Step 4. Assessing Client Preferences

In this training step, we provide a hands-on guide to assessing client preferences in a reliable, relational, and effective way - tailored to the individual person.

This means dialogue: inviting clients to express their preferences, exploring with them the rationale and robustness of these choices, sharing our own views, and reviewing and revisiting, where appropriate, the decisions that have been made.

Clients’ strong likes and dislikes can be assessed across treatment, therapist, and activity preferences. Initial preference assessment might involve asking two open-ended questions:

1. What do you strongly dislike or despise in treatment?
2. What do you strongly like or desire?

It proves useful to attune care to two or three strong client preferences. This can make the most impact and maximize cost-effectiveness. In other cases, however, clinicians will want - or have the opportunity - to explore client preferences in a more comprehensive and detailed manner across the course of psychotherapy.

Having explored strong likes and dislikes at a general level, we typically explore the three preference categories. Questions about treatment preferences are most likely to be asked at initial assessment - or even on first contact - and their appropriateness will largely depend on the client’s familiarity with the psychotherapy domain.

Having looked at how and what to assess in clients’ strong likes and dislikes, we now examine when to assess client preferences. The short answers, as to most clinical questions, are, “Whenever indicated,” and, “It depends.”

Initial contacts are likely to be the principal time point in at which client preferences are assessed. For therapist and treatment preferences, this is essential, as work cannot commence until clients make some decisions about their preferred clinician and desired treatment tack.

When working with within-treatment preferences, the start of a session is often a helpful time to discuss with clients their preferred methods and topics. The end of each session, likewise, provides an opportunity to review how the sessions progressed and whether the client has any preferences regarding future sessions.

Let’s end this training step with a series of “What if?” questions frequently asked by active listeners.

What if a client expresses no strong preferences?

That may be the case, particularly if clients have not had mental health treatment before or if they do not desire control in their lives. It may also involve an unassertive interpersonal style or cultural proscription. It may reflect the fact that the client is intent on “getting on” with care and does not feel too strongly about how that’s done (provided it works). In that case, prolonging a discussion about patient preferences may prove unhelpful and, paradoxically, be against the client’s preferences!

In all these instances, we advise feeding back this understanding to the client and discussing their disinclination (without conveying that they should or must have strong preferences). For instance, a listener might say, “I noticed that you didn’t have any strong preferences about our contacts at this time. Is that about right?”

What if a client says they want one thing but then starts trying to do another?

That certainly happens. For instance, clients can say that they want to talk about their past, but in sessions, they focus on present experiences and concerns. Clients’ preferences change, or clients, despite themselves, veer off from what they know they need to talk about (the initial topic/concern) and avoid core conflicts. The solution? Talk to clients about it: Highlight the disparities and see which paths the client wants to travel.

What if I do not want to ask the client explicitly? Isn’t it better to trust my intuitive sense of what a client wants?

Probably not. Clinicians undoubtedly intuit a lot in their work, but research consistently demonstrates that psychotherapists’ assumptions about what their clients are experiencing or wanting are frequently incorrect. In addition, we can project onto our clients our own preferences for therapy.

What if asking clients about their preferences results in discomfort or confusion?

Such patients tend to fall into one of three categories: dependent or insecure (“But you are the expert. How would I know what I want?”), those with conventional (paternalistic) expectations about health care professionals (“You tell me what is best, and I will do it”), and therapy naive or inexperienced (“I do not know yet; this is all new to me”).

The latter group can be reassured that it is completely natural and probably expected not to know their strong likes for a new service. Several alternative routes then present themselves. First, remind clients that they are experts on their preferences: “Could you tell me what you like about people in general?” Second, ascertain preliminary preferences by strong dislikes: “What are a few pet peeves bout interpersonal relationships?” Third, agree to ask about their preferences again after a few contacts.

The former groups of clients pose more clinical challenges, as they do in psychotherapy generally. We advise practitioners to treat their clients’ interpersonal dependency, insecure attachment, or rigid conventionality regarding treatment preferences as they would all matters. This will assuredly not be the only instance of those interpersonal patterns manifesting in session, only an early instance.

What if I think the patient’s choice is wrong, that what they want is not the best thing?

Discuss it directly with them. Tell them about your concerns and your perspective. SDM is about dialogue and working together to co-determine the best solutions. The client has their expertise, but so do you, and bringing that into the dialogue is a key part of making the best decisions together.

What if I don’t want to assess client preferences at all? What about my preferences? 

This question is usually asked in a sarcastic or petulant tone by high-reactant colleagues. Our response is frequently: Well, then you are reading the wrong training path! Of course, we value and honor therapist preferences, too. Psychotherapy should and can fit the professional as well as the patient.

But here’s the critical difference: Not assessing and accommodating, when feasible, your patient’s strong preferences directly leads to higher dropout, lower satisfaction, and worse treatment outcomes. That’s imposing your preferences at the expense of your client. We do not find that clinically or ethically defensible.

Use the box below to write a summary on how you can assess user/client preferences at 7 Cups. Reflect and write any questions you can use and how you can tackle any obstacles that may come up.