To the Editor: In the April 2008 issue of the Journal, Nancee Blum, M.S.W., et al. (1) reported the positive effects of a 20-week Systems Training for Emotional Predictability and Problem Solving (STEPPS) group treatment compared with that of standard therapy (including individual psychotherapy and psychotropic medication) but no additional group treatment. Patients with borderline personality disorder were assessed on several core symptoms and emergency department visits. STEPPS has been presented as a broad approach, which includes numerous components of well-established manualized psychotherapies, such as dialectical behavior therapy, shown to be effective in the treatment of borderline personality disorder (2, 3).
However, several factors in the study conducted by Blum et al. remain unclear, and further explanation may help to better support their conclusions of an effective psychotherapeutic intervention.
First, more patients in the STEPPS group received individual psychotherapy compared with patients in the standard condition group. In addition, individual therapists were informed about the STEPPS program. To clearly define the effect of STEPPS, it would have been helpful to know the degree to which each individual therapist integrated elements of the program into therapy treatment.
Second, the authors stated that improvement for the treatment as usual group alone appeared to be mostly confined to the first half of the treatment period. This conclusion seems premature, since Borderline Evaluation of Severity Over Time Scale scores and Clinical Global Impression (CGI) ratings showed benefits of STEPPS only within the last 4 weeks of treatment, whereas no data were presented for most primary and secondary outcome measures for weeks 12 or 16. Important amelioration of psychopathology with the discontinuation of therapy is particularly surprising, since our experience with dialectical behavior therapy has shown that there is, in most cases, a tendency for a patient’s symptoms to worsen before leaving the therapy, reflecting the patient’s fear of falling back into dysfunctional behavior. Since patients with borderline personality disorder are rather sensitive to changes in interpersonal relations, this paradox effect between weeks 16 and 20 should be assessed in future studies using STEPPS.
Third, dialectical behavior therapy has been repeatedly shown to reduce suicide attempts and self-harm (2, 3). It would be interesting to learn of the exact number of suicide attempts and self-harm acts in both groups.
Last, the 1-year follow-up analysis should have included baseline values prior to treatment, which would have allowed for observation of any positive treatment effects of data for week 72, as opposed to the absence of significant symptom worsening between weeks 20 and 72.
1.Blum N, St John D, Pfohl B, Stuart S, McCormick B, Allen J, Arndt S, Black DW: Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up. Am J Psychiatry 2008; 165:468–478
2.Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL: Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 1991; 48:1060–1064
3.Linehan MM, Tutek DA, Heard HL, Armstrong HE: Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Am J Psychiatry 1994; 151:1771–1776
The authors report no competing interests.
This letter (doi: 10.1176/appi.ajp.2008.08030390) was accepted for publication in July 2008.