Building the first step: a review of low-intensity interventions for stepped care

Within the last 30 years, a number of psychosocial interventions for alcohol use disorders (AUDs) have received empirical support. Evaluations of these interventions have employed well-controlled randomized trials involving large numbers of individuals and substantial follow-up periods. These trials provide strong support for such interventions as motivational enhancement, cognitive-behavioral treatment, and 12-step facilitation treatment [1]. In addition, it is now clear that individuals who obtain timely help for AUDs have better outcomes than those who do not [2,3].Despite these advances, only about 25% of individuals with AUDs access any form of help, empirically supported or otherwise [4-7]. When help is sought, it often occurs 10 or more years after the onset of symptoms of disorder [8]. If several intensive psychosocial treatments are relatively effective, but most individuals in need do not access them, it seems logical to place a priority on developing more engaging interventions. Accordingly, after briefly describing findings about barriers to help-seeking, we focus on identifying a palatable array of innovative and effective low-intensity intervention strategies that surmount these barriers and are suitable for use within a stepped-care model.Empirical studies of help-seeking over the last two decades highlight a number of reasons why individuals with AUDs delay or never seek treatment. One key set of factors involves individuals’ perceptions of negative concomitants of treatment, including stigma [9,10], dislike of the prevalent group format and the emphasis on spirituality in treatment and self-help groups [10], lack of privacy [10], concern that treatment is ineffective [11], and disinterest in abstinence goals [10,12].Other common reasons individuals cite for not entering treatment involve a desire for autonomy or a wish to “handle problems more on their own” [9,11,12] and the belief that their alcohol problems are not serious or may improve on their