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All content in this area was uploaded by Peter A Cornish on Mar 20, 2017
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REINVENTING SERVICES THROUGH STEPPED CARE
Running head: REINVENTING SERVICES THROUGH STEPPED CARE
Meeting the Mental Health Needs of Today’s College Student:
Reinventing Services through Stepped Care 2.0
Psychological Services © APA1
Peter A. Cornish
Memorial University of Newfoundland
Gillian Berry
The George Washington University
Sherry Benton
University of Florida
Patricia Barros Gomes and Dawn Johnson
The George Washington University
Rebecca Ginsburg, Beth Whelan and Emily Fawcett
Memorial University of Newfoundland
Vera Romano
McGill University
Author Note
Dr. Sherry Benton is the inventor of Therapist Assisted Online (TAO) and the Chief Science Officer for
TCI, the company that distributes TAO. All data handling and data analysis evaluating the effectives of
TAO was conducted independently and not by company employees. With special thanks to Chief
Physician, Dr. Norman Lee and Senior Associate Dean of Students, Mark Levine. Correspondence
concerning this article should be addressed to Peter Cornish, Student Wellness and Counselling Centre,
Memorial University of Newfoundland, St. John’s, NL A1C 5S7 Canada. Contact: pcornish@mun.ca.
1 This prepublication version of the article may not exactly replicate the authoritative document published in the
APA journal. It is not the copy of record.
REINVENTING SERVICES THROUGH STEPPED CARE 1
Abstract
A new stepped care model developed in North America reimagines the original United Kingdom
model for the modern university campus environment. It integrates a range of established and
emerging online mental health programs systematically along dimensions of treatment intensity
and associated student autonomy. Program intensity can be either stepped up or down depending
on level of client need. Because monitoring is configured to give both provider and client
feedback on progress, the model empowers clients to participate actively in care options,
decisions and delivery. Not only is stepped care designed to be more efficient than traditional
counseling services, early observations suggest it improves outcomes and access, including the
elimination of service wait lists. This paper describes the new model in detail and outlines
implementation experiences at three North American universities. While the experiences
implementing the model have been positive, there is a need for development of technology that
would facilitate more thorough evaluation.
Keywords: stepped care, online mental health, service models, empowerment, change
management
REINVENTING SERVICES THROUGH STEPPED CARE 2
Meeting the Mental Health Needs of Today’s College Student: Reinventing Services through
Stepped Care 2.0
Despite valiant efforts, many university and college counseling centers are failing to meet
the needs of their students. Counseling center directors report difficulties meeting the demand:
88% of directors report that students may not receive timely treatment, 79% report that students
are not seen as often as optimal unless they are in crisis, 75% do not offer weekly appointments,
73% report that their clinical staff work overtime (usually without compensation), and 35%
report having wait lists (Reetz, Barr & Krylowicz, 2014). With growing media attention on
campus mental health, questions are being raised about unacceptable wait times, convoluted
procedures for accessing supports, ever increasing symptom severity and cuts to funding – all
within the context of growing student diversity and higher needs (Bishop 1995; 2006).
Rationing services is an inevitable result of increasing demand without a corresponding increase
in resources. Strategies like spreading out sessions to once per 3 or 4 weeks or using waitlists can
reduce treatment effectiveness and decrease retention rates (DiMino & Blau, 2012; Reese,
Tolandi & Hopkins, 2011). Stepped care represents a model for rationally distributing limited
mental health resources to maximize the effectiveness of services based on the needs of all
students. This article explores the historical context for current problems in college student
mental health and proposes a model for improving service delivery through stepped care. This
article also describes examples of implementation concerns and challenges from a variety of
perspectives.
Therapy is difficult. It is not a simple process and disorders such as depression, PTSD, or
panic attacks are seldom resolved within the average 3-4 sessions utilized by students. Several
sources of variability affect psychotherapy outcomes: the therapeutic alliance, the intervention
strategies employed and the therapist’s clinical expertise, along with client variables such as
REINVENTING SERVICES THROUGH STEPPED CARE 3
culture, preferences, and expectations (Hubble, Duncan, Miller & Wampold, 2010). Treatment
duration ranges from single sessions, to several meetings, to several years. Attendance can be
weekly, bi-weekly, or monthly with session duration ranging from10 minutes to an hour.
These realities are often overlooked as university and college counseling centers strive,
with limited resources, to be all things to students while somehow meeting professional,
individual, administrative, familial, moral, societal and legal obligations. Counseling centers are
often charged with meeting unrealistic expectations of students, faculty, parents and staff to “fix”
students’ problems. Students arrive in counseling offices often feeling overwhelmed by the
various demands of university life. Despite the expectations for full service comprehensive
mental health programming, counseling centers situated within the context of communities of
higher learning are better suited for setting conditions that enable students to solve their own
problems creatively and independently.
Historical Context
How did we arrive at this juncture of unprecedented interest in mental health and well-
being without corresponding investment or innovation in programming? Historically, counseling
centers focused on vocational and career counseling (Ogston, Atlmann & Conklin, 1969;
Warman, 1961). A secondary role included handling traditional presenting problems of
adjustment issues and individuation (Heppner & Neal, 1983). Students were predominately white
males from upper-class communities. With the introduction of the post-war GI bill in the United
States, colleges and universities welcomed more economically as well as racially diverse groups
(Hodges, 2001). This expansion of the student body justified a nominal fee charged for mental
health services.
By the 1980s, demand for mental health services increased in part due to the emergence
of more effective medications that allowed students with psychiatric illnesses, who required
REINVENTING SERVICES THROUGH STEPPED CARE 4
ongoing support, to attend college (Benton, Robertson, Newton & Benton, 2003; Heppner, Good,
Hills & Ashby, 1994; Johnson, Heikkinen & Ellison, 1989; Pledge, Lapan, Heppner, Kivlighan
& Roehlke, 1998; Stone & Archer, 1990). Some post-secondary institutions attempted to curb
the demand for services through the introduction of session limits while others increased student
fees. More recently, mass media interest in college and university mental health has led to
headlines like: “How Cambridge University Almost Killed Me”, “How Colleges Flunk Mental
Health”, “Universities Failing on Mental Health” and “Are Universities Doing Enough to
Support Students with Mental Health Problems?” (Jones, 2014, October 6; Baker, 2014,
November 2; Sanderson, D. 2015, October 9; Denham, J., 2013, March 21). With this increased
scrutiny, growing consumer expectations and extended administrative oversight, campus
counseling and mental health centers have been urged to become more accountable to
stakeholders. In this context, it has become increasingly important to clarify the service mission
or model, to explain and justify the intervention strategies and set realistic and measurable
outcomes (Bishop, 2006).
It is important to ground revised missions and models in solid epidemiological data.
Youth (age 12-25 years) have the highest incidence and prevalence of mental illness. Most
mental disorders have their peak age of onset within the second and third decades of life
(Pedersen, Mors, Bertelsen, et al., 2014). Approximately 75% of mental health difficulties have
their onset in childhood, adolescence or young adulthood (Carver, Cappeli, Davidson, Caldwell,
Belain & Vloet, 2015). Despite the high onset and prevalence, youth access to mental health
programming is the poorest of all age groups (de Girolamo, Dagani, Purcell, Cocchi & Mcgorry,
2012). It should not be surprising then that when young adults arrive on campus, there is
considerable demand for a wide array of psychological services. University and college
counseling services throughout North America are experiencing yearly increases of up to 15% in
REINVENTING SERVICES THROUGH STEPPED CARE 5
the demand for treatment, and students are increasingly wait-listed and/or experience long
intervals between sessions (Mistler, Reetz, Kyrowicz & Barr, 2012).
Mental health issues are often first detected in educational settings or by primary care
family physicians. Given that youth are not frequent users of primary health care and given that
approximately 80% of youth access secondary or post-secondary institutions (Shaienks,
Gluszynski & Bayard, 2008), efficient and effective delivery of mental health programming in
educational settings becomes crucial.
Any attempts to improve service accessibility or efficiencies should take into account the
fact that youth spend much of their time connected or living online. Interventions should
consider that young people now socialize, communicate and discuss their fears, insecurities and
problems online. Youth are more likely to disclose mental health concerns online than anywhere
else (Ivancic, Perrens, Fildes, Perry & Christensen, 2014; Rice, Goodall, Hetrick, et al., 2014).
While internet-based mental health programming has been offered in Australia for more than a
decade, very little online mental health programming is available in North America. This
represents a missed opportunity for reaching a segment of the population most in need of mental
health support. In addition, internet services complement traditional therapy services which are
expensive and in short supply.
In light of these trends, the Mental Health Commission of Canada (MHCC) has called for
the development of a more efficient system - one that provides early and rapid assessment as
well as systematic and monitored access to the most effective but least intensive treatment
(Mental Health Commission of Canada, 2012). According to the MHCC, “a more systematic
approach to the flow and efficiency of mental health-related services [is needed], so that people
are able to access the most appropriate and least intensive services, treatments or supports
required to meet their needs” (Mental Health Commission of Canada, 2012, p. 53). Such a
REINVENTING SERVICES THROUGH STEPPED CARE 6
system could not only reduce the chronicity of mental illness throughout the lifespan, but could
also serve to prevent more serious mental health issues from developing. In the United States,
increases in demand for service, as well as greater focus on the need for student retention and
service provision for distance learners, non-traditional students, and students from varied
cultures has led to interest in exploring new strategies, such as early alert programing aimed at
preventing attrition due to the onset of mental illness (Balon, Beresin, Coverdale, Louie &
Roberts, 2015; Eisenberg, Hunt & Speer, 2013; Bruner, Wallace, Reymann, Sellers & McCabe,
2014; Meilman & Weatherford, 2016; Prevatt & Young, 2014; Shadick & Akhter, 2014; Temple,
2013; Trenz, Ecklund-Flores & Rapoza, 2015).
The Promise of Stepped Care
Traditionally, psychotherapy has been delivered through 50-minute face-to-face,
individual sessions with one counselor and one client. It has become increasingly clear to many
college and university counseling center directors that this model will not resolve supply and
demand problems. The model is expensive and often does not fit the lifestyles or needs of
today’s students who live much of their lives online and expect immediate solutions. We will
likely never be able to hire our way out of the service demand problem. The field could benefit
from a paradigm shift that expands access to effective resources without a large corresponding
increase in capital outlay. To this end, a more sustainable stepped care model that organizes
programming in a systematic, yet flexible structure is recommended to meet the needs of
students across the range of problems, personal preferences, and acuity. Both the implementation
of the model and the programming itself described in this paper are rooted in stages of change
and empowerment theory (Christens, Peterson & Speer, 2014; Perkins & Zimmerman, 1995;
Prochaska, Wright & Velicer, 2008; Zimmerman, Rappaport & Seidman, 2000). Changing to a
stepped care model may be difficult for providers who have worked and trained predominantly in
REINVENTING SERVICES THROUGH STEPPED CARE 7
the traditional model. Effective change management in counseling center organizational structure
and processes requires the same kind of sensitivity and focus characteristic of acceptance and
commitment therapy (Hayes, Luoma, Bond, Masuda & Lillis, 2006) that we provide to our
clients.
Stepped care has been shown to be especially valuable in primary or secondary health
care systems, such as university and college counseling centers and outpatient mental health
clinics, where demand for service far outweighs supply (Reetz, et al., 2014). Originally
developed for primary care in the United Kingdom, stepped care has recently been re-imagined
(O'Donohue & Draper, 2011) for rapid access to mental health services in a wide range of
settings. The model offers the lowest level of intervention intensity warranted by the initial and
ongoing assessments. Treatment intensity can be either stepped up or down depending on the
level of client distress or need. Many promising online mental health tools that have been
developed and are available for purchase or licensing can be applied at various levels within the
stepped care model. Some of these have been evaluated with positive results for mild to severe
client symptom severity (Benton, Heesacker, Snowden, & Lee, 2016; Hadjistavropolous,
Alberts, Nugent, & Marchildon, 2014; Hadjistavropolous, Nugent, Alberts, Staples, Dear, &
Titov, 2016).
For the most part, mental health services are organized in a manner that is neither
accessible nor enticing to youth most in need. While youth live much of their lives online,
programs and providers are rarely accessible in this environment. Despite the fact that almost 80
percent of people experiencing mental health problems are not ready to take action towards
change (Norcross, 2003) most mental health programs are designed as if clients are prepared to
accept treatment recommendations immediately and make the difficult lifestyle changes
prescribed by practitioners.
REINVENTING SERVICES THROUGH STEPPED CARE 8
Traditional evidence-based mental health treatment interventions are designed to be
intensive and offered one-on-one by highly paid specialists. Lower intensity and less expensive
care that could address mental health concerns before they become acute or chronic are virtually
non-existent in North America. Such lower intensity care may be seen as more palatable to the
large proportion of those in need who are not quite ready to accept all the challenges of ongoing
psychotherapy or making needed lifestyle change. Less intensive online programs can also allow
users to test the waters of change before embarking on more demanding tasks associated with
mental health recovery. With such programs embedded in a system of care which can be rapidly
adjusted according to continuously monitored outcome data, users of the service could receive
the type of care they need when they most need it. Because monitoring is also configured to give
continuous client feedback on progress, the approach empowers clients to become actively
involved in care options and decisions.
The research on the United Kingdom model of stepped care has produced mixed results.
While some studies indicate stepped care is superior to treatment as usual (Oosterbaan,
Verbraak, Terluin, et al., 2013; van der Aa, van Rens, Comijs, et al., 2015), others indicate that
outcomes are no better than treatment as usual (Seekles, van Straten, Beekman, van Marwijk &
Cuijpers, 2011; van Straten, Tiemans, Hakkart, Nolen, Donker, 2006). Meta-analyses which
included a broad range of studies of varying step configuration drew similar conclusions (van
Straten, Hill, Richards & Cuijpers, 2015). In all of the studies, fewer steps were involved and
none included online programming. What is most intriguing, however, is the implied conclusion
that outcomes similar to treatment as usual would be considered failures. As long as the model
can achieve efficiencies without compromising outcomes, outcomes similar to treatment as usual
should be considered evidence of success.
REINVENTING SERVICES THROUGH STEPPED CARE 9
Stepped Care 2.0
We have developed a 9-step model of mental health care (see Figure 1) that we refer to as
Stepped Care 2.0. In contrast to first generation programs (see reviews by: Grochtdreis,
Brettschneider, Wegener, et al., 2015; Nordgreen, Haug, Lars-Göran, et al., 2016; van Straten,
2006; 2015) which include fewer steps, little or no online programming and/or no community
based interventions, this new version includes same day access and multiple levels of internet-
based programming. It also organizes clinical and healthy campus (American College Health
Association, 2012) promotion and prevention activities on dimensions of intervention intensity
and stakeholder autonomy/responsibility. This last feature – healthy campus activity has been
described elsewhere ([author identity masked] & Fuller, 2014).
At step 1, client walk-ins are handled through a decentralized primary care case
management system in which all providers assume responsibility for at least one half day of
scheduled and walk-in consultations. Prior to all sessions, clients complete the Behavioral Health
Measure (BHM-20/43) on tablets in the waiting room. In accordance with a phase-model of
psychotherapy change, the BHM assesses suicidal risk, well-being, symptom severity and life
functioning. It is offered through the CelestHealth system which includes both psychotherapy
readiness and therapeutic bond scales (Bryan, Kopta & Lowes, 2012). The CelestHealth system
was adopted because if its capacity to monitor outcome trajectories associated with three phases
of change (increase in well-being, decreased symptoms, improved life functioning), readiness for
change and the therapeutic alliance.
Single-session psychotherapy theory (Hoyt & Talmon, 2014), based for the most part in
solution-focused therapy principles, forms the basis for the primary care walk-in approach. The
term “single session therapy” is somewhat misleading because unlike brief therapy or long-term
therapy, consultation is open-ended and flexible as is the case with visits to a primary care
REINVENTING SERVICES THROUGH STEPPED CARE 10
physician. Further mirroring primary medical care, Stepped Care 2.0 providers are highly skilled
generalists who conduct brief focused assessments and deliver an initial intervention often
involving a behavioural prescription. Each provider is responsible for managing all cases that
present during their scheduled walk-in consultation coverage times. Referrals to other providers
or trainees are permitted but typically provider availability is scarce. As such, providers are
motivated to refer clients to lower steps of care unless client presentation complexity warrants
“stepping up.” Lowering treatment intensity can simply involve using time more judiciously
(e.g., 5, 15, 30 or 50 minute sessions either weekly, biweekly, monthly, etc.) or could involve
referrals to online programming, self-help books, drop-in programs or some combination thereof.
Suggested interventions and guidelines for step assignment are presented in Table 1. More
objective step assignment guidelines will follow the development and implementation of an
analytics technology platform currently in the design phase.
Responsibility for step decisions is a collaborative process between the client and
counselor. By the end of the initial (step 1) session, a shared plan is developed and written on a
behavioral prescription form demarcated by step level. The plan is described to clients as
tentative and flexible. Provider email addresses or phone numbers are written on the bottom of
the form and clients are encouraged to make direct contact should they wish to alter the plan or
they miss a scheduled session. Providers openly acknowledge that with a brief intake assessment
and initial solution-focused interventions, important underlying issues could be missed and that
follow-up may be necessary. Risk is mitigated through this transparent open-ended process by
shifting responsibility to the client to make contact as needed.
Step 2 involves providing access to self-help materials in the form of educational
resources including books, pamphlets and online media. Although research on the effectiveness
of informational self-help for mental health reveals mixed results, most studies indicate that it
REINVENTING SERVICES THROUGH STEPPED CARE 11
can be effective when used in combination with some therapeutic support (Gould & Clum,
1993). According to Norcross, Krebs & Prochaska (2010), up to 80% of clients are not ready to
engage in the change process when they first seek professional help. Both motivational
interviewing methods and psychoeducation are often employed by counselors in an effort to
prepare clients for taking more active responsibility for change. Providers at this step prescribe
educational materials aimed at increasing mental health literacy and outlining the costs and
benefits associated with either avoiding or committing to the change process.
Step 3 involves the use of interactive online self-help resources, which are essentially
workbooks configured for internet application. There is currently considerable private sector
development of online interactive programming in the self-help field, but access can be
expensive and until recently it has been mostly geared to institutional users such as employee
assistance firms. Several free or inexpensive smartphone apps are available; however, they have
less sophisticated interactive capabilities. WellTrack is a tool, with combined web- and app-
based technology, that has been adopted by approximately 50 campuses. It has both clinic-based
and outreach / healthy campus applications. Clinical tools include basic CBT and mindfulness
modules. Counselors have found this tool to be useful for students who may not be ready to fully
engage in the change process but are ready to explore what might be involved in making small
changes. In such cases, counselors simply provide a card that includes instructions and a code for
accessing the online tool. Depending on the presenting issues, counselors may or may not
schedule a follow up session to review the WellTrack experience.
Step 4 involves interactive psychoeducational, professionally facilitated skill-building
workshops. A variety of peer and professionally led online chat and face-to-face interventions
(both mental health and academic skill-building) are offered on a drop-in, single-session basis or
through short rolling series of coaching workshops. Psychoeducational coaching sessions have
REINVENTING SERVICES THROUGH STEPPED CARE 12
been found to improve coping for clients with mild to moderate symptoms (Van Deale, Hermans,
Audenhove & Van den Bergh, 2012). For clients with higher levels of stress, the increased
mental health literacy afforded by such sessions has been found to improve treatment adherence
and outcomes (Greenberg, Constantino & Bruce, 2006; Swartz, Zuckoff, Grote, Spielvogle,
Bledsoe, Shear & Frank, 2007).
Step 5 involves therapist-assisted e-mental health programming. Cognitive behavioural
and interpersonal therapy modules have long been available in Australia (e.g., Mewton, Wong &
Andrews, 2012) and more recently in Canada (Hadjistavropoulos, Thompson, Ivanov, et al.,
2011). In the US, Therapist Assisted Online Treatment (TAO) was originally developed for
treatment of anxiety but has been expanded, applying more sophisticated evidence-based
transtheoretical treatments for both anxiety and depression. Clinical trials indicate that therapist-
assisted e-mental health is effective in primary and secondary health care settings (e.g., Kessler,
Lewis, Wiles, et al., 2009; Hedman, Ljotsson, Kaldo, et al., 2014). A Swedish study employing a
randomized controlled trial of therapist-assisted internet-based cognitive behavioral therapy
(ICBT) concluded that ICBT is more cost-effective than face-to-face therapy (Hedman,
Andersson, Ljotsson, Andersson, Ruck & Lindefors, 2011). Clients enrolled in therapist assisted
e-mental health programs are typically assigned to a provider who spends 15 to 20 minutes per
client, per week providing online web coaching and support as participants work through the
modules. Outcome monitoring is built into these programs. Therapist assisted ICBT studies have
demonstrated superior outcomes for clients with wide-ranging symptom severity in comparison
to traditional therapy (Benton, et al., 2016; Hadjistavropolous, et al., 2016).
Step 6 involves the provision of traditional face-to-face group counseling designed to
respond to the trending needs observed at walk-ins or on therapist caseloads. For example, when
more clients present with depression, additional sections of a depression group are offered.
REINVENTING SERVICES THROUGH STEPPED CARE 13
Mindfulness group sections are expanded when stress or anxiety become more prevalent at walk-
in. When relationship conflict and family of origin issues prevail, additional Yalom-style
interpersonal process groups are offered (Yalom, 1995). Although research on group therapy
over the past 50 years has consistently indicated outcomes on par with, or exceeding one-on-one
treatment (Fuhriman & Burlingame, 1994), both clients and providers seem reluctant to make
use of this efficient service modality (Strauss, Spangenberg, Brähler & Bromann, 2014). We
have found that successful referrals to group therapy improve within a stepped care framework
which reduces risk of referral error given the systematic monitoring and capacity to step up or
down the intensity of care as needed. When describing the stepped care model to clients at the
walk-in consultations, we say that group therapy is intensive. By referring to group work as
intensive a clear message is delivered to clients that group therapy is challenging and that to feel
comfortable and benefit they would need to be ready to take full advantage of the power of this
level of intervention. Sometimes the effect is reminiscent of paradoxical interventions (Erickson,
1959) insofar as clients that might otherwise balk at the prospect of expressing vulnerability in a
group environment, openly rise to the challenge.
Step 7 involves one-on-one counseling or therapy. As is the case with step 6, we state
explicitly at walk-in consultations that one-on-one therapy is intensive and that clients need to be
ready to take on challenges associated with difficult change processes. Session duration and
frequency is determined by clinical judgment and ongoing outcome monitoring. Counselors are
encouraged to use time creatively and with some flexibility. Some clients with severe
symptomatology are seen weekly for sessions ranging from 20 to 50 minutes. Others are seen for
brief check-ins on a bi-weekly basis. Clients who are in the recovery or maintenance stage may
be seen only every three or four weeks with self-help resources (typical of Step 2) assigned as
REINVENTING SERVICES THROUGH STEPPED CARE 14
homework. Clients with chronic mental health conditions requiring longer-term or prolonged
intensive treatment are referred to more specialized community-based services.
Step 8 involves outpatient psychiatric consultation (with follow-up care provided by
family physicians) for those clients who fail to show progress by step seven. A thorough
psychiatric assessment is conducted and follow-up consultation is provided to the primary care
physician and individual therapist.
The highest level of intervention, step 9, involves health system navigation, intensive
case management, crisis support for clients with chronic conditions, support for students with
substance use and behavioral conduct violations as well as help accessing more intensive
external community services such as admission to a hospital psychiatric ward. Some students
receiving support at this level, such as those on the autism spectrum, respond well to support
from paid student peers (often 2-3 times per week). Peers operating at this step assist students on
the autism spectrum to navigate daily campus life by mitigating potential disruptive social
interactions. Most step 9 activities are coordinated by case managers who liaise with campus
officials, staff and faculty as well as community based agencies to ensure continuity of care.
Implementation Experiences
Stepped Care 2.0 is currently being piloted at our counseling centers and the change
management process is well under way. Training has been provided in shorter-term models of
care, including single session therapy, shortened sessions and mental health coaching approaches
to counseling. The more rapid walk-in consultation process along with greater expertise with
brief interventions, including use of online tools, has allowed for the elimination of waitlists.
Providers have received group and online therapy training and assume responsibility for
implementing programming in both areas.
REINVENTING SERVICES THROUGH STEPPED CARE 15
The additional group and online programming introduced as we adopted stepped care has
produced the service capacity needed to accommodate the increased number of clients served
through daily walk-in clinics. Providers are in full control of managing their own caseloads and
they decide when to use traditional intensive one-on-one interventions or refer to the less
intensive group programs, problem-solving coaching sessions or online programming. The
following are examples of concerns, challenges and opportunities voiced by clients, service
providers and administrators during the transition to stepped care.
I Really Like Having this Plan: A Client Perspective
When students present at walk-in clinics, they are typically seen within two hours, and
often within the first hour. Although most students prefer this same-day service, some opt for
scheduling a slot in the first 30 minutes of a three-hour walk-in clinic with wait times typically of
two to three weeks. At an initial session, student expectations about treatment are assessed and
are sometimes adjusted by briefing them on the stepped care model. Based on a composite drawn
from elements of two separate client presentations during a walk-in consultation period, the
following is a description of a typical student experience:
Justine arrived at 10:15 on Monday morning requesting counseling services. She
indicated that she had not been seen previously at the center and was informed of the
walk-in consultation process. She decided to avail of the walk-in service. Justine was
provided with an iPad walk-in assessment form which, along with demographic items,
included an administration of the BHM-20 outcome tracking measure. She completed
the forms within five minutes and at 10:25 a.m., a senior psychologist, Dr. G, serving in
the role of primary care mental health consultant, greeted her in the waiting room.
Upon entering the consultation office, Dr. G reviewed the limits of confidentiality
and outlined the stepped care model. She explained that the university had recently
REINVENTING SERVICES THROUGH STEPPED CARE 16
adopted an innovative system for improving service access, treatment effectiveness and
empowerment of students seeking services. She showed a graphical representation of
the model and indicated where they were in the process (i.e., walk-in consultation – step
1). Dr. G. said that prior to the adoption of stepped care, wait times were much longer
with only two high intensity services available - group and individual therapy. Stepped
care she explained, had expanded the options to fit better with wide ranging student
needs. Dr. G added that some students, at least initially, prefer to “dip their toes into”
the process of change with less intense programs that are educational in nature and self-
directed.
Then Dr. G stated that outcome monitoring tools, such as the BHM-20 that
Justine completed in the waiting room, are used to assess and re-assess the impact and
appropriateness of the programming offered. She added that by reviewing the results
today, and on any future visits, they could decide together on treatment options best
suited to her circumstances. Before discussing Justine’s BHM-20 results, Dr. G asked if
Justine had any questions. Justine replied, “No, it seems to make sense.” Dr. G showed
an iPad screen shot of the BHM-20 results to Justine. The results indicated that Justine’s
level of distress was moderate with elevations on general and social anxiety. Justine
responded “sometimes” to the critical item, “wanting to harm someone.” When queried,
Justine said that her stress was “getting so high” that she was afraid she might get the
urge to “cut or scratch” herself like she did during her first year of high school. She
clarified that her response was only in reference to harming herself not others.
At this point, Dr. G asked open-ended questions about Justine’s reasons for
seeking services. Justine indicated that she had seen a counselor previously at another
university and was taking 20 mg of Paxil for anxiety. However, over the past two weeks
REINVENTING SERVICES THROUGH STEPPED CARE 17
her symptoms had returned following an argument with her father. Dr. G asked about
what had been helpful to her in her previous counseling and Justine said she liked being
able to “just talk” but that it didn’t really change her symptoms much. Justine said she
really wanted to learn about strategies for relaxing or dealing with her thinking which
she said “gets messed up” whenever things get busy or there is conflict. She said that
she also feels awkward and nervous in social situations and large spaces. Justine seemed
eager for solutions but worried that with her part-time job, full course load and long
commute time, she would have a hard time attending regular sessions.
Dr. G described three different online programs that are designed to introduce
techniques for managing thoughts and feelings related to stress. Both Dr. G and Justine
decided that the low intensity self-help program, WellTrack, would not be enough
because Justine expected she would procrastinate without any follow-up. They agreed to
try the TAO (therapist assisted online) program because the weekly 15-minute coaching
sessions could easily fit into her tight schedule and would help motivate her to do the
modules and exercises between sessions.
Dr. G said that she thought Justine may also benefit in the future from a therapy
group for anxiety but wondered aloud if this might be too intensive and anxiety
provoking for Justine right now. Justine agreed, saying, “I could never talk about this in
front of a group of strangers.” Dr. G said, “The TAO program is a good choice right
now and would likely reduce your anxiety.” She added, “The group might be an option
once you pick up some of the basic CBT skills through TAO.” Justine seemed uncertain
but agreed it was a possibility.
Dr. G wrote the plan out on a “behavioral prescription” pad checking off the box
beside the mid-level TAO program as a first step and putting a question mark beside the
REINVENTING SERVICES THROUGH STEPPED CARE 18
high intensity group therapy box for the anxiety group as an option for the future. She
showed Justine a copy and asked her how she felt about the plan. Justine said she was
pleased with it. Dr. G informed Justine that an email invitation would come from TAO-
connect later that day. Below her name on the plan, Dr. G wrote down her contact
information and encouraged Justine to reconnect at any time if she wished to adjust the
plan. She scheduled an appointment for the first 15-minute TAO coaching session for
the following week. Justine smiled, holding up the prescription, as she reached for the
door and said, “I really like having this plan.”
But I Didn’t Train for This: A Post-Doc Perspective
Provider experiences adapting to stepped-care have generally been positive but varied. As
with any major change, implementation may be met with initial reluctance or resistance. Given
that many training programs do not prepare clinicians on flexible single-session therapy models
(e.g., Hoyt & Talman, 2014), professional development opportunities offered through a period
for adjustment may be helpful. The following represents the experience of a post-doctoral
counselor:
Today I discussed with my Director how I was feeling anxious, uneasy, and even
unsure about the new stepped care model. I said to her that I felt unsure about seeing
clients now because I feel the urge to follow stepped care in a perfect way; otherwise, I’m
thinking to myself that I would be putting clients at risk. Moreover, following this model
seems contrary to the best practices I learned so recently in graduate school. I was taught
that the therapy process takes time, and that we need to be respectful of the client’s pace.
What I understood so far from this model was that I was supposed to prescribe something
immediately to the client, and that, sadly in my opinion, only a small portion of my
REINVENTING SERVICES THROUGH STEPPED CARE 19
clients would receive actual therapy, simply because I was not going to have any time to
see them.
I saw so many challenges to my accustomed practice: too much information,
procedures to follow, and decisions to make for the client. I felt the pressure to grasp all
this information in order to do what is now expected from me here. At first I wasn’t sure
exactly what was making me anxious since I had previously been pretty confident with
my counseling approach. Then I realized with frustration I was losing the part of myself
that trained so hard to be a good therapist!
In tears, I was able to share those feelings and uncertainties with my Director.
After inquiring about where my anxiety was coming from, then learning that this feeling
was new for me, my Director attributed it to normal anxiety associated with
implementing a completely new service model. Then, abruptly she initiated a role play—
by the way, I am not a fan of role plays, but I went there anyway because I was desperate
and I trusted that she knew what she was doing. I was anxious as I played the role of
therapist. I tried to assess the client’s problems and offered options from the model. I
tried so hard to do it right. As soon as I finished, I knew I missed some of the most
important pieces—joining with the client, my presence in the room. I was too directive
and cold. We reversed roles.
As the client, I was offered options. After listening to my (role-playing client’s)
concerns, the therapist (my Director), presented options for services using the metaphor
of a food court. There are so many options, and it is up to me to choose what I will get. I
did not feel like I was shopping for services, nor that I was denied the service I was
seeking. In fact, as the client in this role, I felt I was gently supported to make a decision
REINVENTING SERVICES THROUGH STEPPED CARE 20
and to own it. I was told that here individual therapy is brief, yet intense and hard work. I
somehow felt heard, and most importantly, I felt empowered. I wasn’t sure quite why.
After a debrief, I realized I felt relieved by my role-playing-counselor’s
suggestion that therapeutic options come in a range of doses. Her invitation for me to be
directly involved in treatment option decision making felt empowering. Finally, the frank
admission that the therapy process itself is hard and that I have to take responsibility for
doing the work led me to trust and feel confidence in her expertise and authority. A
notable shift occurred. The powerful experience of being cared for sensitively, efficiently
and honestly, rekindled my confidence. I was encouraged to draw on my own sensitivity
and genuineness, qualities that I recognized in prior training made me a good therapist. I
believe now I will figure out a way to be that same good therapist within the context of
the new model.
I said to my Director that maybe notions of good therapy and of the good therapist
need some rethinking. I had always been a firm believer that therapy is hard work, and
that the client should be the one doing it. My job is simply to facilitate this process. If
therapy is about empowering clients to make meaning and own decisions in their lives,
now I can see that the stepped care model does just that.
I Can’t Do it That Way: A Trainee Perspective
In supervising trainees, we remind them to consider adjusting what is taught to fit with
their own particular style and personality. One size does not fit all. As licensed practitioners in
the field, we take our own advice on this by acknowledging that the stepped care model can be
REINVENTING SERVICES THROUGH STEPPED CARE 21
implemented in many different ways. A trainee describes her experience with discovering she
needed to find her own way of “doing stepped care:”
Having previously completed two practicum placements at the counseling center
in the “pre-stepped care” era, I felt unprepared to work with this new model as I began
my predoctoral internship. In my first week I attended a stepped care training seminar
facilitated by my supervisor. I understood the model as presented. During the seminar I
volunteered to role play a client at a walk-in consultation session. In the role of client, I
was expecting to receive traditional weekly counseling for my social anxiety and to
learn ways to deal with my father’s verbal abuse. Despite my expectations, the walk-in
counselor’s explanation of the new model made sense and I actually felt the solutions
offered were better than I had expected.
Later, as I practiced how I would introduce the model to clients at my first walk-
in clinic, I had a hard time making it sound right. I lacked the confidence and credibility
embodied by my supervisor (Dr. G.), who was also the Director of the Center. My first
session was a flop. My client had years of experience of free counseling offered at
another university and her scores on the BHM-20 indicated very little distress. She did
not seem able to articulate any clear goals. Having just come from the stepped care
seminar, I felt it would be a mistake to offer her intensive therapy. I did my best to play
up the less traditional options, but no dice – she had come for individual therapy and
that was what she was determined to get. I felt like I was being too pushy and so with
some feelings of guilt and a little resentment I found space in my schedule to begin
seeing her next week.
In my next walk-in clinic, I convinced one student to accept an invitation to
participate in the therapist assisted online program (step 5) and two others to join a
REINVENTING SERVICES THROUGH STEPPED CARE 22
group (step 6). I couldn’t bring myself to offer the lowest intensity programs but at least
I had avoided the dreaded step 7 (individual therapy)!
But my sense of accomplishment was short-lived. I soon learned that the student
referred to the online program never completed the registration, one of the group
referrals did not meet the group screening criteria and the other group client never
showed up for any sessions. Clearly I didn’t have the hang of it.
I decided to observe another therapist conducting stepped-care walk-ins. This
therapist took a different approach – it began as I had been trained, with asking the
client to say in her own words what issues she wanted to work on. This therapist
explained the model after about five minutes and she tailored the message using some of
the client’s words and by focusing on the issues of importance to her. In this context the
stepped care options seemed more natural and logical. Unlike my previous efforts, this
therapist did not appear to be trying to sell a product or convince a reluctant buyer. In
the end I found my own style which had a blend of both approaches – a much shorter
explanation of the model at the beginning with details explained after hearing the
client’s story.
I Can Work Fast: A Counselor Perspective
Sometimes clients present in tears at the reception desk when there is no walk-in
counsellor available. With the stepped care model, we avoid putting support staff in the role of
gatekeepers. As such we encourage them to seek out a professional staff member to connect with
students in distress even when it appears initially that no such staff are available. The key
principles are access, care and efficiency. We have found that it is possible to support clients
through a rapid “touch point” – a brief connection which includes listening and a successful
REINVENTING SERVICES THROUGH STEPPED CARE 23
micro-intervention. The following is a composite case example of an unscheduled 10-minute
micro-intervention:
I was not scheduled for walk-in consultations on Friday morning, as this time is
reserved for administrative meetings and case conference. While in the midst of
discussing a complex case of a student in need of case management services, a knock
came on the conference room door. Ms. B, the administrative assistant who manages the
reception desk, said “I know that we don’t offer walk-in coverage on Friday mornings,
but I think this student really needs to be seen now. She’s quite upset and crying. I took
her down to the group room so she could have some privacy.” I agreed to see her.
Lucy entered my office red-eyed and holding a small wad of used tissues. She
was silent, she stared at the floor, one leg trembling. Her anxiety was evident. I gently
asked her, “what brings you in to the Counseling Center today Lucy?” Lucy looked up
from her boots and said, “I’m sorry, I have anxiety and I just had to leave class because
I was overwhelmed.” I thought about our stepped care model and how I’ve come to
enjoy working in 15, 20, 30 minute increments rather than the traditional 50-minute
session. I immediately got to work.
I reflected to Lucy how it must have felt to flee from class and commended her
for seeking support. I asked Lucy to reset both feet on the ground and to rest both hands
on her thighs palms down. I followed suit, so that Lucy could follow my movements. I
then asked Lucy to turn her attention inward and to focus on any thoughts or feelings
that she was experiencing. A scaled question followed, “Lucy, on a scale of 0-10 with
ten being the most anxious and 1 being the least, where is your anxiety right now. Lucy
responded quickly, saying “9.” I nodded to acknowledge her answer.
REINVENTING SERVICES THROUGH STEPPED CARE 24
I felt my energy pick up because I had a plan. I could deliver a quick
intervention! I am a mindfulness teacher and believe in the power of the breath as a way
to settle the mind and the body. I explained to Lucy that we would be doing a breathing
exercise called “take five.” Lucy watched as I took five long breaths. I immediately felt
more relaxed, grounded and focused. I invited Lucy to close her eyes if she was
comfortable, if not she could simply lower her eyes to the floor. Lucy closed her eyes.
My breath was audible and I encouraged Lucy to place her hand on her stomach so she
could feel her diaphragm while it expanded and slowly deflated. At first her breath was
shallow throat breathing however, by breath three I noticed her hand on her stomach
gently moving in and out with her breath. Lucy looked more relaxed, her face softening
and shoulders dropping. We were breathing in unison and I decided we could go for
eight breaths rather than five.
The eighth breath came to a close and Lucy opened her eyes, “That was
amazing, I feel so calm.” I smiled and said, “You have all you need to settle yourself;
it’s right here, it’s always with you.” Lucy smiled and said, “My breath?” I nodded and
inquired about the scale she had done earlier, “Where are you now Lucy on that scale
from 0-10?” “I’m a two!” she said. Breathing a sigh of relief and smiling, I wondered if
Lucy was ready to move on with her day. Before I was able to inquire Lucy said, “I
think I’m ready to go back to class.” In less than 10 minutes Lucy learned a new skill,
one that she can take with her wherever she goes.
You Should Ask for Real Therapy: A Colleague’s Perspective
Interventions at counseling centers represent a broad spectrum of theoretical orientations.
Typically, in our application of cognitive behavioral therapy, for instance, we instruct clients on
challenging myths and faulty beliefs or assumptions. This is particularly important when
REINVENTING SERVICES THROUGH STEPPED CARE 25
implementing a new model because many will assume that the old model is the only one that
works when in fact it is failing us. Some university stakeholders were initially skeptical but
concerns were quickly assuaged by dispelling myths and informing them about the model.
In my role as Chief Physician, I informed the Director of the Counseling Center
that student union representatives were concerned that students were waiting too long for
counseling follow-up sessions. Physicians working with me in the University Health
Clinic had expressed similar concerns.
The Director met with our physician group and the student representatives
separately. We told the Director that we had been recommending to students weekly
cognitive behavioral therapy for depression or anxiety because that is “what the evidence-
base says works best.” The students replied that the Counseling Center did not offer
weekly sessions but rather that students were often assigned online programming or
might only see counselors every two or three weeks and sometimes just briefly. When the
Director asked us if the students themselves were unhappy with the supports offered, we
noted that students had not actually complained.
At this point, the Director asked if we would like to know more about the new
stepped care model at our next staff meeting. We said yes. We were particularly
impressed by the evidence he presented on the effectiveness of low intensity CBT
(Bennett-Levy, Richards, Farrand, et al., 2010). The Director told us that he had already
met with student union leaders who had expressed concerns about the perceived wait time
for follow up visits. He said that he delivered a similar presentation and that the student
leaders expressed no concerns after learning about the new model. We left the
presentation intrigued and relieved, feeling confident that the model was appropriate. A
REINVENTING SERVICES THROUGH STEPPED CARE 26
few weeks later, the student newspaper published an article outlining the uniqueness and
effectiveness of the model.
Breaking Out of the “Black Box” – An Administrator Perspective
While senior administrators typically value the mental health support provided by staff at
counseling centers, they sometimes express frustration with the fact that communication often
travels only in one direction in compliance with privacy laws (Behnke, 2008). Counseling
centers have been accused of operating in a “black box” where no one, including administrators,
are able to assess operations. Decisions for hiring more counselors are often made following a
rash of suicides. Requests for additional staff are sometimes backed up by opinion surveys of
counseling directors who perceive a spiraling mental illness epidemic (Reetz, et al., 2014). In
such cases, neither the reports nor decisions are based on epidemiological mental health data
(Varlotta, 2012). Greater transparency and rigor in reporting is needed to ensure counseling
centers are well aligned with the academic mission of universities. A more collaborative, data-
driven administrative decision making process (Varlotta, 2012) would be welcomed by senior
administrators and counseling directors alike. We argue that opening up the black box for
redesign should include participation of non-clinical administrators. Redesign of the service
model, whether stepped care or some other model, should be collaborative. The Associate Dean
of Students stated:
After struggling with the growing number of students needing access to our mental health
services for years, we came to the realization that our model was not sustainable. When
the management of our counseling center brought the stepped care model to my attention,
it was easy to see the many ways it would benefit our students and move our services
forward. Reducing our waiting list, easy access to appointments, continuity of care, and
providing a larger array of “tools” to assist today’s college student are goals that the
REINVENTING SERVICES THROUGH STEPPED CARE 27
stepped care model helps us to reach. The response from various stakeholders including
students, colleagues around campus, parents and senior leadership at the university
continues to be positive. From an administrative perspective, the financial impact of the
model is still unknown. However, it seems unlikely to cost more. On the contrary, the
investment in online tools, apps, and other 24/7 resources for students to use and for
clinicians to recommend has the possibility of making the model cost-effective.
We are Struggling with this New Model: It Clashes with our Values
At the Stepped Care 2.0 piloting universities, some counselors continue to struggle with
the new model, the emphasis on rapid access, flexible session length, reduced emphasis on pre-
treatment assessment and changes in workload. These struggles are to be expected and should be
welcomed as a natural part of a healthy transformation process. Stepped Care 2.0 deviates from
traditional graduate training models and standard treatment guidelines. Initial assessments are
more focused on presenting concerns, with less attention to client history, diagnosis or case
formulation. The following represents the views expressed by three counselors:
Our own differences, values and approaches as counselors are just as important to
consider as client variables when implementing stepped care. Clients who have a chronic
mental health history or a high level of symptom complexity on intake may require
longer and more frequent face-to-face sessions. Without flexible implementation
procedures, we worry that we will disappoint, short-change, or provide insufficient care
to such clients. In addition, we are not trained in conducting single session interventions
and have little experience with 15 or 30-minute appointment lengths. We need time to
familiarize ourselves with the theory and philosophy underlying the model as well as
unfamiliar program content associated with the various steps. We feel uncomfortable with
REINVENTING SERVICES THROUGH STEPPED CARE 28
the videoconferencing component of therapist-assisted online therapy, and are struggling
to manage the technology.
We need opportunities to explore how our values, philosophies, and theoretical
orientations relate to the Stepped Care model. We continue to experience strain
associated with psychologically “holding” larger caseloads. To help us adjust and learn
new skills, non-clinical duties need to be reduced. The time freed up could be used for
training in single session assessment approaches (e.g., Hoyt and Talmon, 2014) and low-
intensity step interventions. We also need time and support to develop our own solutions
through trial and error. As our caseloads increase we need more administrative support
and templates for streamlining documentation procedures. In place of current technology
that is sometimes cumbersome and comes with a steep learning curve, we need more
user-friendly technology that is seamless, that facilitates, rather than hinders the transition
to the new model.
What Stepped Care 2.0 Looks Like: A Parent Perspective
Parents have also expressed reactions to the new service model. While it would be easy to
dismiss overly involved parent interests as intrusive, it is possible to harness that energy by
joining forces in support of improved care. Calls from parents range from polite inquiries on
treatment access to advocating aggressively for unrealistic and unnecessary service levels. If the
stepped care service model rationale is well described, stakeholders, including parents, may
respond positively. The following is a composite of conversations the Director at The George
Washington University has had with several parents:
I had been on the phone night after night for hours, trying to calm my daughter down. She
was going over and over how she felt anxious and unmotivated. When I told her to go to
the counseling center she was reluctant, but went eventually on my insistence. So many
REINVENTING SERVICES THROUGH STEPPED CARE 29
things went through my mind about whether the process would be useful or not and I
considered alternatives such as paying out of pocket for a community provider. I was
shocked when she reported back that she had been presented with a choice of several
options and could “step up” depending on her “specific need.” My initial thought was to
call and complain, to demand that she be given a full course of psychotherapy, but when I
heard her consider the options so thoughtfully, I could see her taking responsibility for
her stress and anxiety with confidence and new optimism.
Of course, not all parents are as cooperative. Complaints range from: “why is a therapist
telling my child to google it” to “this is not the service she was promised at orientation.” Stepped
Care 2.0 is not meant to duplicate comprehensive specialist services available elsewhere in the
health system. Instead it aims to provide more realistic expectations of campus mental health
supports by shifting away from a consumer model to a philosophy of empowerment, autonomy
and shared responsibility. This philosophy, of course, is at the heart of academic teaching,
learning and scholarship missions of colleges and universities.
Transitioning to Stepped Care
The piloting universities are at different stages of implementing and evaluating stepped
care. Memorial University of Newfoundland developed the Stepped Care 2.0 model and
implemented it in 2014. The George Washington University received training in the model in
2015 and implemented that fall. McGill University has undergone initial training and began
implementation in 2016. Memorial University managed without waiting lists for years, initially
with a combined scheduled / walk-in intake system and more recently (beginning in 2014) a
walk-in-only intake system. In contrast, both McGill and George Washington Universities had
waiting lists prior to the implementation of stepped care.
REINVENTING SERVICES THROUGH STEPPED CARE 30
With an unyielding wait list – one that had survived several administrations and various
fruitless attempts to reduce wait times (i.e. by recruiting additional contract staff, re-organizing
the management structure) - the counseling management team at The George Washington
University were ready to consider more radical service model change. In the winter of 2015, The
George Washington University had a waiting list of 266 students with a 14 business-day lag
before an intake session could be scheduled. The change process began with an environmental
scan of comparable universities, as well as informal consultations with colleagues willing to
share service model innovations and procedures. The Stepped Care model was selected for its
“no wait list” claim and the expanded range of service intensity tailored for the diverse mental
health needs of students.
After the Stepped Care model was customized to fit The George Washington context, it
was presented to and approved by the senior university leadership. The model was then
presented to counseling staff during a three-day training event in May 2015 and a description
was circulated shortly afterwards for input from the wider university campus community.
Counseling staff were fully involved with the implementation process including the development
of protocols in June through August 2015. A non-negotiable launch date for Stepped Care model,
along with the new same-day intake process was set for the first day of classes in the fall
semester 2015. Staff anxiety was ameliorated with administrative assurances that the impact of
the change would be closely monitored and that adjustments would be made to the model as
necessary. The waitlist was eliminated immediately with the introduction of a walk-in-only
intake system. Few adjustments were needed and through the first year of stepped care there was
no wait list, some staff turnover and a higher student counseling attendance rate.
Memorial University has committed approximately $30,000 per year to fund online
programming and monitoring technology. In contrast, The George Washington University
REINVENTING SERVICES THROUGH STEPPED CARE 31
implemented the model with minimal cost (i.e., by providing some professional development to
staff, launching a series of rolling educational workshops and self-help packets containing
YouTube video links to serve as low-intensity (steps 2-5) programming). While all three piloting
institutions continue to seek additional funding to support expanded online programming, the
model can be implemented at low cost.
Preliminary Data
We will undertake a systematic evaluation of the model following the development of a
technology platform designed specifically for monitoring and informing stepping decisions.
While preliminary, the available evaluation data are encouraging:
Efficiencies Pre- and Post-Stepped Care
As is the case with most universities, the number of clients seen at our counseling centers
has been increasing each year. With tightening budgets and resulting instability of staffing levels
we determined that simply reporting total clients or appointments over the implementation period
would not give an accurate indication of efficiency. Instead we calculated the number of clients,
appointments and counseling hours per full-time equivalent staff members at both Memorial
University and George Washington University prior to and following stepped care
implementation. We also calculated the attendance rates prior to and following implementation.
Percentage changes in clients per counselor, appointments per counselor, session attendance and
counseling hours per counselor after implementation of stepped care are illustrated in Figure 2.
The number of clients and appointments per counselor increased as did the attendance rate. In
contrast, the counselor time per client decreased slightly. These results suggest that stepped care
implementation was associated with more rapid care and increased counselor productivity.
Client Satisfaction Pre- and Post-Stepped Care
REINVENTING SERVICES THROUGH STEPPED CARE 32
Service satisfaction surveys were administered at Memorial University of Newfoundland
over a three-year period to clients at all first and third visits using an in-house questionnaire with
items keyed on a five-point Likert scale. Scores ranged from 1 (very dissatisfied) to 5 (very
satisfied). Completion of the forms upon presentation to the reception desk was voluntary. Given
counselor and predoctoral resident turnover of 38% during the three-year observation period, the
effect of counsellor was controlled in the analysis.
Adjusted mean satisfaction scores are summarized in Table 2. A series of Oneway
ANCOVA tests (controlling for counselor) revealed that assumptions of homogeneity of
variance were violated (Levine’s Test of Equality of Error Variance) for items 3, 4, 5 and 6 (p <
.05). Kruskal-Wallis non-parametric H tests conducted on these items (including a pairwise post-
hoc comparison) revealed that the “time spent with counselor” (item 3) mean score distribution
during the post-launch year was significantly lower than that of the launch year, χ 2 (2, n = 481) =
6.94, p < .05. Similarly, a Oneway ANCOVA and Fisher’s LSD post-hoc comparison revealed
that the “extent to which counseling helped me deal with my concerns” (item 7) mean score was
significantly lower post-launch in comparison to the launch year F (2, n = 481) = 3.04, p < .05. It
is not clear why the launch year scores were higher than the post-launch scores. There were no
observed significant differences between pre-launch and post-launch groups for any of the eight
satisfaction items. Notwithstanding the differences between launch and post-launch years, client
satisfaction, including “time spent with counselor,” remained high and unchanged post-launch
compared to pre-launch of the stepped care model.
Step 5 TAO Outcomes
Therapist Assisted Online (TAO) is typically offered at step five in the stepped care
model. TAO was developed and first implemented at the University of Florida in 2013. It was
REINVENTING SERVICES THROUGH STEPPED CARE 33
introduced to Memorial University of Newfoundland in 2015 and will be implemented soon at
George Washington and McGill Universities.
We compared outcomes for students receiving TAO treatment to those of students
receiving traditional face-to-face psychotherapy. The benchmarking data included 13,664 clients
who were seen at 46 different college and university counseling centers and one community
mental health center for eight or fewer sessions (Owen, Adelson, Budge, Kopta, & Reece, 2014).
The Owen et. al. sample clients were administered the BHM-20 by the computer-based Celest
Health System - Mental Health (Bryan, Kopta, Lowes, 2012) prior to each session.
The TAO treatment group included 785 clients from 24 college and university counseling
centers who were seen for eight or fewer sessions. TAO clients completed the BHM-20 on the
TAO online platform prior to each session. High scores on the BHM-20 reflect good mental
health; the lower the score, the more severe the symptoms. We calculated means and standard
deviations at session one and eight for each group, then calculated Cohen d effect size and effect
size r for each group. Table 3 illustrates the means, standard deviations, Cohen’s d effect size
and effect size r for the two treatment groups.
Treatment with TAO had slightly higher effect sizes compared with the Owen et. al.
sample on the Global Mental Health, Well-being, and Life-functioning scale. TAO had a
significantly higher effect size than the Owen et. al. sample on the symptom scale primarily
because the sample had lower scores, indicating greater acuity at intake. The effect sizes were
somewhat lower (i.e., d = 0.49 – 0.73) for TAO at Memorial University due to higher variance
and less regular use by clients and counselors in the early launch days when data were collected.
Nevertheless, the effect sizes are comparable in terms of explained variance if not better than that
of 50-minute therapy. The results support the use of lower intensity treatment in the stepped care
REINVENTING SERVICES THROUGH STEPPED CARE 34
model. They suggest that treatment with shorter sessions supplemented with online educational
resources are at least as beneficial as traditional 50-minute face-to-face therapy.
Stepped Care Community of Practice
Our three universities have established a community of practice through which we share
resources, develop innovative practices and provide staff training both onsite and online via web
conferencing and webinars. Since May of 2015, our team has delivered on close to 30 requests
for stepped care presentations and training across North America. We expect this community of
practice to grow and would welcome participation of additional colleges and universities.
Discussion
Based as it is in a primary care mental health philosophy (Frank, McDaniel, Bray, &
Heldring, 2004), Stepped Care 2.0 represents a substantial departure from typical college mental
health services and established best practices. Early evidence and anecdotal observations
outlined in this paper suggest the model has potential; however, implementation comes with
challenges and more systematic evaluation is needed. Innovation is sometimes disruptive (see
Christensen, C., Grossman, J. H. & Hwang, J., 2009), and requires professional risk taking which
increases real or perceived liability. The model may be at odds with mainstream counseling
theoretical orientations and could disrupt traditional professional identities and ethical values.
Stepped Care 2.0 can be seen as challenging existing ethical guidelines that focus exclusively on
clients who have already accessed care. On the contrary, by focusing only on clients who have
been assigned to professionals, licensing bodies are silent on the ethical implications of sessions
limits, wait lists and other gate-keeping practices on those who cannot access care. While the
stepped care model is not yet supported by an extensive body of evidence, access is less
restricted and practice-based monitoring processes guiding decision making and care ensure that
outcomes are maximized.
REINVENTING SERVICES THROUGH STEPPED CARE 35
According to the Directors at all three piloting universities, energy and morale of
providers seems to have improved for most staff members with the introduction of stepped care,
but a minority of providers have struggled to adapt. At The George Washington University, staff
turnover was high, and while the move to stepped care was a contributing factor, turnover had
been high previously for a variety of unrelated reasons.
The innovative nature of the model can serve as a catalyst for sites experiencing low
morale or awaiting overdue organizational change. In such cases, high level institutional support
and investment are important. Implementation can be supported through endorsement by senior
administrators, including risk managers, as well as by investment in technology, professional
development and change management strategies aimed at achieving efficiencies while improving
overall care. Counseling centers considering adoption of the model will benefit by designing and
implementing changes in collaboration with all campus stakeholders, including trainee feeder
programs. Finally, such partnerships could allow access to research funding and the wide ranging
expertise needed for designing and evaluating the emerging practices.
Conclusion
Traditional models of counseling are not meeting the needs of our college and university
students. Stepped Care 2.0 has been proposed as a system for rationally distributing limited
mental health resources to maximize the effectiveness of services for all students. Unlike models
evaluated with equivocal results in Europe (Seekles et al., 2011; van Straten, et al., 2015), this
version of stepped care includes online programming, rapid access and an empowering process
for collaborative client-counselor treatment-option decision making. For both clients and
providers, attention to readiness for change is an important factor to consider during
implementation of the model. One of the most rewarding aspects of the model for providers,
clients and stakeholders in our three universities is that stepped care is eliminating wait lists and
REINVENTING SERVICES THROUGH STEPPED CARE 36
allowing much more rapid access to programming. Early data indicate high levels of efficiency
and client satisfaction with this reimagined version of stepped care and superior outcomes for
therapist assisted online programming. Although the model is showing promise, more research is
needed. Future research may consider the possibility that counseling centers vary in the extent to
which stepped care is adopted or online resources are integrated into service models. There is a
need for developing a more sophisticated technology platform to monitor outcomes and ensure
more objective treatment level decision making. Such a platform could also enable further
student empowerment through the development of personal health record monitoring.
REINVENTING SERVICES THROUGH STEPPED CARE 37
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REINVENTING SERVICES THROUGH STEPPED CARE 47
Figure 1
Stepped Care 2.0 Step Levels in Relation to Intervention Intensity and Student Autonomy/Self-
Advocacy
REINVENTING SERVICES THROUGH STEPPED CARE 48
Table 1
Stepped Care 2.0 Clinical Interventions
Step
Number
Description
(and associated
BHM20 assessment
criteria)
Clinical Intervention Examples
1
Walk-In
Consultation/Watchful
Waiting
Administer BHM43 at walk-in (and BHM20 at subsequent
steps when appropriate)
Informed consent on stepped care treatment model
30-minute intake/consultation
Formulate and prescribe treatment or watchful waiting
with a one to two-week follow-up
2
Informational Self-
Help (for low to
moderate symptom
complexity, low
readiness, low risk)
Books; pamphlets
AnxietyBC.com resources
Center for Clinical Interventions (cci.health.wa.gov.au)
Counseling Center Village (ccvillage.buffalo.edu)
Mindfulness resource list with links
Bridge the gApp (bridgethegapp.ca)
Transitions app (teenmentalhealth.org)
3
Interactional Self-Help
(for low to moderate
symptom complexity,
low to moderate
readiness, low risk)
MoodCheck (iOS)
WellTrack (mywelltrack.com) without counselor
involvement
Breathing Room positive psychology online depression
treatment (breathingroom.me)
e-CHECKUP TO GO (echeckuptogo.com)
MoodGym CBT and Interpersonal treatment for mood
disorders (moodgym.anu.edu.au)
6 ACT Conversations
(emedia.rmit.edu.au/communication)
MoodKit iOS app (thriveport.com)
4
Coaching / Drop-In
Educational Sessions
(for moderate
symptom complexity,
low to moderate
readiness, low risk)
Academic skills drop-in clinic
Life coaching
Career orientation and interpretation sessions
Daily mindfulness drop-in sessions
Thought Helper web program (thoughthelper.com)
Relationship support group
Green Mindfulness (mindful indoor gardening)
DBT Diary app (diarycard.net) coaching sessions
Online peer chat (local program built into 7 Cups of Tea
platform - www.7cups.com)
REINVENTING SERVICES THROUGH STEPPED CARE 49
Step
Number
Description
(and associated
BHM20 assessment
criteria)
Clinical Intervention Examples
5
Therapist-Assisted
Online (for moderate
to high symptom
complexity, low to
moderate readiness,
low to moderate risk)
TAO-Connect for anxiety and depression (taoconnect.org)
WellTrack with counsellor coaching (mywelltrack.com)
6
Intensive Group
Therapy (for moderate
to high symptom
complexity, high
readiness, low to
moderate risk)
Anxiety & Depression Group
Yalom-Style Interpersonal Therapy Group
Healthy Lifestyles Group
Relationship Skills Group
Mindfulness Group
7
Intensive Individual
Therapy (for high
symptom complexity,
low to high readiness,
moderate to high risk)
Single session
Brief sessions (5, 15 or 30 minutes)
50-minute sessions
Weekly, biweekly, monthly sessions
With junior, senior trainees
With experienced counselors
8
Psychiatric
Consultation (for high
symptom complexity,
low to high readiness,
high risk, non-
responsiveness to
therapy)
90-minute initial assessment
Referral back to GP
Consultation with GP, case managers and/or counsellors
Follow-up only when justified
9
Case Management –
Referral to Tertiary or
Acute Care (for high
symptom complexity,
low readiness, high
risk, non-
responsiveness to
outpatient care)
Case management and systems navigation assistance by
university-based case managers on Students of Concern
(SOC) Committee
Supervised intensive paid student peer support for
students of concern (including autism spectrum,
addictions, code violations)
“Red Folders” support and referral tool in faculty offices
Community outpatient referrals
Referrals to private practitioner
Referrals to specialist treatment programs (eating
disorders, trauma, DBT)
Inpatient hospitalization
REINVENTING SERVICES THROUGH STEPPED CARE 50
Figure 2
Percentage changes in clients per counselor, appointments per counselor, session attendance
and counseling hours per counselor after implementation of stepped care
+16.8
+7.7 +7.6
-2.5
+18
+5
+13.6
-1.1
-5
0
5
10
15
20
Number Clients/Counsellor Counselling
App/Counsellor
Session Attendance Counselling
Hours/Counsellor
MUN GWU
REINVENTING SERVICES THROUGH STEPPED CARE 51
Table 2
Contrast Pre-Launch, Launch and Launch Year Client Satisfaction Controlling for Counselor
Satisfaction Survey Items
H and F Tests
(n = 481)
p
M Pre-
Launch
(SE)
M
Launch
(SE)
M
Post-
Launch
(SE)
1. Length of time waited
to be seen
F (2) = 1.67
.19
4.23
(0.104)
4.25
(0.078)
4.07
(0.067)
2. Length of time in
waiting room before
the appointment
F (2) = 1.75
.17
4.18
(0.114)
4.12
(0.086)
3.95
(0.074)
3. Total amount of time
spent with the
counsellor
χ2 (2) = 6.94
<.05
4.45
(0.085)
4.64*
(0.063)
4.40*
(0.071)
4. Technical skills of the
counsellor
χ2 (2) = 0.18
.91
4.45
(0.086)
4.59
(0.065)
4.52
(0.056)
5. Extent to which I felt
understood
χ2 (2) = 4.53
.10
4.33
(0.088)
4.63
(0.066)
4.51
(0.057)
6. The personal manner
of the person I saw
χ2 (2) = 2.09
.35
4.58
(0.076)
4.79
(0.057)
4.79
(0.063)
7. Extent to which the
counselling helped me
deal with my concerns
F (2) = 3.04
<.05
4.14
(0.104)
4.36*
(0.078)
4.15*
(0.067)
8. Overall evaluation of
my visit(s)
F (2) = 3.06
.13
4.28
(0.060)
4.51
(0.069)
4.39
(0.060)
REINVENTING SERVICES THROUGH STEPPED CARE 52
Table 3
Contrast of Step 5 (TAO aggregate and TAO Memorial University) and Step 7 (50-minute
therapy) treatment effectiveness
BHM Scale
Mean at
intake
SD at
intake
Mean
session 8
SD
session 8
Cohen’s
Effect
size
Effect
size R
Global Mental
Health
Owen et. al
2.56
0.65
2.92
0.63
0.562
0.27
TAO aggr.
2.46
0.57
2.94
0.6
0.82
0.379
TAO MUN
2.23
0.63
2.56
0.77
0.49
0.24
Symptoms
Owen et. al
2.82
0.67
3.15
0.65
0.499
0.242
TAO aggr
2.17
0.58
3.17
0.59
1.57
0.617
TAO MUN
2.5
0.64
2.8
0.67
0.61
0.29
Well-Being
Owen et. al
1.76
0.86
2.24
0.78
0.554
0.267
TAO aggr.
1.79
0.78
2.38
0.73
0.73
0.343
TAO MUN
1.46
0.86
2.56
0.86
0.63
0.3
Life Functioning
Owen et. al
2.16
0.82
2.49
0.84
0.2
0.1
TAO aggr.
2.18
0.75
2.63
0.83
0.55
0.273
TAO MUN
1.92
0.39
2.16
0.25
0.73
0.34
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