Stepped Care as a Heuristic Approach to the Treatment of Alcohol Problems

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Stepped Care as a Heuristic Approach to the Treatment

of Alcohol Problems

Mark B. Sobell and Linda C. Sobell

Nova Southeastern University

A stepped care approach to treatment decisions for alcohol problems consists of the application of decision rules derived from practice in other areas of health care. The treatment used should be (a) individualized, (b) consistent with the research literature and supported by clinical judgment, and (c) least restrictive but still likely to be successful. Used in this way, stepped care emphasizes serving the needs of clients efficiently but without sacrificing quality of care. Issues concerning stepped care are discussed, and the application of a stepped care approach to alcohol treatment services is described.

Although the effectiveness of treatments for many mental health problems is modest at best, every day service providers must make decisions about how to treat clients. In some settings, treatment decisions are made according to an approach called stepped care

(Abrams, 1993; Joint National Committee on Prevention, Detec- tion, Evaluation, and Treatment of High Blood Pressure, 1997; Orleans, 1993; M. B. Sobell & Sobell, 1993b). Until very recently, such procedures have seldom been considered for the treatment of alcohol problems. In this article, we first discuss stepped care as heuristic guidelines for providing efficient and clinically appropriate services. Then we describe how this approach could be used in the treatment of alcohol problems. Finally, we discuss applications of a stepped care approach to the planning of community services, including both prevention and treatment interventions.

S t e p p e d C a r e as a H e u r i s t i c

In this context, heuristic means helping solve a problem with techniques that are self-improving. This description captures the essence of the stepped care approach to health care decisions. The problem is what treatment procedures should be used for a given client at a given time. In this regard, stepped care incorporates principles to guide decision makers in treatment choices. In addition, the approach is self-correcting, as it includes monitoring the results of decisions and making new decisions if the previous ones have poor outcomes. Figure 1 illustrates the basic features of a stepped care approach.

One essential component of the stepped care approach is that when an individual first enters the clinical service system, the initial treatment is determined on the basis of clinical judgment and the present knowledge base. This feature is especially impor-

Mark B. Sobell and Linda C. Sobell, Center for Psychological Studies, Nova Southeastern University.

The preparation of this article was supported in part by Grant 2 ROI AA08593-04AI from the National Institute on Alcohol Abuse and Alco- holism and by Grant U84/CCU414602 from the Centers for Disease Control and Prevention.

Correspondence concerning this article should be addressed to Mark B. Sobell, Center for Psychological Studies, Nova Southeastern University, 3301 College Avenue, Fort Lauderdale, Florida 33314. Electronic mail may be sent to [email protected].

tant for areas of health care, particularly the alcohol field, where etiologies are not well-known and cures are nonexistent (Gordis, 1987; Institute of Medicine, 1990; Miller, Andrews, Wilbourne, & Bennett, 1998; Miller et al., 1995). Knowledge about the relative efficacy of available treatments is vital to being a competent professional, and it is where client-treatment matching research has its greatest impact. Unfortunately, such knowledge is often limited to broad generalities based on efficacy studies conducted under major constraints (Seligman, 1995). Moreover, recommendations based on efficacy studies may need to be qualified by case management issues and by other factors not usually considered as part of controlled trials (e.g., acceptability of the treatment to the client). In such instances, clinical judgment and the provider's experience can be invaluable. The importance of clinical judgment and sensitivity to case management and idiosyncratic issues suggests that the application of a stepped care approach requires treatment decisions to be made by experienced clinicians and not by relatively untrained personnel or on the basis of questionnaires. In a stepped care approach, the selection of any treatment, including the initial procedures, is made with attention given to the following three fundamental principles of health care (M. B. Sobell & Sobell, 1999).

1. Treatment should be individualized, not just with regard to the presenting problem but also with regard to other factors, such as client beliefs and resources, and available treatment resources. 2. The treatments selected should be consistent with the con- temporary research literature. It is recognized that research is more advanced in some areas than others, but whatever the level of knowledge the clinician should be familiar with and use state-of- the-art information.

3. The recommended treatment should be least restrictive but still likely to work. Restrictive as used here refers not just to the physical effects of treatment on the client but also to restrictions on the client's lifestyle and resources (i.e., the total cost of the treatment to the client, personally as well as financially). One result of adhering to this guideline is that more intensive treatments are reserved for more extreme problems.

Having made an initial treatment recommendation and gained the cooperation of the client, the use of a stepped care approach is at one level straightforward. On the basis of the above guidelines, sequential treatment decisions are linked together. The treatment is 573

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574 SOBELL AND SOBELL

Figure 1. A stepped care approach to the delivery of health care services. From Addictive Behaviors Across the Lifespan: Prevention, Treatment, and Policy Issues (p. 150), by J. S. Baer, G. A. Marlatt, & R. J. McMahon (Eds.), 1993, Beverly Hills, CA: Sage. Copyright 1993 by M. B. Sobell and L. C. Sobell. Adapted with permission.

conducted, and the client's status is monitored. If the client is improving, the treatment is continued or possibly stopped if the presenting problem has been resolved and the outcome appears stable. If the client is showing few or no signs of change, further interventions are implemented. Considered in more detail, as occurs shortly in discussing the use of stepped care in the treatment of hypertension, it becomes apparent that although the stepped care approach is straightforward, this is not to say that its implemen- tation is easy. Many issues need attention, such as how it is to be determined whether the treatment is working sufficiently and how known risk factors should affect sequential treatment decisions. For example, "stepping up" treatment is not limited to increasing treatment intensity. Although in many cases it may be reasonable to provide more of the same treatment, there will also be cases where changing the type of treatment may be justified (e.g., admission to a residential treatment program or using a different treatment). A change in treatment may result from a discussion with the client that identifies other factors that are interfering with the treatment (e.g., marital problems). However, no matter how complicated the factors that must be considered, the decision about how to proceed when progress is not evident should be based on the same principles as the initial treatment decision. In general, changes in treatment should be performance based (i.e., based on the client's functioning).

T r e a t i n g H y p e r t e n s i o n : A n E x a m p l e o f S t e p p e d C a r e An excellent example of how stepped care is used in the medical field involves the treatment of hypertension. The 1997 report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure first reviews empirically validated treatment strategies available for the treatment of hypertension, describing seven aspects of lifestyle modification that can be helpful (e.g., reduce sodium intake, increase aerobic activity, and reduce dietary saturated fats and cholesterol), more than five dozen different medications, and several combinations of different medications. Treatment recommendations vary depending on risk groups (e.g., gender, age, or diabetes), degree of blood pressure elevation, evidence of target organ damage, presence of clinical

cardiovascular disease, medication side effects, and other risk factors. The hypertension stepped care algorithm has a structure similar to that in Figure 1 but includes much more detail and decision rules. Generally, the sequence begins with lifestyle mod- ifications, increases to drug treatment if the individual's blood pressure remains elevated, and proceeds to the use of alternative drug(s), with referral to a hypertension specialist if none of the other strategies are successful. As in Figure 1, treatment strategies are chosen to be consistent with the empirical literature as related to the presenting symptoms (i.e., problem severity) and other risk factors. For example, individuals who are initially assessed as at high risk for a coronary event or stroke should be started on medication with minimal delay, and persons with extremely high blood pressure or target organ damage may need immediate hos- pitalization. In addition, when sufficient blood pressure reduction has been achieved, a "step-down" treatment should begin aimed at determining the minimal intervention level or lifestyle modification sufficient to maintain blood pressure within normal limits. The algorithm for the treatment of hypertension demonstrates that although the concept of stepped care is easy to understand, its clinical application requires considerable knowledge and the ac- curate assessment of presenting symptoms and individual risk factors. A final consideration in the application of stepped care in the treatment of hypertension is the recognition of factors that may adversely affect an individual's compliance with the recommended treatment, such as expense, medication side effects, unwillingness to discontinue an ineffective therapy, and reluctance to modify one's lifestyle.

A d v a n t a g e s to U s i n g S t e p p e d C a r e as a Heuristic Although stepped care might be used to establish ideal treatment models (i.e., linking together highly specific treatments), for several reasons it is preferable to use stepped care as clinical decision rules. First, one of the strengths of using stepped care as a heuristic is its performance-based flexibility--determination of whether to continue or change strategies is based on the client's response to treatment rather than preset rules (e.g., 12 sessions of a certain treatment). Second, whenever possible, treatment decisions should be empirically supported, and considerable progress has been made in identifying approaches that have been evaluated as effective or possibly effective for treating particular disorders (see, e.g., the special section on empirically supported psychological therapies that appeared in the February 1998 issue of this journal). The stepped care approach emphasizes using empirically supported treatments. However, the availability of empirically supported treatments varies considerably among disorders. Moreover, as noted by Seligman (1996), establishing a comprehensive database covering all possible permutations and combinations of treatments, particularly client-treatment interactions, is not feasible. Thus, to some degree, clinicians must depend on factors other than research findings in making treatment decisions. Typically, one's clinical judgment is used in the absence of a research base. Unfortunately, the validity of clinical judgment is very controversial (Dawes, 1994; Meehl, 1960) and at the least lacks strong empirical validation.

After the initial treatment decision, a stepped care approach offers an alternative to relying solely on clinical judgment. Once treatment begins, further treatment decisions are based on whether the client is making satisfactory progress toward established goals

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(i.e., performance based). Although such evaluations are not without complications (e.g., what is satisfactory progress?), they have the advantage of using within-treatment findings as a basis for client-treatment matching. This is helpful because most research on client-treatment matching has been based on pretreatment assessments of clients. However, recent studies in substance abuse (Breslin, Sobell, Sobell, Buchan, & Cunningham, 1997) and depression (Ilardi & Craighead, 1994) have found that early responses to treatment are important predictors of posttreatment functioning. Specifically, individuals who have successful outcomes are likely to have made substantial positive changes within the first few sessions of treatment.

Another reason for favoring stepped care as a heuristic is that as the knowledge base continues to grow, treatment decisions will change. What is considered the most appropriate intervention today may be considered less effective in the future (e.g., bleeding was once a common method of treating some medical problems). Using the stepped care approach as a heuristic avoids setting in place treatment linkages that become obsolete as new knowledge is discovered. Stepped care is also appealing because it can incor- porate interventions not typically considered in the same clinical repertoire as psychotherapy. The approach can include self-help groups, advice from friends, bibliotherapy, computer-based interventions, and community programs, as well as interventions in general health and mental health settings in addition to specialized programs.

C o n s i d e r a t i o n s in the U s e o f S t e p p e d C a r e One possible concern about implementing a stepped care approach is that clients may seek out treatments that would not be recommended in a stepped care approach (e.g., services that may be inordinately restrictive or expensive) or seek continued services when they are not considered necessary. Such issues are not limited to a consideration of stepped care but rather reflect general questions about the relationship between health care services, the people who use them, and our society. The main question in such cases concerns the effects that marketing might have on promoting the use of inefficient or unnecessary services and the question of who should bear the cost for services that are desired by clients but are unnecessary. These health care policy issues are important, but they go well beyond the scope of this article.

A second general issue, but one that relates to the first, is that in some ways stepped care can be considered as a procedure that is useful for identifYing treatment failures and then providing further treatment. If one takes the view that some individuals will not change regardless of the treatment, then a sequence of stepped- care-guided treatment decisions for such an individual could become an extraordinary drain on health care resources. Although such an outcome is possible, it could result from any approach to care. The central issue is not one of using a stepped care approach, but rather at what point and by what criteria should decisions be made that further treatment is no longer justified (e.g., should 90-year-olds receive liver transplants?). Once again the appropriate forum for such considerations is at the public health policy level. Although stepped care can advise about what treatment to consider next if further treatment is to be undertaken, it cannot advise about whether further attempts will be worthwhile, affordable, or successful.

An issue related to policy considerations and one that compli- cates dealing with alcohol problems is that the stepped care model considers what happens to an individual during a single treatment episode (even if the episode involves the use of several sequential treatment procedures). Tucker (1999), however, noted that alcohol problems tend to be recurrent and of varying intensity and has suggested that recovery from alcohol problems should be considered to be a process that plays out over time and can be influenced by the helping environment as well as treatment. Thus, treatment is one set of experiences within a greater context, and it interacts with that context rather than acting in isolation. If the behavior change process is viewed in this way, with treatment as one of the possible components, then it becomes helpful to consider the provision of care as a long-term endeavor. In this regard, it has been suggested that for some alcohol abusers extended case monitoring might be more cost-effective over the long run than a series of independent treatment episodes (Stout, Rubin, Zwick, Zywiak, & Bellino, 1999). In such cases, clients are assigned a case monitor who contacts them periodically after completion of their formal treatment. Although the contacts become less frequent, they may extend for years. Because the monitor's role is to "provide assessment of functioning and offers of help" (Stout et al., 1999, p. 24), it is not necessary that the monitor have extensive clinical training and contacts can occur by phone. An evaluation is presently under way of the cost-effectiveness of extended case monitoring as compared with standard care (i.e., episode by episode; Stout et al., 1999).

Another issue regarding stepped care concerns those for whom minimally restrictive treatments are not successful. In this regard, stepped care does not advocate that a minimal intensity treatment be used with all individuals with a given disorder, but only for those for whom case management issues do not weigh against such an intervention and for whom the evidence suggests the likelihood of a positive outcome. Thus, clients should not be treated by an approach where failure is likely, if better alternatives are available. Because stepped care is an individualized approach, not all those who enter treatment must start at the most nonintensive level of care. In fact, as noted earlier, more severe cases are likely to be directed toward more intensive treatments. In other words, the occurrence of failures can be minimized by good initial treatment decisions. Lastly, even where the literature and clinical judgment suggest a strong likelihood of a positive outcome, some people will not respond positively. An advantage of a stepped care approach is that it includes monitoring clients' status and changing strategies when a lack of progress is observed. The fact that some will not respond well to a treatment of choice would not warrant using inappropriately restrictive treatments for most cases or using approaches that waste resources.

T h e A p p l i c a b i l i t y o f S t e p p e d C a r e in the T r e a t m e n t o f A l c o h o l P r o b l e m s

Stepped care has an important role to play in the treatment of alcohol problems, but it is a role that has yet to be enacted by the alcohol field. Although reviewing the history of the treatment of alcohol problems in the United States is well beyond the scope of this article, there are some important historical issues that make adoption of a stepped care approach a priority at this time. Briefly, when alcohol treatment services were first developed, they were not based on research but on folklore largely reflecting the influ-

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576 SOBELL AND SOBELL ence of Alcoholics Anonymous (AA) and its 12 steps (Pattison,

Sobell, & Sobell, 1977). As the field developed, it came to be dominated by Minnesota model treatment programs, structured to be similar to the program used at the Hazelden Foundation in Minnesota (Anderson, McGovern, & DuPont, 1999; Cook, 1988a, 1988b). Until recently, these 28-day residential programs were the rule rather than the exception for treatment of alcohol problems in the United States (McCaul & Furst, 1994). These programs have continued despite considerable epidemiological data showing that there is an imbalance between treatment needs and the types of services available (M. B. Sobell & Sobell, 1993b). In particular, there is a deficiency of treatment resources for individuals who have less severe alcohol problems (M. B. Sobell & Sobell, 1993b). This deficiency is found mainly in the world of clinical practice (Institute of Medicine, 1990). For example, in reviewing treatment efficacy studies, Miller et al. (1995) concluded that brief interventions have the greatest evidence for efficacy and also have been the focus of the largest number of studies. Interestingly, nearly all of the studies involved problem drinkers, individuals whose alcohol problems were not severe (M. B. Sobell & Sobell, 1993a). Thus, there is a need to make brief interventions available to problem drinkers in clinical service settings (Institute of Medicine, 1990). Recently, two important developments have suggested that brief interventions can also be effective for individuals with more severe alcohol problems.

The first development involves a reanalysis of data published in 1976 (Orford, Oppenheimer, & Edwards, 1976). Those data involved alcohol abusers given either one session of advice/coun- seling or a standard regimen of individualized care that could have included inpatient as well as extended outpatient treatment. The overall finding of this study was that although the participants improved considerably, there was no difference in outcome between the treatments (Edwards et al., 1977). However, on the basis of 2nd-year outcome data, Edwards et al. reported an interaction showing that individuals with less severe problems had a better outcome with the brief treatment than the standard, more intensive treatment and persons with severe problems did better with the standard treatment. This finding reinforced the notion that brief treatments should be used for individuals with less severe problems. This conclusion, however, was changed several years later when Edwards and Taylor (1994) published a further analysis but using I st-year outcome data (which would be expected to better demonstrate "treatment" effects). They found no evidence of an interaction between dependence severity and type of treatment; rather, they found that even those individuals with more severe problems did as well with one session of treatment as with the standard treatment.

The second development was the reporting of results from Project M A T C H (Matching Alcoholism Treatment to Client Het- erogeneity), a large multicenter randomized controlled trial spon- sored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA; Allen, Anton, et al., 1997; Allen et al., 1999; Allen, Mattson, et al., 1997; Carroll et al., 1998; Cisler, Holder, Long- abaugh, Stout, & Zweben, 1998). Project M A T C H compared the effectiveness of three different manualized outpatient treatments: 12-step facilitation, cognitive-behavioral, and motivational enhancement. The latter two approaches were developed on the basis of research, whereas the former represented a clinically common but relatively unevaluated approach. Another important difference was that the motivational enhancement treatment involved 4 treat-

ment sessions, whereas the other two approaches involved 12 sessions. The main finding of Project M A T C H was that the three approaches did not differ significantly in treatment effectiveness even when severity of dependence was considered (Allen, Matt- son, et al., 1997). Although there was no outcome-based evidence that one treatment approach should be recommended over another, from a public health standpoint and from a stepped care standpoint, the differences between treatments are considerable (e.g., the brief motivational enhancement treatment was less restrictive; M. B. Sobell, Breslin, & Sobell, 1998). For a more resource-consuming treatment (i.e., 12 sessions) to be used over a less costly treatment (4 sessions), the more costly treatment should produce a superior outcome because fewer cases can be treated with the same funds using the more expensive treatment. Thus, in the absence 9 f factors weighing against brief treatments, and from the standpoint of cost-containment, brief interventions are a good first treatment of choice for most individuals who have alcohol problems (M. B. Sobell & Sobell, 1999).

In view of the potential significance of the cost-effectiveness findings of Project MATCH, it is important to recognize that a full accounting of treatment costs involves more than the number of sessions. Likewise, a full accounting of benefits goes beyond focal problem symptom reduction. For example, besides the time spent in sessions, costs can include time that both the therapist and the client spend outside of the sessions (e.g., therapist preparing for sessions, client completing homework, and client making arrange- ments to attend sessions; Yates, 1994). Similarly, whether treatment is working and what the benefits are can be considered from different perspectives, including the clients', therapists', clinical supervisors', administrators', third-party payers', and researchers' (Howard, Moras, Brill, Martinovich, & Lutz, 1996).

Two other recently completed studies also have implications for how a stepped care approach might be used in the treatment of alcohol problems. The first was a controlled trial that evaluated the effectiveness of guided self-change (GSC), a brief cognitive- behavioral motivational intervention for alcohol and drug abusers (M. B. Sobell & Sobetl, 1993a) delivered in either an individual or a group format (L. C. Sobell, Sobell, Brown, & Cleland, 1995; M. B. Sobell & Sobell, 1995). The main components of GSC treatment include goal self-selection, self-monitoring, brief read- ings and homework assignments, personalized feedback, and the use of a motivational interviewing style by therapists (M. B. Sobell & Sobell, 1993a). Recent versions of the GSC intervention have also used a decisional balance exercise developed by Janis and Mann (1977) to help clients understand the sources of their motivation.

Although GSC was developed for use with individuals who have mild to moderate alcohol problems, in the study comparing individual and group formats the treatment was extended to drug abusers. A total of 232 alcohol abusers and 55 drug abusers voluntarily participated in the study. As in previous GSC studies (M. B. Sobell & Sobell, 1993a; M. B. Sobell, Sobell, & Gavin, 1995), there was marked improvement from pretreatment to l-year posttreatment. However, as in Project MATCH, there were no significant differences in outcome between conditions for both alcohol and drug abusers. From a health resource standpoint, though, the group format was considerably more cost-effective, achieving a cost savings of 42% over individual treatment.

Another recent study, by Breslin et al. (1997), has implications for a stepped care approach. In that study, an analysis of predictors

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of treatment outcome for 212 problem drinkers included therapist prognosis, client demographic and drinking history variables, and several within-treatment measures (e.g., drinking and self- efficacy) as predictor variables. Therapists' ratings of their confi- dence that clients would improve significantly predicted outcome when only pretreatment variables were included in the analysis, but when within-treatment variables were included therapist prognostic ratings were no longer significant, consistent with other studies of clinical versus statistical prediction (Dawes, 1994). The strongest predictor of 6-month treatment outcome was reports of drinking early in treatment. Specifically, problem drinkers who continued to have some heavy drinking days (five or more drinks) during the first three sessions of a GSC treatment were likely to have poorer outcomes at follow-up than those who reduced their heavy drinking early in treatment. This relationship held even when pretreatment drinking levels were statistically controlled. This suggests that besides selecting an initial treatment that is judged to be best matched to a client, it may be possible to base further stepped care decisions on clients' early responses to .treatment rather than monitoring for an extended interval. Thus, it appears that a within-treatment, "performance-based criterion" for undertaking further treatment decisions is feasible.

Given the above, one might speculate about the structure of a stepped care approach as applied to the treatment of alcohol problems. As with all clinical services, a competent assessment is first necessary. However, even here stepped care principles apply in determining what level of assessment is necessary. In some cases, a small set of questions needs to be posed, with the answers suggesting various ways of proceeding. For example, is the individual suicidal or a threat to others? Is the individual intoxicated, and if so at what level? This latter question is important for two reasons. First, there is evidence that alcohol abusers provide in- valid information about their recent drinking if they have alcohol in their system when giving the report (M. B. Sobell, Sobell, & VanderSpek, 1979). This could temper conclusions drawn from assessment data. In such cases, the individual should be asked to return when alcohol free to complete the assessment. Second, consideration must be given to the possibility that the individual is likely to suffer withdrawal symptoms on cessation of drinking and thus will need detoxification. Even when clients need detoxification, stepped care still provides a useful model for treatment decisions. For example, it is now well established that for many individuals who are physically dependent on alcohol ambulatory detoxification can be successful (Abbott, Quinn, & Knox, 1995; Hayashida et al., 1989; Stockwell et al., 1991). Such an alternative is important because ambulatory detoxification is far less expensive than inpatient detoxification. However, just because in most cases detoxification can be safely accomplished on an outpatient basis does not mean that ambulatory detoxification should always be the treatment of choice. Major withdrawal from alcohol may involve delirium tremens and seizures, both of which require medical attention. Because such symptoms cannot be predicted with certainty, an important consideration in deciding the feasibil- ity of ambulatory detoxification is past history and whether the individual can be continuously monitored (e.g., by family or friends). If monitoring is not available, inpatient detoxification would be a good choice for an individual who may experience serious symptoms, even if the research literature strongly suggests that ambulatory detoxification is successful in most cases.

Another triage factor that must be considered in treatment planning is living accommodations. It is not uncommon for individuals with severe alcohol problems to be homeless or to live in conditions highly conducive to continued drinking (e.g., with other alcohol abusers). Again, immediate needs require attention (i.e., residential care should be considered) if treatment is to have an opportunity to be effective. Finally, triage should consider the possibility of psychiatric comorbidity and physical disorders that could complicate treatment decisions. In each case, however, stepped care guidelines can be used.

Unless there are extenuating circumstances, such as discussed above, research suggests that the first treatment of choice is likely to be a brief outpatient intervention with progress closely monitored. Although assessment procedures are not discussed in detail here, it should be apparent that an extensive assessment typically is not done with brief interventions. Rather, the assessment is usually limited to demographic information, drinking practices, history and consequences, and any other issues that may affect treatment planning, such as dependence severity, and other drug use (L. C. Sobell & Sobell, 1998). More in-depth assessments may be performed during the course of treatment if the individual is not improving sufficiently, but there would be little basis for perform- ing a comprehensive psychological assessment of all individuals who present for treatment of alcohol problems. For those individuals who do not respond satisfactorily to treatment, however, additional assessment is important and can be used to make further treatment decisions.

For someone who did not respond satisfactorily to brief treatment, the next step could involve additional sessions of the same treatment (a quantitative increase) or using a different treatment (a qualitative change, but still a step up in the total amount of treatment). The decision about whether the next step should vary in quantity or in quality should be made on a case-by-case basis, considering factors such as whether the individual has shown some change, the individual's belief that the treatment is or is not a good match, the individual's level of motivation, and what treatment resources are readily available (an often overlooked real-world constraint on treatment decisions). Along the dimension of intensity, options include extended outpatient treatment or more frequent outpatient treatment, day programs, or a residential program. Because at this time there is no evidence of differences in treatment effectiveness related to amount of treatment (Annis, 1986; Edwards et al., 1977; McLachlan & Stein, 1982; Miller et al., 1995), the basis on which treatment decisions will be made rests largely on case management factors (e.g., can the individual take time off of work without risking serious consequences? Is the home environment supportive of recovery? Does the individual lack social support? Is the individual subject to social pressures to drink? What resources are available to pay for services?).

With regard to changing treatment quality, that picture has been complicated by the findings of Project M A T C H (Allen, Mattson, et al., 1997) and the failure to demonstrate outcome differences between treatments with radically different philosophies or to find meaningful client-treatment interactions. The relative lack of a clear empirical basis for client-treatment matching heightens a tension that is intrinsic to treating clinical disorders where highly effective methods have not been identified. In these circumstances, scientist-practitioners will often find it necessary to base treatment decisions on practical considerations. There is no way to solve this dilemma other than to develop an adequate set of empirically

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5 7 8 SOBELL AND SOBELL supported decision rules. However, until such rules are available,

treatment decisions will still need to be made. For now, the recommendation is to use empirically supported treatments when available and applicable and in their absence base treatment decisions on current knowledge and what makes sense for a given case. Stepped care accommodates this approach and adds the guideline that decisions to change treatments should be performance based.

rational approach to service delivery, stepped care emphasizes serving the needs of clients efficiently, but without sacrificing quality of care. Stepped care is consistent with how professionals provide services for other health problems, and continuing eco- nomic pressures can be expected to favor the use of such an approach as a sensible way to use limited resources to treat alcohol problems.

T h e U t i l i t y o f S t e p p e d C a r e for E a r l y I n t e r v e n t i o n a n d f o r S e r v i c e P r o v i s i o n P l a n n i n g

A stepped care approach can also be applied to the broader public health perspective to guide how limited resources can be used efficiently and effectively. At a societal level, interventions to remediate alcohol problems need not be conventional treatments. In fact, the first avenue o f change for many is self-change or natural recovery (i.e., without formal help or treatment). W h e n the full spectrum of alcohol problems is considered, there is even some evidence to suggest that natural recovery is the most prevalent form of recovery (L. C. Sobell, Cunningham, & Sobell, 1996). An initial approach at a public health level that is highly consistent with stepped care is to attempt to facilitate natural recoveries. Such recoveries put little drain on the health care system. Although it is beyond the scope of this article, a major effort is under way in Canada to facilitate natural recoveries in the community (L. C. Sobell, Cunningham, Sobell, Agrawal, et al., 1996). Another resource that is not considered formal treatment is the use of self- help programs, such as A A and Self Management and Recovery Training, a r a t i o n a l - e m o t i v e therapy self-help program derived from Rational Recovery. Community efforts spent encouraging natural recovery and the use of freely available community resources could potentially yield a large dividend in low-cost recoveries as part of a well-planned public health system. Also, a great deal of evidence has now accrued showing that brief, low-cost interventions as part of primary care health services can have a substantial benefit in reducing the alcohol use of heavy drinkers (NIAAA, 1995; Substance Abuse and Mental Health Administra- tion, 1997). Similar efforts at social service agencies might provide another way of delivering cost-effective brief interventions. Be- cause large numbers of cases respond to nonintensive treatments, the proportion of cases that need more intensive treatments will be reduced, just as occurs with other health problems (e.g., hypertension).

On the basis of the above, it should b e evident that good treatment p l a n n i n g for alcohol services should make b r i e f treatments widely available. Such treatments are least restrictive and low cost. To conserve resources, our health care system should capitalize on m i n i m a l necessary levels of care. A n efficient system would also develop effective linkages b e t w e e n services, so services are not unnecessarily duplicated within a c o m m u - nity. In summary, appropriately n o n i n t e n s i v e treatments should b e the initial treatment in most cases. However, c o n s i s t e n t with stepped care principles, treatment decisions should always be individualized.

C o n c l u s i o n

In conclusion, the stepped care approach consists of a set of guidelines for efficient and cost-effective delivery of services at both the individual and community service system levels. As a

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