Step 3. Identifying Your Scope and Limits of Competence

Without clinical expertise, practice risks becoming tyrannised by evidence. - David Sackett  

A foundational premise of evidence-based practice (EBP) holds that research alone will never suffice to make a clinical decision. Indeed, the straight extrapolation of controlled research to practice does not qualify as EBP. Such a linear approach lacks clinical sophistication, sensitivity, and real-world application. Clinicians understandably rail against such naivete and deride it as untenable “cookbook practice.”

There are powerful research reasons (as we have seen) and ethical arguments (below) for considering client preferences.

First, preference assessment and accommodation conveys a deep respect for our clients and their ways of seeing and understanding their worlds. The ethical codes of all mental health professionals contain the core principle of according dignity to the people with whom we work. Second, assessing and accommodating our clients’ preferences means respecting their rights to be autonomous, self-governing agents, another core principle of all professional frameworks. Third, attending to client preferences is a means of “valuing each client as a unique person”. It is a recognition that our clients are not uniform, machine-made products, but individualized beings with distinctive wants and needs.

Such honoring of differences is not only crucial at the individual level but also at the cultural one - and across other sociocultural divides. When we ask, we share power. Rather than compounding feelings of powerlessness, we help such marginalized clients feel that their views can, and should, matter: that they have the right to determine their own pathways towards change.

The take-home here is that the best care requires the integration of client preferences and culture into mental health treatment. It is not a luxurious add on or a clinical option; it proves necessary.

Given the dedication many of us have to individualizing care, it may be easy to assume that we are already sufficiently engaged in preference work. Why do more?

The research shows, however, that there is clearly room for improvement. Approximately a third of clients coming into National Health treatments in England and Wales, and who had a preference for a particular treatment, felt that they were not given adequate choice. Similarly, almost 90% of people with schizophrenia reported that they felt only partially involved or completely uninvolved in their choice of treatment.

For some clinicians, a tailored approach to psychotherapy may mean being open to any preferences that clients, themselves, express: “If clients want something, they’ll ask.” The problem here is that it does not consider the inevitable power dynamic that exists. A related danger is therapists assuming or intuiting that they know what clients want, without specifically asking. Alas, the research shows that there are many gaps, and often our felt sense is not an accurate indicator of what clients want or need.

Thus, we invite you to consider now your own scope of practice and limits to your competence. What is your own scope of practice? By this, we mean what are you (a) competent and (b) willing to offer to your clients?

Assessing and accommodating clients’ preferences is not about being a jack-of-all-trades, nor is it about becoming a chameleon who changes colors to whatever a client requests. Rather, it is about offering flexibility within defined parameters - and, when necessary, referring clients elsewhere.

Assessing your willingness to offer diverse activities is also an important consideration and, to some extent, independent of your competence to do so. For those activities you are competent to deliver, now ponder whether there are any that you are not willing to provide. Alternatively, there are probably treatments and activities that you are not yet competent to provide but would like to develop skills to do so.

You may find it useful to use the Cooper-Norcross Inventory of Preferences (C-NIP; use online here; it can also be downloaded from www.c-nip.net/) to deepen an awareness of your scope of therapeutic styles. For each of the 18 dimensions presented there, circle the range within which you are (a) competent and (b) willing to provide. This exercise can prove valuable if you ask your clients to complete the C-NIP because it may identify areas of compatibility and incompatibility.

Another benefit of completing the C-NIP in this manner is that it underscores the psychotherapist’s flexibility. In fact, we have been playfully accused of using this exercise to demonstrate that the vast majority of active listeners are integrative in practice; very few of us are purists.

After using the C-NIP and reflecting on this step, identify and list the aspects of your listening practice you are willing and able to vary.