Introduction
Systems Training for Emotional Predictability and Problem Solving (STEPPS; Blum et al., Reference Blum, Pfohl, John, Monahan and Black2002) is a manualized, cognitive behavioural therapy-based group treatment programme for patients with borderline personality disorder (BPD). STEPPS is based on the premise that patients with BPD lack skills to deal with their emotion instability. To achieve emotional stability, patients learn basic emotion and behaviour management skills (Blum et al., Reference Blum, Pfohl, John, Monahan and Black2002). A recent systematic review of the current studies concluded that STEPPS seems to be an effective treatment for patients with BPD (Ekiz et al., Reference Ekiz, Van Alphen, Ouwens, Van de Paar and Videler2022). To date, no studies have been conducted into the effects of STEPPS in older adults. Personality disorders (PDs) persist into old age with a prevalence rate between 10 and 14.5% in the general population (Penders et al., Reference Penders, Peeters, Metsemakers and Van Alphen2020). However, BPD symptoms do seem to change over the course of life. Symptoms like impulsivity, self-harm and anger appear to decrease, while interpersonal disturbances, emotional dysregulation and affective symptoms do not appear to abate over the course of life (Frías et al., Reference Frías, Palma, Solves, Martínez and Salvador2017). These findings suggest that emotion regulation problems in PDs persist into old age, albeit the manifestation can change. Adequate treatment options for older adults with PDs are needed. STEPPS might connect to the psychotherapy expectations of older adults, as it places emphasis on psychoeducation, and is highly structured, skill-enhancing and problem-focused (Laidlaw and Thompson, Reference Laidlaw, Thompson, Laidlaw and Knight2008). The aim of the present study was to explore the outcome of STEPPS in older adults with (B)PDs.
Method
Participants
The sample was obtained from patients attending STEPPS at an out-patient clinical centre of expertise for personality disorders and developmental disorders in older adults in The Netherlands. Inclusion criteria were: a recent (<1 year before the start of STEPPS) diagnosis of at least one PD (determined with the Structured Clinical Interview for DSM-5 Personality Disorders, SCID-5-PD), at least three traits of BPD, emotion regulation difficulties, age of at least 55 years, and motivation to participate in the programme. Exclusion criteria were patients with neurocognitive, autism spectrum, and major substance abuse disorders, acute co-morbid psychiatric conditions disabling the treatment of the PD, IQ-score lower than 85, and patients not proficient in Dutch.
Measures
The primary outcome measure of this study was changes in severity of BPD symptoms. This was measured with the Borderline Evaluation of Severity over Time (BEST), a self-report questionnaire used to assess the severity of BPD symptoms. This measurement is incorporated in STEPPS and is completed by patients on a weekly basis.
Secondary outcome measures were psychological distress and severity of maladaptive personality functioning assessed by the Symptom Questionnaire-48 (SQ-48) and the Severity Indices of Personality Problems - Short Form (SIPP-SF). SQ-48 contains subscales for depression, anxiety, somatization, agoraphobia, aggression, cognitive problems, social phobia, work functioning, and vitality. SIPP-SF contains five domains: (1) self-control, the ability to control emotions and impulses; (2) identity integration, the ability to tolerate frustration and experience life as meaningful; (3) relational functioning, the ability to maintain and engage in relationships; (4) responsibility, the ability to set realistic goals and achieve those goals; and (5) social concordance, the ability to cooperate with others.
Protocol and design
In this study, the Dutch version of STEPPS (Vaardigheidstraining Emotie Regulatie Stoornis; VERS) was used. The Dutch STEPPS entails adjustments to the original (American) STEPPS-protocol, including adjunctive individual sessions once every fortnight, and 19 (instead of the original 20) group sessions.
The current pilot study entails a naturalistic pre- and post-treatment research design. SQ-48 and SIPP-SF were administered around weeks 1 and 19 of the therapy. BEST was administered weekly. For the BEST, the mean score of weeks 1 and 2 was used as the pre-treatment score, and the mean score of weeks 18 and 19 as the post-treatment score. The study protocol was approved by the local ethics committee of the participating clinical centre.
Analyses
Outcome variables were tested on the assumption of normality, using Kolmogorov–Smirnov tests. To determine differences between pre- and post-treatment, paired samples t-tests were conducted for the five normally distributed variables (i.e. BEST, SQ-48, SIPP-SF identity integration, SIPP-SF relational functioning, and SIPP-SF responsibility). Wilcoxon signed rank tests were conducted for the two variables that were not normally distributed (i.e. SIPP-SF self-control, and SIPP-SF social concordance). Furthermore, effect sizes were calculated and interpreted. For the t-tests, a Cohen’s d of .2 indicated small, .5 medium and .8 large effect sizes, and for the Wilcoxon signed rank tests an r of .1 indicated small, .3 medium and .5 large effect sizes.
Results
Participant characteristics
Thirty-nine patients participated in five different STEPPS treatment groups between March 2018 and October 2020. Nine patients (23.1%) agreed to participate in the study, but did not complete the treatment. Three patients (7.7%) declined participation. Three patients (7.7%) did not meet the inclusion criteria. Therefore, 24 patients (61.5%) completed the treatment programme and were included in the present study. Sixteen (66.7%) of these 24 participants were female. Ages ranged from 56 to 72 years (mean±SD 63.9±4.6). Mean (SD) Global Assessment of Functioning at the beginning of treatment was 47.9 (7.2). Eleven (45.8%) participants were diagnosed with BPD, three (12.5%) with avoidant PD, two (8.3%) with obsessive–compulsive PD, five (20.8%) with unspecified PD, and three (12.5%) with other specified PD. There were no significant differences in age (t 31=.820, p=.418), gender (χ2(1)=.000, p=1.000) or Global Assessment of Functioning (t 31=–.550, p=.587) between completers (n=24) and drop-outs (n=9).
Treatment outcomes
As can be seen in Table 1, there was a statistically significant decrease in pre- vs post-treatment scores on the BEST (t=6.106, d.f.=14, p<.001), yielding a large effect size (Cohen’s d=1.577). The first step of the programme (i.e. psychoeducation) yielded a mean drop of 3.8 (SD=9.9) on the total score of the BEST. The second step (i.e. emotion management skills) yielded a mean drop of 11.1 (SD=11.4). The third step (i.e. behaviour management skills) yielded a mean drop of 3.8 (SD=7.7). Most gains seemed to be made during the second step of the treatment.
Pre- to post-STEPPS comparisons of outcome measures
BEST, Borderline Evaluation of Severity over Time; SIPP-SF, Severity Indices of Personality Problems - Short Form; SQ-48, Symptom Questionnaire-48.
‡ Number of outcome measures available;
* Paired samples t-test;
** Wilcoxon signed rank test.
The SQ-48 total score did not demonstrate a significant difference (t=1.946, d.f.=20, p=.066). Within the subscales of the SQ-48, however, significant decreases were found for depression (t=2.157, d.f.=20, p=.043, Cohen’s d=.471) and cognitive problems (t=2.346, d.f.=20, p=.029, Cohen’s d=.512).
A Wilcoxon singed rank test showed a statistically significant increase of SIPP-SF self-control (Z=−2.578, p=.010). The effect size was large (r=.576). A t-test demonstrated SIPP-SF identity integration to increase significantly (t=−2.276, d.f.=19, p=.035). The effect size was medium (Cohen’s d=.509). There were no significant differences for SIPP-SF relational functioning (t=−.597, d.f.=19, p=.557), SIPP-SF responsibility (t=−.342, d.f.=19, p=.736) and SIPP-SF social concordance (Z=−1.836, p=.066).
Discussion
STEPPS is a group treatment programme for patients with BPD. To date, no studies on STEPPS have been conducted in older adults. The aim of the current study was to explore the efficacy of STEPPS in a sample of older adults with PDs. Results demonstrated decreased BPD symptoms, improved ability to control emotions and impulses, and an improved ability to tolerate frustration and experience life as meaningful. Improvements on BPD symptoms and controlling emotions and impulses demonstrated large effect sizes.
There were no significant differences between pre- and post-treatment results for other secondary outcome measures: i.e. psychological distress (total score), the ability to maintain and engage in relationships, the ability to set realistic goals and achieve those goals, and the ability to cooperate with others. The non-significant results on most subscales for psychological distress, as measured with the SQ-48, were unexpected. The small sample size in this study and the lack of specific norms of the SQ-48 for older adults may be factors contributing to a type II error for outcome on the factor psychological distress. Another explanation for a possible false negative outcome is that the STEPPS protocol needs adaptations for older adults (Melssen et al., Reference Melssen, Ekiz, Videler, Freije and van Alphen2022), in order to decrease psychological distress. Furthermore, interpersonal symptoms of BPD seemed not to improve after STEPPS. Interpersonal skills are taught in the third step of the treatment. Participants demonstrated less progress in this part of STEPPS. An explanation for interpersonal symptoms not improving might be a finding specific to our sample of older adults. In sessions 13–19, behaviour management skills are taught. Topics in this section are goal setting, healthy eating, sleeping, exercise, leisure, physical health, self-harm avoidance, and relationship behaviours. The content of these topics in the STEPPS protocol might not be suitable for all age groups. For example, ways to build and maintain healthy relationships might differ for a studying and single adolescent vs a retired and married older adult. Currently, Melssen et al. (Reference Melssen, Ekiz, Videler, Freije and van Alphen2022) are conducting a Delphi study to investigate whether the original STEPPS protocol should be adapted for older adults, and if so, which adaptations should be made for a better fit.
This pilot study has some methodological limitations. First, the absence of a control group limits the conclusions that can be drawn regarding effects that might be addressed to the intervention. A second limitation is the small sample size (and small number of completed outcome measurements, e.g. BEST), further underlining the necessity of replicatory studies. Third, there is possible measurement bias because two measurements used (i.e. BEST and SQ-48) lack psychometric properties for older adults.
In summary, this is the first empirical study investigating treatment of emotion regulation problems in older adults with PDs. Results suggest that STEPPS is feasible in the young old and is associated with positive outcomes. At the end of treatment, patients reported fewer BPD symptoms, improved skills in controlling emotions and impulses, and an improved ability to tolerate frustration and experience life as meaningful. No significant changes were found in most domains of psychological distress and interpersonal skills. The next step to efficacy research is a mixed method approach of quantitative and qualitative research to evaluate necessary changes to the STEPPS protocol for older adults.
Supplementary material
To view supplementary material for this article, please visit: https://doi.org/10.1017/S1352465822000443
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Acknowledgements
None.
Author contributions
Erol Ekiz: Conceptualization (equal), Data curation (equal), Formal analysis (lead), Methodology (equal), Project administration (supporting), Writing – original draft (lead), Writing – review & editing (lead); Arjan Videler: Conceptualization (equal), Data curation (equal), Formal analysis (supporting), Methodology (equal), Supervision (equal), Writing – original draft (supporting), Writing – review & editing (equal); Machteld Ouwens: Conceptualization (equal), Data curation (equal), Formal analysis (supporting), Methodology (equal), Project administration (lead), Supervision (equal), Writing – original draft (supporting), Writing – review & editing (equal); Sebastiaan Van Alphen: Conceptualization (equal), Data curation (equal), Formal analysis (supporting), Methodology (equal), Project administration (supporting), Supervision (equal), Writing – original draft (supporting), Writing – review & editing (equal).
Financial support
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
All authors declare that they have no conflicts of interest.
Ethical standards
Authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the BABCP and BPS. All subjects were provided oral and written information concerning the study. Subjects’ informed consents were documented. The study was approved by research ethics committee of GGz Breburg, Tilburg, The Netherlands (reference number CWO2018-13).
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