STEPPS in different UK service settings February 2014 Renee Harvey Consultant Clinical Psychologist
Nancee Blum, Norm Bartels, Don St John, Bruce Pfohl, 2009
OVERVIEW OF STEPPS Psychoeducational Group Cognitive Behaviour Therapy + Schema Therapy 20 Weeks 90 120 minutes 8 12 per Group 2 Group Leaders, CBT trained. 1:1 Reinforcer Reinforcement team evening
After STEPPS STAIRWAYS 24 Lessons Two-weekly One year STEPPS graduates only
STEPPS and STAIRWAYS
Other versions In Germany: VERS-Training : The Netherlands In Italy:
Worldwide 47 USA States 6 Provinces in Canada UK Australia New Zealand Europe: Spain France Germany The Netherlands Norway Belgium Italy Argentina Kenya South Africa Japan Prisons in: Minnesota Nevada Florida Wisconsin California Pennsylvania Iowa
STEPPS in the UK 2006: International Conference : London 2007: First Group: Horsham, W Sussex Sussex
Next Groups: 2007-2013 Highland Edinburgh Dumfries & Galloway Manchester Milton Keynes Oxfordshire Berkshire Somerset Surrey Sussex Essex London Kent
RESEARCH AND OUTCOMES TO DATE Note: STEPPS has been recognised in 2012 in the USA by NREPP (the Substance Abuse and Mental Health Services Administration s National Registry of Evidence-based Programs and Practices).
Evidence base - Blum et al.,(2002): N=52 (no control group) BEST : Significant decrease Negative behaviours: decrease BDI (depression): Highly significant decrease PANAS : highly significant decrease - Netherlands (Freije et al., 2002): n=56 Measured on SCL-90 : found decrease in: Depression Anxiety Interpersonal anxiety Global Severity Index
Evidence base (2) Blum et al., 2008: Am J Psychiatry, 165 (4), 468+ n=65 ZAN-BPD : decrease in total, and all subscales : (affective, cognitive, impulsivity and interpersonal domains) Improvements in measures of : impulsivity, negative affectivity, mood, and global functioning No difference in self-harm, suicide attempts or hospitalisations (but low baseline) Fewer visits to emergency department All gains maintained at follow up
Evidence base (3) Van Wel, EB, et al. (2009) De effectiviteit van de vaardigheidstraining emotieregulatiestoornis (VERS) Tijdschrift voor Psychiatrie, 51, 5+ n = 79 RCT STEPPS vs TAU Symptom reduction significant (70% vs 47%) % complete recovery low for both groups Greater improvement in QOL, esp on follow up No difference in suicide attempts No difference in service use
STEPPS in prison settings 2 Studies: Black, Blum and colleagues, 2008, 2011 on male and female offenders with BPD Significant improvements in symptoms, mood and negative affectivity Decrease in disciplinary incidents Decrease in self-harm behaviours Increase in positive behaviours Positive subjective evaluation of programme
In the UK Harvey, Renee, Black, Donald W, Blum, Nancee Systems Training for Emotional Predictability and Problem Solving (STEPPS) in the United Kingdom: A preliminary report. Journal of Contemporary Psychotherapy, December 2010, vol./is. 40/4(225-232), 0022-0116;1573-3564 (Dec 2010) Gracie, J. & Scott-Lodge, L. (2013). First STEPPS: Outcomes from Systems Training for Emotional Predictability and Problem Solving. DCP Scotland, Review Issue, p. 3258.
Implementation of STEPPS within the PD pathway in Sussex Phase 1 Phase 2 Phase 3 Phase 4 Tier 4 Forensic/ Residential (Future) Tier 3 1. Bluebell House 2. Lighthouse Tier 2 STEPPS and STAIRWAYS Early intervention Tier 1 CAMHS P/C 2007
TIER 2 STEPPS: Jan 2007 to Sept 2013: 460 people started a STEPPS Group 299 (65% completed 20 weeks) STAIRWAYS : 8 teams currently running or planning groups.
Outcomes Audit information being gathered. Reports from each group: Dramatic improvements in 2-3 participants in each group Demonstrable benefits in most of rest Popular with clients. Demand increasing Popular with clinicians.
Average Total Score STEPPS in Sussex: 2011 to 2013 Average Total BEST Score 52 50 48 46 44 42 40 38 36 34 32 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Lesson P < 0.01; n = 36
Score 1998 Pilot Study West Sussex: 6 groups Best Scores (Week 1 to 1 year follow -up) 50 48 46 44 42 40 38 36 34 32 30 1 4 7 10 13 16 19 1-YR Weeks FOLLOW UP P < 0.001; N=28
1998 Pilot Study West Sussex: 6 groups Significant reductions (post group, 6 months and 1 year post group): Beck Depression Inventory Core: overall measure and all subscales PANAS-X ZAN-BPD: overall measure and all subscales ( includes measure of self-harm and suicide attempts) After one year: Significant reduction in: MCMI-III: Borderline Scale SCL-90-R: Global Severity Index and Positive Symptom Distress Index
A Key principle: Service User Involvement Volunteers Group graduate participation in delivery Training and support
Supported by: Crisis support Peer-to-Peer internet support network (IRIS) PD services: Bluebell House Lighthouse Complex needs / personality disorder Tier 3 (Bluebell) Tiers 1-3 (Lighthouse) Partnership working: Sussex Partnership Volunteers 3 rd Sector 3 psychological therapy streams Preparation STEPPS focussed intensive therapies Non-STEPPS intensive therapies + Community programme
Duration (days) Ward Stays 400 350 300 250 200 150 100 50 0 6-12 months prior 0-6 months prior 0-6 months post 6-12 months post 12-18 months post Prior and Post Members attending Bluebell House
Duration (days) CRT Contact 120 100 80 60 40 20 0 6-12 months prior 0-6 months prior 0-6 months post 6-12 months post 12-18 months post Prior and Post Members attending Bluebell House
Number of Presentations A&E/ UTC Attendance 20 15 10 5 0 6-12 months prior 0-6 months prior 0-6 months post 6-12 months post Prior and Post Members attending Bluebell House 12-18 months post
The model: Common factors Attachment Trust Hope Recovery orient. PLUS Safety and risk management: Crisis planning Support Skills and Life Management: Psychoeducation Skills: STEPPS Life skills Housing Finances Childcare Health Spiritual needs Psychological Therapy: Dealing with trauma Self-development (Re-)engagement with community, life, Work P R I O R I T Y
STEPPS in the Tier 3 Service: Challenges: Variability in participation Some struggling with reading Group size More 1:1 work Clinicians: Positive influence on Tier 2 work Noticing changes in people * Reduction in Sect.136 presentations reported
TIER 1: CAMHS Pilot Group: Feb July 2012 Parallel groups for young people and parents / carers 8 participants aged 16-18 male and female 9 parents/family members 2 group leaders per group 2 nd group with revised Manual: Jan 2014
Preliminary feedback: Young people very sensitive to anything seeming childish The material definitely needs modifying The importance of thorough assessment Working with the system for good support, communication and crisis management The importance of follow-up.
From the Young People: It has helped me to look differently at my emotions and know that it s okay to feel that way. It has helped a lot. I am more aware when I am vulnerable to harm I have had to face up to my difficulties and have been taught how to better communicate myself to others. I can communicate better and no longer self harm.
From the Parents/Carers The only people who understand what I m going through are here, on a Tuesday night Trying to understand what I may have done, and working with guilt feelings I have backed off, and she is taking responsibility for the first time My husband and I both feel we have changed and have noticed this change of behaviour in one another
I can see changes in front of my eyes I m not sure I can believe it yet! This has been a godsend I feel we have a future a future as mum and daughter as friends and as her reinforcer which is how we laughingly refer to me! However It s early days will the change last? There is a lot of secrecy I don t really know yet
TIER 1: Early Intervention: Primary Care Pilots started : March 2012 (Essex and Sussex). Manual revised (preliminary) - Shortened - Modular format Adults, mixed gender, 8 to 12 per group
Adapting the programme Tier 1: STEPPS-EI (16 weeks) Tier 2: STEPPS + Clinician Reinforcement + System reinforcement + STAIRWAYS Tier 3: Preparation for groups Building motivation STEPPS STEPPS consolidation STAIRWAYS CAMHS: STEPPS-YP (18 weeks) + Parents/Carers Group + Clinician Reinforcement
Thanks! Contact info: renee.harvey@sussexpartnership.nhs.uk