The ability to effect change determines our felt experience of self-efficacy. Beliefs about how change occurs transform our experience and engagement with the world, yet these aspects of our worldview are often unspoken. It’s seems bizarre to proceed with the work of change in therapy without establishing a shared and explicit understanding of how the person attempting to change (i.e., the client) thinks about the change process: what their preferences and history with it are. As therapists, we must help each client develop in ways which that client finds meaningful (not in ways which the therapist finds meaningful). The more we understand about our clients, the easier this becomes.

Attending to client preferences is one of the key elements required for a strong therapeutic alliance. Doing so is empowering for clients and represents a more co-created space in which people can feel witnessed, understood, and accepted—where they can do the work of healing.

What are Client Preferences in Therapy?

“Client preferences” are the unique inclinations, ideas, beliefs, or expectations each client has about the therapeutic process. They tend to fall into three main categories:

• Treatment preferences: therapeutic orientation, specific kinds of interventions clients may want, etc.

• Preferences about the therapist: any number of factors: older/younger, gender, language, etc.

• Activity preferences: frequency of therapy, what/when in their life we focus on, online/in-person, particular techniques such as meditation practices or emotion-focused artwork (interventions and techniques here rather than broader approaches), and so on

Combine the client’s therapeutic preferences with their broader beliefs about how change occurs. Think of these preferences as being each client’s own micro-culture. ‘Worldview’ is another name for this. Examples include:

• How they conceptualize change occurring, and so on

• How clients perceive and value family and friends

• How clients seem to construct their identity and select values, and which aspects are most important to them

• Relevant fundamental assumptions the client seems to make about themselves and the world

• Any quirks and relevant specifics from their family of origin

• How clients use language (and how they want/expect you to use language)

• How clients often build relationships (your alliance with them is very likely a microcosm for this)

I explicitly discuss role induction in first sessions, so I start asking about preferences early on. Some clients might have an expectation that you’ll be in an ‘expert’ role and it may seem unusual for them to have you asking these kinds of things—this is a good time to discuss collaboration and who’s doing what work. The therapist’s role is to co-create a one-way supportive relationship and maybe provide some guidance, but we can’t go home with our clients and do the “hard work” of change on their behalf. Also, discussing what clients don’t want (i.e., negative preferences) in therapy can be just as important as discussing what they do want.

Incorporating client preference into therapy is like any culturally competent counselling, just at the very individual level (which isn’t too different than ‘normal’ cultural competence, if you think about it). Other elements such as history of trauma, cultural background, level of affluence, any potential neurodivergence—all kinds of factors—these also overlay and inform our clients’ preferences about therapy and the alliances we build with them.

John C. Norcross and Mick Cooper (2021) published an excellent and thorough book on this whole subject: Personalizing Psychotherapy: Assessing and Accommodating Patient Preferences if you’re interested in taking a deeper dive.

Why care about Client Preference?

“At its heart, counselling and psychotherapy is a relationship. Everything that happens in therapy takes place in the context of a relationship between the client and the therapist. As a result, an adequate understanding of the role of client preferences in therapy needs to incorporate a relational perspective,” (McLeod).

Research has found that a client’s likelihood of dropping out of therapy reduces by up to 50% if the work and alliance is aligned with client preferences—and clients have a 58% better chance of showing greater improvement from therapy when it matches their preferences (see this meta-analysis). Further, research has repeatedly demonstrated that it’s all too easy for there to be a discrepancy between the perceptions of a therapist and their client about how the work is progressing, that in up to 2/3rds of cases therapists and clients can have (at least) somewhat different perspectives about the goals for their therapy. Problems with preferences are a likely candidate if you’re having a lot of single session clients, though also consider the other characteristics of effective therapists if your clients seem to drop out early.

Accurately discerning a client’s expectations and beliefs about change in therapy can help with attunement, rapport, and goal alignment. Role induction and stage-matched interventions are important and closely related concepts.

Direct ways to ask clients how they conceptualize change occurring: 

• How do you think problems develop? 

• How do you think problems resolve? 

• How do you think people change?

• How did you decide to come here?

• In the weeks leading up to therapy, who was giving you advice about this concern, and how did you decide to utilize the advice or not?

• What worked and didn't in previous therapy?

• Do you think change happens slowly or quickly? Why?

• What stories are you telling yourself that don’t serve you anymore?
  
  

Listen for beliefs about change in how clients describe their experience with:

• Expectations about change

• Level of self-efficacy (Locus of control, role of persistence, failure, responsibility taking vs blame, etc.)

• Barriers to change occurring    

• Is the client implicitly expecting someone else to change?   

• Is the client experiencing burnout?

• What aspects of their worldview or schema impact change in therapy?

• These hints could be mentioned in any context: physical, emotional, cognitive, environment

It’s a balance to re-frame or discuss changes with a client while still honouring their worldview. Counselling theories provide a way to “organize clinical data, make complex processes coherent, and provide conceptual guidance for interventions,” (Hansen, 2006).  Regardless of the particular theory, it gives clients a way to ‘re-story’ their experience, which is essential for healing. People often show up feeling that an area of their life is chaotic, confusing, or un-tamable. Counselling gives clients a way to organize that experience that makes sense, “promoting mastery over experiences that were formerly unmanageable,” (Hansen). I prefer theories that leave lots of room for a client’s worldview, such as SFT, narrative approaches, and so on.

Remember that every behaviour is an attempt to meet a need, so consider what goals the client’s actions are aimed at (often self-protection).

Additional questions for reflection and discussion with clients: 

• What makes this client presentation make sense? 

• What positive function is the problem serving in the client's life? 

• How does the problem gain its strength? 

• Is there anything you (the client) would miss about the problem if it was gone? 

• When have you experienced similar feelings before in your life?

• What kinds of things helped in your previous therapy that we could borrow to make our work together better? What didn’t work? Anything we should stay away from?
  
  

A Tool to Explore this with Clients

Norcross and Cooper recently developed the Inventory of Preferences (C-NIP); it covers 4 areas, whether the client:

• Wants the therapy to be more therapist-led, or more client-led

• Wants encouragement to go into strong emotions or not

• Wants to focus on their past, or their present and future

• Wants warm support or more focused challenge

I doubt I’d literally hand this to a client in session, but you could do so and then discuss it. At minimum, it provides structure when discussing therapy preferences with your clients. Here’s a look at it below, or download the full PDF here, or there’s an online version. Similar to any useful outcome measure, the intention for the tool is to facilitate a discussion that helps your alliance and therapy to improve.

Reflection Exercise

Reflect on a time you came up against something in your life that caused you to need to change (e.g., a significant loss, change, or failure). How did you respond throughout this process—internally, externally, behaviourally, interpersonally?

What role did fear play in these decisions and actions? Did fear slow you down? Freeze you? Energize you? I wonder about your level of self-efficacy during this time, and how it relates to your past, your baggage, your ACE score, traumas (or lack thereof), and so on. Did you need or want help? Was it available? What are your beliefs about how change occurs?

Therapists should endeavour to not put their beliefs onto their clients. Each of us conceptualizes change differently and approaches challenging moments with a different history—which can vastly alter how we think about the change process. Clients and therapists tend to hold many unconscious assumptions about this process, so the more deeply therapists understand their own beliefs about change, the more effectively they can stay out of the client’s way. Perhaps the reason why we have so much trouble with these questions of change is that we aren't in touch with it in our selves.

Credit goes to my colleague E.W. for this exercise.

Conclusion

Once a person understands the above concepts and can think about them fluidly, it becomes just another thing that we simply listen for all the time, and it can inform any therapeutic approach. “Change talk” can be a direct focus of discussion at times, though in my sessions it’s typically an organic part of the larger discussion. Beyond change and existentialism, understanding a client’s preferences strengthens the therapeutic alliance. Delving into another person’s worldview is a rich and fascinating experience, and it’s best done in a similar manner to meditation—remain curious and be completely open to what’s there.

Sources:

Cooper, Mick. (2021). Source

Hansen, James. (2006). Counseling Theories Within a Postmodernist Epistemology: New Roles for Theories in Counseling Practice. Journal of Counseling & Development. 84. 10.1002/j.1556-6678.2006.tb00408.x.

McLeod, John. (2015). Source

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