Chapter 18: Putting It All Together: Working With Clients in the Three-Stage Model

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Welcome to the Deep Dive, where we unpack complex ideas and really extract those essential insights from your sources.

I'm your guide today.

We're kicking things off with a quote that I think really captures the heart of therapy.

It's from Anais Nin, and the time came when the risk to remain tight in a bud was more painful than the risk it took to blossom.

That's beautiful.

It really sets the stage for growth, doesn't it?

Yeah.

Which is exactly what we're exploring today.

Exactly.

Our mission is to journey into Clara E.

Hill's helping skills, specifically that critical final chapter, putting it all together.

Right, the three stage model and practice.

Yeah.

And this Deep Dive is really for you, the aspiring counselors, the psychology practitioners out there.

We want to help you move beyond just knowing the individual skills to actually integrating them, you know, managing whole sessions, thinking about cases holistically.

It's about building that practical roadmap for when you're actually sitting with a client.

We'll touch on, well, pretty much the whole process from the intake.

That crucial first step.

Yeah, and the work between sessions, which is huge, all the way through ongoing therapy, determination,

and even handling those really challenging situations.

Okay, so let's dive into that first encounter, the intake session.

You said it's more than paperwork.

Oh, absolutely.

It's multifaceted.

You're trying to understand why they're there, obviously, formulating maybe a preliminary diagnosis, assessing for immediate risks, safety first, always.

And figuring out the best way forward, the treatment plan.

Exactly.

So you need to gather quite a bit of information efficiently.

Like what specifically?

Beyond the basics, the demographics.

Right, you need the presenting concerns.

What brought them in now?

How urgent does it feel?

And you want details, the feelings around it, the thoughts, how it impacts relationships.

So the effective cognitive relational pieces.

Precisely.

And the problem's history, what they think contributes to it, how intense it is, what they've already tried.

Got it.

What else?

A brief psychosocial history, family background, current relationships, work or school, living situation.

But always as it relates to the problem they came in with.

You don't need their whole life story necessarily, but the relevant context.

And health stuff, too.

Definitely.

Current health, meds, any substance use, including caffeine, alcohol, sleep, eating, exercise.

It gives you a fuller picture.

And you mentioned risk assessment earlier.

That seems critical.

Absolutely vital.

Danger to self, danger to others, substance abuse.

You have to ask directly.

And finally, what do they expect from therapy?

Both the process, what happens here, and the outcome.

What changes are they hoping for?

So you're gathering all this data, which sounds quite directive, lots of questions.

It is directive.

You often have to use close questions for specific facts.

But here's the key.

You must do it while using attending and exploration skills.

Like reflecting feelings, restating.

Exactly.

Summarizing.

You need to make the client feel comfortable, feel heard, even while you're gathering this necessary info.

Otherwise they might shut down or you just get superficial answers.

That makes sense.

You need the connection to get the real story.

Right.

And interesting research by Tipton and Hill actually found that clients who do return for more sessions,

the engagers tend to experience fewer negative indicators during intake.

Negative indicators.

Like what?

Maybe feeling judged or rushed or misunderstood.

Engagers also spent more time discussing goals and their problems.

It suggests maybe they were less resistant to begin with, or perhaps the helper did a So that first hour is incredibly influential.

Hugely.

And the intake usually ends by asking about commitment.

Sometimes suggesting a trial period, maybe three to six sessions can help if someone's hesitant.

Less pressure.

Okay.

So the client leaves.

Session's over.

Not for the helper.

This is where some really deep work happens.

The behind the scenes stuff between sessions.

Case conceptualization.

Exactly.

This is your thinking time,

developing hypotheses,

educated guesses,

really about where the client's problems come from, what the underlying themes might be, and thinking about what interventions might actually help.

You're building this mental map of their world.

How do you actually do that effectively?

Well powerful tools include reviewing your sessions, listening back to audio, or even better watching video recordings if you can.

That sounds intense.

It can be.

But imagine pausing after you say something and asking,

what was I thinking,

feeling?

What was the client reacting to?

What might I have done differently?

It's incredible for self -awareness.

And process notes.

Absolutely.

Writing notes right after the session helps capture things while they're fresh.

You document the obvious stuff, the manifest content.

What they talked about.

Right.

But also the underlying content.

The unspoken meanings, the things between the lines.

You look for their defenses, their barriers to change.

How are they avoiding difficult feelings?

You mentioned transference and counter -transference too.

Yes.

Transference is about the client's reactions to you based on their past relationships.

Counter -transference is your emotional reaction sparked by the client.

Both are super important to notice.

And then assessing your own work.

Yeah.

A quick personal assessment.

How did my interventions land?

What would I change next time?

All this reflection helps you spot those underlying themes.

Like recurring patterns.

Is there a pattern of being passive?

Or always needing to be liked?

Or constant anger?

These themes are like signposts pointing towards the core issues.

This sounds like it requires ongoing learning too.

Definitely.

You need to stay updated on theories, research.

Pick a theoretical orientation that resonates and keep learning.

And crucially, especially when you're starting out, get supervision.

Supervision seems key for this conceptualization part.

Invaluable.

Yeah.

A supervisor helps you bounce ideas, explore hypotheses, and manage your own stuff.

Like counter -transference.

It keeps you grounded and ethical.

So intake done.

Between session, work done.

How do you actually kick off that next session?

You said it's not just picking up where you left off.

Right.

Flexibility is paramount.

So much can happen in a week or even a few days in a client's life.

You can't assume they'll be in the same headspace or want to talk about the same thing.

So what are the options for starting?

Several ways.

You can just sit quietly and let the client begin.

Though some might need a little coaching on that expectation.

Okay.

Or you could offer a brief summary of the last session.

Ask how they felt about the last session.

Or perhaps most commonly, just ask simply, what's on your mind today?

Or what would you like to talk about?

So be ready for anything, but respond to them in the moment.

That's the essence of it.

Big challenge for new helpers, for sure.

And once you start, focus becomes important, right?

To avoid just drifting.

Absolutely.

Sessions without focus can feel unproductive.

Usually, a clear focus emerges around a specific incident, a particular feeling, or a behavior they're struggling with.

How do you find that focus?

Typically, you ask what's troubling them now.

The book gives an example of Michael, who started talking about his grandmother's death.

But it quickly became clear the real heat was around a recent breakup.

So the helper skillfully shifted the focus there.

If a client genuinely can focus, well, then the lack of focus itself might become the focus.

Interesting,

and respecting their choice of topic.

Crucial.

Even if you think something else is more important, like if Moira wants to talk philosophy while you're worried she's failing classes,

early on you generally follow her lead, unless there's immediate danger.

Build trust first.

So skills for focusing.

Observe them closely, whereas the energy, the emotion, reflect the feelings connected to what seems most important, then you can kind of branch out from that central point, explore related areas, but keep coming back.

And always link it back to their experience.

Yes.

Even if they talk about someone else, my boss is impossible, reframe it to their experience.

You sound really frustrated with your boss.

You can help them change their reaction.

You can't change the boss.

More effective, more ethical.

Okay, this leads us into the main part of therapy, the working phase.

You mentioned cycling through exploration, insight, and action, the EIA model.

Exactly.

This is the engine of the middle sessions.

You respond to what the client brings by moving through these stages.

So exploration is digging deep into thoughts and feelings,

talking it through.

Then insight is about making connections, seeing patterns, understanding why things are the way they are, gaining new perspectives.

And action is the what now part.

Making changes.

Could be changes in thinking, feeling, or actual behaviors.

The ultimate goal.

For the client to learn this EIA process themselves, so eventually they don't need you as much.

Making ourselves redundant, ideally.

In a good way.

Therapy goals and length vary hugely, of course.

Brief therapy, maybe 12, 20 sessions, might focus on symptom relief, like fear of public speaking.

Okay.

Longer term work tackles deeper interpersonal patterns or issues like trauma, grief, finding meaning.

And sometimes, in longer therapy, the relationship itself becomes a focus.

Well, conflicts or tensions might arise between helper and client.

Using immediacy skills, where you talk directly about what's happening in the relationship right now, can be incredibly powerful.

It offers a corrective relational experience.

Like a safe place to practice new ways of relating.

Precisely.

They learn new patterns with you that they can then take out into the world.

Let's make this EIA model concrete with that example of Maria from the book.

The university student.

Great idea.

So, exploration.

The helper starts open -ended, tell me about yourself.

Maria talks anxiety, feeling stuck, not talented.

The helper reflects, you sound anxious.

Ask open questions about her family role, like being the mediator in her parents' divorce.

Allowing her to go deeper.

Right.

And she eventually connects this to her interest in psychology.

Then insight.

How does the helper facilitate that?

By asking things like, what got you so excited about helping skills?

Then offering an interpretation, a hypothesis.

I wonder if being the helper in your family.

Made her interested in the field.

Exactly.

Maria connects with that.

The helper also challenges her self -criticism about not being smart, pointing out her good grades.

And then offers another interpretation, linking her family worries to her study difficulties.

Helping her see the connection.

Yes.

Leading to awareness, even anger.

And then challenging her need to be the mediator.

Helping her see her parents might manage without her in that role.

And finally, action.

The helper transitions.

So what would you like to do differently?

Maria quickly comes up with setting boundaries with her parents, suggesting therapy for them.

The helper helps her troubleshoot.

Like what to do if mom calls late.

Practical strategies emerge.

Study in the library.

Turn off the phone.

So it's collaborative problem solving.

Yes.

Maria feels empowered.

The helper reinforces this, sets limits for future sessions.

But also gives concrete steps for exploring her major career tests.

Visiting the career center.

She leaves feeling much better.

That's a fantastic illustration of the EIA flow.

And you mentioned ending sessions on time.

Crucial for boundaries.

Start on time, end on time.

And end by briefly reinforcing their work, encouraging them to take it outside the room.

Okay, so therapy progresses, but eventually it has to end.

Let's talk termination.

Right.

If the goal is independence,

then ending the relationship, termination, is a necessary planned part of it.

It's not about a cure.

It's about fostering self -reliance.

When does termination happen?

Well, sometimes it's practical agency session limits.

Someone moves, money runs out.

The external factors.

Ideally though, in open -ended therapy, it's a joint decision.

The client feels ready, they've reached their goals, or maybe hit a plateau.

And ethically, we have to terminate if the client is no longer benefiting.

You mentioned the family doctor model.

Yeah, but Manon Gurman's idea.

Therapy isn't necessarily a one -time fix for life.

It's more like seeing your doctor for specific issues, knowing you can come back if something else comes up later.

Another crisis, a life transition, takes the pressure off finding a permanent cure.

So how do you actually do termination well?

It sounds like it could be emotional.

It often is.

For both people.

Loss is involved.

Man emphasized planning it.

There are basically three steps.

Okay, what are they?

One,

looking back, review what they learned, how they changed, get feedback what was helpful, least helpful, it helps consolidate the games.

Makes sense, too.

Looking forward.

Discuss future plans, any issues still needing attention because no therapy solves everything, and how they'll find support outside therapy.

You might gently challenge unrealistic plans here.

And three.

Saying goodbye, acknowledging the unique relationship, sharing feelings about it ending, and actually saying farewell.

It sounds like it needs time, not just tacked on to the last five minutes.

Absolutely not.

You should initiate the conversation several sessions in advance.

Challenges can arise, feelings of loss, disappointment, maybe even clients avoiding it by quitting abruptly.

Open communication is key.

Sometimes, termination isn't the right step, but a referral or transfer is needed.

Correct.

If a client's needs go beyond your expertise,

say, a severe eating disorder, active substance dependence, serious mental illness, or if they need a different type of help, like family therapy instead individual.

What's the difference between referral and transfer?

Referral is giving them names, contact info, resources, and they take it from there.

Transfer is more active, you might help connect them with the new therapist, maybe even have a joint session, ensuring a smoother handover.

And explaining why is important.

Crucial.

Explain clearly, kindly.

You don't want them feeling rejected, inadequate, or like they're a bad client because you can't help them with that specific issue.

Okay, let's shift to those really tough situations, the ones that really test you.

Right.

And the big caveat here.

These require significant training and ongoing supervision.

Beginners should never handle these alone.

Good point.

What about reluctant or resistant clients?

Very common.

Reluctance is more passive,

maybe lack of trust, fear of change, shame.

Resistance is more active pushback, feeling forced into therapy, negative attitudes.

How does it show up?

Lots of ways, often subtle.

Sticking to safe topics, unrealistic goals, blaming everyone else, being late, forgetting payment, intellectualizing everything, dropping bombshells at the end of the session, or sometimes being openly hostile.

How does that feel for the helper?

Confusing, frustrating, maybe panicky or angry,

or feeling guilty like I should be able to help everyone.

Important to check those self -defeating thoughts.

So what works?

First, normalize it.

See it as avoidance, usually rooted in fear, not malice.

Try to empathize.

Think about your own resistance to change.

Look at your own interventions.

Could you be provoking it somehow?

So self -reflection again.

Always be empathic.

Try to join with them.

Understand their resistance rather than fighting it.

Name it directly.

Invite them to explore it.

Don't just ignore it or give up.

Collaborate on finding incentives for change.

What about clients who get angry?

That sounds stressful.

It is highly stressful.

Often triggers fear or anger in the helper too.

But the key is to treat anger like any other feeling.

Encourage them to talk about it openly.

Help them explore what's underneath it.

Help them express it safely, verbally, and then decide what, if anything, to do about it.

Your job is to listen without judgment, without getting defensive.

What if their anger is actually justified about something you did?

Then you apologize sincerely and change your behavior.

If it doesn't seem justified, you still listen.

Then take it to supervision to understand the dynamics better.

OK, a really serious one.

Clients with suicidal ideation.

Extremely serious.

Suicide is a major cause of death.

You must take any hint or gesture seriously.

No brushing it off.

What do you do?

Direct assessment is crucial.

You have to ask specific questions.

Are you thinking about suicide?

Do you have a plan?

Do you have the means?

Have you tried before?

Ask about substance use, withdrawal, giving things away, feelings of hopelessness, future plans.

Who knows about this?

That sounds hard to ask.

It can be.

But asking does not put the idea in their head.

It shows you're taking them seriously, that you can handle hearing their deepest fears.

It can be a relief for them.

When is the risk considered high?

If they have clear intent, a specific lethal plan, and the means available, that's an emergency.

Immediate actions.

Number one, consult your supervisor immediately.

Number two, ensure safety.

That might mean hospitalization, voluntary, or if necessary, involuntary.

Number three, if hospitalization isn't needed right away, maybe a safety contract, a written promise not to harm themselves and to call a crisis line, or you if urges intensify.

What else?

Number four, with supervisor guidance, you may need to notify their support system, family, friends.

Confidentiality limits are different when there's imminent danger to self or others.

Number five, provide resources, crisis lines, support people, maybe extra sessions, phone check -ins.

And crucially, number six, document everything.

Your questions, their answers, your consultations, your decisions, your actions, everything.

What should helpers avoid doing?

Don't minimize their feelings, oh, you'll feel better tomorrow.

Don't give false reassurance.

Don't be afraid to ask the direct questions.

And importantly, mobilize other resources.

Don't become their only lifeline.

That's too much pressure.

And if the worst happens, helpers need their own support supervision therapy to cope.

One last challenging area,

sexual attraction and therapy.

Yes.

Yeah.

Surprisingly common, something like 87 % of helpers report feeling attracted to a client at some point, feeling it isn't the ethical breach.

Acting on it is.

Absolutely.

Any kind of social relationship outside sessions or obviously any sexual contact is unethical and deeply harmful to the client.

So what do you do with those feelings?

Talk about them with supervision.

That's the safe professional place to process them, understand where they're coming from and make sure they don't negatively impact the therapy.

Supervisors can normalize it and help you maintain boundaries.

And if the client expresses attraction to the helper?

It's a tricky balance.

You allow them to express their feelings like any other feeling, but you don't reciprocate or encourage it.

You maintain clear professional boundaries.

Any involvement outside the therapeutic context is off limits.

Wow.

OK, so we've really covered a lot ground here, integrating everything from Clara Hill's final chapter.

Yeah, from the detailed work of intake and that vital between session thinking.

Through managing the flow of subsequent sessions, beginning focusing that EIA cycle.

To the planned process of termination, making referrals and navigating those really difficult, complex client situations.

It really underscores that these aren't just isolated skills you learn from a textbook.

Not at all.

They're integrated practical abilities you weave together to build rapport, foster real insight and hopefully help clients make lasting changes.

It's about becoming thoughtful, flexible, ethical,

truly effective.

It's clear the journey to becoming skilled is ongoing, constant learning, reflection and really courageous engagement with the work.

So as you listening reflect on all this, here's a final thought.

How might embracing the messiness, the inherent complexities and uncertainties of helping people rather than searching for some rigid formula or cookbook,

how might that ultimately make you a more authentic and maybe more impactful guide for the people you serve?

Something to really consider.

Thank you for joining us on the Deep Dive.