Systems Training for Emotional Predictability and Problem Solving (STEPPS): theoretical model, clinical application, and preliminary efficacy data in a sample of inpatients with personality disorders in comorbidity with mood disorders

S. Boccalon1, R. Alesiani1, L. Giarolli1, L. Franchini2, C. Colombo2, N. Blum3, A. Fossati1

1 Università Vita-Salute San Raffaele, Milano, e Servizio di Psicologia Clinica e Psicoterapia, San Raffaele Turro, Istituto Scientifico “San Raffaele”, Milano; 2 Università Vita-Salute San Raffaele, Milano e Unità Operativa di Riabilitazione dei Disturbi dell’Umore, San Raffaele Turro, Istituto Scientifico “San Raffaele”, Milano; 3 Department of Psychiatry, University of Iowa College of Medicine and University of Iowa Health Care, Iowa City, IA

Objective

Despite the common opinion about the difficulty of treating patients with personality disorders, significant research data support the efficacy of different techniques of treatment, both cognitive-behavioural and dynamic. The aim of our preliminary study is to analyze the effectiveness of the model of STEPPS group therapy (Systems Training for Emotional Predictability and Problem Solving) in a sample of inpatients with personality disorders comorbid with mood disorders, using a longitudinal design with a 6-month follow-up.

Methods

Our sample included 20 inpatients with BPD or prominent BPD features comorbid with mood disorders, as assessed with the SCID-II. Outcome measures were the number of self-destructive behaviours and hospitalizations during the STEPPS treatment and 6 months after the end of therapy.
All patients completed a self-report questionnaire (Filter Questionnaire) to identify distorted thoughts before starting therapy, at the end of treatment and 6 months later. During treatment, patients were asked to fill-out a daily diary (EIC) to assess their emotional reactions. Our aims were to monitor emotional intensity over time and to identify their key triggers and how to manage emotional crises.

Results

Nine of the 20 subjects (45%) included in the sample completed STEPPS: drop-out rate was 55%. There were no significant differences in number of hospitalizations and self-destructive behaviours between subjects who completed the program and subjects who dropped-out. The presence of more Histrionic (U = 23.5, p < .01) and Passive-Aggressive (U = 32.5, p < .05) traits was the only significant difference between the two groups. Patients who completed the program showed a significant and progressive decrease in the number of self-destructive behaviours (X² = 11.47, p < 0.01) and hospitalizations (X² = 16.85, p < 0.001).
Friedman test showed a significant decrease of “Distrust” over time (X² = 7.68, p < 0.05) and a significant decrease of EIC scores over time (X² = 58.71, p < .005).

Conclusions

Despite the small sample and the lack of a control group, our preliminary results could suggest that STEPPS is effective in reducing the number of self-destructive behaviours and hospitalizations and that these results may be stable also at followup.
The score reduction on “Distrust” at the 6-month followup may indicate that STEPPS decreases pessimistic expectations about self and others and that it mobilizes resources and skills that patients are able to rely on even after the end of the group treatment. The trend of EIC shows that also the perceived emotional intensity in relation to distressing events decreases over time.

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