Step 8. Adopting Client Preferences
Everyone can definitely be pleased, but not simultaneously and not by one person or thing. - Mokokoma Mokhonoana
The quality of health care in the United States and the United Kingdom is exceptional in some categories but dismal in others. Compared with many countries, the United States and the United Kingdom rank poorly in meeting client preferences and in providing culture-sensitive services (World Health Organization, 2011). In other words, conventional health care has not taken seriously client culture and preferences.
In prior steps, we looked at how clinicians can invite, assess, and discuss the preferences of each client. In this step and the next several, we describe the four fundamental choices, affectionately known as the four As, about any particular client preference.
That’s adopt, adapt, alternative, or another. We can adopt into the treatment the expressed strong like or dislike, we can establish and work towards an adapted version of that strong preference, we can explore with the client clinical alternatives, or else we can collaborate with the client on identifying another, more suitable treatment resource.
The first choice (or the first A) is by far the most straightforward and pleasant for practitioners: adopting the client’s strong preferences. What’s not to like? Clients typically feel respected and heard, practitioners enjoy tailoring to individual differences, and professional research, ethics, and standards support the entire process.
That process is accorded multiple names - adopting, accommodating, honoring, integrating, implementing - and we shall employ them interchangeably.
We incorporate clients’ strong likes (or avoid the strong dislikes) when they are compatible with our clinical expertise, ethical codes, and research evidence. Doing so solidifies the therapeutic relationship, enhances the clinician’s confidence, maximizes the probability of client success, and halves the possibility of premature termination. In our experience, at least one of the client’s strong preferences can be honored in the course of care; indeed, we cannot locate a single exception among our clients.
Consider the assessment and treatment of Annique’s recurrent depression. For reasons of cost and style, her treatment preference was for a time-limited, active psychotherapy with, in her words, a focus on “the important relationships in my life. That’s what makes me tick.” The research evidence, the clinician’s expertise, and Annique’s preferences all pointed towards interpersonal psychotherapy, an evidence-based psychotherapy for treatment of acute depression in which the clinician was trained and skilled.
Here are the strong preferences, gleaned from the Cooper–Norcross Inventory of Preferences (C-NIP) results or in-session questions, from my (JCN’s) last 10 adolescent and adult outclients. We have subsequently adopted all of these activity preferences throughout treatment:
- refrain from repetitive “uh-huhs” (minimal encouragers) that the client experienced as irritating in a prior therapist
- honor (“not judge”) the meaning of the client’s dreams
- combine psychotherapy with an antidepressant medication (prescribed by a colleague)
- develop between-session exercises or homework assignments
- inform the client consistently of his diagnosis and treatment rationale
- work with the client’s partner in occasional conjoint sessions
- recommend some online self-help resources
- shun cognitive behavior therapy (CBT; although recommended by her partner) in favor of relational-psychodynamic therapy, which previously proved effective
- schedule therapy sessions every 2 weeks in the interest of cost-efficiency
- avoid pushing the client into action prematurely: “Let me talk and explore my issues”
Over the years, we have adopted hundreds (perhaps thousands) of the treatment preferences of our adolescent clients. Less verbal and less informed than adults about the process of therapy, they nonetheless highly value the ability to express themselves and exert some control over their treatment. Which person sits where, which game to play, who begins the session, how much the therapist pushes for conflictual material, how to involve parents/caretakers, and more, constitute opportunities for likes and dislikes. Asking youth what they dislike or despise in teachers usually provides a solid working knowledge of what to avoid in sessions, at least initially.
Adopting to client preferences should not take clinicians beyond their scope of practice but it can take them up to its edges. Managing this balance between authenticity as a practitioner, and being flexible, is one of the essential meta-competences for preference accommodation.
Watch the following video on adopting client preferences:
Share your reflections on adopting client preferences in the box below. Think back to your invitation practices and the C-NIP results you have received from a client: how can you adopt such preferences?