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Clinical Psychologist
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/rcnp20
Adapting Systems Training for Emotional
Predictability and Problem Solving (STEPPS) for
older adults with personality disorder: a Dutch
Delphi study
Erol Ekiz, Sebastiaan P. J. van Alphen, Annemiek M. E. L. Melssen, Machteld
A. Ouwens & Arjan C. Videler
To cite this article: Erol Ekiz, Sebastiaan P. J. van Alphen, Annemiek M. E. L. Melssen, Machteld
A. Ouwens & Arjan C. Videler (02 Oct 2023): Adapting Systems Training for Emotional
Predictability and Problem Solving (STEPPS) for older adults with personality disorder: a Dutch
Delphi study, Clinical Psychologist, DOI: 10.1080/13284207.2023.2261599
To link to this article: https://doi.org/10.1080/13284207.2023.2261599
© 2023 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Group.
Published online: 02 Oct 2023.
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Adapting Systems Training for Emotional Predictability and Problem Solving
(STEPPS) for older adults with personality disorder: a Dutch Delphi study
Erol Ekiz
a,b
, Sebastiaan P. J. van Alphen
a,b,c,d
, Annemiek M. E. L. Melssen
c
, Machteld A. Ouwens
a,b
and Arjan C. Videler
a,b
a
PersonaCura, Clinical Centre of Excellence for Personality Disorders and Autism in Older Adults, GGz Breburg, Tilburg, The Netherlands;
b
Tranzo, Scientific Centre for Care and Wellbeing of the Tilburg School of Social and Behavioural Sciences of Tilburg University, Tilburg,
The Netherlands;
c
Clinical Centre of Excellence for Personality Disorders in Older Adults, Mondriaan Mental Health Centre, Heerlen-
Maastricht, The Netherlands;
d
Personality and Psychopathology Research Group (PEPS), Department of Psychology (PE), Vrije
Universiteit Brussel (VUB), Brussels, Belgium
ABSTRACT
Objective: Systems Training for Emotional Predictability and Problem Solving (STEPPS) is
a group therapy in which patients with personality disorder are taught emotion and behaviour
regulation skills. Since older adults regulate their emotions dierently than younger adults,
age-specic aspects are suggested to be taken into account in the treatment. Objectives of this
study were to determine expert consensus on the applicability of STEPPS for older adults and
determine which adjustments should possibly be implemented for a better t for older adults
with personality disorder.
Method: A group meeting involving seven experts, with expertise in psychological therapies
with older adults, was held. The Delphi method was applied in order to reach consensus on three
main statements regarding the applicability of STEPPS in older adults with personality disorder.
Results: Most experts (86%) voted against the statement implying the current STEPPS program
is applicable for older adults. All experts voted in favour of the statement that adjustments to
the STEPPS program at the content level are required. Consensus (≥66.7%) was reached among
the experts that adjustments to the STEPPS program are also required at the process level.
Conclusions: STEPPS is considered to be applicable for older adults with emotion regulation
problems and personality disorder but needs adaptations to enhance its feasibility and ecacy
in later life.
KEY POINTS
What is already known about this topic:
(1) Systems Training for Emotional Predictability and Problem Solving (STEPPS) is an evidence-
based psychotherapeutic treatment for patients with borderline personality disorder.
(2) Promising results have been found for STEPPS in older adults.
(3) Several studies recommend adapting psychotherapeutic treatments for older adults.
What this topic adds:
(1) Consensus was reached among experts, stating that STEPPS needs adaptations to enhance
its feasibility and ecacy in later life.
(2) Adapting STEPPS for the young old (60–75 years) is recommended as a useful starting point.
(3) A main recommendation concerned including themes into the STEPPS program that are
more relevant for ageing.
ARTICLE HISTORY
Received 9 May 2023
Accepted 12 September 2023
KEYWORDS
STEPPS; borderline
personality disorder;
emotion regulation; older
adults; Delphi study
Introduction
In ancient Greece, the oracle of Delphi was one of the
most visited and most revered sacred places. People
came from far and wide to hear the divine prophecies
of the Pythia, the high priestess. The oracle was con-
sulted for important political and personal decisions by
prominent people. The Pythia sat in a cauldron on
a tripod and went into a religious trance. She passed
on revelations from the gods, giving the consultants
guidance on a subject where they needed advice.
Nowadays, in topics lacking empirical data, the scien-
tic method named after Delphi can oer solace. The
Delphi technique is a systematic method, in which
independent participants with relevant expertise are
subjected to questionnaires, in order to reach reliable
consensus (Dalkey & Helmer, 1963). Since little is
known about evidence-based treatment of emotion
regulation problems in later life, the Delphi technique
CONTACT Erol Ekiz e.ekiz@ggzbreburg.nl
CLINICAL PSYCHOLOGIST
https://doi.org/10.1080/13284207.2023.2261599
© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-
nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or
built upon in any way. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.
might be a useful method in providing consensus-
based recommendations on the matter.
There is increasing evidence that psychological
therapies are eective in late-life mental disorders,
such as depression and generalised anxiety disorder
(Cuijpers et al., 2014, 2020; Gonçalves & Byrne, 2012).
Several studies also investigated the feasibility and
associated eects of psychotherapy for personality dis-
orders (PD) in older adults, such as Systems Training for
Emotional Predictability and Problem Solving (STEPPS;
Ekiz et al., 2022), dialectical behaviour therapy (Lynch
et al., 2007), and schema therapy (Videler et al., 2018).
STEPPS has been found feasible in the treatment of PD
in later life (Ekiz et al., 2022). STEPPS is a 20-week group
therapy based on cognitive behavioural therapy prin-
ciples. During STEPPS, patients are given psychoeduca-
tion about borderline personality disorder (BPD) and
are taught emotion and behaviour regulation techni-
ques to cope with emotional vulnerability in day-to-
day events (Blum et al., 2002). The emotion regulation
techniques help patients cope with intense emotions
and maladaptive cognitions. The behaviour regulation
skills help patients manage their daily life in such a way
that patients can build healthy lifestyle patterns and
prevent emotion regulation problems to arise.
STEPPS focuses on PD-related emotional dysregula-
tion, as it is an important underlying factor of BPD
(Putnam & Silk, 2005). Most studies investigating the
ecacy of STEPPS have been conducted in younger
adults with a mean age of 33 years (Ekiz et al., 2023).
Black et al. (2018) reported that the response to the
STEPPS program did not dier by age. However, in this
study, age was dichotomised, comparing patients
younger than 40 years old (N = 60) with patients of
40 years and older (N = 15). Importantly, the oldest
participating patient in this study was 50 years of age
(Black et al., 2013). Research by Hofer et al. (2015)
suggests that older adults (i.e., ≥60 years) regulate
their emotions dierently compared to younger adults.
For instance, older adults are more likely to use sup-
pression as an emotion regulation strategy. A study
concerning 169 patients diagnosed with BPD found
that younger patients (16–25 years) reported higher
levels of aggression and suicide attempts, whereas
older patients (>45 years) reported higher levels of
somatisation, symptoms of depression and anxiety,
and more functional decits (Frías et al., 2017).
Beatson et al. (2016) conrm that the phenomenology
of BPD in older adults diers from younger adults,
complicating the (timely) diagnosis in older adults.
The authors state that PD-related emotional dysregu-
lation persists into old age, with older adults with BPD
demonstrating other forms of self-harm (e.g., drug
abuse, non-compliance with therapeutic advice).
These results suggest that emotion regulation pro-
blems in patients with BPD might have dierent man-
ifestations in dierent age groups and therefore might
need a dierent therapeutic approach or emphasis in
its treatment.
A common recommendation in studies in older
adults seems to be that psychological treatments for
older adults need adaptations (e.g., Knight, 2004;
Lynch, 2000; Videler et al., 2017). In a Delphi study
involving older adults with PD, consensus was reached
among 35 experts about the importance of integrating
gerontological aspects as themes in psychotherapy
with older persons (Van Alphen et al., 2012). These
gerontological aspects include beliefs about and con-
sequences of somatic disorders, as well as cohort-
related and sociocultural beliefs. Similar consensus on
adaptations in psychotherapy for older adults with PD
emerged in a cross-validation study in the United
States (Rosowsky et al., 2018). Nonetheless, empirical
data on adapted psychological treatments for older
adults with PD are scarce. As pointed out by Konrat
et al. (2012), older adults are often not included in
scientic research, as age limits of 18–65 are generally
used. In the psychiatric research eld, not only age but
also exclusion criteria such as substance abuse, suicide
risk, comorbidity, and use of medication are frequently
seen (Kennedy-Martin et al., 2015). This largely pre-
vents older adults’ participation in research,
a situation that is disproportionate to the rapidly grow-
ing group of older adults in society. Although research
on older adults is challenging because of the interac-
tions among biological, psychological, and social fac-
tors, it is also necessary if society is to provide for the
specic needs of this population.
Since there are indications that emotion regulation
strategies and their manifestation dier during the life
span, it has been suggested that the STEPPS program
needs adaptations to better serve older adults with PD
(Ekiz et al., 2022). The aim of the present study was (1)
to determine the level of expert consensus on the
applicability of the present STEPPS program for older
adults with PD (≥60 years), and (2) consensus on which
adjustments should possibly be implemented in the
program for a better t for older adults.
Method
In this study, the Delphi technique was applied. This
method is relevant to explore topics that lack empirical
data. Some key principles of the Delphi technique have
been described in the literature, including anonymity
of the expert panel, multiple rounds of responses by
2E. EKIZ ET AL.
the panel, controlled feedback between the rounds,
and a statistical summary of the group consensus
(Rowe & Wright, 1999). However, the application of
the Delphi technique is extremely varied and hetero-
geneous; the technique comes in dierent guises
(Powell, 2003). Following the method as used by
Legra et al. (2017), we performed a Delphi study invol-
ving a group meeting instead of distributing question-
naires (Yousuf, 2007). In this group meeting, experts in
the eld were asked to express their opinions and oer
suggestions for possible adjustments to the current
STEPPS program. Consensus was dened as
a minimum of 66.7% voters in favour or against the
statement. We chose a group meeting, and thus a non-
anonymous Delphi method, since there is, to the best
of our knowledge, a limited number of experts on the
subject. An advantage of this approach is that rounds
of responses by the panel and feedback by the chair
are more uent and iterative. Another advantage of
the Delphi method is that a group of experts is guided
to a nal decision (McKenna, 1994). Iteration seems
a crucial principle for this process. The iteration process
of the Delphi method allows generating a high quan-
tity and quality of creative insights and ideas (Donohoe
& Needham, 2009) and ensures reliability and gener-
alisability of outcomes (Day & Bobeva, 2005). Since one
of the aims of the current study was to make STEPPS
more suitable for older adults, it was important to
create an optimal setting for new and creative ideas
to arise.
Selection of the chairman and experts
The selection of the chairman was carefully considered
by the research team. The established criteria were an
experienced clinical worker with (1) expertise in
STEPPS and (2) a certain distance from the eld of
psychotherapy with older adults, to ensure an inde-
pendent position. We invited Horusta Frije, clinical
psychologist, who was largely responsible for the intro-
duction and dissemination of STEPPS in the
Netherlands since 1998, and is experienced in psy-
chotherapy in younger adults with PD.
Experts were dened as follows: (1) possessing
a minimum of 5 years of experience in psychological
therapies with older adults with PD and (2) having
anity and/or experience with the STEPPS program
in the Netherlands. This led to 10 identied potential
experts who were invited by email to participate.
Seven (70%) potential experts agreed to participate,
two (20%) decided not to participate due to a lack of
time, and one (10%) agreed to participate but later
withdrew due to health issues. Most experts (85.7%)
were experienced mental health professionals at
a Clinical Centre of Excellence for Personality
Disorders in Older Adults. The seven participants
included three psychologists (43%), one nurse practi-
tioner (14%), and three nurses (43%) working in ger-
iatric psychiatry. All experts (100%) were Dutch.
All subjects were provided oral and written informa-
tion concerning the study. Subjects’ informed consents
were documented. The study was approved by
research ethics committee of GGz Breburg, Tilburg,
the Netherlands (reference number CWO 2020-03).
Procedure
The structure and content of the Delphi meeting were
determined by the research team and the chairman in
several pre-meetings. Three statements, one for each
round, were established in these meetings. The state-
ments served as a starting point for each round of
discussion in the face-to-face Delphi meeting. The
statements were as follows:
(1) The current STEPPS program is suciently
applicable to older adults in mental health
settings.
(2) Adjustments to the STEPPS program at the con-
tent level are required.
(3) Adjustments to the STEPPS program at the pro-
cess level are required.
For the Delphi meeting, no preparation was required
for the experts. Each statement was presented on
a PowerPoint slide and briey introduced by the chair-
man, after which the discussion started. During the
discussion, the chairman encouraged the experts to
engage in open dialogue and to think creatively and
unconventionally. At the end of each round, the chair-
man provided the panel a short summary of the dis-
cussed topics. Furthermore, voting for the statement
(yes/no) took place in an open, non-anonymised man-
ner. The meeting lasted 3 hours in total, with a break of
20 minutes after the completion of the voting regard-
ing the second statement. Forty minutes were reserved
for the introduction, voting round, and discussion of
each starting-point statement. The meeting was video-
recorded for qualitative analysis afterwards.
Results
The participation rate was high, with all seven experts
(100%) joining in discussion in all three rounds.
Discussion of the statements proceeded in a natural
manner, which had the eect that the content of the
CLINICAL PSYCHOLOGIST 3
discussion was sometimes about another proposition
that had yet to come or had been discussed before. At
the end, full consensus was reached on the second
statement, and sucient consensus was reached on
the rst and third statement (see also Table 1).
Statement 1: the current STEPPS program is
suciently applicable for older adults in mental
health settings
Six of the seven experts (86%) considered the statement
to be false, implying that the current STEPPS program is
not suciently applicable to older adults with PD. The
discussion then revealed several concerns about parti-
cular parts of the program being ill-suited for the target
group, i.e., older adults with PD. First, the examples,
pictures, and movie clips used in the current program
do not always apply to the lived experience of older
adults. Second, the themes included in the current
STEPPS program (e.g., work and intimate relationships),
are not fully suitable for older adults, and more relevant
themes (i.e., experiences of loss and mourning, physical
limitations, polypharmacy dened as using ve or more
medications, and nding meaning in life) are being
missed. Moreover, some existing themes are relevant,
but experts stated these themes focus mainly on
younger adults with PD. For example, the manifestation
of destructive behaviour as described in the current
program is more overt (e.g., “attacking boyfriend with
a vase and smashing it on his head”), whereas the
manifestation of destructive behaviour among older
adults with PD is being described as more hidden and
ego-syntonic (e.g., neglect of self-care). Additionally,
older adults may nd their social networks have
become quite small, and they may encounter diculty
in marshalling a reinforcement group, which is part of
the STEPPS program. Third, in group therapy with older
adults, discussion material often includes reminiscing
memories of “the old days”. This is not explicitly
included in the current STEPPS program. Five experts
(72%) stated this should be added for older adults, to
provide them the opportunity for life review and to help
them achieve closure. Lastly, it was noted that there are
dierences between the younger cohort of older adults
with PD (60–75 years) and the older cohort of older
adults with PD (75 years and above). Each group might
need other adaptations to the program.
Statement 2: adjustments to the STEPPS program
at the content level are required
Regarding this statement, consensus was reached with
all seven experts (100%) stating that they agreed with
this statement. First, the experts suggested emphasising
positive psychology and positive interventions (e.g.,
mentioning adaptive cognitive schemas next to mala-
daptive ones) throughout the program (100%). Second,
some used terminology, like BPD, was considered to be
stigmatising. Experts suggested referring to “emotion
regulation problems” better reects the common core
problem participants with dierent PDs deal with (86%).
Third, all experts agreed with the suggestion that
including an abstract at the end of every session in the
manual would be of signicant value. Fourth, experts
Table 1. Overview of agreement among the Delphi experts per statement.
Round Statement
Votes in favour of state-
ment (%)
Votes against state-
ment (%)
First The current STEPPS program is sufficiently applicable for older adults in mental health
settings.
14 86
The program should provide opportunities to reflect on life and talk about “the old days”
for better closure.
72 28
Second Adjustments to the STEPPS program on content level are required. 100 0
The program should have a stronger emphasis on positive psychology and positive
interventions.
100 0
Refer to “emotion regulation disorder” instead of “borderline personality disorder”
throughout the program.
86 14
Include an abstract at the end of every session in the manual. 100 0
The transition from the second component to the third component of STEPPS is too
abrupt for older adults.
100 0
Typical age-related changes in life are underexposed in the program. 86 14
Third Adjustments to the STEPPS program on process level are required. ≥66.7* ≤33.3*
Follow-up or booster sessions should be added to the program. 43 57
An extra group sessions regarding the emotion regulation skill “challenging thoughts”
should be added.
100 0
The original protocol should be rewritten into shorter sentences. 100 0
The group sessions should follow a recurring structure. 100 0
Font size should be increased. 43 57
STEPPS: Systems Training for Emotional Predictability and Problem Solving.
*This statement reached consensus, with at least two-thirds of the experts voting in favour of the statement. However, due to damage to the video-
recording, the voting could not be checked. Therefore, the exact percentages of consensus are missing.
4E. EKIZ ET AL.
stated that the transition from the second component
of the treatment program (i.e., emotion regulation tech-
niques) to the third component (i.e., behaviour regula-
tion techniques) is too abrupt for older adults (100%).
Also, the third component entails dierent life domains.
Experts stated that certain changes in life, typical for
later life (e.g., acquiring new social roles, experiences of
loss and mourning), remain underexposed (86%).
Consensus was not tested with regard to the follow-
ing suggestions, which were oered for consideration
only. The experts suggested adding a discussion around
values in life. Furthermore, experts recommended
rewriting existing topics to be more appropriate for
the target population. An example is a session related
to healthy eating habits, which for older adults should
also focus on eating suciently and choosing a diet that
keeps blood-sugar levels within healthy ranges for dia-
betic older adults. Finally, an additional session regard-
ing self-destructive behaviours typical for older adults
with PD was recommended.
Statement 3: adjustments to the STEPPS program
at the process level are required
Although partial consensus was reached regarded this
statement, points made by the experts largely con-
cerned content level rather than process level. First,
the experts’ opinions varied on the topic whether to
add one or more follow-up or booster sessions within
a year after the last session. Consensus was not reached
(43%) regarding this topic. Dierences in personal
experiences with follow-up sessions formed the basis
for the variation in opinions. Second, full consensus was
reached regarding expanding the focus on early mala-
daptive schemas, part of the emotion regulation skill
‘challenging thoughts’, from one to two group sessions.
Experts stated that the pace of the sessions regarding
this emotion regulation skill was too high for older
adults. Third, all experts agreed that the original proto-
col should be rewritten into shorter sentences to
increase readability. Fourth, all experts agreed the ses-
sions should follow a recurring structure, with several
adjustments (e.g., two relaxation exercises, one at the
start and one after the break, instead of one relaxation
exercise). Lastly, there was no agreement (43%) on
increasing the font size of the STEPSS workbook.
Discussion
The aim of this study was to examine possible adapta-
tions to the STEPPS program, to increase its applicability
to older adults with poor emotion regulation strategies
and PD. Given the current lack of knowledge about
STEPPS in older adults, we chose an exploratory techni-
que through a face-to-face meeting of a group of
experts, following the Delphi method. The main out-
come was that experts suggested adapting the STEPSS
protocol for older adults with PD. Main recommenda-
tions concerned including themes that are more rele-
vant with ageing into the program (such as physical
limitations, life review, polypharmacy, experiences of
loss and mourning), including an abstract at the end
of every session in the manual, adding extra group
sessions to the program to generate more time for
several high-paced themes, using short sentences to
increase readability, and using a recurring session struc-
ture. Furthermore, experts recommended that exam-
ples, pictures, and movie clips used in the sessions
should better t the lived experience of older adults.
Experts also suggested that referring to “emotion reg-
ulation problems” better reects the common core pro-
blem older aged participants with dierent PDs
participating in STEPPS deal with. As Chanen (2021)
has stated, it is important to understand and recognise
the heterogeneity and uniqueness of BPD in dierent
people. This is even more relevant for BPD in later life, as
biopsychosocial ageing processes can lead to a dierent
manifestation of BPD symptoms (Van Alphen et al.,
2012), and as stigma and therapeutic nihilism are even
more prevalent towards older people with BPD (Khasho
et al., 2023). Finally, in accordance with recent attention
on integrating positive schemas, such as success and
emotional fullment, in schema therapy with older
adults (Van Donzel et al., 2021; Videler et al., 2020), the
expert panel suggested focusing more on positive
aspects of life by adding those to the protocol. These
ndings are in line with earlier studies suggesting that
psychological treatments for older adults need adapta-
tions (e.g., Knight, 2004; Lynch, 2000; Videler et al.,
2017). As for STEPPS, this may be due to the ndings
that older adults regulate their emotions dierently
than younger adults (Hofer et al., 2015) and that per-
sonality pathology manifests dierently in older adults
compared to younger adults (Van Alphen et al., 2012).
Not all themes included in the original protocol
were considered applicable to both the third and
fourth phases of life. The third phase refers to the
ages 60 to 75, the years following one’s working life,
in which the older person is still actively involved in
many pursuits (Wahl & Ehni, 2020). In this phase, the
loss of positions and social roles predominates, neces-
sitating the acquisition of new roles. In the fourth
phase of life, at approximately 80 years and older,
frailty and deterioration in various areas become
more central (Wahl & Ehni, 2020). In this phase, loss is
a central concept, and it can refer to the loss of health
CLINICAL PSYCHOLOGIST 5
and loved ones; as a result, these older adults nd
themselves facing impending death, which often
induces existential anxiety. The distinction between
the “young old” and the “older old” also emerged as
an important consideration among the experts. This
raises the question: for which age group of older adults
with PD should the STEPPS protocol be adjusted – the
young old or the older old? Based on our clinical
experience in which STEPPS has been provided to
adults between the ages of 56 to 72 (Ekiz et al., 2022),
we suggest adapting the protocol for older adults in
the third phase of life as a useful starting point.
There are several strengths and limitations to this
study. This study is a rst step into integrating an
adjusted STEPPS into geriatric psychiatry. In order to
achieve this, experts were brought together to deter-
mine the level of consensus on what these adjust-
ments should be for a better t of STEPPS for older
adults with PD. The Delphi technique, which is a widely
used systematic method, was used to close a scientic
gap. A strength of this study is that several authors are
experienced in conducting Delphi studies in scienti-
cally unexplored areas of geriatric psychiatry (e.g.,
Heijnen-Kohl et al., 2022; Legra et al., 2017; Rosowsky
et al., 2018; Van Alphen et al., 2012, 2003). Another
strength is that the iterative character of the Delphi
technique, as used in the current study, allowed for
mutual discussion and the emergence of creative
ideas. However, a consensus method such as the
Delphi technique can be characterised as gathering
limited scientic evidence and having a low level of
reliability (Yousuf, 2007). When considering the levels
of evidence for therapeutic studies, expert opinion can
be seen as Level V (i.e., lowest level) evidence (Burns
et al., 2011). Furthermore, although the face-to-face
Delphi method has some advantages, such as enhan-
cing creativity and encouraging an open discussion,
there are also constraints. Possible risks are mutual
inuence, dominant individuals, and social pressure
(Legra et al., 2017). In the evaluation and the qualita-
tive analysis of the video-recording afterwards, we
concluded that these risks were minimal regarding
the experts, but it may have been dicult for the
chairman to take a fully independent position,
prompted by her broader interest in improving the
existing protocol for more than only older adults.
Another limitation is that the expert panel consisted
of a small number of experts and that all experts were
Dutch. The latter may have cultural implications, redu-
cing the generalisability of the ndings to an interna-
tional context. Although the small number of experts is
representative of the current (Dutch) research and
clinical practice on STEPPS for older adults, results
should be interpreted with caution. Potential blind
spots of the expert panel could be overcome by having
a broader representation of (international) experts.
Lastly, the experts were all clinicians, meaning that
the patient perspective was not included in this
study, and possible useful input from this important
group was missed.
The overall conclusions are that STEPPS is considered
to be applicable to older adults with PD-related emotion
regulation problems, but it needs adaptations to
enhance its feasibility and, possibly, its ecacy in later
life. A rst step in determining which adaptations are
useful has been taken by means of this study. To make
the expert opinion results more robust, a cross-
validation Delphi study is recommended. The STEPPS
protocol has been translated into various languages,
including German, Italian, and Spanish, implying the
use of STEPPS in multiple countries (Black & Blum,
2017). It is recommended to include as many countries
as possible in which STEPPS is applied in the cross-
validation study, in which professionals who meet the
same criteria as used in the present Delphi study are
invited to participate. Furthermore, involving the
patient’s perspective through qualitative research is
advocated. An adapted protocol that meets the needs
of older adults with PD and that better ts their lived
experience could be tested rst in a mixed-method
design, examining its eects on, for example, emotion
regulation, personality functioning, and psychological
distress. A nal step would be a randomised controlled
trial of a further adapted STEPPS protocol, ne-tuned for
older adults with PD, to assess its ecacy.
Acknowledgments
We would like to thank Horusta Freije and the participating
experts for oering their valuable time and input in the study.
Disclosure statement
No potential conict of interest was reported by the author(s).
Funding
This research did not receive any specic grant from funding
agencies in the public, commercial, or not-for-prot sectors.
ORCID
Erol Ekiz http://orcid.org/0000-0001-7143-5157
Arjan C. Videler http://orcid.org/0000-0002-2175-3453
6E. EKIZ ET AL.
Ethical statement
The authors have abided by the ethical principles of the
Declaration of Helsinki. All subjects were provided oral and
written information concerning the study. Subjects’ informed
consents were documented. The study was approved by
research ethics committee of GGz Breburg, Tilburg, the
Netherlands (reference number CWO 2020–03).
Data availability statement
The data that support the ndings of this study are available
from the corresponding author upon reasonable request.
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