Jonny Hutchinson, Trainee Counselling Psychologist, University of Roehampton

This blog is a response to one of the points raised in Ong, Murphy, and Joseph’s (2020) critique of the pluralistic approach to counselling and psychotherapy. For reasons of space, I’ve chosen to address just one particular aspect of their argument, but see their full paper for other critiques.

Ong et al. (2020) ask, ‘should a client’s wants and needs precede the ontological position of the person-centred approach of trusting the client’s actualising tendency towards growth?’ They point us towards Rogers (1966) during his developing ideas of client-centred therapy: that the actualising tendency denotes when the person moves in a constructive direction for both their own individuality as well as for their interconnectedness with others. A classical person-centred perspective might argue that explicit attempts by therapists to elicit clients’ wants and needs is an example of an external force interfering with this actualising tendency. However, I will present research showing that clients value and appreciate clinician input regarding their wants and needs, and that we should trust in the intelligibility of such client experiences.

Whether Rogers would have liked it or not clients, now, do seem to want more from us. Joosten et al. (2008) systematically reviewed 11 randomised control studies in healthcare and mental health contexts that compared shared decision-making interventions with non-shared decision-making interventions. Six of these studies found a positive effect of shared decision making on patient satisfaction, increasing patient knowledge, depression outcomes, quality of life, anxiety, and general health status and long-term effects of wellbeing. The remaining five lacked statistical power to detect the significance of shared decision making. Similarly, Ahmad, Ellins, Krelle & Lawrie (2014) found an increasing trend, from 44 to 48 percent of patients in the past decade of national inpatient surveys, wanting more involvement in their care decisions, with the remainder satisfied with their involvement. Adams (2007) surveyed adults from community care settings living with severe and long-standing psychological distress. Respondents reported wanting more involvement in their care decisions than they had previously experienced and were less likely to prefer a passive role. As such, these findings imply UK patients over the last decade see their involvement in decisions relating to their care as increasingly desirable.

This wider shift in attitudes to shared decision making creates an ethical imperative to find out more about how to do this ethically and collaboratively within talking therapies. Gibson et al. (2018) investigated how therapists and clients engaged in shared decision-making in pluralistic therapy for depression. The protocol being researched at the University of Roehampton has been shown to have adequate outcomes, retention rates, and levels of acceptability. The results for this protocol have shown that 71.8% of clients (n = 28) showed reliable improvement and 43.6% (n = 17) showed reliable recovery (Cooper et al., 2015). Analysis of this data set across 14 clients revealed that explicit attempts at shared decision making were initiated by clients on 54 occurrences, versus therapist-led on 120 occurrences. So, it is not true to say that it is always the therapist’s agenda to initiate these conversations and that clients do not feel shared decision-making is important in therapy.

Clients in the Gibson et al. study also felt that their therapists encouraged and supported their activity in decision making discussions, and that this was helpful for facilitating a shared decision-making process. This supports research that clients want to be involved in decisions relating to their care. According to one client in the Gibson et al. study, ‘the [shared decision-making process] helped me to say what it is practically that I want to change in my life through therapy’ (p 98). 

Clients also reported that these conversations helped them feel acknowledged: ‘By having these conversations, the therapist kind of reassured me that like, it’s okay to make decisions like that and to know what you want out of counselling. So the therapist helped me to be able to express my opinions and things’ (p99).

Clients saw this acknowledgement as useful for facilitating shared decision discussions and for encouraging participation in future discussions. Six clients felt it reminded them of their inherent resources to be involved in their treatment decisions and to have some control over them. One client said, ‘It made me feel empowered, but it also then it made me feel like I was empowered by myself’ (p103).

Overall, this shared decision-making process led to clients feeling listened to and understood. ‘I think everything [Therapist] said there was– deeply understood perfectly how I felt’. This understanding was also true for clients’ preferences: ‘it was clear that the [Therapist] had been listening, which was quite cool, like get my preference’ (p103).

A critique of Gibson et al.’s research might be that clients experienced these feelings and perceptions because they had external loci of evaluation. However, I’d argue that facilitating clients’ own feelings of ‘empowerment’ – as some clients described it – is more than just superficial, but really mattered to them, and was enduring to how they engaged in the process of therapy and growth. If we do not invite the findings of this research into our awareness for careful reflection then we fall prey to a stance of, ‘Clients might think that they want X, but really they don’t — this type of change is just superficial’. This stance, in itself, seems to hold a strongly ‘expert’ position in which the therapist puts their own knowledge of the client above the client’s own understanding of themselves and their process. This expert position is particularly perilous given patients not receiving their psychotherapy preferences were almost twice as likely to drop out of therapy prematurely (Swift et al., 2018).

The work of Gibson et al. suggests that a primary role of therapists is to promote client engagement in their own process, perhaps centred on what they want out of therapy, and more broadly in life.

I am excited to broaden the narrative as we continue to use methods of research, such as consensual qualitative inquiry, that invite clients to share their experiences of therapy that were more or less helpful. This method shifts the question from whether or not the actualising tendency is a given, to instead discovering from clients how much they want our input as therapists to facilitate this ongoing, but sometimes unclear, process of becoming.