STEPPS group treatment for borderline personality disorder in The Netherlands

Trade between countries usually involves products. However, one successful export from the United States to the Netherlands, Norway and several other countries is a cognitive therapy treatment program created by University of Iowa experts to help people with borderline personality disorder.

The treatment program, called Systems Training for Emotional Predictability and Problem-Solving (STEPPS), augments standard treatment -- medication and individualized psychotherapy -- in order to give people with borderline personality disorder techniques to raise self-awareness and self-management.

People with the disorder struggle to manage intense emotions, experience frequent suicidal thoughts and can engage in self-damaging, impulsive behaviors. Their relationships with others are often unstable because of inconsistent or intense moods.

Borderline personality disorder, characterized in the STEPPS program as emotional intensity disorder, is found all over the world at about the same prevalence rate, said Nancee Blum, social work specialist in psychiatry in the UI Roy J. and Lucille A. Carver College of Medicine. Blum pioneered the treatment program along with colleagues Don St. John, UI physician assistant in psychiatry; Norm Bartels, a clinician in Wheaton, Ill.; and Bruce Pfohl, M.D., UI professor of psychiatry.

"Borderline personality disorder crosses many cultural lines. Sharing a treatment approach to benefit patients and experts in other countries has been exciting and gratifying," said Blum, who also is an adjunct faculty member in the UI College of Nursing and the School of Social Work in the UI College of Liberal Arts and Sciences.

Recently, experts in the Netherlands reported that 80 percent of their mental health facilities now have STEPPS-trained therapists using the Dutch version of STEPPS. In April, Blum will go to London to introduce the program to clinicians there. Meanwhile, the STEPPS manual is being translated for use in Norway, where therapy groups are starting. In addition, the group treatment approach has spread to Argentina, Australia, Canada, New Zealand and Spain.

STEPPS involves 20 weekly group meetings where patients learn to change some of the ways they think about themselves and others, and adopt specific skills for managing their intense emotions. Patients learn new behaviors related to eating, sleeping, exercise, physical health and relationships. Patients also learn new ways to communicate about the disorder with others in their "system," which includes health care professionals, relatives and significant others, and close friends. As part of STEPPS, patients invite these individuals to attend an educational session.

"The STEPPS emphasis is on learning emotional management and behavioral skills so that the symptoms are less bothersome and people can instead move on to more satisfying activities in their lives," Blum said.

Exporting STEPPS began in 1997 Blum when described the program at an international conference. At the end of the talk, two psychiatrists from the Netherlands approached her and said they were interested in the program, especially because they were responsible for mental health services for one million people in their country.

A lunch meeting soon led to a visit by Blum to the Netherlands, where she trained 25 clinicians. Within the year, the STEPPS materials were translated into Dutch, and many clinicians were running groups in two cities. The Dutch program then expanded to many other sites.

"Our collaborators in the Netherlands soon had data, similar to ours, that showed people who had been treated through STEPPS had fewer days of hospitalization and better improvement in their symptoms," Blum said.

The collaboration received a new boost in 2005, when one of the Dutch collaborators joined Blum, Pfohl and Donald Black, M.D., UI professor of psychiatry, as part of a symposium at the American Psychiatric Association, and Blum returned to the Netherlands in fall 2005 to provide additional training.

Several researchers in the nearly decade-long collaboration recently published a paper on their joint efforts in the January-March 2006 issue of the Annals of Clinical Psychiatry.

Researchers at the UI and in the Netherlands also are analyzing additional data on program outcomes. UI investigators include Pfohl and Black, who is the principal investigator on the UI study.

In the United States, individuals with borderline personality disorder account for approximately 20 percent of mental health in-patient hospitalizations. Borderline personality disorder is commonly diagnosed in persons between ages 18 and 25. Women are three times more likely than men to be diagnosed with the condition.