Mick Cooper, Professor of Counselling Psychology, University of Roehampton

Asking clients about their preferences, and trying to accommodate them, is right at the heart of pluralistic practice. But what is that actually like for clients? Do clients want us to ask them about their preferences? Do they find it helpful? And what if they don’t know what their preferences actually are? We know from the evidence that assessing and accommodating preferences is, overall, helpful, but so little is known about how or why this might happen, and how things are seen from the client’s side of the room.

Several years ago, when I was working with Joshua Swift (Idaho State University) on his meta-analysis chapter of the quantitative research on preferences, he said that it would be great if, one day, we could also do a qualitative study to see how clients experienced preference work. I agreed, and some time later a funding opportunity came up from the Division of Counselling Psychology (BPS) to bid for some money to do this work. We were fortunate to win the funding, and appointed Gina di Malta to work as our Researcher on the project; with Hanne Oddli (University of Norway), a world-leading qualitative researcher on clients’ experiences, also involved.

What about the qualitative method to use? ‘Thematic analysis’, ‘interpretative phenomenological analysis’, ‘grounded theory’? I love most of these methods, but one approach I’d never used, but had always been really drawn to, was consensual qualitative research (CQR), developed by the brilliant psychotherapy researcher Clara Hill and her colleagues in the United States. CQR had always impressed me because, uniquely, the coding and analysis process is all done as a team, so that there’s a constant triangulation between different researchers’ viewpoints. It sounded very ambitious, but I was keen to try it, and we were amazingly lucky to have one of its founders, Sarah Knox (Marquette University) join our research team to guide us through the method.

At our therapy research clinic at the University of Roehampton, we were offering clients with symptoms of depression up to 24 sessions of pluralistic therapy (for those of you who don’t know, this is a collaboration integrative form of therapy). So we used that as the context to conduct the study, interviewing 13 clients in total. We started interviewing clients, at the end of their therapy, about how they found the preference work: Did they find it helpful? If so, in what ways did it help? And also questions about the kinds of preferences they had and where their preferences had come from? Rather than asking generally, we’d start the semi-structured interviews by asking the clients about one particular preference and then focus on that — then another preference if there was one, etc. And then, as the data came in, we’d meet weekly (for about a year or so, either as a whole team or in pairs) and analyse it. First we broke the transcribed interview data into different ‘domains’, depending on what the client was talking about. Then, for each client, we summarised the core of what they were saying in each domain. After that, we brought all the ‘cores’ together to summarise the responses across clients. As per CPR methodology, Joshua worked as ‘auditor’, meaning that we’d send him the analyses at particular points and he’d given us feedback on where he thought we could improve it. All this checking and cross-checking meant that the analysis wasn’t any one individual’s interpretation of the data, but a collective, multi-perspective understanding. One thing I really learnt during this process was how different two people’s interpretations of the data could be — sometimes, we’d spend a whole hour arguing about what a client had been trying to say! It made me realised how ‘subjective’ any individual analysis was going to be: not wrong, but less representative of how most people might understand the data as compared with having a team working together. The team work was also a lot of fun and a chance to really thrash out understandings with informed and experienced colleagues.

So what did we find? The write-up of the results and the rest of the paper are now available here, published open access (i.e., available to everyone, which is great) in the highly-respected journal Psychotherapy Research.

Did the clients like being asked about the preferences?

Generally, we found that they did, though we needed to be really careful about introducing our own biases here. What was particularly interesting was why the preference work was helpful. John Norcross and myself, in our book Personalizing psychotherapy: Assessing and accommodating patient preferences, had suggested three possible reasons: 1. Because it gives clients what they know is best for them, 2. Because it helps client feel empowered, 3. Because it helps to develop the alliance. In fact, we found most evidence for the third of these reasons: that being asked about their preferences helped clients feel safer, more trusting, and more listened to by the therapist. At the same time, we found some clients didn’t find it helpful being asked about their preferences; and, also, some clients found it was helpful when the therapist did things that was counter to their preferences. So it was a nuanced picture here, and clearly one that suggests a need for ongoing communication between therapist and client as the work unfolds.

What kinds of preferences did clients have?

There’s quite a bit of quantitative work, to date, on what clients want to happen in the therapy room (particularly using our new C-NIP measure, see for instance here), and our qualitative data triangulated well with these findings. Typically, clients wanted quite an active style of therapist, with the therapist leading the way rather than being passive or disengaged. But they also wanted the therapist to be warm, to listen, and to give them space to explore.

Where did clients’ preferences come from?

A really interesting question we explored, which hasn’t been investigated in the literature at all to date, was the origins of clients’ preferences. Clients indicated three sources. First, their preferences were a result of things about themselves or their current circumstances: for instance, they knew they were someone who liked a lot of space to talk. What I found particularly interesting here was that, sometimes, clients wanted the thing they knew really matched their personality (e.g., ‘I like talking about the past, so let’s do that’) and sometimes they wanted the thing that was opposite of how they typically did things (e.g., ‘I like talking about the past, so I know, in therapy, I need to focus on the present’). Second, their preferences emerged from the current therapy: for instance, the therapist did something, like ask them about their childhood, and then they realised that was really helpful. Third, their preferences came from their previous episodes of therapy, and particularly unhelpful experiences: like being pushed to talk about something they really didn’t want to.

Did client preferences change over time?

This was another really interesting and new question, and generally we found a mixed picture: some preferences changed, but some didn’t. So, for instance, some clients would come in wanting direction and guidance, and still want that by the end of therapy; whereas other clients might want to talk about their past at the start of therapy, but by the end realise it was more helpful to talk about their present.

What facilitated preference work?

We really wanted to know what clients felt would help, or hinder, the assessment and accommodation of preferences, but we did not find so much here. The main facilitating factor was being actively asked by the therapist what their preferences were, the main inhibiting factor was their own reluctance of shyness to disclose what they really wanted.

Conclusions

As with all good studies, by the time we got to the end of it, we probably had more questions than answers. I wanted to know more, for instance, of where clients’ preferences came from; and the intricate and nuanced patterns of changes, or stability, of preferences over time. And how, more exactly, did preferences help to build the therapeutic alliance and what was the effect of that? These are all questions that I really hope future researchers will follow up through qualitative (or perhaps also quantitative) work, and it shouldn’t be too difficult: interview clients who are involved in a therapy where there is preference assessment and accommodation, and talk to them about what they’re experiencing (with the appropriate ethical scrutiny in place, of course). That’s what I love about qualitative research: you can just talk to clients, deeply, about what’s going on for them: what could be a better way of finding out about therapy processes and outcomes!

But our research does also have some important implications for practice. Asking clients about their preferences, generally, seems to be a good thing, as part of forming a strong early working alliance. There’s something here for me about just getting that collaborative ‘energy’ going from the start: forming the kind of relationship where you can talk easily about the process of therapy itself, and what clients might or might not prefer–if anything–along with developing a warm and supportive bond. And you can ask clients about preferences that come from their own characteristics and situation, that might come from previous episodes of therapy, and also as the therapy progresses–what are clients finding helpful or not? Actively asking clients about preferences, rather than assuming clients will just say them, seems to make sense. There’s also something here, consistent with the quantitative research, that generally clients do seem to want a quite active style of therapy. I think this raises questions about more ‘passive’ forms of practice (as some types of person-centred and psychodynamic work can be experienced): at the very least, be alert to the fact that some clients here will want a more active therapist presence.

Maybe my biggest learning from this project, as above, is just the sheer value of talking to clients about what works for them in therapy. It’s such a rich, nuanced, complex wellspring of data: there’s so much we can learn about what’s best, particularly if we can put our own biases and agendas to one side. And, of course, there’s no easy, black-and-white answers: and what clients say in general is never as important as what the individual client in front of us. But qualitative research with clients can give us some brilliant insights about where we start from, what to consider, and where or where not to possibly go. It’s where research meets practice (and theory and self-development too): a way of developing therapeutic practice that is fundamentally pluralistic in its evolution as well as in its application.

Acknowledgements

Photo by Nathan Dumlao on Unsplash

Publication

Cooper, M., Di Malta, G., Knox, S., Oddli, H. W., & Swift, J. K. (2023). Patient perspectives on working with preferences in psychotherapy: A consensual qualitative research study. Psychotherapy Research, 1-15. https://doi.org/10.1080/10503307.2022.2161967 (available open access)