Interventions with a primary focus on Phase 1

Personality disorder integrated care pathway
NHS Highland

Most of the evidence base for the treatment of personality disorder relates in particular to borderline personality disorder. Perhaps understandably, given the dramatic, resource intensive and risky presentations associated with marked emotional and behavioural dysregulation, almost all the published literature for borderline personality disorder describes interventions with a focus on Phase 1 (stabilisation).

While stabilisation is of paramount importance, it should usually be regarded as a means to enable the subsequent phases of treatment to take place and not as an end in itself. Clinical experience suggests that if subsequent phases of treatment are not undertaken when necessary, relapse to previous unhelpful patterns of behaviour is likely, impeding the patient’s recovery. As explained in more detail in the General Principles Section, subsequent phases of treatment may not always require formal input from mental health services and may be worked through by the person using their own personal and interpersonal resources. For example, a person with emotional and behavioural dysregulation but without a significant trauma history
may attain sufficient behavioural and emotional stability from completion of the STEPPS program to allow meaningful reflection on, and changes to, longstanding patterns of behaviour. This might mean that the person recognises that lack of structure and meaningful use of time had helped to maintain their difficulties in the past. They may decide to join new social groups and enter employment (Phase 2).

The improved interpersonal and social landscape which results may contribute to an improved sense of self and connection to their family, friends and- wider society, reducing the likelihood of future relapse, distress and dysfunction (Phase 3).

Dialectical Behaviour Therapy (DBT)

What is it:

Treatment generally lasts for 6 months to 1 year. 

DBT is a structured intensive CBT-based Phase 1, tier 3 treatment for people with severe borderline personality disorder. Treatment generally lasts for 6 months to 1 year. Each week the patient attends a 2 hour skills training session in which 2 DBT therapists teach skills of mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness. It takes 26 weeks to
complete a cycle of the 4 skills modules. Patients often complete 2 cycles of skills training.

In addition to the skills training, each patient attends for 1 hour of individual therapy each week with the same therapist. This involves the patient recording daily emotions, behaviours and thoughts on a diary card which is reviewed in session with a view to enhancing and generalising skills.

  • DBT is not used as a stand-alone treatment but represents part of an overall care plan.,
  • DBT is delivered by the Personality Disorder Service in Inverness, serving the whole of NHS Highland.

Who is it for:

Individuals with severe borderline personality disorder. DBT is primarily a technology of behavioural and emotional stabilisation and has an evidence base in reducing parasuicidal behaviour and psychiatric hospitalisation. Individuals are required to be on the Care Program Approach for the duration of their involvement in DBT.

Who it is not for:

Less severe forms of borderline personality disorder (consider STEPPS). Personality disorders without a severe borderline component. Patients who pose risks which are unmanageable in a community group setting.

How can it be accessed:

In NHSH, the DBT program is a specialist service. Referrals are taken from secondary and specialist mental health services. The PDS encourages contact to discuss possible referrals.

Systems Training for Emotional Predictability and Problem Solving (STEPPS)

What is it:

STEPPS Treatment lasts for 20 weeks. 

STEPPS is a highly manualised, tier 2, CBT-based skills training program with a systems component for people with borderline personality disorder and traits. The principle focus is on Phase 1 (stabilisation). STEPPS was originally developed as an add-on to usual treatment rather than a stand alone treatment.  During that time the individual attends a weekly 2 hour skills training session in which 2 STEPPS skills trainers teach skills addressing a broad range of difficulties
associated with borderline personality. Individuals are given specific homework each week related to the topic of the session and they are also asked to record situations of high emotional intensity. The first half of each session comprises a review of homework and new skills are taught during the second half.

Significant others are involved as part of the reinforcement team and are given recommendations on how to respond to the person with BPD in a situation of emotional intensity. Participants should ideally also have an individual skills reinforcer with whom they should meet weekly — this can be anyone with some knowledge of mental health issues for example a GP, CPN, mental health social worker etc. The idea is that the participant brings the homework to the reinforcer, explains that week’s topic and discusses any problems, in much the same way that a child asks for help with school homework from a parent. The individual skills reinforcer and the significant others make up the reinforcement team.

A session for members of the reinforcement team is usually offered early in the 20 week program.

Who is it for:

Individuals with moderate borderline personality disorder and or borderline features. Severely behaviourally dysregulated individuals are more likely to benefit from the more intensive DBT.

Who is it not for:

People who do not fulfil criteria for borderline personality disorder or experience borderline features. Patients who pose risks which are unmanageable in a community group setting.

How can it be accessed:

Each CMHT runs its own STEPPS group and referral of possible candidates should the made to the CMHT.

Cognitive Behaviour Therapy for Personality Disorder (CBTpd)

What is it:

CBTpd treatment typically lasts for 30 sessions over a period of one year, which is a longer course of treatment than in standard CBT.

CBTpd is a modified individual cognitive behaviour therapy for individuals with personality disorder. It primarily focuses on Phase 1 (stabilisation) and 2 (making sense) but there may be some work on Phase 3 (making connections) for some patients.

There is more of an emphasis on a developmental perspective than in standard CBT and a written narrative formulation is developed with the individual early in the therapy process. Early treatment targets include behavioural stabilisation, especially of harmful behaviours. Later phases of treatment attempt to reduce other overdeveloped behaviours and increase underdeveloped behaviours. Cognitive work focuses on the level of core beliefs rather than at the level of
automatic thoughts as in standard CBT.

Who is it for:

Individuals with personality disorder, although best evidence is for borderline personality disorder. Individuals who are unable to benefit from a group based treatment, for example people with hearing impairment, may also find CBTpd more suitable.

Who is it not for:

People who do not fulfil criteria for personality disorder.

How can it be accessed:

CBTpd availability within the PDS is currently limited but referrers can contact the PDS or locality Clinical Psychologist/CBT therapist to discuss the possibility of this intervention for particular patients

STAIRWAYS (follow-on group from STEPPS)

What it is:

STAIRWAYS is a one-year long, twice monthly advanced group program developed for clients with borderline personality traits and disorder who have completed the 20-week STEPPS program.

The reduction in frequency from the weekly STEPPS program is designed to encourage group members to seek out non-therapy activities between meetings. Each session lasts for 2 hours. New participants are able to join the group at frequent intervals as opposed to STEPPS which runs as a 20 week closed group. The program, which is cognitive-behavioural in orientation, reinforces and expands on the skills learned in STEPPS with the aim of improved management of emotional intensity.

There is also an emphasis on the application of the new skills to specific goals and challenges in the occupational, educational, recreational and interpersonal domains. The primary focus of STAIRWAYS is on enhancing Phase 1 emotion regulation skills, although there is increased focus on Phases 2 and 3 compared with STEPPS.

Who is it for:

Individuals with moderate borderline personality disorder and traits (perhaps in early remission) who have completed STEPPS and are relatively behaviourally stable. 

Who is it not for:

People who have not completed STEPPS. People who are significantly behaviourally dysregulated.

How can it be accessed:

STAIRWAYS is currently offered within the Inverness CMHT on a limited basis only.