Mick Cooper, Professor of Counselling Psychology, University of Roehampton

Is it always helpful to ask clients in counselling and psychotherapy about their preferences, and to fully accommodate them?

Of course, from a pluralistic standpoint, that is the wrong question to be asking. Overall, meta-analyses do show that preference accommodation is associated with reduced drop out and a small improvement on clinical measures. But that does not mean that the individual client in front of us will necessarily experience those benefits. Pluralism means acknowledging that different clients may need different things at different points in time, and that principle is also relevant to practices that are characteristically ‘pluralistic’ too.

But how can we predict when preference accommodation might be beneficial?

As a first step, our colleague, John McLeod, has recognised that preference accommodation might have impacts in three, potentially independent, ways.

First, there are the potential effects of making a choice. That is, the impact on the client of being given the opportunity to choose between different goals, task, methods, etc.

Second, there are the potential effects of treatment matching. This is the impact on the client of working with the particular goals, tasks, or methods that they have expressed a preference for.

And then, third, there is the effect on the therapeutic alliance.

The effects of making a choice

So what are the effects of being able to make a choice. In many cases, as we’ve found in our research on shared decision making, clients may feel respected, valued, and empowered by being offered this opportunity. However, other research shows that having choices can also feel overwhelming.

This might be partly determined by the client’s need for independence, or for control. Some people really want to have choice in matters; others are less keen to, and prefer others to make decisions for them. But this is also likely to vary a lot by situations, and probably how much someone knows about something is likely to be a key factor (the technical term being domain familiarity. For instance, if I go to a restaurant (say Chinese), where I know the food style back-to-front, I’m going to feel really patronised if someone starts ordering for me. But if I go to a restaurant that is unfamiliar to me (say, Madagascan), I’m likely to be much happier letting someone order my food.

Then there is also whether the choice matters to me or not. If it’s ordering food at a night out at a restaurant, probably, choice won’t be incredibly important either way. But if it’s deciding what mortgage to buy, or a medical treatment for my children…

So what we could predict from this is that the accommodation of preferences is likely to be more important for clients who like having choice, control, and independence in their lives; and perhaps less important–or maybe actively unhelpful–for clients at the other ends of these spectra. But also clients who know more about counselling and psychotherapy–in particular, through having past experiences of it–may feel more valued and empowered by being asked about their choices.

The effects of treatment matching

Then there’s the potentially beneficial, or deleterious effects, of getting the thing that you actually asked for. But we know from research that what people want and what people may actually need, are not always the same thing. So the effects of treatment matching are only ever likely to be as beneficial as the knowledge someone has of what actually works for them.

Again, domain familiarity (i.e., experience of being in therapy) probably plays a crucial role here. If someone has had previous episodes (as many of our clients have) then there’s a good chance that they’ll have developed some knowledge of what does, genuinely, work for them (just like I know, after years of going to Chinese restaurants, what I like). For instance, they’ll have learnt that long silences make them feel very uncomfortable, or that they find it really valuable exploring past relationships in therapy. By contrast, someone who is new to therapy may not really have any idea or experience of what is helpful for them. They may have experience from talking to friends or family of what works that they can draw on but, for some clients, there may just be a blank when they are asked about what they find helpful in interpersonal relationships.

In some cases, too, clients’ views on what works for them may be an expression of particular biases, assumptions, or defence mechanisms that actually pull against what will be, ultimately, most healing. For instance, a client may feel very uncomfortable in silences and express a preference for them not to be there, but learning to tolerate uncomfortable social encounters may be of the utmost therapeutic value.

The effects of a strengthened therapeutic alliance

When people give me choices about things, and then take my preferences into account, I tend to feel better with them. That’s not always a straightforward thing: someone can offer choice, say tickets for the theatre, in a very cold and disinterested way. But, generally, the offer of choice brings with it a sense of collaboration, bond, working together–all the things that are representative of a good therapeutic alliance.

That’s something we’ve seen in our qualitative research, talking to clients about the experience of being in pluralistic therapy. They don’t always say that preference accommodation was the key to their psychological change, but what they do seem to say is that they appreciate the therapist trying: asking them what they want and then trying to meet their preferences. It’s experienced as a sign of good will, of respect, of trying: even if they don’t get it right.

Who’s that likely to be most important to? That’s really not clear to me, and the research doesn’t tend to show any particular moderators of alliance effects. Maybe clients who find the alliance difficult will be affected more by this… but it could be the other way around: that those who are able to form good alliances do even better when there’s other factors to ‘solidify’ it. I guess it’s an empirical question that we’ll need to research to see.

Conclusions

I’m increasingly beginning to think that any process of preference elicitation and accommodation in therapy should probably be preceded by a question or two to the client about the extent to which they want to be involved in these choices. At the very least, that would give the therapist a steer on how much to focus on metatherapeutic communication. Alternatively, perhaps a gentler way in may be to ask clients about past experiences of therapy, and what they liked and didn’t like. From the research, and from my own clinical experiences, having past experiences of therapy is probably as good a proxy indicator as you can get of whether or not a client is likely to have preferences for therapy.

What the research also shows is the nuances and subtleties involved in effective preference accommodation work. Clients’ preferences, at times, may be an expression of their defence mechanisms, but this does not mean swinging to the other extreme that ‘There is no point asking clients about their preferences.’ In many cases, certainly in my clinical experience, clients do have a good sense of what is right for them. So, as we say in the pluralistic field, we need to try and avoid ‘either/or’ thinking, and instead stay with the complexity of issues and practices. Therapy with a client who likes to be autonomous, who knows himself or herself well, and who has had lots of previous therapy, may really benefit from preference accommodation. By contrast, preference accommodation may be of little added value for a client who is new to the experience of therapy, limited in their self-knowledge, and wanting the safety of being told what to do. And, of course, it might turn out that, for these specific individuals, the benefits of preference accommodation are entirely the other way around. So, as with all clinical skills, there are no certainties or definites in how we should work. What is needed is sensitivity, subtly, and being responsive and in dialogue with the unique individual in front of us. If nothing else, at least that will help to consolidate the therapeutic alliance.