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To the Editor: We thank Drs. Schulte-Herbrüggen, Koerting, and Roepke for allowing us the opportunity to clarify several points about the STEPPS program and our randomized controlled trial.
First, because STEPPS is adjunctive, it is added to whatever therapy the patient is currently receiving (e.g., medication, individual psychotherapy). We encourage individual therapists to familiarize themselves with STEPPS when one of their patients is enrolled in the program, but this is not required. We did not involve individual therapists in our randomized controlled trial, and thus there was no way of knowing the degree to which they incorporated STEPPS elements into their therapy.
Second, Drs. Schulte-Herbrüggen et al. feel that 1) our statement that most of the early improvement for the treatment as usual alone group was premature and 2) our report of improvement in the STEPPS plus treatment as usual group that occurred from week 16 to week 20 was surprising. The former statement was based on our analysis of Figure 2 (mean scores across time) for the primary outcome (Zanarini Rating Scale for Borderline Personality Disorder total score) and one of the secondary outcomes (Beck Depression Inventory score). Because this tendency did not hold across all outcomes, we agree that it was premature to make strong conclusions attributing improvements to only a portion of the treatment program. Future research should address the issue of why patients are less likely to worsen before leaving the STEPPS program (relative to other therapies). It could be that 1) the systems component helped to mitigate patients’ fears of falling back into dysfunction and 2) the 1-year follow-up period acted as a buffer that enabled patients to continue to feel attached to the program.
Third, Dr. Schulte-Herbrüggen et al. point out that dialectical behavior therapy reduces suicide attempts and self-harm acts and STEPPS does not (1). Although true, this comparison may not be appropriate because unlike dialectical behavior therapy, STEPPS is not a comprehensive program and it lasts 20 weeks, whereas dialectical behavior therapy lasts 1 year. As we pointed out, reports of reductions in suicide attempts and self-harm acts attributed to dialectical behavior therapy (or the Bateman and Fonagy program ) have generally followed ≥1 year of active treatment. These studies also required patients to be suicidal at intake, which we did not.
Finally, Dr. Schulte-Herbrüggen et al. suggest that the 1-year follow-up analysis should have included baseline values. Since we did not know whether the effect of the STEPPS program would follow the same pattern during the 20-week treatment period and 1-year follow-up, our strategy was to test for a treatment effect within each period. We considered testing from baseline to week 72 but chose not to in order to limit the number of statistical tests and because of the large proportion of patients who were lost to follow-up.
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