Journal of Consulting and Clinical Psychology Copyright 2000 by the American Psychological Association, Inc. 2000, Vol. 68, No. 4, 573-579 0022-006X/00/$5.00 DOI: 10.1037//0022-006X.68.4.573 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 appropri- ate 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. Stepped Care as a Heuristic 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 addi- tion, 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 sobellm@cps.nova.edu. 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, recommen- dations 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 sug- gests 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 treat- ments 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