Complexities of Working with Client Preferences
Caroline Burke, psychotherapist in private practice, Personal Development Tutor, IICP.
The pluralistic approach—which prioritises the perspective of the client, their goals, and preferences—has challenged me personally. I trained as a psychodynamic psychotherapist, so the organic unfolding of a client’s story within the cultivation of a therapeutic relationship, unrestricted by time, is the landscape I am familiar with. Integrating pluralism into my clinical practice, therefore, is a work in progress.
Some clients come to therapy having no prior experience of counselling or psychotherapy and no idea whatsoever of what they want to get from it. They just need to talk to someone other than their friends or family with the hope that it will somehow help them to alleviate whatever discomfort they are experiencing at the time. Other clients present with a clear agenda and are quite articulate around expressing both what they do and do not want. For example one client said to me, ‘I don’t want this touchy-feely approach, I want clear direction.’ While I feel it is important to hear and validate that intention, there is a part of me that cannot help but be curious around what that is about. The dilemma for me, therefore, is around finding a way to facilitate a client’s preferences while also remaining congruent around my preference for creating space to see what develops. There is a wonderful quote in Sue Monk Kidd’s book When the heart waits where she says ’to know exactly where you are headed, may be the best way to go astray. Not all who loiter are lost’. This really speaks to me and my passion around the practice of psychotherapy.
The pluralistic approach, while placing importance on establishing client preferences, does not suggest that we, as therapists, ignore our experience and intuition. Rather it promotes an honest and open dialogue between client and therapist—which feels collaborative in the endeavour—to facilitate a positive outcome for the client.
For example, if a client comes to see me and states clearly that they do not want to discuss their childhood I am aware that my instinctive reaction to that is that that may be exactly what they need to discuss! For me, what feels appropriate in that situation is to say something like:
I hear very clearly that you do not want to discuss your childhood and I want to respect that. This is your session and I want to try to meet your preferences/needs here but would it be ok to share with you where my thoughts go to when you make that statement?
If the client agrees, I can then be honest around the fact that I have a curiosity about their childhood experience. An interaction such as this allows for a more congruent and authentic dialogue between us. The client’s preference for not discussing their childhood is respected but the interaction feels collaborative.
Another possible outcome of an interaction such as the above is that the client, on hearing my thoughts, may get in touch with their fear around revisiting their past and may soften around their resistance to discussing some aspect of their childhood. This may have a bearing on their need for support at this time. This may not happen initially or indeed may not happen at all, which is perfectly OK. However, I feel there is something about naming my curiosity, as opposed to not, that creates an openness to re-visiting the issue, if and when the client feels they have developed a sufficiently strong therapeutic relationship with me. On the other hand, if I do not express my thoughts on the matter and attempt to conduct the therapy in the manner which the client has stated, not only am I a little compromised in terms of my congruence but the possibility of exploring something—which may prove to be very significant for the client—is shut down.
What seems important to me, therefore, is that a dialogue occurs between client and therapist which validates the client’s preferences within the framework of the therapist’s knowledge and experience, while feeling collaborative throughout. This is the ideal scenario of course, but it’s not always easy to achieve.
In the context of client preferences, perhaps the most important choice of all for the client is the choice of a therapist. It feels important to remind ourselves that no matter how many theories/modalities we know, how skilled we are, how empathic, etc, we will not be the right therapist for every client that walks in the door… and that’s OK. I find myself comparing it to online dating—the picture is attractive, you seem to share similar interests/values, have a shared sense of humour, etc., but when you meet there is simply no spark! It’s nobody’s fault, nobody did anything wrong, it’s just not there and you can’t cultivate it. I think the same can be true for therapy. Again, the pluralistic approach speaks to this in its philosophy that one size does not fit all. I feel, where possible, that it’s important to encourage clients to think about whether or not they feel we are a good fit before making another appointment.
I wonder therefore in services where clients do not have a choice of therapist, to what extent that lack of spark or connection impacts on the effectiveness of the therapeutic experience for both client and therapist. From a personal perspective, I have experience of both scenarios. My first therapeutic encounter was after the loss of my only sister in 2002 and I was given the name of a therapist by a friend of mine (also a practising therapist herself). In hindsight, she really wasn’t the right person for me but I was very vulnerable at the time and felt that, because she was recommended to me, I should stick with her—which I did, for much longer than, perhaps, I should have. My last experience of personal therapy was a few years ago and the minute I met my therapist and shook his hand I felt comfortable and safe. I could sense his grounded presence and felt a connection. That experience turned out to be truly transformative.
To conclude, the issue of client preferences is a complex one. From the choice of therapist to the navigation of the therapeutic encounter itself, there is no doubt that not one size fits all. The pluralistic approach endeavours to facilitate a collaborative therapeutic engagement which is respectful both of the client’s autonomy and the therapist’s knowledge and experience, with a view to facilitating healing. It is a tentative balance to find and maintain, and one which continues to stretch me as a therapist.