Step 2. Recognizing the Power of Preference Work
The mark of a civilized human being is the ability to read a column of numbers and weep. - Bertrand Russell
A wide variety of treatment preferences have been studied in the research. Researchers have compared client choices among different approaches/orientations (e.g., cognitive behavioral, psychodynamic, experiential), formats of psychotherapy (e.g., group, family, individual, digital), lengths of psychotherapy, and characteristics of psychotherapists (e.g., genders, ethnicities, sexual orientations, personality characteristics). They have also asked clients to express preferences for psychotherapy versus medication versus combined treatment, self-help versus formal treatment, and in-person care versus Internet-based health care.
Several meta-analyses (statistical compilations of the results of multiple studies) have examined the effect of client preferences on mental health outcomes. The meta-analyses reached similar conclusions: receiving the favored treatment results in lower dropout rates and better clinical outcomes. Hence, here we canvass the two largest and most recent meta-analyses.
Regarding dropout, analysis of data from 28 studies (3,237 clients) revealed that the overall preference effect for treatment completion was highly significant, both statistically and clinically. The odds ratio of 1.79 indicated that clients whose preferences were not matched or who were not given a choice of their treatment conditions were 1.79 times more likely to terminate prematurely than clients who were matched to their preference or who were given a choice of their conditions.
That’s a huge impact: Clients not assigned to their preferred treatment were almost twice as likely to leave treatment early!
These findings are consistent with those from a separate meta-analysis of 31 randomized controlled trials looking at interventions that can substantially increase attendance at psychotherapy sessions. The single most effective method is to give clients a choice of appointment time or therapist.
Regarding psychotherapy outcome, Swift et al.’s (2019) analysis of data from 51 studies (16,269 clients) also found a highly significant effect of preference accommodation (d = 0.28). This effect size indicated a small to moderate meaningful difference in outcomes in favor of clients given their preferred psychotherapy.
Preference accommodation may have a larger or smaller effect depending on the client; however, client age, gender, and years of education did not show any group differences in the meta-analyses. That is, the impact of preference was similar across populations.
The size of the preference effect among clients of color is still unknown because too few studies have been conducted to compare the power of the effect to White clients, but it is as least at large. Further examination of the psychotherapy preference effect has also indicated that the preference matching effect may be particularly important in briefer interventions. That is, the shorter the contact, the more effective it is to accommodate the clients’ likes (and dislikes).
Windle and colleagues (2019) independently assessed the effect of client treatment preference on dropout rates and treatment outcomes. Receiving a preferred mental health treatment exerted a medium reduction in dropout risk (relative risk = 0.62) and a positive impact on the therapeutic alliance (d = 0.48). Overall, then, these meta-analytic findings essentially replicate the earlier meta-analyses that accommodating client preferences in mental health treatment decreases dropouts and increases the alliance and probably outcome.
Meta-analytic research has also been conducted on a frequent treatment preference: medication and/or psychotherapy. A meta-analysis of 34 English-language studies estimated the proportion of clients preferring psychological treatment relative to medication for mental disorders. 75% of adults preferred psychotherapy across the studies; this was consistently the case for both treatment-seeking and non-seeking populations. Younger clients and women were significantly even more likely to choose psychological treatment. Clients are three times more likely to want psychotherapy than psychotropic drugs.
At the same time, there has been a steady decline in the percentages of clients receiving psychotherapy, along with a concomitant increase in the use of psychotropic medication. The disconnect is profound: Scores of controlled trials have demonstrated that psychotherapy is as effective as medications for a host of mental disorders, and the vast majority of clients prefer psychotherapy, yet medications alone continue to proliferate.
Amid the torrent of meta-analyses, let us not lose the overarching message: Multiple meta-analyses establish that personalizing treatment to preferences produces multiple benefits.
Take a mindful moment to consider the direct practice implications: Personalizing care to the entire person improves success and decreases dropouts.
Adapting your care to client preferences is effective in strengthening the therapeutic relationship, reducing premature termination, and improving psychotherapy success. Respectfully and collaboratively inquiring about client preferences can exert dramatic effects on their treatment.
For example, John Norcross had the following conversation in his second meeting with a bright, funny, but also depressed teenager with attention-deficit/hyperactivity disorder:
Client: What should I call you?
Therapist: What would you like to call me?
Client: Oh, so this is one of those shrink tricks where you answer a question with another question? [Smiling.]
Therapist: Oh, so you have had shrinks ask you questions instead of answering yours? [Client and therapist laugh together for about 30 seconds.]
Therapist: Seriously, call me what you like.
Client: Anything at all?
Therapist: Testing my limits so quick? [Smiling.] Nothing vulgar, please.
Client: Well, “Dr. Norcross” sounds too official. “Dr. John” sounds like you’re my pediatrician.
Therapist: Anything in between those sound right to you?
Client: “Norcross,” just “Norcross.”
Therapist: Sure, that works.
Client: And thanks for not being an asshole about it. At the hospital, they were all about rules and titles. Feels here that I can talk freely, and you, kinda, treat me like a person.
That interaction set the tone for the personalized psychotherapy. The client would frequently have new names for Dr. Norcross, depending on the content of the last session and his experiences in the subsequent week. Sometimes Dr. Norcross was called “Splinter” (the master of the Teenage Mutant Ninja Turtles), “Girl Whisperer” (when they talked about how to approach girls), “The Sex Guy” (when they discussed masturbation), “Freud” (when they examined his vivid and repetitive dreams), “Detective McGruff” (the crime dog, when they explored the negative consequences of marijuana on his mood and medication), and others. His name became the client’s personal idiom and representation of him.
Reflect on the above facts that demonstrate the effect of understanding and accommodating client preferences on psychotherapy. How do you currently personalize your conversations and accommodate users?
Note: While you are not required to share personal information with users at 7 Cups, you can share a first/nickname or part of your username to be addressed with.