Step 9. Offering Adapted Preferences

When preferences cannot be adopted, even temporarily, the conflicts are typically with the clinic’s or clinician’s available resources, clinical wisdom, ethical code, or the research evidence. In many cases, the clinician is not practically able to meet the client’s preferences, and alternative options are not available.

Offering clients an adapted version of what they want has the obvious advantage that it retains as much of the client’s original desire as possible and maintains some degree of clinician responsiveness. The disadvantages include the possibility of clients not receiving their preferred approach and thus losing the demonstrated effects of improved outcomes and decreased dropouts. Adapting is a halfway, or three-quarters, measure of balancing these competing considerations.

In adaptation, clients are offered a modified version of their treatment, therapist, or activity preferences when their original preferences are unavailable or unlikely to prove effective.

For example, the client expresses an intense desire for a treatment with limited research evidence, such as constantly practicing self-affirmations in front of a mirror. Adhering to that preference will, with a high degree of probability, not serve the client’s long-term interest. But ignoring the client’s strong desires hurts the therapeutic alliance and treatment outcomes. Thus, we may seek a middle way: a responsive treatment that aligns somewhat with the client’s desires and that possesses proven efficacy.

Let us consider 2 examples, at the level of treatment preferences, of Annique and Marv, and then another example at the level of activity preferences, of Hamza.

In Annique’s case, this mismatch would occur when the best research and clinical expertise converge in recommending IPT (or another research-supported therapy) and antidepressant medication to treat her recurrent depression, but Annique rejects one or both of these components. For instance, she might

• want to discontinue antidepressant medications due to a dislike of “chemical solutions”;
• express a preference for a discredited treatment, such as sitting an hour a day in an “orgone energy” accumulator;
• decide that her primary goal lies in developing insight into the intrapsychic and family origins of her depression, as opposed to focusing on symptom reduction.

Adaptation would attempt to preserve some of her preferences while maintaining beneficence and an effective treatment. The therapist thus might offer a research-supported insight-oriented therapy, such as brief psychodynamic therapy, without medication for her depression. That adapted care thus realigns Annique’s strong preferences with the best available research and clinical expertise.

Our second example of adapting preferences concerns a delightful elderly client, Marv, who presented with severe anxiety and depression. He ardently sought individual psychotherapy combined with homeopathic remedies. Alas, homeopathy for mental disorders has been repeatedly shown in randomized controlled trials to be inferior to conventional medications and to produce outcomes essentially similar to placebos.

The clinician could have adopted, temporarily at least, the clients’ preferences, but Marv’s suffering was intense, and he was facing psychiatric hospitalization, which he desperately wanted to avoid. Thus, Marv was immediately encouraged to read several consumer-friendly meta-analyses on the dubious effectiveness of homeopathy for his conditions and asked to consider sequencing his treatment options: first conventional antidepressant medicine for short-term relief, then homeopathy for (possible) long-term effects. He agreed to begin conventional medications as a first step. These quickly reduced his suffering, avoiding hospitalization or deterioration, and psychotherapy commenced with success.

As a subsequent step, Marv sought homeopathic remedies, but that proved unsuccessful after four different remedies over a 6-month period. He subsequently returned to maintenance doses of conventional antidepressants and occasional psychotherapy sessions.

In the case of Hamza, a mismatch between what he wanted from treatment and his clinician’s evidence-based understanding took place in activity preferences. Hamza presented with high levels of depression and anxiety and was becoming increasingly withdrawn from his college and social environment.

The therapist’s view, based on an understanding of behavioral principles, was that Hamza needed to be encouraged to get out and reengage with his world. The more he withdrew, the more anxious and isolated he became. Hamza sensed this pattern, as well.

However, he also indicated that, based on a previous episode of CBT, it was unhelpful for him to be told by a therapist, “If you don’t do what I’m suggesting, you’re not going to get better.” He related that it left him feeling guilty, ashamed, and even less confident to go out into the world. The adaptation challenge was to find methods of communicating to Hamza that he could change his behaviors, without implying that he was “bad” or “wrong” if he did not. A delicate balance needed to be struck between helping Hamza own some responsibility and, at the same time, avoiding his strong dislike of feeling blamed.

Adapting client preferences due to the clinician’s discomfort enters the murky waters of professional conduct. It is the client’s treatment, after all, and ethical codes insist that we privilege client autonomy. But that is not an absolute value; clinicians are entitled to their own preferences, values, and theories.

Three common clashes concern the relative amount of therapist direction/structure, the extent of emotional intensity in session, and the relational balance of support and challenge. These dimensions are measured by the C-NIP precisely because they emerge frequently.

Active listeners should remain mindful that many clients enter treatment preferring that the clinician is directive - providing structure, offering homework, teaching skills, and focusing on goals - far more than most mental health professionals, themselves, would want.

In sum: Adaptations entail modifying, supplementing, or sequencing preferences that prove suitable for all involved.

Watch the following video on offering adapted client preferences:

Recall a recent listener chat topic one of your clients had, and any client preferences that came up. How can you adapt those preferences? Share your reflections and any thoughts on obstacles that came up.