Mick Cooper, Professor of Counselling Psychology, University of Roehampton

Yesterday, my lovely osteopath said to me at the start of our session, ‘What would you like to work on?’ It was unexpected and I smiled: funny to be on the other side of preference assessments.

My response wasn’t what I have written about: ‘Erm…. no idea,’ I said to her. Then smiled again: ‘You decide.’

One of the criticisms of asking therapy clients about their preferences is that they often don’t know, and it can make them feel put on the spot. So what was it like for me to be asked that question?

First: yes, it was true, I didn’t know at that moment. But, actually, it still felt good to be asked, and putting it back to my osteopath was a way of saying, ‘I trust you to do what is best for me.’ In our recent research asking therapy clients how they experienced preference work, one of the big things we found is that a lot of it was about developing the relationship—perhaps even more so than matching to the clients’ preferences, per se. That is, when clients were asked what they wanted from therapy, they felt more trusting of the therapist and more listened to, regardless of whether they knew what they wanted or not at the specific time.

For me, there’s a massive difference between someone saying to me: ‘We’re doing this…’ and ‘Why don’t we try this…. but let me know if you want to do something different.’ With the latter, it feels like there is so much more space, freedom, respect. I actually don’t mind being told what to do a lot of the time—and sometimes I really want it—but there’s a mile of difference for me depending on whether or not I feel I can input if I want to. Because if I can input, I’m not really handing over control. I’ve still got a say in what’s going on. It feels like someone is, temporarily, looking after me, not taking away my rights and ability to be self-determining.

One thing I’ve really learnt in preference work is that it’s not just about those then and there moments, but about what it sets up for the therapy overall. It’s about creating an atmosphere, a culture, a relationship: one of collaboration and partnership. So if you ask a client what they want, gently, and they say they don’t know, don’t be discouraged: it can happen a lot, and it doesn’t necessarily mean it was the wrong question to ask. Just maybe the client couldn’t answer it at that point in time.

Because the other thing I realised with my osteopath is that, actually, I did have some pretty strong preferences. Like I really wanted to work on my foot because it’s still hurting after I strained it badly. So why did I just say ‘I don’t know’ when I was asked about my preferences? Partly I think I was just a bit surprised—I had expected her to lead the way—partly I had my head elsewhere and needed some time to settle in. Did I need her to ask me more questions to bring those preferences out? Partly, but I was actually just really pleased with her getting on with what she thought was best, and then as things came to me I could feed them in. But, yes, I think it might have helped if she had asked me again, say half way through the session, about anything that I particularly wanted to use the time on. I think I could have been a lot more articulate there.

So, in therapy, as we’ve learnt, clients may just need some time to articulate their preferences, and they may need to try some things out to find out what works for them. In fact, in our qualitative research, we found that a lot of client preferences emerged from what was happening in the sessions themselves. Clients, for instance, were asked about their childhoods, or they did some chair work, and then they thought, ‘Wow, that was really helpful, I’d like to do that again.’ So having some regular times when you can ask clients about their preferences and any new ones that have emerged—for instance, at regular review sessions—can be really good practice for ensuring that any emerging preferences are incorporated into the therapy work.

This morning I went to my pharmacy to pick up a fairly urgent repeat prescription. They didn’t have it and told me to contact the GP surgery. I rang the surgery and they told me it was the pharmacy’s fault. When I rang the pharmacy, they told me the surgery hadn’t signed it off. Finally, some hours later, I got the prescription through, but it was a frustrating and annoying process and I did get scared I’d just be left without the medication for days on end. It was an experience of powerlessness—I had no choices. And no-one seemed to particularly care about what that experience might be like for me or what I might be needing or wanting. Of course, if the pharmacist had said to me, ‘What are your preferences here?’ and I’d said, ‘I want my medication,’ and they’d said, ‘OK, but we still can’t give it to you,’ that wouldn’t have added much benefit to my experience. But that asking and engaging with preferences seems to be a hallmark of a system that actually cares and wants things to go well for you. And also one that engages with you personally and as a person: not as one more number to be shoved through whatever systems and procedures and mechanisms are put in place.

The sad thing is, of course, that I got personalised preference assessment in a private context; a brick wall of disinterest in a vastly under-resourced public service. Assessing and accommodating preferences requires resources: if everyone is stretched to their limits, flexibility is going to be a lot harder to come by. But even so, whatever the limitations, those small questions—’What would you like here?’ ‘How might we use this time?’ ‘Any strong preferences for what we do or don’t do?’—can, I think, achieve so much. It sets up a relationship of care, interest, and collaboration; and safety, because it’s an indication of a willingness to share control. The benefits of actually matching to clients’ preferences, and the benefits of introducing into the therapeutic relationship a willingness to match preferences, may be two very different things.

Acknowledgements

Photo by Emiliano Vittoriosi on Unsplash