Mick Cooper, University of Roehampton

Recently, I’ve been talking to colleagues–and trying to get my head around–the different kinds of preferences that clients might have in counselling and psychotherapy. At the heart of a pluralistic approach is listening to, and trying to accommodate, client preferences; and thinking about the different types can help practitioners recognise the many different areas in which we can be responsive to clients.

In the literature, the most well-cited taxonomy comes from a series of meta-analyses by Joshua Swift and colleagues (which I had the fortune to co-author in its latest iteration, see here). This distinguishes three types of client preferences:

• Treatment preferences: the macro-level therapeutic approach that a client would prefer, such as CBT or person-centred therapy.
• Activity preferences: the activities that clients hope they and their therapists will engage with during the course of therapy.
• Preferences about the therapist. The kind of practitioner that the client would like to work with, such as Black or lesbian.

This distinction is a really simple and clear one, and a great way to organise the research evidence. One of the limitations, though, is that activity preferences range from the therapist’s way of working (as we assess with our inventory of preferences) to the format of the therapy, such as inpatient versus outpatient. So some more nuancing may be needed as the literature on client preferences develops.

One way of categorising some of these activity preferences comes from research that Fani Papayianni and I did into moments of metatherapeutic communication (or what can be called shared decision-making) (see paper here). We found that these collaborative discussions could focus on six different subject areas, four of which might be domains of client preferences. These are:

• Goals: What clients want from the therapeutic work;
• Methods: The particular techniques and strategies they would like to use, such as chair work or behavioural experiments;
• Topic: The specific things that they would like to talk about, such as their mother or their current relationship;
• Understandings (or formulations): Their preferred ways of making sense of their difficulties.

To this, I might add something like therapist style. This is similar to methods, but less about the particular techniques that the client wants and more about the therapist’s way of being. This is, I think, what our inventory of preferences is trying to get at, where we assess whether clients want therapists to be: (a) more or less directive, (b) more or less emotionally intense, (c) past or present focused, and (d) warmly supportive or challenging.

Another way to sub-divide the activity category would be into therapist activities and client activities. This is a distinction that John McLeod and I used in our original 2011 pluralistic book, and has the advantage that it highlights what clients want themselves to do, as well as what they are wanting from their therapist. For instance, a client may prefer to talk a lot in therapy, or try to solve problems in their lives. This distinction, then, opens up a whole new area for researching, and writing about, client preferences: How about an inventory, for instance, asking clients what they would most like to contribute to their therapeutic work? At the same time, the problem with this client/therapist distinction is that it tends to ignore the ‘in between’. If a client, for instance, wants to discuss past neglect in therapy, is this something for them to do, their therapist, or something that they are inevitably both involved in?

I’ve also been thinking that there’s an important distinction between between-treatment preferences, and those that are within-treatment. What I mean by this is that some of the things that a client wants, such as CBT or a female therapist, are things that are of relevance to the particular therapy that a client enters into. Treatment preferences and preferences about the therapist are particularly of this between-treatment type. But then there are preferences, mainly of the activity type, that are to do with what the client wants once they are in a therapeutic relationship, such as the use of chair-work or challenge from the therapist. These within-treatment preferences are, perhaps, of greatest interest to pluralistic and integrative therapists, because they are about the ways in which we can tailor our work to the particular clients that we are working with. Between-treatment preferences, of course, are also important, but they are more to do with who we should, and should not, work with.

All the taxonomies, to this point, focus on different kinds of preference content. But a very important distinction that my colleague John Norcross makes is between strong preferences, and those that are more weakly held. For John, it is the strong preferences that are of critical importance to assess. If a client does not mind too much either way, it may not make much difference how the therapist works. But if the client strongly wants one thing–or strongly does not–then whether the therapist accommodates this or not may be of much greater significance.

This also touches on another dimension of preferences that John McLeod recently flagged up to me–as found in his research with Jillian Walls and Julia McLeod (see here): between positive preferences and negative ones. For instance, a client may really want to be given homework to do, or they may really hate it. It would be fascinating to research the comparative effects of these preferences. I think some of us have a sneaking suspicion that it’s not doing what clients hate, rather than doing what they like, that might have the strongest effect on therapeutic outcomes.

In conclusion, there’s many different ways of thinking about client preferences, and what I’ve discussed here is just a start. I’m sure readers will have their own ideas about how preferences could be organised, and do leave a reply with your own thoughts. What I, personally, love about research in this area–and in relation to the pluralistic approach more generally–is that there is just so much we still don’t know, and that means so much still to think about and discover. Pluralistically, we’ve all got something to contribute to generating knowledge in these areas: researchers, theorists, clinicians, supervisors and, of course, clients. So what way of thinking about client preferences makes most sense to you?