The concept of stepped care is eminently sensible. At its core, stepped care is the idea that the intensity of treatment should be varied according to patient need. It is difficult to imagine any competent clinician disagreeing with the suggestion of matching treatment intensity to patient need. For psychologists, however, there is an urgency for strong advocacy and involvement to raise the awareness of decision-makers in Government and within the Primary Health Networks (PHNs) regarding the value to the community of the role of psychologists within a stepped-care model.
In Australia, stepped care has been adopted nationally and is an explicit policy of the Primary Health Network (PHN) initiative. The PHN Guidance document, produced by the Australian Government’s Department of Health (2016), defines stepped care as “an evidence-based, staged system comprising a hierarchy of interventions, from the least to the most intensive, matched to the individual’s needs. While there are multiple levels within a stepped care approach, they do not operate in silos or as one directional steps, but rather offer a spectrum of service interventions. Stepped care is a different concept from ‘step up/step down’ services” (p. 2). In the same document the Government describes its unequivocal stance on stepped care: “Stepped care is central to the Australian Government’s mental health reform agenda and should be used by PHNs to guide mental health activity. PHN regional mental health planning and commissioning of services will be founded upon a stepped care approach” (p. 1).
The appropriateness of stepped care as a guiding principle for the efficient use of clinical services seems undeniable. The implementation of stepped care, however, has been less than straightforward. The stepped care system in England and Wales provides an excellent example of some of the most important and contentious aspects to implementation. With an initial budget of £173 million between 2008 and 2011 (Department of Health, Great Britain, 2008), the Improving Access to Psychological Therapies (IAPT) program had an explicit focus of making psychological treatment more accessible to more people.
The United Kingdom’s IAPT
From the outset, IAPT adopted a stepped-care approach but, to do this, treatment was divided into ‘high-intensity’ treatments and ‘low-intensity’ treatments. Of course, devising high-intensity and low-intensity treatments implies that we should expect to find high-intensity and low-intensity problems in the population. One could certainly question the sensibility of dichotomising people’s problems according to a two-factor intensity model. The practical difficulties of deciding, at an initial interview, to which category a person’s presentation best applies should also be acknowledged. Regardless of these seemingly important considerations the high and low intensity framework is the current prevailing model in IAPT.
In the IAPT model, people with mild to moderate problems are, ideally, offered the low-intensity treatments first over a maximum of three sessions. Typically, these treatments are online therapies and self-help programs. If people don’t show satisfactory improvement after three sessions they are, at least in principle, ‘stepped up’ to a high-intensity treatment which is an evidence-based treatment such as cognitive behaviour therapy (CBT). In the IAPT system, the low-intensity therapists are called Psychological Wellbeing Practitioners (PWPs) and the high-intensity therapists are most commonly clinical or counselling psychologists. The PWPs complete a one-year training course involving one day each week of off-site training (Department of Health, Great Britain, 2008).
Australia’s New Access
In Australia, a modified version of IAPT called New Access commenced in 2013. Instead of PWPs, this stepped care model employs New Access Coaches for the low-intensity treatment. New Access has four steps: contact with a general practitioner is step one; low-intensity CBT with a New Access Coach is step two; high-intensity CBT is step three; and accessing secondary mental health services is step four. (Cromarty, Drummond, Francis, Watson, & Battersby, 2016). Given the differences in health systems, if a patient in the Australian system needs to be stepped up from step two to step three, they need to return to their GP for a referral to a suitable clinician.
The Australian pilot study evaluated only step two of the model not the entire stepped-care model (Cromarty et al., 2016). This is important to understand because some of the most problematic features of the Multi Clinician Stepped Care (MCSC) model, such as what level to assign people to and how to efficiently manage the stepping, were not examined. In this pilot, people without a university degree were able to become New Access coaches. Self-referral to New Access was also a feature of this pilot (Cromarty et al., 2016) which further complicates implementation of this part of the model into the full stepped care model. The low-intensity CBT was offered over six sessions (whereas the IAPT model provided three sessions at the low-intensity step) and “time-limited, proven interventions” (p. 490) were used.
Continuous outcome monitoring was adopted in this model and impressive recovery rates were reported for depression and anxiety (Cromarty et al., 2016). It appears, however, that people with moderate (or worse) depression and anxiety, as indicated by scores on standardised questionnaires, received treatment in the pilot (Cromarty et al., 2016). This highlights the implementation difficulties with the MCSC model since low-intensity stepped care is reportedly designed for people with mild to moderate problems. It should also be noted that a comparison group was not used when considering the benefits of treatment. Critically, when discussing the rollout of this program the authors emphasised the importance of “maintaining the high degree of supervision, training, and monitoring” (p. 491).
What does the evidence tell us?
In both the United Kingdom (UK) and Australian systems, therefore, a decision was made to create an entirely new workforce of therapists in order to implement stepped care. MCSC systems are more common in the literature than Single-Clinician Stepped Care (SCSC) systems although there is some evidence of the effectiveness of SCSC systems (Brooks, Smith, Young, Sutherland, Ackland, & Sandbach, 2007). Crucially, there does not appear to be any empirical evidence to indicate MCSC is more effective than SCSC.
In an attempt to appreciate the rationale for prioritising an MCSC system over an SCSC system and, consequently, creating the need to develop a new workforce to assist in implementing the model, I completed a systematic review which is currently being reviewed for publication. The review sought to examine the evidence regarding comparisons of MCSC with SCSC. Conducting the review was invaluable in revealing many details about the practicalities of implementing the systems as well as methodological nuances in evaluating the approaches.
There have been many randomised controlled trials (RCTs) conducted which, typically, compare stepped care with a comparison group. The comparison group is often a group receiving what is described as the ‘full treatment’. So the comparison group might receive 12 sessions of CBT whereas the stepped-care group commences with a low-intensity treatment and participants are regarded as having completed treatment when they reach a predetermined criterion. The basic protocol, therefore, is that one group is kept in treatment for a predetermined number of sessions, while participants in the other group can exit when they achieve a particular outcome. One study, for example, compared stepped care with direct face-to-face CBT (Nordgreen et al., 2016). In this study only 28 participants in the stepped-care group received face-to-face CBT compared with 84 participants in the comparison group. In the stepped-care group, 57 participants either completed treatment or were lost to treatment before being offered face-to-face CBT (Nordgreen et al., 2016).
Many of the stepped-care studies, therefore, appear to demonstrate that not all people need what is described as the ‘full’ treatment to experience benefit. This is a crucial point to emphasise because there is a marked and enduring disconnection between the number of sessions that treatments are typically designed to be and the number of sessions patients typically attend in routine clinical practice (Carey, Tai, & Stiles, 2013). While many RCTs have demonstrated that treatment benefits can be experienced in a predetermined, arbitrarily chosen number of treatment sessions, no RCTs have demonstrated that a particular number of sessions is necessary for treatment to be effective for all patients. Ideally, treatment should be delivered flexibly and responsively according to the needs of individual patients. Arguably the best way of providing such treatment is with a single, skilled clinician.
Despite the useful information that was obtained during the conduct of the systematic review, the question driving the review was unable to be answered. That is, there were zero studies in which a comparison between MCSC and SCSC was explored. Therefore, the decision to create a new workforce was not based on the results of any existing research.
Given that there is no empirical evidence to support MCSC over SCSC, it is difficult to understand how policymakers would arrive at a decision to divide a task that could be done by one person, into a task that requires at least two people. While it could be argued that it might be an inefficient and expensive use of a clinician’s time to be delivering low-intensity cognitive behaviour therapy, one wonders how more inefficient and expensive that would be than to have a low-intensity therapist delivering the therapy and then referring the person to a high-intensity therapist if required. In an MCSC model there are at least two therapists, rather than one, who need to be trained, supervised, and importantly, paid.
Crucial decisions need to be made in an MCSC model that are not so critical in an SCSC system. For example, if a patient is to be matched to treatment intensity according to current level of need, it would seem that the clinician conducting the initial assessment would need to be highly skilled. In IAPT, however, starting patients at the first step has been described as the “default position” (Van Stratten, Hill, Richards, & Cuijpers, 2015, p. 231) and, in practice, the initial assessments are often conducted by duty managers, case managers, or inexperienced staff members with insufficient training or psychological knowledge (Binnie, 2015; Clark, Layard, Smithies, Richards, Suckling, & Wright, 2009; Richards & Borglin, 2011).
Whereas in an SCSC model, treatment intensity could be varied flexibly and responsively by a skilled clinician according to the patient’s current needs and circumstances, in an MCSC model, varying treatment intensity requires a referral to another clinician. Negotiating these various transitions in IAPT has proven to be troublesome. For example, Richards and Borglin (2011) reported that, “at every point in the patient flow 27 per cent of patients either don’t turn up, don’t come back, or drop out” (p. 58). This is ironic, but also concerning, given that the purpose of the entire IAPT system is to improve access to psychological therapies.
I have only highlighted a small number of the implementation difficulties here, however, when the literature is considered systematically and impartially, there appears to be only limited evidence to indicate that the prevailing model for the organisation of mental health services should be a stepped care approach (Van Stratten et al., 2015) particularly when different workforces are used to deliver different treatments at different steps.
Psychologists have a role in stepped care
Despite the lack of certainty regarding the sensibility of implementing stepped care on a widespread scale, it is here to stay for the time being and psychologists could play key roles in improving the performance of the service. There are at least four areas in which psychologists could assist PHNs to deliver appropriate and accessible treatments for people experiencing difficulties in psychological functioning:
- Conducting initial assessments to determine the most appropriate intensity of treatment based on current level of need;
- Delivering evidence-based psychological treatments;
- Supervising minimally trained colleagues who are also providing services within the stepped care model; and
- Assisting PHNs to evaluate the performance of their system and the outcomes being achieved.
Obviously, the details regarding the ways in which psychologists would be engaged to conduct these tasks within each PHN’s jurisdiction will need to be established. But by harnessing the clinical, supervision, and research and evaluation expertise of psychologists, PHNs will be able to improve the efficiency and effectiveness of the range of services that are available to community members through stepped-care systems. Importantly, the full range of psychologists’ skills will be employed for the benefit of the communities we serve.
The author can be contacted at [email protected]