The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 5
5 - Highly Usable
The intervention has operationalised principles and values, core components that are measurable and observable, a fidelity assessment, identified modifiable components
Core Components
STEPPS is a manualised group treatment programme, delivered over twenty weeks. Each session is 90-120 minutes. The groups have two facilitators and 8-12 group members. Group sessions are supported by individual ‘reinforcer’ sessions. Each group member will have a personal reinforcer which may be a partner, friend, or family member as well as a professional reinforcer within the mental health team (i.e. CMHN, Psychologist, OT etc.). Group members are encouraged to meet individually with their reinforcers throughout the programme to support them with consolidation of skills learned.
The STEPPS course is made up of 3 parts: awareness of illness, emotion management and behaviour management skills. The course focuses on learning skills for emotional regulation- distancing, challenging, communicating, problem solving and distracting. As well as behaviour management skills including eating, sleeping, exercise, abuse avoidance. The final sessions are on relationship and interpersonal skills.
The STEPPS group has been researched with adult populations, with participants both with and without a formal diagnosis of BPD where emotional dysregulation and interpersonal difficulties are central to presentation.
STAIRWAYS (2) has been developed as a follow on for graduates of the STEPPS programme where skills are consolidated.
Fidelity
Practitioners delivering STEPPS receive training and ongoing clinical supervision. Practitioner competence and fidelity to treatment can be monitored and evaluated using appropriate measures, e.g., via recording of treatment sessions and use of fidelity checklists to determine practitioner adherence against a CBT or STEPPS competency assessment tool. The Cognitive Therapy Scale-Revised (3) or the STEPPS adherence scale (4) ensure therapist fidelity to the STEPPS model. Facilitator guidelines are provided within the STEPPS manual for each group session. These guidelines detail a step-by-step session plan for facilitators to follow thereby ensuring consistency within treatment delivery.
Modifiable Components
The programme has been modified for other populations and settings such as forensic, adolescents, inpatient units, therapeutic community and parenting groups (5)
The Early Intervention Manual has been developed for people experiencing mild symptoms and has been shortened to 13 weeks. This is delivered in Scotland.
STEPPS has been delivered in Scotland in both group face to face and delivered online with additional video resources created by NHS Staff available in NHS Scotland.
The UK version of the manual has changes to terminology from US to UK. For example, spelling, grammar, and vocabulary were changed from US to UK English. Vocabulary changed to be more relevant to UK audience i.e. “Cheerleading” statement changed to “encouraging” statements (6).
In 2012 a second edition STEPPS manual was published which incorporates several changes and additions to the original manual.
STEPPS has been adapted for young people. Shuppert et al. (7) developed a version of STEPPS named Emotion Regulation Training. STEPPS-YP (STEPPS- young people), was later developed in 2014 for ages 16-20 by the original STEPPS authors (8), with 18 opposed to 20 sessions. A modified UK version is in development. There is no peer review published research studies specifically exploring STEPPS-YP which have been identified.
Supports - Rating: 5
5 - Well Supported
Comprehensive resources are available to support implementation, including resources for building the competency of staff and organisational practice as a standard part of the intervention
NHS Education for Scotland offer the 2-day training. Boards who have a robust implementation plan have supported staff to take the intern or apprentice route. The “apprentice “will observe the 20-week programme and will be supported to delivery elements of the programme under supervision. Then will receive supervision to deliver the programme.
Support for Organisation / Practice
Implementation Support
Organisational and leadership support has a significant role to play in the implementation of a STEPPS (Systems Training in Emotional Predictability and Problem Solving) programme. Training implementation where possible should be supported by Specialist Multi Professional teams/and or services for people with personality disorder with expertise in the assessment and management of personality disorder. For boards without a specialist service, the Psychological Therapies Training Coordinator (PTTC) situated within each board provides a key link to NES (NHS Education for Scotland) and Heads of Service for Mental Health and Psychology to ensure the implementation plan is fully supported.
The implementation of STEPPS requires a coordinated approach to service delivery. It is recommended that Mental health Services and Psychology Services work closely together. When providing psychological treatment to people with borderline personality disorder as a specific intervention in their overall treatment and care, NICE recommend the use the Care Programme Approach (CPA) to clarify the roles of different services, professionals providing psychological treatment and other healthcare professionals (9).
Administration support should be considered when implementing STEPPS groups as there is regular administration tasks to be undertaken on a week-by-week basis. Administrative Services should ensure that copyright of the manual is always adhered to.
NHS Education for Scotland have developed a data collection form specific to STEPPS to support the implementation and evaluation of STEPPS training. The data collection form is available on request with the understanding that data is then shared with NES.
Implementation support for the group programme itself is provided by board-based trained supervisors who support the application of the intervention. In addition to supervision some boards have a regular consultation group supported by personality disorder services.
Reinforcers
At week one, clients identify their reinforcement team. Clients are encouraged to enlist non-professional, as well as professional care providers, and to help teach the skills by sharing the appropriate materials. Professional Reinforcers training is delivered when required by Trained STEPPS facilitators.
Start-up Costs
There is no start-up costs associated with training provided through an NHS Board or by NES. Each person receiving training via NES shall receive a training manual which has costs associated but is not transferred to participants. Additional manuals can be purchased from www.steppsbpd.com
Staff are required to attend two full days if receiving NES training.
Building Staff Competency
Qualifications Required
Lead facilitators will hold an undergraduate degree in a relevant area (e.g., nursing, psychology, medicine) and will have completed postgraduate training in CBT (PG Diploma, MSc or Doctoral level). The lead facilitator will have completed the two-day STEPPS workshop delivered by NES or observed the 20 Week STEPPS programme being delivered by a STEPPS trained colleague, which is commonly referred to as the apprenticeship/intern Route.
Co-facilitators will have completed the two-day STEPPS workshop delivered by NES and/or observed the 20-week STEPPS programme being delivered by a trained colleague, commonly referred to as the apprenticeship/intern route.
Training Requirements
STEPPS training provided by NES involves attendance at a 2-day training course with a mix of didactic and experiential learning delivered online. Alternatively, STEPPS facilitators can be trained via the internship/apprenticeship route, by co-facilitating a group with 2 experienced and trained group facilitators. This allows training to be cascaded and sustainable within departments.
Supervision Requirements
Regular (minimum 1 hour a month) supervision by a supervisor who is a CBT therapist and STEPPS facilitator and who has completed the following pathway of supervision training:
- NES Generic supervision competences training (GSC) (or equivalent)
- NES Specialist Supervision Training: CBT (adult or child focus)
It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/). There is additional training available that specifically supports CBT supervision skills.
Evidence - Rating: 5
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Theory of Change
STEPPS Builds on Cognitive and Behavioural Therapy Principles. It is also derived from a family systems approach, STEPPS focuses on the teaching of skills in Emotion regulation and Behavioural Skills to enable patients to manage their symptoms of borderline personality disorder. It also focuses on the teaching of skills to those whom the patient regularly interacts and shares information with about their disorder i.e. their system.
Randomised Control Trials
Blum, N., St John, D., Pfohl, B., Stuart, S., McCormick, B., Allen, J., ... & Black, D. W. (2008). Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1 year follow up. American Journal of Psychiatry, 165(4), 468-478
Bos, E. H., Van Wel, E. B., Appelo, M. T., & Verbraak, M. J. (2011). Effectiveness of Systems Training for Emotional Predictability and Problem Solving (STEPPS) for borderline personality problems in a ‘real-world’ sample: moderation by diagnosis or severity? Psychotherapy and psychosomatics, 80(3), 173-181.
Bos, E. H., Van Wel, E. B., Appelo, M. T., & Verbraak, M. J. P. M. (2010). A randomized controlled trial of a Dutch version of Systems Training for Emotional Predictability and Problem Solving for borderline personality disorder. Journal of Nervous & Mental Disease, 198(4), 299–304.
Adults - Rating: 5
Research Design & Number of Studies – Children and Young People
Two studies (7,10) were identified using Emotion Regulation Training, an adapted version of STEPPS for young people. The first was a pilot randomised controlled trial (RCT) and the second a larger RCT by the same group.
Research Design & Number of Studies – Adult
A systematic review of the STEPPS programme identified 3 RCTs and 11 non-controlled trials using pre versus post treatment research designs (11) 13. The initial RCT with 124 participants was conducted by Blum et al. (2008)(5), the second and third RCTs were conducted by Bos et al. (12,13) in the Netherlands. The latter RCT included 168 participants using a ‘real world’ sample, including participants with sub threshold BPD.
Outcomes Achieved – Children and Young People
Both RCT’s on the ERT program found no difference between treatment (ERT plus treatment as usual) and control group (treatment as usual) on BPD symptoms (7,10).. There was no long term follow up. Rates of attrition were mixed.
Outcomes Achieved - Adult
- Improvement in BPS symptoms with moderate to large effect sizes (5,12,13).
- Gains maintained at 6-month (Bos et al., 2010) (13) and 12-month follow up (14).
- Improvements in quality of life, maintained at 6-month follow up (12).
- In a sample representative of routine clinical practice (range of severity of symptoms and diagnosis), STEPPS was superior to a treatment as usual control group, particularly in patients with higher baseline severity scores (12).
Need
Comparable Population
Community Mental health Teams have many clients with symptoms of personality disorder from a mild to severe in range. The STEPPS programme was developed as an adjunct to treatment for adults with borderline personality disorder treated in outpatient settings. The STEPPS programme has also been adapted for Early Intervention or for those who may be experiencing mild symptoms of personality disorder.
Desired Outcome
STEPPS has been shown to effectively reduce symptoms of borderline personality disorder and improve quality of life at post treatment and follow up.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
STEPPS is based on cognitive behaviour and family systems theories. It teaches cognitive behavioural and interpersonal skills. The values fit with the Scottish Government ‘Vision for Health and Social Care’, improving mental health and reducing stigma and inequality (15)
The STEPPS programme provides information to both participants and to their friends or family members who have been identified by the participants as a reinforcer for their new skills. Non-Professionals who have been identified by the client and have agreed to become a reinforcer for the group programme are offered training to become a Reinforcer for the programme.
- Do the underpinning theory and the underlying mental health condition addressed by the intervention align with the requirements of your organisation?
Priorities
Provides a stepped care approach to personality disorder and can improve access to psychological Interventions for people with mild to moderate symptoms of personality disorder.
Existing Initiatives
Health Improvement Scotland’s Personality Disorder Improvement Programme supports increasing access to psychological interventions (16).
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
STEPPS can be delivered by healthcare professionals (e.g. psychologists, psychiatrists or mental health nurses) who have undergone training to support its’ delivery. Staff are required to assess each client for suitability for STEPPS programme. There may be additional screening undertaken before suitable participants are recruited to group. If 12 clients are assessed, and administrative task undertaken then staff time for client contact pre group is approximately 21 hours. Each group will require preparation time of 1 hour and then is delivered over 90 to 120 mins each week approximately 60 hours over 20 weeks. Administration completed by facilitators post group approximately 10-15 mins per group member which includes the completion of group process notes specific to session, recording of outcome measures and updating of case management systems.
Technology Support
STEPPS can be delivered without access to technology but access to video platforms for remote delivery can be useful, as is access to methods of recording sessions for supervision. Arrangements should be made to provide some additional information to clients on the use of Near me or Teams when required.
Administrative Support
There will be a regular need to print manuals prior to group commencement and routine outcome measures as required pre group. Administrative task pre group completed by admin staff copying of manual for client use. Approximately 90 minutes. Copying of Outcome measures each week 15 mins.
Financial Support
Financial support will be required for face-to-face group delivery where there is a need to supply refreshments for the group and resources for teaching emotion regulation skills.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
