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Stepped care in university counselling, explained

Where stepped care came from, how Irish and UK university counselling services use it, and what the evidence says about its strengths and limits.

By Myndgard Limited

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Ask most university counselling services in Ireland or the UK how they organise their work and you will hear the phrase "stepped care". It is used so widely that it can mean quite different things from one campus to the next. This post traces where the idea came from, how it has been adapted for students, and where the evidence is strong and where it is thin.

Where the idea came from

The core principle is simple: offer the least intensive intervention that is likely to help first, monitor progress, and step up to something more intensive if needed. In a 2005 narrative review in the British Journal of Psychiatry, Bower and Gilbody described stepped care as a response to the gap between demand for psychological therapy and available supply. They were also clear that its benefits rest on assumptions: that brief interventions produce comparable outcomes for many people, that the model saves resources, and that patients and therapists find "minimal interventions" acceptable.

The model became mainstream through England's Improving Access to Psychological Therapies programme, launched in 2008 and now called NHS Talking Therapies. Its manual (version 7, updated March 2024) states that services use "a stepped-care model, which works according to the principle that people should be offered the least intrusive intervention appropriate for their needs." Psychological wellbeing practitioners deliver low-intensity work such as guided self-help at step 2, and people who do not fully recover are stepped up to high-intensity therapy at step 3.

NICE guidance has supported this approach for over a decade. Its 2011 guideline on common mental health problems (CG123) set out stepped-care pathways; NICE withdrew it in May 2024 because its recommendations are now covered by condition-specific guidelines. The 2022 depression guideline (NG222), for example, says to consider "the least intrusive and least resource intensive treatment first (guided self-help)" for less severe depression.

Stepped care is not "everyone starts at the bottom"

The NHS manual is explicit on a point that is often lost. People with more severe depression, social anxiety disorder or PTSD should receive high-intensity treatment from the outset. And where it is clear someone needs high-intensity therapy, services "should avoid requiring them to receive a step two intervention first", because doing so uses more therapist time and worsens waiting times and patient experience. Stepped care, done well, includes a good assessment that places people at the right step.

How university services have adapted it

In Ireland, stepped care is part of national mental health policy. Sharing the Vision (Department of Health, 2020) describes a stepped approach that "seeks to ensure that each person can access a range of options of varying intensity to match their needs", with stepping up or down depending on the stage of recovery.

Some Irish university services adopted the model well before that policy. In a 2015 profile of the University of Limerick's service, the then director described four steps: psychoeducational classes and self-help programmes as the entry point, short-term therapy of around six to eight sessions, longer-term therapy, and referral to psychiatry or other specialist services. The model was introduced in response to waiting lists of "four to five weeks", with 60 students waiting at one point.

Trinity College Dublin also uses a stepped-care model, described in a 2023 Times Higher Education piece as having ten steps. Its counselling director said the service usually sees 10 to 12% of students and had seen 15% in the previous year.

In North America, Cornish and colleagues' Stepped Care 2.0 (2017) reworked the UK model for campuses. It adds online programmes and peer support at the lower steps, allows stepping down as well as up, and uses routine monitoring so students and providers both see progress. The authors reported positive early experiences at three universities, including the elimination of waitlists, but called for more thorough evaluation. A Portuguese university reported in 2024 that most of its 295 students waited less than a month to access each step, while noting that the findings were preliminary.

What the evidence supports

The evidence for stepped care as a whole is more modest than its popularity suggests. A 2015 meta-analysis by van Straten and colleagues found that stepped care for depression had a moderate effect compared with care as usual (d = 0.34 at six months, across 10 trials and 4,580 patients). However, the models varied a lot in steps, treatments and criteria for stepping up, and the authors concluded there was "only limited evidence to suggest that stepped care should be the dominant model of treatment organization".

A cluster randomised trial in English NHS services (Delgadillo and colleagues, 2022) compared stepped care with stratified care, in which patients were matched to low or high intensity at assessment using an algorithm. Reliable and clinically significant improvement in depression was higher with stratified care (52.3% versus 45.1%). Stratified care cost about £105 more per patient, mainly because more people went straight to high-intensity therapy. The trial was in adult NHS services rather than universities, but it raises a fair question about how much can be gained by better matching at the start.

The critiques, fairly stated

  • It can become a rationing device. If lower steps exist mainly to manage a queue, students may experience them as a hurdle rather than help. Trinity's students' union, in a 2023 report, credited the stepped-care model with easing pressure but said it was not "a substitute for a well-resourced counselling service". The same report found waits for counselling after assessment rose from three weeks to five and a half weeks between 2017/18 and 2021/22.
  • Stepping depends on measurement. Decisions to step up or down need routine, session-by-session data. Without it, "stepped" care can drift into a fixed sequence.
  • "Step" means different things. Because services define their own steps, comparing outcomes between institutions is difficult.

What this means for counselling services

  • Define your steps in writing, including the criteria for stepping up, stepping down and starting higher.
  • Assess well at the front door. Not everyone should start at step one.
  • Collect brief, validated measures routinely so stepping decisions rest on data rather than session counts.
  • Be honest with students about what each step is and why it is offered, so lower-intensity options feel like help rather than a gate.
  • Track waits at each step, not just the first one.

Sources