- About The Stepped Care Guide
- Section 1: Context and Definition
- Section 2: Steps Explained
- Section 3: Case Studies
- Section 4: Implementation Experiences
- Section 5: Final Thoughts
But I Didn’t Train for This – A Post-Doc Perspective
Provider experiences adapting to stepped care have generally been positive but varied. As with any major change, implementation may be met with initial reluctance or resistance. Given that many training programs do not prepare clinicians on flexible single-session therapy models (e.g., Hoyt & Talmon, 2014), professional development opportunities offered through a period for adjustment may be helpful. The following represents the experience of a postdoctoral counselor:
Today I discussed with my Director how I was feeling anxious, uneasy, and even unsure about the new stepped care model. I said to her that I felt unsure about seeing clients now because I feel the urge to follow stepped care in a perfect way; otherwise, I’m thinking to myself that I would be putting clients at risk. Moreover, following this model seems contrary to the best practices I learned so recently in graduate school. I was taught that the therapy process takes time, and that we need to be respectful of the client’s pace. What I understood so far from this model was that I was supposed to prescribe something immediately to the client, and that, sadly in my opinion, only a small portion of my clients would receive actual therapy, simply because I was not going to have any time to see them.
I saw so many challenges to my accustomed practice: too much information, procedures to follow, and decisions to make for the client. I felt the pressure to grasp all this information in order to do what is now expected from me here. At first I was not sure exactly what was making me anxious since I had previously been pretty confident with my counseling approach. Then I realized with frustration I was losing the part of myself that trained so hard to be a good therapist!
In tears, I was able to share those feelings and uncertainties with my Director. After inquiring about where my anxiety was coming from, then learning that this feeling was new for me, my Director attributed it to normal anxiety associated with implementing a completely new service model. Then, abruptly she initiated a role play—by the way, I am not a fan of role plays, but I went there anyway because I was desperate and I trusted that she knew what she was doing. I was anxious as I played the role of therapist. I tried to assess the client’s problems and offered options from the model. I tried so hard to do it right. As soon as I finished, I knew I missed some of the most important pieces—joining with the client, my presence in the room. I was too directive and cold. We reversed roles.
As the client, I was offered options. After listening to my (role-playing client’s) concerns, the therapist (my Director), presented options for services using the metaphor of a food court. There are so many options, and it is up to me to choose what I will get. I did not feel like I was shopping for services, nor that I was denied the service I was seeking. In fact, as the client in this role, I felt I was gently supported to make a decision and to own it. I was told that here individual therapy is brief, yet intense and hard work. I somehow felt heard, and most importantly, I felt empowered. I was not sure quite why.
After a debrief, I realized I felt relieved by my role-playing- counselor’s suggestion that therapeutic options come in a range of doses. Her invitation for me to be directly involved in treatment option decision making felt empowering. Finally, the frank admission that the therapy process itself is hard and that I have to take responsibility for doing the work led me to trust and feel confidence in her expertise and authority. A notable shift occurred. The powerful experience of being cared for sensitively, efficiently and honestly, rekindled my confidence. I was encouraged to draw on my own sensitivity and genuineness, qualities that I recognized in prior training made me a good therapist. I believe now I will figure out a way to be that same good therapist within the context of the new model.
I said to my Director that maybe notions of good therapy and of the good therapist need some rethinking. I had always been a firm believer that therapy is hard work, and that the client should be the one doing it. My job is simply to facilitate this process. If therapy is about empowering clients to make meaning and own decisions in their lives, now I can see that the stepped care model does just that.