A preferred relationship: A response to client preference
Mike Moss; counsellor and supervisor, The City of Edinburgh Council
‘It isn’t the technique, it isn’t the therapist, it isn’t the lack of training. It isn’t the new wonder drug, it isn’t the diagnosis. It is our clients own inborn capacities for selfhealing, and it’s the meeting – the relationship in which two or more sovereign or sacred ‘I’s’ meet as ‘we’ engage with significant questions of existence. ‘(Maureen O’Hara, 1995)
I would like to offer a response to an article which appeared in the April 2021 edition of BACP’s Therapy Today called ‘Working with client preferences’ by Mick Cooper & John Norcross.
It appeared that Cooper and Norcross were suggesting it was the therapist who is best placed to help the client understand what they might need from therapy at the beginning of the work, and if the client’s preferences are not within the scope of the therapist’s experience, the therapist should be able to signpost the client to a different modality. It seems the autonomy of the client and the skills of the therapist are being ignored. In my experience it is good practice to create the conditions for the client to explore their preference more deeply and in this process a level of mutuality is formed and the therapeutic relationship can begin. I am aware choice may be more limited in employee assistance programmes and the public and voluntary sector as I imagine there may not always be the resources yet to offer clients the preferences described in Cooper and Norcross’s article. I believe that focusing on the client’s preferences—as if they were a customer in a shop—and offering a number of different ways they may prefer to engage limits the clients experience towards discovering their own power, and also limits the scope and experience of both the client and therapist learning from each other and creating something unique.
I have wondered about how best I might express my own view here in writing my response and will attempt to explore my feelings as clearly as I can. There was something that didn’t feel quite right for me throughout reading the article. It was hard to define at first. Not that the article wasn’t well written or the points well argued, or that I don’t have admiration for the work of its authors. I do genuinely think they make a lot of valuable points. There was, however, something in reading the article which felt like it was missing. Thinking about this now I realise what it might have been.
The article moved me to thinking about how I might respond as a client and also how I might respond as a therapist, reflecting my experience as if I were a client being asked about all my preferences, or if I was a therapist meeting a client for the first time. I didn’t feel there was enough in the article for me to connect to how my feelings might be held by the way of the therapist being suggested. It felt very much like there would be too many demands for me to come up with ideas about what may or may not be preferable, instead of just meeting to see if we might be able to resolve some of the presenting issues and find our way together, as if on a journey discovering where our relationship might lead.
I also want to acknowledge I find it somewhat difficult to identify my concerns without appearing to argue against client preferences, which I am not. I do believe my preferences as a client, and having a choice of the kind of therapy I want is of great value to my sense of autonomy and for my mental health. I certainly do not intend to take something valuable away from the client’s experience at the start of therapy, as it is so important the client feels heard. It may also be the client hasn’t looked at different kinds of therapy before meeting their therapist and they are unsure of what it might be like for them. However, I am aware there is a great deal of information online about the different types of therapy and also many therapists advertise online, so the risk of getting it ‘wrong’, I believe, will be limited.
Clients will want to be clear about the way the therapist works, and will also be aware of how the therapist makes them feel, and I want to be clear, by stating my own preferences here. I believe that, as a client, I may not entirely know what I need. However, I would need to know that the therapist would have to communicate that they were listening to me, trying to understand me and that, to some extent, they cared about me. Also that my concerns would be taken seriously, and the therapist would be honest about how they might help, by agreeing to work with me to resolve some of what I was struggling with on my own. I know, as a therapist, if a client asks for something I genuinely feel unable to offer, I will explain my response as best as I can and trust the client can make up their mind from there. I may suggest another kind of therapy, which might be more suitable, but not every time.
In my career I think I have only done this once, or maybe twice. Mostly I talk with clients about their preferences in terms of trying to understand them as best I can by being curious and supportive and interested. I may not manage this very well at times, but I do try to show I am trying to understand them as much as I can and, interestingly, this might be what some clients respond to best. I may also offer my understanding about how the client appears to me, and in so doing, it is possible what they are coming to therapy for and what they feel they may need may become clearer to both of us.
I firmly believe that it is in these first tentative steps, of not knowing and maybe getting it wrong sometimes, but trying to understand as best as I can, is where the therapeutic relationship begins. However, it appears to me that Cooper and Norcross are relying primarily on a client’s preferences at the start of therapy, in ‘preference’ to how the client is, and what brings them to therapy. They identify three main types of client preference which they believe the therapist should attend to, which they claim will help to identify what the client needs, by considering: the kind of treatment they prefer, the type of therapist they would prefer, and the types of activities they might prefer. My immediate response is that this might be too much of a demand on the client, who, if they haven’t already sought out a particular type of therapy, may feel somewhat confused and overwhelmed by choice. It has to be remembered that most clients seeking help are possibly feeling vulnerable and anxious, and may not have the energy to make a number of decisions early on in therapy about what they need, and may even seek reassurance from the therapist rather than being asked to consider a list of things as if they were choosing to buy something from a shop.
Cooper and Norcross also consider an example of a client who is seeking ‘warmth and reassurance from their therapist’ and where the therapist believes this might not be what is required. And they go on to suggest that perhaps helping this client to ‘learn to tolerate anxieties and tensions’ would be more effective. It appears that, even in offering client preferences, the therapist in this instance can hold a view of what might be best for the client. Later it is argued there might be some clients’ requests which ‘will not prove helpful’. I have two responses to these assumptions. My first response is that I can understand the therapist having a different view from the client and this is always worthy of consideration. However, this is only the therapist’s view. It may be that, in exploring this view further with the client, it may contribute to a positive and open dialogue if done with sensitivity and care. My other response is towards the attitude of the therapist who appears to show little regard for the warmth and reassurance the client may be seeking, which feels cold, and may discourage the client from entering into safe relationship with the therapist.
It has been suggested in the BACP Good Practice across the Counselling Professions (2021) guidelines that the technique and approach of the therapist may not be influential factors in themselves, as research has shown two of the most influential factors in effective therapy is the quality of the relationship and also the therapist’s skills to create that relationship. The good practice guidelines go on to state that it has also been proven that it is the relationship that heals and not necessarily the methods used. I believe this clearly shows if our work as therapists is about genuinely trying our best to help clients heal, then we should consider how we are at the beginning of every contact and consider what we need—to be able to offer our best in relationship—attending to the needs of the client who asks for help.
I cannot know, at the start of my work with a client, what our relationship will be like, nor can the client, but as humans I believe we have a sense of what feels right for us. And if a new client feels there is something that may be useful for them, and they experience themselves being heard and not judged, and believes the therapist is genuinely trying to understand them, then these may be the indicators which determine the client’s preference. And these may be the indicators which may go on to help develop an effective therapeutic outcome. I trust that where it is my intention to be my ‘best’ to help, and where the client’s intention is to want to be helped, then this goal may be experienced by both the client and I as our therapeutic relationship grows.
I also feel it is important to emphasise that in being human, both therapist and client ultimately share similar experiences of not always knowing what we need, and yet, whether it is in our thinking or motivation or mood. I believe we instinctively sense what feels right for us and know what seems to fit. The therapeutic relationship has always felt exploratory and collaborative to me. I always try to be in the spirit of being curious and patient, and spontaneous and creative, and wanting to help as best as I can, while trusting the client will find their own way towards change and growth and healing; and that our mutual relationship is important, even if I do get in the way sometimes. I also believe the client and therapist can know both consciously and/or unconsciously what is needed, even if it is to pause at times and trust the space of not knowing.
Similarly to Carl Rogers, I believe it is in the experiencing of a nurturing climate, which the therapist endeavours to create, where what he described as an ‘actualising tendency’ becomes evident. And one aspect of this tendency is for the capacity of the individual in a growth-promoting environment ‘to move toward self understanding and self direction’. And, importantly, this directional aspect of the person can be relied on, even when it is not fully known, and that we all have the necessary resources stored in ourselves to transform our experience.
Cooper and Norcross also consider how the therapist should assess client preferences, and suggest a first step is to ask ‘What is my scope of practice?’ I want to add here, publicly, that I do not actually know the scope of my practice. I do know, for sure, I do not work with couples or families or groups or addictions, so I can easily turn down any such requests, and I am clear I only work with individuals. And yet, even in my work with individuals, I certainly don’t think my scope has been reached. My scope continues to grow, I think, and change with each contact with a client, colleagues, supervisees, listening to a podcast, reading an article, listening to a child, or going out for a walk on a sunny day.
I also believe I have the capacity to continue my learning, the end of which I don’t think I will ever know. I am also aware that I work very closely with my supervisors to help me with this process of constantly becoming a therapist, and believe if I am to be genuinely open and available to my clients, I have to be genuinely open and available to the mystery of life. And by not always knowing what my preferences are, I may discover new preferences available to me as they emerge. And who knows if a client will ever want to work with someone like me, who doesn’t always know what is right for them, or himself, and who is still learning to be a therapist.
And finally, I do agree with Cooper & Norcross that there is still much more to learn in how we can effectively help clients, and while research and practice appear to ‘attest to the success of preference work’, I also believe there are other ways to meet the client’s needs. Cooper & Norcross have asked some important questions in the article ‘Working with client preferences’ and I have felt challenged at times. However I still believe we should look again at the focus on client preferences, in light of the factors which show that the therapeutic relationship is the main element towards healing. And as relationships come in all shapes and sizes, the best fit might be to genuinely and warmly ask a client on first meeting with them ‘How can I help?’, noticing how I feel as a therapist to the client’s response to this question, and noticing how I feel as a client to the therapist’s response to my answer, may be the best indication of the way the relationship has begun.
This article was previously published in Person-Centred Quarterly (PCQ) in Autumn 2021 and in the Spring Summer 2022 edition of Counselling in Scotland, the journal of COSCA (Counselling & Psychotherapy in Scotland). PCQ and COSCA have given permission for this article to be posted on the pluralistic practice website.