Incorporate Preferences

As we continue our exploration of client retention and how this can decrease stress for clinicians by increasing the consistency of clients attending treatment, we will be looking at Chapter 4 - “Incorporate Preferences” from the book, Premature Termination in Psychotherapy - Strategies for Engaging Clients and Improving Outcomes, written by Joshua K. Swift and Roger P. Greenberg.

Most clients have specific desires regarding what they hope will happen in psychotherapy.  These hopes and desires for treatment are referred to as client preferences, and addressing them is another way for therapists to reduce premature discontinuation in their practice.

Although most therapists would say that they care about their clients’ opinions and desires for treatment, actually taking steps to accommodate client preferences doesn’t often occur.  Frequently, therapists fall into the trap of believing that they know what treatment and conditions their clients ought to prefer - the doctor-knows-best model.

Patient preferences for therapy generally fall under one of three main categories: role, therapist, or treatment-type preferences.

Role preferences

consist of the behaviors and activities clients desire themselves and their therapist to engage in while in therapy.  Examples of role preferences include desires for the therapist to take an advice-giving or a listening role, inclination for or against the inclusion of between-session homework, and preferring treatment to be offered in an individual or group format.

Therapist preferences

consist of the characteristics and attributes that clients hope their therapist possesses.  Therapist preferences can focus on demographic characteristics, such as desires for a therapist of a particular ethnicity, age, or gender.  Although these characteristics may not seem to be all that important in determining treatment outcomes, for some clients, they are critical.  Preferences for therapist demographic characteristics most likely play the largest role in decisions about starting therapy.  However, once the therapist and client have started working together, preferences about the therapist's interpersonal characteristics may play a larger role in clients’ decisions to drop out.

Treatment-type preferences

Refer to the kind of intervention that is hoped for.  The most evident treatment-type preference would be a preference between psychotherapy and medication.  Some clients prefer a specific type of treatment orientation (patient-centered, CBT, psychodynamic, etc.).  These preferences may come from previous successful or unsuccessful experiences in treatment as well as other sources.

2 ways integrating client preferences into the treatment decision-making process can reduce premature dropout.

1. It addresses both costs and benefits that might lead a client to choose to either drop out or continue in psychotherapy.
2. It has the potential to reduce the likelihood of premature discontinuation because it creates an opportunity to build the client’s hope.

In contrast to the benefits that come with integrating client preferences and allowing a client to make a choice among treatment options, not accommodating preferences and not giving choices can actually be seen as a cost in therapy.  Removing clients’ freedom to choose or ignoring their preferences can result in negative feelings and disappointment, which in turn may lead to a lack of motivation to engage in treatment and eventually drop out of therapy.

Putting it into practice

Simply performing an initial inquiry of preferences, although useful, may not be adequate to fully integrate preferences into the treatment decision-making process.  For starters, many clients may be hesitant about expressing their preferences.  Clients may see therapists as experts or authority figures and thus may be uncertain whether it is appropriate for them to share their own opinions.  Therapists should take time to help clients acknowledge their own expertise and help them bring their voice to the decision-making table.

Although most preference discussions occur early on in therapy, therapists may want to revisit their clients’ preferences occasionally as sessions progress.  The process of revisiting preferences is helpful for several reasons.

1. First, client preferences for treatment can change over time.  Changes in life circumstances and experiences can lead to a desire for a different treatment approach or emphasis.
   1. Preferences may shift as clients gain experience with a therapist and a more trusting relationship is developed or as they gain experience with a treatment and see that it is not exactly what they had expected when indicating their initial preference.
2. Second, despite the therapist's best attempts, the client’s preferences might not be met.  Clients sometimes have difficulty articulating what they want early on in treatment, and therapists sometimes have difficulty understanding exactly what their clients’ preferences are.
   1. Regularly checking in with the client concerning his or her preferences helps the therapist ensure that there is continued agreement on the appropriate goals and tasks for therapy.

When situations arise that client preferences cannot be met, one option is to refer the client to another provider who might be able to better accommodate his or her preferences.  However, this solution is not always possible and may frequently not be the best course of action.  Instead, when initial preferences cannot or should not be met, the therapist can first attempt to gain a better understanding of the reasons for the client’s preference.  Once these reasons are understood, the therapist may be able to help the client see other ways in which those underlying preferences can be met or help the client better understand why his or her preferences would be contraindicated.  The therapist and client can then decide together whether they want to try one of the other therapy options or whether a referral to another provider or clinic is needed.

The goal throughout this process is to help clients feel like they are equal partners with a legitimate opinion and stake in deciding what is going to happen in their treatment.