Stepped Care

Step 4 provides specialist treatments within NICE guidelines. In comparison to other steps, Step 4 treats a small minority of people. This is usually because the treatments in steps 2 and 3 haven't helped them enough, or because they are at risk of self-neglect or harm, functional impairment or are dealing with more complex conditions, which possibly include other social factors or chronic, multiple diagnoses.

Step 4 is usually made up of a range of highly qualified therapists such as experienced Cognitive Behavioural Therapists and EMDR therapists.

The needs of people receiving Step 4 services are likely to be more complex, so it is probable that people will be receiving a combination of medication and other treatments. Although some treatments may be similar to those in Steps 2 and 3, the treatment is likely to be more intense or for a longer duration.

This level is provided by Cognitive Behavioural Therapists and High Intensity Therapists (HITs). The therapists deliver Cognitive Behavioural Therapy (CBT) for clients experiencing moderate to moderately severe depression and anxiety disorders. This step is appropriate for you if you haven't noticed an improvement in response after trying the treatments at Step 2 or another previous therapy. Treatment at this level involves attending some more in-depth workshops dealing with things like depression, Generalised Anxiety Disorder and panic.

You can expect the workshops and a Step 3 therapist to;
• Identify and understand your problems
• Provide you with up-to-date and helpful information, including handouts, booklets or links to websites, to read and inform you on where to get further information which might help.
• Introduce you to self-help activities to help you overcome your difficulties.
• Develop skills to change unhelpful ways of thinking
• Recognise unhelpful coping strategies and develop skills to adapt your behaviour so you can do more of the things you want to do
• Set ‘homework’ tasks with you at the end of each session, based on your individual needs and goals.
• Help you to acquire tools and techniques to help yourself, improve your wellbeing, and that will help you minimise and prevent future problems.
• Identify ways to work towards your goals and aspirations
• Regularly review your progress through discussion and through the use of standard questionnaires.

Psychological Wellbeing Practitioners (PWPs) work at Step 2 within NHS Talking Therapies services. This is the first step within the model which is provided by NHS Talking Therapies services. It seeks to use the least intrusive method of care possible, which involves low-intensity group workshops that last around 3-4 weeks, covering topics such as depression, panic and anxiety, stress reduction, and worry reduction. The workshops are also a chance for you to make connections with others going through similar difficulties.

You can expect workshops and Psychological Wellbeing Practitioners (PWPs) at Step 2 to:
• Provide you with up-to-date and helpful information, including handouts, booklets or links to websites, to read and inform you on where to get further information which might help.
• Introduce you to self-help activities to help you overcome your difficulties.
• Signpost you to other organisations, services or groups that may be able to help you.
• Set ‘homework’ tasks with you at the end of each session, based on your individual needs and goals.
• Help you to acquire tools and techniques to help yourself, improve your wellbeing, and that will help you minimise and prevent future problems.
• Work closely with your GP and anyone else involved in your care and treatment.
• Regularly review your progress through discussion and through the use of standard questionnaires.
• Help you make the best use of any medication that your GP has prescribed by giving you information e.g. about side-effects.

This is a very active form of treatment which supports you in taking a proactive role in your recovery. Although the sessions are important, the work which you complete in-between sessions is essential for you to practise and apply new skills in your life. Being ready, willing and motivated to engage with these exercises together with out-of-session tasks is therefore essential to your recovery.