Step 12. Avoiding Common Pitfalls

Mental health professionals, as a group, are dedicated to individualizing care and are interested in learning how to do so more effectively. After all, who can argue against personalizing treatment to the individual in ways that demonstrably improve outcomes? It is like prizing Mom and apple pie. Not surprisingly, the therapeutic relationship and matching clients to therapists and therapy emerge as among the most desired skills that clinicians want from research.

We should avoid the crimes of Procrustes, the mythological Greek giant who would cut the long limbs of clients or stretch short limbs to fit his one-size iron bed. We should not be imposing a Procrustean bed onto unwitting consumers of psychological services. Psychotherapists ought to be adapting to clients, not the converse.

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. Shared Decision Making (SDM) research has consistently shown that doctors, nurses and other clinicians often think they are sharing decisions more than their clients do.

Here are 4 common pitfalls: 

1. Of course, I respond to any requests my clients make, so why do I need to ask?

The problem here is that it does not consider the inevitable power dynamic that exists in the psychotherapeutic dyad, however “person-centered” the clinician may feel themselves to be. Research has demonstrated that clients are constantly deferring in treatment to their clinicians. They may feel, for instance, that they do not have a right to ask, that the clinician knows best, or that their therapist will become annoyed with them and terminate treatment if they say what they would like. To break through these barriers, psychotherapists need to actively invite clients to state their preferences and make it clear that these are welcome contributions. Assuming this will happen rarely suffices.

2. I am attuned to my clients, so I already know or intuit what they want.

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.

An example of this phenomenon was when I (MC) had an “intuitive” sense that the client needed to talk about her current anxieties, but the client - quite rightly - recognized that she needed to explore more deeply her past. Developing the capacity to recognize and draw on our intuitive, embodied understandings is a clinical competence. But so too is the capacity to stand back from these feelings and recognize them as a single and limited source of information on how best to proceed with clients.

3. I am trained, so I should know what works best for my clients.

Maybe, maybe not. What worked for one person may not work best for another, especially if that person differs in their cultural identities.

Arrogant impositions of therapists’ cultural beliefs in terms of gender, race/ethnicity, sexual orientation, and other intersecting dimensions of identity are culturally insensitive and patently less effective. By contrast, therapists’ expressing cultural humility and tracking clients’ satisfaction markedly improves client engagement, retention, and treatment outcome.

4. Well, it worked for me!

Another potential pitfall is assuming that our clients want what we want. It is tempting to conclude, for example, that because we despise psychotherapists giving us advice or reassurance, that our clients will despise that too. Perhaps you have watched painfully as a fellow professional deposits her treasured life learnings onto an unwitting and unprepared client. This is particularly problematic when what has worked for that professional proves radically different from what works for the client.

Psychologically, this is known as the false consensus effect: we see our own behavioral choices and judgments as more common than they actually are.

Listening and engaging with client preferences work. It works because it conveys respect to the client, and helps the therapy to be tailored to their particular needs and wants.

And it is not hard to do: it requires an awareness of your own scope of practice, a willingness to find out from clients any strong preferences, and then the capacity to discuss this and tailor your work accordingly. Don’t overdo it - preference work is not the be-all and end-all of therapy - but it is one means by which you can help your clients to feel more comfortable and engaged in the therapy work, and to get more out of it.

Watch this video on how not to assess clients:

Reflect on these tips and share how you can improve your listening practice.