I Cannot Do It That Way – A Trainee Perspective

In supervising trainees, we remind them to consider adjusting what is taught to fit with their own particular style and personality. One size does not fit all. As licensed practitioners in the field, we take our own advice on this by acknowledging that the stepped care model can be implemented in many different ways. A trainee describes her experience with discovering she needed to find her own way of “doing stepped care”:

Having previously completed two practicum placements at the counseling center in the “pre-stepped care” era, I felt unprepared to work with this new model as I began my predoctoral internship. In my first week I attended a stepped care training seminar facilitated by my supervisor. I understood the model as presented. During the seminar I volunteered to role play a client at a walk-in consultation session. In the role of client, I was expecting to receive traditional weekly counseling for my social anxiety and to learn ways to deal with my father’s verbal abuse. Despite my expectations, the walk-in counselor’s explanation of the new model made sense and I actually felt the solutions offered were better than I had expected.

Later, as I practiced how I would introduce the model to clients at my first walk-in clinic, I had a hard time making it sound right. I lacked the confidence and credibility embodied by my supervisor (Dr. G.), who was also the Director of the Center. My first session was a flop. My client had years of experience of free counseling offered at another university and her scores on the BHM-20 indicated very little distress. She did not seem able to articulate any clear goals. Having just come from the stepped care seminar, I felt it would be a mistake to offer her intensive therapy. I did my best to play up the less traditional options, but no dice—she had come for individual therapy and that was what she was determined to get. I felt like I was being too pushy and so with some feelings of guilt and a little resentment I found space in my schedule to begin seeing her next week.

In my next walk-in clinic, I convinced one student to accept an invitation to participate in the therapist assisted online program (step 5) and two others to join a group (step 6). I couldn’t bring myself to offer the lowest intensity programs but at least I had avoided the dreaded step 7 (individual therapy)!

But my sense of accomplishment was short-lived. I soon learned that the student referred to the online program never completed the registration, one of the group referrals did not meet the group screening criteria and the other group client never showed up for any sessions. Clearly I didn’t have the hang of it.

I decided to observe another therapist conducting stepped-care walk- ins. This therapist took a different approach—it began as I had been trained, with asking the client to say in her own words what issues she wanted to work on. This therapist explained the model after about five minutes and she tailored the message using some of the client’s words and by focusing on the issues of importance to her. In this context the stepped care options seemed more natural and logical. Unlike my previous efforts, this therapist did not appear to be trying to sell a product or convince a reluctant buyer. In the end I found my own style which had a blend of both approaches—a much shorter explanation of the model at the beginning with details explained after hearing the client’s story.