Step 10. Offering Alternatives to Client Preferences

We respectfully propose alternatives to clients’ strong likes and dislikes when we believe their preferences will not be most suited to the particular context or when it does not produce the desired results. Clinicians may propose an alternative because the client shows signs of deteriorating, is not making any progress with their preferred approach, refuses to continue it, or threatens to discontinue.

Just because a client desires something does not mean that the therapist automatically provides it. Ethical, legal, and clinical constraints still bind the therapist to responsible and effective practice. In certain cases, clients may lack motive congruence: Their explicit, self-attributed preferences bear little relation to their implicit, actual desires. There are indeed limits of meeting client desires.

When unable or unwilling to adopt or adapt client preferences, we propose therapeutic alternatives. Those alternatives are preceded by, and embedded within, an in-session sequence of processes. We use the mnemonic the three Es:

• Explain your reasoning for not accommodating. This is largely a cognitive frame; for example, ethics do not permit that, or research does not support that preference.
• Empathize with probable client disappointment. This is largely an emotional response.
• Educate clients about the proposed alternative. Conduct role socialization or client education about the value of, for example, emotional work and in-session discussion of the client-therapeutic relationship.

Here’s a slightly edited a transcript of the male therapist working with the female client who preferred multiple hugs in treatment sessions. He follows the three Es in proposing an alternative.

T: I completely understand your desire for lots of hugs in our sessions. That’s who you are and how you relate to others.

C: Yes. My family and I are big on the hugs [smiling].

T: My code of ethics and, well, my therapy style advises against frequent physical hugs with clients. That’s to protect clients, to keep therapy professional. How will that feel to you if we work together?

C: Not sure. I understand the need to keep things professional, but . . . [trails off].

T: I sense your hesitancy, you being unsure. And perhaps disappointed that I cannot give you the hugs?

C: Yes, some disappointment. But I get your reasoning. Hugs can be misinterpreted . . .

T: Exactly. And we want no misinterpreting here. This should be a safe place, a trusting place for you.

C: Uh-huh [nodding slowly].

T: I would like to propose that instead of physical hugs, I give you lots of verbal hugs - support and validation. That you feel I am embracing you with words. Could that work?

C: I think so . . . That’s how it works with my [medical] doctor. She’s not much of a hugger, but I know that she likes and cares for me.

T: That’s exactly how I hope you feel about our therapy relationship. Lots of support. And I can certainly meet your other strong preference for homework between sessions. Would you like to try that? Or prefer that we find another therapist who might give physical hugs?

C: Definitely with you. It’ll work just fine.

The relational heart of the matter is listening and seriously considering the client’s perspective. Even when we cannot adopt or adapt the client preferences, it is done with empathy and validation and full explanation: Share your belief when the expressed preferences are not in the client’s best interest so that treatment decisions can still be made collaboratively.

Before treatment commences, there are several areas when we cannot adopt or adapt client preferences: limits of practitioner competencies, ethical conflicts, and nonprogressing clients (also known as treatment failures). Each of these may merit an alternative approach.

Clients may desire a practitioner of a particular demographic (e.g., female, gay, Latinx) or experience (e.g., a therapist who is a parent, married, recovering alcoholic) that does not match their assigned clinician. Or they may seek medication from a nonprescriber or conjoint family therapy from someone not trained or proficient in it.

One of our residents recently evaluated a 21-year-old male client seeking therapy in a university counseling center for social anxiety. The intake interview proceeded well until the clinician described her preferred and well-researched intervention. The client cited religious values that proscribed some of those CBT methods and instead explicitly requested a religious-accommodative approach that entailed trusting God and surrendering to the anxiety, in contrast to cognitive restructuring and exposure.

The resident had little experience in religious-accommodative approaches and no competence in the surrender or acceptance method but wanted to honor the preferences as far as possible. Should the clinician consult a clergy person, try to convince the client of the value of CBT, begin by adopting the preferred approach, adapt parts of the preference, or propose an alternative?

We were befuddled on how to proceed. Although there is considerable research to support religious accommodation, there are no known RCTs on the client’s desired treatment in particular. In fact, most of the outcome research supports the opposite of the client’s preference. We wanted to support the client’s autonomy but simultaneously uphold the ethical principle of beneficence.

The bottom-line question was whether the probable outcomes justified incorporating the preference. When we “staffed” the case, fellow clinicians reached no consensus and recommended all of the preceding clinical options.

As in the case of the client who preferred multiple hugs, sometimes clinicians will need to say “no” to a client’s wants and offer alternatives because they are inconsistent with the practitioner’s ethical or professional frame.

Watch this video on offering alternative preferences:

Consider this chat scenario: A client (user) at 7 Cups shares that they prefer self-harm as a way of "coping" with sudden anxiety. In the box below, use the three E's to write an alternative response/preference.