficult to disengage from treatment. Therapists shy away from informing the patient that she has the diagnosis because to pronounce the diagnosis not only would be equivalent to a type of “death sentence” (as we used to be afraid of telling patients that they had cancer or schizophrenia), but it would also cause fear of the rage that the therapist is certain to encounter from the affectively dyscontrolled patient.

Much has changed in the last 10–15 years, but unfortunately too many therapists still feel that borderline personality disorder is untreatable and is a lifelong drain on the energy of the therapist, the psychopharmacologist, and the entire mental health system. While it is true that people with borderline personality disorder utilize mental health resources to a far greater extent than their 1%–2% prevalence would suggest (1), the idea that these patients never change or improve needs revision.

Substantial research now sheds light on many of these mythical assumptions. There is strong evidence from the McLean Study of Adult Development that 40% of patients with borderline personality disorder remit after 2 years, with 88% no longer meeting Diagnostic Interview for Borderlines—Revised or DSM-III-R criteria after 10 years (2) . The temporal stability (or lack of it) in a borderline personality disorder diagnosis has also been examined in the Collaborative Longitudinal Personality Disorders Study, and findings suggest that about one-half of those who meet borderline personality disorder on intake no longer meet DSM-IV criteria 24 months later (3) .

Even more surprising and myth-debunking is the number of well-designed controlled studies in support of effective treatment for borderline personality disorder patients. These studies, for the most part, are randomized controlled trials of therapies that range from cognitive behavior, such as dialectical behavioral therapy (4) and other more straightforward cognitive behavioral therapies (5), to psychodynamic and psychoanalytically based therapies, which include mentalization-based therapy (6) and transference-focused psychotherapy (7), to the blend of cognitive and dynamic therapies in schema-focused therapy (8) . And not surprisingly, as therapies that appear to be effective emerge, there are now articles urging that patients be informed of their borderline personality disorder diagnosis (9) . It is interesting that most of these interventions are in the nonpharmacologic arena, while psychopharmacologic treatment of borderline personality disorder remains unclear, uncertain, and in general unimpressive.

The article by Blum et al. in this issue of the Journal is another step along the path of developing and testing more useful and reasonably successful psychotherapeutic interventions for borderline personality disorder. What is intriguing about the study by Blum et al. is that this nonpharmacologic intervention called Systems Training for Emotional Predictability and Problem Solving (STEPPS) is essentially an augmentation of or adjunct to treatment that is already occurring for the borderline personality disorder patient. It combines 20 weekly sessions of cognitive behavior and skills training elements with a systems component or approach that involves family members, significant others, and health care professionals with whom the patient interacts regularly. The randomized controlled trial study design measured STEPPS plus treatment as usual (N=65) or treatment as usual alone (N=59) every 4 weeks through the 20 weeks of treatment. The study found that the STEPPS intervention affords greater improvement in the affective, cognitive, interpersonal, and impulsive domains of borderline personality disorder; greater improvement in mood and impulsivity; decreasing negative affect; and greater overall global improvement when compared with treatment as usual without STEPPS. STEPPS is brief, adjunctive, and easy to use by a wide range of mental health professionals.

While the STEPPS intervention did not lead to significant between-group differences for suicide attempts, self-harm, or other measures of crises, the importance of the intervention should not be diminished. There are a number of treatments for borderline personality disorder that do decrease suicidal attempts or self-destructive behavior, but some of those that improve suicide do not necessarily improve depression any more significantly than the control intervention (4, 5, 7) . It would appear sensible to use STEPPS as an adjunct, particularly to an intervention in which effectiveness is limited in areas where STEPPS has been shown to have beneficial impact. Perhaps as we study the impact of specific and different psychotherapeutic interventions, we may be able to combine or sequence various interventions to get a greater degree of the effectiveness of psychotherapy. For example, in the case of dialectical behavioral therapy, where impact on depressed mood is not impressive, the strategy of augmenting the treatment with STEPPS might provide more extensive overall benefit.

In addition, STEPPS has what the authors label as a “systems” component. By systems, the authors expect that there is involvement of a friend or relative who is willing to learn about borderline personality disorder and who participates in psychoeducational sessions to help him or her respond better to some of the dysfunctional and certainly confusing and affect-provoking behaviors displayed by the patient. There is a need for more interventions that involve the systems that surround the patient with borderline personality disorder, since it is often the people who interact with the patient who remain perplexed and stymied in knowing how to respond to their patient, friend, or relative with the disorder. STEPPS then provides another systems-based treatment available to families and significant others, along with interventions such as the Family Connections Program of the National Education Alliance for Borderline Personality Disorder (www.neabpd.com). In addition, the patient is expected to be in ongoing therapy and have a mental health professional available to STEPPS in the event of a crisis.

The STEPPS study is a well-designed effectiveness study and was carried out in a thoughtful way, although with a high dropout rate, which is unfortunately not uncommon in such studies. In addition to the randomization, the study is also naturalistic in that outside psychotherapeutic and psychopharmacologic treatments were not controlled other than the requirement of having an outside therapist. It is to the researchers’ credit that they were able to combine the best elements of a randomized controlled trial with this naturalistic aspect of ongoing “outside” treatment.

In an editorial in the June 2007 issue of the Journal, Glen O. Gabbard, M.D. (10), referring to a point made by Daniel X. Freedman many years ago, suggested that we should be cautious not to pit one therapy against another in an attempt to find the very best. What is so helpful about having STEPPS in our therapeutic black bag is that it complements other therapies and need not replace or compete with them. To paraphrase what Marsha Linehan said in her keynote address to the International Society for the Improvement and Teaching of Dialectical Behavior Therapy in Philadelphia in the Fall of 2007, we should derive great satisfaction in knowing that there are a number of different types of interventions that appear effective for borderline personality disorder. The greater the number of available effective interventions, the better the chance that a patient may be able to improve to a degree where she feels that life is once again, if it ever was, worth living. Then we will have more evidence to erase the myth that borderline personality disorder is untreatable and that the diagnosis relegates the patient to a life of helplessness and hopelessness.