ORIGINAL ARTICLE
A Randomized Controlled Trial of a Dutch Version of Systems
Training for Emotional Predictability and Problem Solving for
Borderline Personality Disorder
Elisabeth H. Bos, PhD,* E. Bas van Wel, MD,† Martin T. Appelo, PhD,* and Marc J. P. M. Verbraak, PhD‡
Abstract: Systems Training for Emotional Predictability and Problem Solv-
ing (STEPPS) is a group treatment for persons with borderline personality
disorder (BPD) that is relatively easy to implement. We investigated the
efficacy of a Dutch version of this treatment (VERS). Seventy-nine DSM-IV
BPD patients were randomly assigned to STEPPS plus an adjunctive indi-
vidual therapy, or to treatment as usual. Assessments took place before and
after the intervention, and at a 6-month follow-up. STEPPS recipients
showed a significantly greater reduction in general psychiatric and BPD-
specific symptomatology than subjects assigned to treatment as usual; these
differences remained significant at follow-up. STEPPS also led to greater
improvement in quality of life, especially at follow-up. No differences in
impulsive or parasuicidal behavior were observed. Effect sizes for the
differences between the treatments were moderate to large. The results
suggest that the brief STEPPS program combined with limited individual
therapy can improve BPD-treatment in a number of ways.
Key Words: Personality disorder, psychotherapy, randomized controlled
trial, psychopathology, quality of life.
(J Nerv Ment Dis 2010;198: 299 –304)
S everal psychological treatments have been developed over the
last decades for persons with borderline personality disorder
(BPD). Dialectical behavior therapy (DBT; Linehan, 1993, Verheul
et al., 2003), mentalization-based treatment (Bateman and Fonagy,
1999, 2004), and schema-focused therapy (Giesen-Bloo et al.,
2006b; Young, 1999) have received the most empirical support.
These new treatment programs are quite valuable and they have
improved BPD treatment in several ways. Yet, for many persons
with BPD, these programs remain out of reach. The programs are
rather lengthy and labor intensive, and not easy to implement in
mental health care settings.
Blum et al. (2002) developed Systems Training for Emotional
Predictability and Problem Solving (STEPPS), a group treatment
program that is relatively easy to implement. The program is brief
and easily learned by therapists of varying backgrounds. It can
complement any other treatment of BPD. STEPPS combines skills
training with general cognitive-behavioral elements already shown
to be effective in this client population (Linehan, 1993; Young,
1999). Besides, it has a strong systems component; family members
and significant others are actively involved in the program.
STEPPS was introduced in The Netherlands in 1998. Once
translated, the program was implemented under the acronym VERS
*Lentis, Groningen, The Netherlands; †Dimence Mental Health Care Overijssel,
Deventer, The Netherlands; ‡Behavioral Science Institute, Radboud Univer-
sity, Nijmegen, The Netherlands.
Supported by Dimence, Deventer and Lentis, Groningen.
Send reprint requests to Elisabeth H. Bos, PhD, Lentis, PO Box 86, 9700 AB
Groningen, The Netherlands. E-mail: eh.bos@lentis.nl.
Copyright © 2010 by Lippincott Williams & Wilkins
ISSN: 0022-3018/10/19804-0299
DOI: 10.1097/NMD.0b013e3181d619cf
The Journal of Nervous and Mental Disease • Volume 198, Number 4, April 2010
(Vaardigheidstraining Emotie Regulatie Stoornis). About 500 Dutch
therapists have been trained in its use (Van Wel et al., 2006).
The efficacy of STEPPS has been investigated thus far by
3 uncontrolled studies (Blum et al., 2002; Freije et al., 2002;
Black et al., 2008) and 1 randomized controlled trial (RCT)
(Blum et al., 2008). The uncontrolled studies indicate that the
program lessens BPD symptoms, lifts mood, and improves qual-
ity of life. The RCT shows that STEPPS plus treatment as usual
(TAU) is more effective than TAU alone, improving the affec-
tive, cognitive, and impulsive domains of BPD, and reducing
emergency department visits. This RCT was done by the group
who developed the program (Blum et al., 2008).
We now present the results from a RCT in which the Dutch
version of STEPPS was compared with TAU in a community health
care setting. This RCT differs from the one by Blum et al. (2008) in
that the STEPPS group program was combined with a basic struc-
tured individual therapy instead of TAU. This low-intensity individ-
ual therapy was adapted to the STEPPS program and was designed
to help consolidate the newly acquired skills. Clinical experience
and patient reports in the Netherlands suggest that the STEPPS
group program is best received when given in combination with
such an adjunctive individual therapy. With this study design, we
also have better control over the content and frequency of the
individual therapy in the experimental condition than when STEPPS
would be combined with undefined “TAU.” This may prevent
confounding of the results.
METHODS
Participants
Patients were recruited from nonacademic outpatient clinics
of 2 mental health care institutes in the Netherlands (Lentis, Gro-
ningen; Dimence, Deventer). Therapists were asked to refer patients
thought to meet DSM-IV criteria for BPD (APA, 2001). The
diagnosis was validated by administering the BPD modules from the
Dutch versions of the Personality Diagnostic Questionnaire (PDQ-
4⫹; Hyler, 1994; Akkerhuis et al., 1994) and the Structured Clinical
Interview for DSM-IV Axis II Disorders (SCID-II; First et al., 1997;
Weertman et al., 1996). Besides, the impulsivity and parasuicide
subscales of the Borderline Personality Disorder Severity Index-IV
(BPDSI-IV; Arntz et al., 2003; Giesen-Bloo et al., 2006c) were
administered; scores had to exceed the established cut-off on one or
both subscales. Subjects were excluded if they did not speak Dutch;
were cognitively impaired (IQ ⬍70); younger than 18 years; treated
involuntary; or presented an imminent danger to themselves or
others. Participants gave written informed consent. The study pro-
tocol was approved by the Medical Ethical Committee for Dutch
mental health institutes.
Study Design
Participants were randomly assigned to STEPPS plus indi-
vidual treatment or to TAU. Between 8 and 12 subjects were
included in each group. If at time of randomization an insufficient
number of study subjects was assigned to a group, the remaining
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Bos et al. The Journal of Nervous and Mental Disease • Volume 198, Number 4, April 2010
spots were randomly assigned to subjects who did not meet full BPD
criteria (these participants with subsyndromal BPD will be the
subject of a future communication). Randomization was done sep-
arately at each location. The STEPPS groups began simultaneously
with a group of patients that started TAU.
Pretreatment assessments (T1) took place following random-
ization, just before the start of the intervention. Post-treatment
assessments (T2) were done after the final weekly session of the
STEPPS program (mean 关SD兴 ⫽ 23.9 关3.6兴 weeks after T1). Fol-
low-up assessments (T3) took place approximately 6 months after
T2 (mean 关SD兴 ⫽ 25.7 关4.2兴 weeks after T2). Outcome measures
were assessed on all 3 occasions.
Intervention
The Dutch version of the STEPPS group program involves 18
weekly sessions and a single follow-up session 3 to 6 months after
the conclusion of the program. The program has 3 main components:
(1) psychoeducation about BPD; (2) emotion management skills
training; and (3) behavior management skills training. STEPPS is
system-based in that friends and relatives of the patients are explic-
itly involved in the program for support and reinforcement of the
newly learned skills (the “support group”). They receive education
about BPD and are instructed how to interact with the person with
the disorder. STEPPS is administered by 2 mental health profes-
sionals, of who at least one is a psychotherapist. For details about the
program, see Heesterman et al. (2004) and Van Wel et al. (2006).
Subjects assigned to STEPPS also received limited indi-
vidual therapy. This therapy was developed as an adjunct to
STEPPS to help consolidate the newly acquired skills and to
stimulate their use. It had a structured format, in which the
previous STEPPS session was discussed as well as the use of the
learned skills in everyday life. The therapy was offered every 2
weeks during the entire study period.
The control condition was treatment as usual, i.e., the stan-
dard treatment for BPD offered at the participating sites. This
treatment consisted of individual therapy from a psychotherapist,
psychologist, or psychiatric nurse, offered every 1 to 4 weeks.
STEPPS-related treatments like DBT or family groups for family
members of the patients were not allowed.
In both conditions, the main treatment could be supplemented
with (medication) contacts with a psychiatrist, social worker, or
other health care professional. We kept track of these contacts on all
assessment occasions.
Treatment Integrity
STEPPS therapists met twice a year under the supervision of
expert trainers to evaluate the procedure and to preserve uniformity.
Individual therapists in the STEPPS condition received a 1-day
training and monthly phone supervision. After each session, indi-
vidual therapists in both conditions completed a self-report ques-
tionnaire by which the content and frequency of the therapy contacts
could be checked.
Efficacy Measures
Primary efficacy measures included general psychiatric and
BPD-specific symptoms, measured with the Symptom Checklist-90
total score (SCL-90; Derogatis, 1983; Arrindell and Ettema, 2003)
and the Borderline Personality Disorder checklist-40 total score
(BPD-40; Arntz and Dreessen, 1992; Giesen-Bloo et al., 2006a),
respectively. The SCL-90 is a self-report questionnaire that assesses
8 dimensions of psychological dysfunction. The total score (range,
90 – 450) represents a measure of overall psychological distress in
the past week. The BDP-40 is a self-report questionnaire with 40
items covering the 9 DSM-IV BPD criteria. It assesses the severity
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of borderline-related symptoms during the last month. The total
score ranges from 40 to 200.
Secondary outcome measures included impulsive and para-
suicidal behavior, and quality of life. Impulsive and parasuicidal
behavior were assessed using 2 subscales of the Borderline Person-
ality Disorder Severity Index-IV (BPDSI-IV; Arntz et al., 2003;
Giesen-Bloo et al., 2006c). This semistructured interview assesses
the occurrence of BPD symptoms in the previous 3 months. The
impulsivity subscale contains 11 items reflecting potentially harmful
impulsive behaviors (e.g., gambling, reckless driving, binge eating).
The parasuicide subscale contains 13 items reflecting self-mutilating
parasuicidal behaviors and suicidal thoughts and attempts. The
interviews were conducted by research assistants who were not blind
to treatment group assignment.
Quality of life was measured with the World Health Organi-
zation Quality of Life Assessment-Bref (WHOQOL-Bref; Skeving-
ton et al., 2004; Trompenaars et al., 2005). This self-report ques-
tionnaire consists of 24 items on 4 domains of quality of life:
physical health, psychological health, social relationships and envi-
ronment; and 2 separate items on overall quality of life and general
health. Domain scores run from 4 to 20, higher scores indicating
higher quality of life in the past 2 weeks.
Statistical Analysis
A power analysis indicated that 34 subjects per treatment
group would be required to have 90% power to demonstrate a large
treatment effect of STEPPS over TAU. Chi square tests and inde-
pendent t-tests were used to compare pretreatment characteristics
between the 2 treatment groups. In the same way, we compared
subjects who dropped out and those who did not. Potential con-
founders were identified by examining which baseline variables
were strongly related to the outcome measures (r ⬎ 0.5; Pocock et
al., 2002). As this was the case for the pretreatment scores of the
efficacy measures, these scores were used as covariates in the
analyses on treatment efficacy.
Linear mixed models and generalized estimating equations
were used to test the efficacy of the STEPPS program. These models
have the advantage of using all available data. We used models with
treatment group, time since intervention (as a categorical variable
with 2 levels), and the interaction between time and treatment group,
with pretreatment scores as covariates. In this model, a significant
main effect for treatment group indicates an overall treatment effect
over the entire study period. The interaction term was added to
assess the effect at the different time points (T2 and T3). General-
ized estimating equations were used to test the BPDSI-IV impulsiv-
ity and parasuicide data. Score distributions on these subscales were
highly skewed. Therefore, scores were dichotomized by calculating
the number of subjects scoring above and below the cut-off on these
subscales.
All available data of patients who received the intervention
according to protocol were used in the analyses. Intention-to-treat
analyses, in which also patients are included who did not receive
the intervention as intended, were performed as well. The per-
protocol and intention-to-treat analyses yielded similar results.
We present only the per-protocol analyses, as we are primarily
interested in “method effectiveness” (as opposed to “use effec-
tiveness”; Sheiner and Rubin, 1995). Analyses were carried out
using SPSS 15.0. A 2-tailed alpha level of 0.05 was used to
determine statistical significance.
RESULTS
Figure 1 presents the flow of subjects through the trial. Of 198
patients assessed for eligibility, 115 were excluded because they did
not meet inclusion criteria or refused further participation. Eighty-
© 2010 Lippincott Williams & Wilkins
The Journal of Nervous and Mental Disease • Volume 198, Number 4, April 2010 Dutch STEPPS Trial

Assessed for eligibility

(n = 198)
Excluded (n = 115):
Did not meet inclusion
criteria (n = 109)
Refused (n = 6)
Randomized (n = 83)
Withdrawal (n = 3) Withdrawal (n = 1)
tics did not significantly differ between treatment groups, and
neither did pretreatment scores on the efficacy measures.
Of the 79 allocated subjects, 13 (16.5%) dropped out of
treatment before T2 or were excluded from the per-protocol analyses
because of protocol violations (Fig. 1). The number of dropouts was
higher in the STEPPS than in the TAU condition (STEPPS 21.4%,
TAU 10.8%), but this difference was not significant (␹2 ⫽ 1.61,
df ⫽ 1, p ⫽ 0.204). Dropouts did not differ in baseline character-
istics or pretreatment scores on the efficacy measures from those
who received the intervention according to protocol (N ⫽ 66).

Efficacy of the Intervention

Allocated to VERS (n = 42) Allocated to TAU (n = 37) Table 2 presents the results from the per-protocol analyses
(N ⫽ 66). The upper part of Table 2 shows the scores on the primary
Dropout (n = 9): Dropout (n = 4): efficacy measures. SCL-90 and BPD-40 symptom scores generally
Removal (n = 2) Declined therapy and study participa- decreased from T1 to T3, and more so in the STEPPS group than in
Job-related reasons (n = 1) tion (n = 2)
Dissatisfied (n = 3) Excluded; partner attended STEPPS- the TAU group. The covariate-adjusted linear mixed-model analyses
Frightened by group (n = 1) oriented family group (n = 2) showed a significant overall treatment effect for both measures. No
Excluded; attended less than 12
sessions (n = 2) significant time or time-by-group interaction effects were observed.
Estimated mean differences at the end of treatment (T2), adjusted for
differences at T1, were: SCL-90, ⫺47.0 (95% CI, ⫺78.2 to ⫺15.9,
Lost to follow-up (n = 1) Lost to follow-up (n = 2) p ⫽ 0.003); BPD-40, ⫺18.7 (95% CI, ⫺31.6 to ⫺5.8, p ⫽ 0.005).
At 6-month follow-up (T3), the differences were smaller but still
significant: SCL-90, ⫺38.4 (95% CI, ⫺67.1 to ⫺9.6, p ⫽ 0.009);
Intention-to-treat analyses (n = 42) Intention-to-treat analyses (n = 37) BPD-40, ⫺14.7 (95% CI, ⫺26.6 to ⫺2.8, p ⫽ 0.016).
Per-protocol analyses (n = 33) Per-protocol analyses (n = 33)
The lower part of Table 2 shows the results for the secondary
FIGURE 1. Flow chart. STEPPS indicates systems training for outcome measures. Quality of life scores (WHOQOL-Bref) gener-
emotional predictability and problem solving plus adjunctive ally increased from T1 to T3. Overall treatment effects were found
individual treatment; TAU, treatment as usual. for Overall Quality of Life and General Health, Physical Health, and
Psychological Health. For Social Relationships the overall treatment
effect was a trend, for Environment the overall treatment effect was
TABLE 1. Baseline Characteristics of the Study Participants not significant. No significant time or time-by-group interaction
effects were observed. In the domain of Psychological Health,
STEPPSa TAUb STEPPS scores were higher than TAU scores particularly at T2
(N ⴝ 42) (N ⴝ 37) (estimated mean difference adjusted for T1 score: 2.08 关95% CI,
Characteristic Mean SD Mean SD 0.76 –3.41, p ⫽ 0.002兴); at T3, this difference was reduced to 0.91
(95% CI, ⫺0.32–2.15, p ⫽ 0.146). With respect to Overall Quality
Age (yr) 32.9 5.6 31.8 9.2 of Life and General Health, Physical Health and Social Relation-
Illness history (yr) 13.3 7.4 11.8 7.1 ships, STEPPS scores were significantly higher than TAU scores
N % N % only at T3 (estimated differences 1.80 关95% CI, 0.30 –3.30, p ⫽
Female 35 83.3 33 89.2
0.019兴; 1.41 关95% CI, 0.15–2.66, p ⫽ 0.028兴; and 1.86 关95% CI,
0.14 –3.57, p ⫽ 0.035兴, respectively), but not at T2 (estimated
Having a partner 22 52.4 25 67.6
differences 1.58 关95% CI, ⫺0.07–3.22, p ⫽ 0.060兴; 0.96 关95% CI,
Education ⫺0.40 –2.32, p ⫽ 0.164兴; and 0.77 关95% CI, ⫺1.08 –2.61, p ⫽
Elementary school 7 16.7 6 16.2 0.431兴, respectively).
Middle school 16 38.1 19 51.4 Table 2 also shows the ratings for the parasuicide and impul-
High school 16 8.1 11 29.7 sivity subscales of the BPDSI-IV. In both conditions, the number of
⬎High school 3 7.2 1 2.7 patients scoring above the cut-off decreased from T1 to T3. There
Employment were no significant differences between the conditions (overall
Employed 8 19.0 5 13.5 treatment effects). Time and time-by-group interaction effects were
Disabled 16 38.1 16 43.2 also not significant. Odds ratios for impulsivity were (T2): 0.81
Other 18 42.9 16 43.2
(95% CI, 0.26 –2.53, p ⫽ 0.716); and (T3): 0.68 (95% CI, 0.22–2.09,
p ⫽ 0.501). Odds ratios for parasuicide were (T2): 2.05 (95% CI,
Convicted last year 4 9.8 2 5.4
0.66 – 6.35, p ⫽ 0.211); and (T3): 1.02 (95% CI, 0.35–2.97, p ⫽
Psychotropic medication 25 60 23 62 0.974).
a
STEPPS indicates systems training for emotional predictability and problem
solving plus adjunctive individual treatment. Clinical Significance
b
TAU indicates treatment as usual. To examine whether the treatment effects were also clinically
relevant, we calculated effect sizes for the results that showed
statistical significance. This was done by dividing the estimated
mean difference between the 2 conditions by the pooled standard
three subjects were randomized, 4 of who withdrew following deviation of the pretreatment scores. This yielded the following
randomization. Thus, 79 patients were allocated to the different effect sizes for the differences between the treatments at T2: SCL-
treatment conditions (42 STEPPS, 37 TAU). Table 1 summarizes 90, 0.68; BPD-40, 0.68; Psychological Health, 0.96. At T3 effect
the baseline characteristics of these 79 subjects. These characteris- sizes were: SCL-90, 0.56; BPD-40, 0.53; Overall Quality of life &

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TABLE 2. Scores on Outcome Measures at 3 Different Time Pointsa and Overall Treatment Effects
STEPPS (N ⴝ 33) TAU (N ⴝ 33) Overall Group Effectb
Measure Mean SD N Mean SD N F df p
c
SCL-90 11.9 1, 58 0.001
T1 263.4 70.4 30 247.4 70.5 29
T2 205.8 60.6 25 248.5 77.8 26
T3 199.2 55.5 30 222.7 82.8 30
BPD-40d 11.7 1, 56 0.001
T1 106.8 24.6 31 101.1 33.3 28
T2 79.7 25.8 26 95.1 29.1 26
T3 78.2 23.0 30 88.6 36.7 30
WHOQOL-Brefe
Overall QOL and GH 8.0 1, 56 0.006
T1 10.1 2.7 31 10.5 3.5 29
T2 13.0 2.7 26 11.6 3.3 26
T3 12.6 3.1 31 11.3 3.6 30
Physical health 5.1 1, 54 0.029
T1 11.2 2.1 31 10.7 3.1 27
T2 13.0 2.5 27 11.7 2.7 25
T3 12.5 2.6 31 11.2 3.2 29
Psychological health 9.2 1, 56 0.004
T1 9.3 2.3 31 8.9 2.3 27
T2 12.2 2.5 27 10.0 2.8 26
T3 12.0 2.6 31 10.8 3.3 29
Social relationships 3.2 1, 56 0.080
T1 10.7 2.1 31 10.7 4.0 28
T2 13.0 3.5 27 12.0 3.7 26
T3 13.4 3.0 31 11.7 4.0 30
Environment 1.3 1, 57 0.260
T1 11.0 2.3 31 11.9 2.9 28
T2 12.7 2.4 27 12.6 2.4 26
T3 12.5 2.4 31 12.8 2.9 30
>Cutoff % N >Cutoff % N Wald df p
BPDSI-IV subscalesf
Impulsivity 0.65 1 0.420
T1 29 87.9 33 31 93.9 33
T2 19 67.9 28 22 73.3 30
T3 20 64.5 31 22 73.3 30
Parasuicide 0.31 1 0.578
T1 18 54.4 33 20 60.6 33
T2 16 57.1 28 13 43.3 30
T3 13 41.9 31 13 43.3 30
a
T1 ⫽ pretreatment, T2 ⫽ end of treatment, T3 ⫽ 6-mo follow-up.
b
Overall treatment effect from linear mixed models (F-tests) and generalized estimating equations (Wald-tests) adjusted for pretreatment scores.
c
SCL-90: Symptom Checklist-90.
d
BPD-40: Borderline Personality Disorder checklist-40.
e
WHOQOL-Bref: World Health Organization Quality of Life Bref. Overall QoL and GH: Overall Quality of Life & General Health.
f
BPDSI-IV: Borderline Personality Disorder Severity Index. Number of patients (%) scoring above the cut-off (cut-off Impulsivity ⫽ 0.5; cut-off Parasuicide ⫽ 0.1).

General Health, 0.61; Physical Health, 0.56; Social Relationships,
0.61. Thus, moderate to large effect sizes were seen for symptom
variables and psychological quality of life at T2. At T3, moderate
effects on symptoms were still present, while also moderate effects
on physical, social and overall quality of life could be observed.
Next, we applied the Jacobson and Truax method (Jacobson
and Truax, 1991; Bauer et al., 2004) to examine whether the
observed changes in individuals were clinically significant. The 2
criteria for clinical significant change (Reliable Change criterion and
passing the cut-off between dysfunctional and functional score
range) were calculated on the basis of the Dutch norm scores of the
SCL-90 for the general community and psychiatric outpatients (21).
Table 3 presents the clinical status of subjects at T2 and T3. The
number of subjects that showed reliable improvement (Reliable
Change criterion met; patients improved and patients recovered) was
considerable, and more so in the STEPPS than in the TAU group:
58.3% versus 29.2% at T2 (␹2 ⫽ 4.15, df ⫽ 1, p ⫽ 0.042) and 70.0%
versus 46.5% at T3 (␹2 ⫽ 3.32, df ⫽ 1, p ⫽ 0.069, trend). Further,

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The Journal of Nervous and Mental Disease • Volume 198, Number 4, April 2010
TABLE 3. Clinical Status According to SCL-90 Scores, by
Treatment Assignment
End of Treatment 6-Month Follow-up
STEPPS TAU STEPPS TAU
Statusa N % N % N % N %
Recovered 3 12.5 1 4.2 3 10.0 5 17.9
Improved 11 45.8 6 25.0 18 60.0 8 28.6
Unchanged 8 33.3 9 37.5 8 26.7 9 32.1
Deteriorated 2 8.3 8 33.3 1 3.3 6 21.4
a
Recovered ⫽ passed cut-off and reliable change criterion; Improved ⫽ passed
reliable change criterion but not the cut-off; Unchanged ⫽ did not pass reliable change
criterion; Deteriorated ⫽ passed reliable change criterion but worsened. Reference is
pretreatment score (T1). Computed for participants with data on the SCL-90; end of
treatment (T2): N ⫽ 48 (24 STEPPS, 24 TAU); 6-mo follow-up (T3): N ⫽ 58 (30
STEPPS, 28 TAU).
the number of patients reliably deteriorated was smaller in the
STEPPS than in the TAU group at T2 (␹2 ⫽ 4.55, df ⫽ 1, p ⫽ 0.033)
as well as T3 (␹2 ⫽ 4.47, df ⫽ 1, p ⫽ 0.035). The number of patients
that met both the Reliable Change criterion and passed the cut-off
score (patients recovered), was small and not significantly different
between the conditions (T2: 12.5% vs. 4.2%; ␹2 ⫽ 1.09, df ⫽ 1,
p ⫽ 0.296; T3: 10.0% vs. 17.9%; ␹2 ⫽ 0.75, df ⫽ 1, p ⫽ 0.386).
Treatment Contacts and Medication Use
Over the entire study period, patients in the STEPPS group
received 15 STEPPS group sessions on average, and had a mean of
8 contacts with their individual therapist. TAU-patients had a mean
of 9 individual contacts with their main therapist. In addition to these
study treatment contacts, TAU-patients reported to have had 31
ambulatory therapy contacts on average with other mental health
care workers (e.g., psychiatrists, psychologists, psychiatric nurses,
social workers). Patients in the STEPPS condition had a mean of 21
additional ambulatory therapy contacts.
At baseline, use of one or more psychotropic medications was
reported by 39 (59%) subjects of the per-protocol group. Medication
use was not different between treatment conditions: 17 (52%)
STEPPS-recipients versus 22 (67%) TAU-recipients (␹2 ⫽ 1.57,
df ⫽ 1, p ⫽ 0.211) received at least one psychotropic medication.
These figures remained relatively stable during the follow-up. Add-
ing medication use (yes/no) as a covariate to the analyses did not
reduce the significance of the results; the effects even became
somewhat stronger. Thus, the study results were not confounded by
medication use.
DISCUSSION
STEPPS combined with an adjunctive individual therapy
was more effective than TAU with regard to BPD-specific and
general psychiatric symptoms as well as quality of life. These
effects persisted during a 6-month follow-up. Effect sizes for the
differences in improvement were in the moderate range for most
measures. The findings support the results of the RCT reported by
Blum et al. (2008) and earlier uncontrolled studies (Blum et al.,
2002; Freije et al., 2002; Black et al., 2008). Importantly, this
RCT on STEPPS is the first done by others than its developers
(Blum et al., 2008).
Although the results show differences between the efficacy of
STEPPS and TAU, the clinical relevance is less evident. Both
groups seemed to take benefit from therapy. In both conditions the
number of patients that could be labeled “recovered” after 1 year
was small. Nevertheless, more than two-thirds of patients who
© 2010 Lippincott Williams & Wilkins
Dutch STEPPS Trial
received STEPPS plus individual treatment showed reliable im-
provement versus fewer than half of patients in the TAU condition.
Importantly, a considerable proportion of patients receiving TAU
reliably deteriorated, while this was true for only a few of the
patients in the STEPPS condition.
Apart from symptom reduction, STEPPS was superior to
TAU in improving quality of life. Immediately after the program this
effect was mainly found in the psychological domain, which may
have been related to the effects observed on the symptom measures.
At follow-up, subjects in the STEPPS condition did better with
respect to physical, social and overall quality of life. Possibly, these
effects only became apparent at follow-up because changes in health
behavior and improvements in interpersonal skills take time to
produce an effect (Howard et al., 1993).
STEPPS plus individual treatment was not superior to TAU in
reducing impulsive and parasuicidal behaviors. It might be that a
more intensive or prolonged treatment (such as DBT) is required to
find differential effects on these behaviors. Another possibility is
that the cut-off used as an inclusion criterion has been too low. The
cut-off for these subscales of the BPDSI-IV distinguishes BPD-
patients from nonpatients (Arntz et al., 2003). There is reason to
expect that this score is too low to detect differential clinical change
(Arntz, personal communication); many BPD patients will routinely
exceed this cut-off, so our sample may not have been sufficiently
impulsive or suicidal at intake to detect a differential treatment
effect. Blum et al. (2008) also found no effect of STEPPS on
suicidal behaviors. These authors also refer to the low base rate of
these behaviors in their subjects to explain this fact.
Another reason to interpret the results on these BPDSI-IV
subscales with caution is that the raters who performed the
BPDSI-IV interviews were not blind to treatment assignment, nor
was interrater-reliability assessed. Admittedly, this is a limitation of
our study. For that reason, we chose not to use the BPDSI-IV as a
primary outcome measure.
STEPPS resembles the skills training group that forms part of
the DBT program developed by Linehan. Interestingly, Linehan
(1993, p25) found no additional value of her skills training alone
beyond TAU. In our study, STEPPS combined with a limited
individual treatment was more efficacious than TAU. Perhaps,
STEPPS-specific factors such as the systems component of the
program (the support group) are effective key elements compared
with Linehan’s skills training.
STEPPS was combined with a relatively basic individual
therapy, the goal of which was to help consolidate the newly
acquired skills and to stimulate their use in everyday life. This is a
difference with the study of Blum et al. (2008), in which STEPPS
was combined with TAU. One reason that we used this design was
to ensure that TAU would not be a confounder. If TAU in the
experimental condition would not be clearly defined, it would
remain unclear whether the differences between the conditions are
due to STEPPS or to differences in TAU. Another reason was that
clinical experience and patient interviews suggest that the STEPPS
group training is most effective when its contents are also system-
atically discussed in individual therapy contacts (Van Wel, unpub-
lished data). Therefore, expert STEPPS trainers in the Netherlands
usually recommend offering the STEPPS group program in combi-
nation with adjunctive individual therapy.
There are 2 other differences between the study of Blum et al.
(2008) and ours. First, the dropout rate in the experimental condition
was lower in our study, and not significantly different from the
dropout rate in the control condition. Only a limited number of our
subjects dropped out for reasons directly related to the nature of the
treatment. Second, we found significant and clinically relevant
effects that were still present at follow-up. Such long-term effects
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Bos et al. The Journal of Nervous and Mental Disease • Volume 198, Number 4, April 2010
were less evident in the study of Blum et al. These observations
might indicate that combining the STEPPS group program with a
STEPPS-adapted adjunctive individual therapy may help enhance
treatment compliance and consolidate the acquired skills.
Of course, it could be that the superiority of STEPPS plus
individual treatment over TAU resulted from the increased attention
paid to patients in the STEPPS condition, as these patients received
a series of group training sessions as well as individual therapy.
However, patients in the TAU condition appeared to have had many
more ambulatory therapy contacts beyond those with their main
therapist. These extra individual contacts presumably outweigh the
group session contacts in the STEPPS condition. So, our results are
not likely explained by a differential number of treatment contacts.
A striking finding is that a large proportion of patients
screened for the study (n ⫽ 109) did not meet research criteria for
BPD. This fact may limit the real world generalizability of the
results. Therapists had referred these patients to the study because
they expected them to meet BPD criteria and presumed they would
benefit from STEPPS. We decided that to better reflect typical
practice conditions we would allow this subsyndromal group to
participate in the randomization. Results from this larger group will
be presented later.
CONCLUSIONS
In summary, this study offers further evidence of the efficacy
of the STEPPS program in the treatment of patients with borderline
personality disorder. More than TAU, STEPPS plus limited adjunc-
tive individual therapy reduced symptomatology and improved qual-
ity of life, also in the longer run. STEPPS was not superior to TAU
in reducing impulsive and parasuicidal behaviors, but this may be
explained by the low base rate of these behaviors in our sample. It
may also be that a more intensive treatment, such as DBT, is
required to find differential effects on these behaviors. The merit of
the STEPPS program is that it is relatively easily learned and
implemented, and nevertheless improves BPD treatment in a number
of ways. Further research to compare this treatment with other
effective treatments is warranted.
ACKNOWLEDGMENTS
The authors thank Erna Berendsen, Fiona Willgeroth, Karin
van der Weele, Femke Adolfsen, Hans Berkelmans, and Donald W.
Black for their contribution to this study.
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