Today there is something new in international literature: stepped-care 2.0.
An innovative approach is offered to a now known problem: the disparity between expressed needs and limited resources. The “innovative” answer is the use of effective but short operating methods, and the use of it means. And stepped-care 2.0 goes precisely in this direction,
This is discussed in the article Meeting the Mental Health Needs of Today’s College Student: Reinventing Services through Stepped Care 2.0, by Peter A. Cornish (Memorial University of Newfoundland) and colleagues, published in the October issue of Psychological Services magazine.
What is stepped care
We can translate the term stepped care as “care for levels“. Before explaining what it is, let’s see together the why and the how; that is the “old” problem and the “innovative” answer.
The “old” problem, as mentioned above, is the disparity between expressed needs and limited resources. Universities in the United States are facing a growing demand for mental health from students, who are increasingly accessing university faculties and campuses, and the need not to increase the costs of health services offered, while maintaining a high level of effectiveness.
The answers attempted all turned out to be inadequate, because they led to:
- an increase in the management costs of the consultancy structures,
- a greater burden for users, in the form of university fees,
- or to an excessive lengthening of waiting times.
All of these responses resulted in mass media blaming grounds as a result of worsening care.
The “innovative” solution actually consists of several actions that reorganize mental care services allowing them not to increase costs and contain waiting times while having optimal results.
Stepped care and Single Session Therapy
A first operation was the introduction of Single Session Therapy (SST) methods as part of the first visit, with direct access.
The authors. taking up what was stated by the first systematizers of this form of intervention (Hoyt and Talmon), they clarify that SST is not an ultra-short therapy, which claims to solve everything in a single session, but a flexible “open-ended” therapy, that is open-term, in which each session, generally only one but sometimes even more, is experienced by both the therapist and the client as if it were the only one available and therefore is focused on solving the current problem by mainly using the client’s wealth of resources .
The second operation consists in defining a level of “disease severity”, in agreement with the client and using standardized assessment methods, so as to be able to set a “level” (step) of care as suitable as possible for the problem, but that it is also the least intense (not all problems manifest themselves with the same severity, not all responses must be of equal intensity).
Nine levels have been identified, ranging from just the first meeting at the open access center, to a program of meetings with a psychiatrist. In between, self-help systems have been inserted – and this is the third operation carried out by the service – also supported by online modalities with or without the support of health professionals.
All levels are always monitored through online assessment systems that allow the center manager to raise or lower the level of care as needed.
The methodology, to which the authors of this article refer, however, refers to experiences underway for years in other realities of the Anglo-Saxon world, such as Great Britain, Canada and Australia. The novelty, interesting, is the introduction of IT tools, starting from the observation that young people make a great use of the internet to communicate their messages, even those of discomfort.
The 9 levels
In a very stringent summary, stepped care 2.0 proposes, through a first visit that takes place at the free access centers (walk-in, in English), to diversify the type of assistance to be provided on the basis of the identified needs.
As mentioned, nine “steps”, or levels of care, are distinguished, according to the figure:
The first level is, of course, the visit to the direct access clinic, where Single Session Therapy is used. The subsequent levels can be managed with online tools, educational material, meetings with operators, etc., up to the last level, the ninth, which involves taking charge by a psychiatrist.
The customer is placed in one of the levels based on the outcome of the first visit, but can move from one level to another, both up and down, based on the conditions that are continuously monitored by the system managers.
Effectiveness and efficiency of stepped-care 2.0
The analysis that the authors made of the available literature relating to “classic stepped-care” shows that there is no evidence of a clear therapeutic advantage of this form compared to the classic form of care; this admission demonstrates the honesty of the columnists.
But they add: “What is interesting is that the conclusion of the superimposition of the outcome of these treatments on the classic one was considered a failure. But since the model achieves greater efficiency without compromising the outcome, these models should be regarded as a success. “
They also point out that in the “classic stepped care” the use of IT means was not foreseen, while the “stepped-care 2.0” version, through the use of online programs, allows on the one hand to increase the needs / resources ratio, and on the other hand, to make adequate care accessible to a greater number of clients at the right time. There is also more space for the “frontal” treatment of those more difficult situations, in which direct meeting is absolutely necessary.
The authors report a more detailed description of the nine levels that goes beyond the intentions of this summary and for which we refer to the article, and also present a series of reflections on stepped-care 2.0 by various subjects.
The annotations of an operator and those of a trainee appear interesting. These expressed an initial resistance to the use of SST because it did not seem to them that a therapy could be managed in such a short time: the training schools suggest that recovery is a path of slow growth that takes a long time.
Stepped.care 2.0 does not offer the possibility of such a practice. Thus, if well introduced, motivated and guided by an attentive supervisor, the resistances can be easily overcome, also due to the fact that the Single Session Therapy can be represented as the only practical alternative to combine the number of requests and the lack of personal or, if you want, adequate time to manage all patients with “classic” therapy.
The results are not lacking and are no less important than those obtainable with classic methods of treatment, and in the article it is interesting to read the reflections also of the patients and the examples of solutions in a single session of events that severely limit the normal activity of the person.
Physician, Health Statistician
Researcher for the Italian Center
for Single Session Therapy
Cornish, P. A., Berry, G., Benton, S., Barros-Gomes, P., Johnson, D., Ginsburg, R., Whelan, B., Fawcett, E. & Romano, V. (2017). Meeting the mental health needs of today’s college student: Reinventing services through Stepped Care 2.0. Psychological Services, 14 (4), 428-442.