European Journal of Psychotherapy and Counselling Vol. 14, No.

1, March 2012, 1932

What do clients want from therapy? A practice-friendly review of research into client preferences
John McLeod*
School of Social and Health Sciences, University of Abertay Dundee, Dundee, DD1 1HG, UK (Received 30 November 2011; final version received 2 December 2011)

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A central theme in pluralistic counselling and psychotherapy is the willingness of the therapist to engage with the clients understanding and experience around what he or she finds helpful. A substantial research literature exists around the topic of client expectations and preferences for different types of psychotherapeutic interventions and activities, and the impact of these factors on the outcome and process of therapy. The findings of these studies are reviewed in relation to their implications for practice. An example of how client preferences can play a role in the process of therapy is illustrated through a case study. Possible directions for further research are discussed. Keywords: client experience; pluralism; practice-friendly review; preferences; principles; research Un tema central en la orientacion psicologica pluralista es la disposicion del terapeuta para involucrarse con el paciente en la comprension de la experiencia de este en cuanto a lo que el/ella siente que lo ha ayudado. Existe una literature extensa acerca de este topico y acerca de las diferentes intervenciones y actitudes de los terapeutas y el impacto de los mismos en los resutados del proceso terapeutico. Se presentan los resultados de estos estudios en relacion con sus implicaciones practicas. Se presenta un caso para illustrar como las preferencias de un cliente pueden influir en los resutados de la terapia. Se discute la posibilidad de nuevas investigaciones y direcciones en este sentido. Palabras clave: Experiencia del cliente; pluralismo; practica amistosa; revision; preferencias; principios; investigacion ` Un tema centrale nel counselling e psicoterapia pluralistici e la volonta del terapeuta di affrontare con impegno la comprensione e lesperienza del ` cliente di cio che lui o lei ritengono utile. Esiste una considerevole letteratura di ricerca sul tema delle aspettative e delle preferenze del cliente ` rispetto a differenti tipi di intervento e attivita terapeutici e circa limpatto di tali fattori sul risultato ed il processo di terapia. I risultati di questi studi *Email: j.mcleod@abertay.ac.uk
ISSN 13642537 print/ISSN 14695901 online 2012 Taylor & Francis http://dx.doi.org/10.1080/13642537.2012.652390 http://www.tandfonline.com

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sono esaminati in relazione alle loro implicazioni per la pratica. Un esempio di come le preferenze del cliente possono giocare un ruolo nel ` processo di terapia e illustrato attraverso un caso di studio. Vengono discusse possibili direzioni per ulteriori ricerche. Parole chiave: esperienza del cliente; pluralismo; ricerca di approccio pratico; preferenze; principi; ricerca ` Un theme central de la psychotherapie pluraliste est la volonte du ` therapeute detre a lecoute de lexperience des clients et de la comprehen sion quils ont de ce qui peut etre aidant. Une litterature scientifique substantielle existe qui decrit les attentes et les preferences des clients pour differents types dinterventions et dactivites psychotherapeutiques et limpact de ces facteurs sur lissue et le deroulement de la therapie. Les resultats de ces etudes sont passes en revue ici et mis en rapport avec leurs implications pour la pratique. Une etude de cas fournit un exemple permettant dillustrer comment les preferences dun client peuvent jouer un role dans le deroulement de la therapie. Des pistes pour des recherches futures sont discutees. Mots-cles: experience du client; pluralisme; revue compatible avec la pratique; preferences; principes; recherche

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Introduction There is a contradiction that lies at the heart of the contemporary practice of counselling and psychotherapy. On the one hand, a great deal of the attraction that therapy holds for clients is that it offers them a place where their own unique and personal experience is taken seriously. Other forms of assistance that are available for problems in living, such as self-help books and websites, or psycho-educational groups, may provide useful ideas and techniques, but it is only in the context of a relationship with a therapist that a person is supported to engage in detailed exploration of the application of these ideas in relation to the complexities of their own life. On the other hand, the individualisation of therapy stops at that point. It is relatively rare, outside of the arena of private practice, that a person seeking help is able to choose their therapist or have much influence on the therapy model that is used. Indeed, there is little discussion within mainstream counselling and psychotherapy theory and practice of the nature of client preferences and the ways in which therapists might respond to them. At the same time, there exists a substantial literature on client preferences for different types of psychotherapeutic experience. In the light of these considerations, Mick Cooper and I have developed a pluralistic framework for therapy that highlights the role of client preferences (Cooper & McLeod, 2011). The aim of this article is to provide a practice-friendly review of research into client preferences for therapy that has the potential to guide the work of pluralistically oriented therapists. Practice-friendly research reviews comprise an alternative to systematic reviews and meta-analyses that focus on methodological rigour (internal validity). Instead, the focus of a practice-friendly

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review is on how research findings might be used to inform practice (external validity). The concept of the practice-friendly review has been used within the Journal of Clinical Psychology over the past decade as a means of making research findings more relevant for clinicians (Comtois & Linehan, 2006; Greenberg & Pascual-Leone, 2006; Logan & Marlatt, 2010; Lundahl & Burke, 2009; Mains & Scogin, 2003; Post & Wade, 2009; Sin & Lyubomirsky, 2009; Solomon & Johnson, 2002). As a means of drawing out the clinical relevance of research findings in client preferences, this article is organised around a series of practice principles that can be derived from current research findings in this area. This article concludes by offering an illustrative case example, and consideration of some suggestions for future research.

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The research literature around client preferences for different types of therapeutic experience The field of research into client preferences for different types of therapy intervention comprises a complex and somewhat fragmented domain of inquiry. Historically, this area of research began with, and continues to be dominated by, the use of self-report questionnaire measures that have been designed to map the structure or dimensions of client attitudes, beliefs, expectations and preferences, and to determine the ways in which these cognitive attributes are affected by demographic variables such as gender, ethnicity and educational level. Further application of these self-report scales has examined the impact of expectations, preferences, and ratings of treatment credibility, on the process and outcome of therapy. The advantage of this methodological approach has been that the attitudes of large samples of both the general public, and also therapy clients, could be assessed in a standardised fashion. The disadvantage of this approach has been that it is based on a professional or expert-derived definition of the nature of attitudes and preferences, and also relies on the possession by the research participant of a conscious awareness of what he or she wants from therapy (Bugas & Silberschatz, 2000). In response to these issues, some researchers have adopted qualitative methodologies, such as in-depth interviews, to document and explore the views and experiences of clients in their own terms. Finally, there have been studies that have used both qualitative and quantitative methods to explore the processes through which preferences are articulated and negotiated within actual on-going therapy interaction. The practice principles that are described in the following sections of this article are informed by all of these different methodological approaches, and by the findings of recent systematic reviews that have been carried out on this topic. Research in this area has employed many different ways of conceptualising the notion of client preference (McLeod, 2012). Researchers have used concepts such as attitudes, beliefs, expectations, treatment credibility and theories of cure to examine contrasting aspects of what clients want from therapy. The relationships between these alternative conceptualisations

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are complex. For example, several studies have been carried out into client expectations, and the impact on client of fulfilment or non-fulfilment of these expectations. However, the concept of expectation can be seen to encompass both what the client anticipates will happen, and what he or she wishes to happen. For the purposes of this article, any research findings that offer an insight into the nature and role of what clients want (preferences) are considered relevant, whether or not the concept of preference is used by the researcher.

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Research into client preferences: identifying practice principles A search was carried out of relevant databases using a series of terms such as counselling, psychotherapy, expectations, preferences and attitudes. Further handsearching was conducted on leading journals, and on reference lists of review articles. More than 50 studies were located that addressed at least some aspect of client preferences for therapy interventions and experiences. For reasons of space, not all of these studies are cited or discussed in this article. The findings of key studies are discussed in relation to a set of practice principles that could be derived from them. The strategy of summarising research findings in terms of principles for practice follows the approach adopted by Levitt, Butler, and Hill (2006), Levitt, Neimeyer, and Williams (2005) and Levitt and Williams (2010), who have proposed that the identification of principles provides a promising means of making pragmatic links between research and practice. Levitt et al. (2005) argue that research reviews that seek to generate procedural rules (i.e. treatment manuals) or abstract empirical generalisations (e.g. meta-analyses) have failed to deliver knowledge that is sensitive to the complexities of therapy practice in most everyday contexts.

Practice principle 1: effective therapy requires a capacity to respond to client preferences There exists a substantial body of evidence that the fulfilment of client preferences has a significant impact on whether a client will stay in therapy, and on the eventual outcome of that therapy. A review by Swift and Callahan (2009) of 26 controlled studies in which clients received either a preferred or non-preferred therapy found that clients who received their preferred therapy were 50% less likely to drop out of therapy early, and reported more beneficial outcomes at the end of therapy. A recent study by Berg, Sandahl, and Clinton (2008) found that fulfilment of outcomes, rather than therapy approach, predicted outcome in a randomised trial of psychotherapy for anxiety disorder. The extensive literature on clienttherapist ethnic matching provides powerful supporting evidence for these conclusions (Farsimadan, Khan, & Draghi-Lorenz, 2011): in general, studies of ethnic matching find that people prefer to meet with a therapist who shares their cultural background, and do less well in therapy when they are allocated to a practitioner from a

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different cultural group. The findings of a historical analysis of trends in research on client expectations and preferences, conducted by Greenberg, Constantino, and Bruce (2006), found that in contrast to research carried out 40 years ago, recent studies have reported stronger evidence of active client preferences and concrete expectations. It is therefore possible that the primary professional training of many practitioners has not incorporated an emphasis on sensitivity to the importance that contemporary therapy clients (who have access to multiple sources of information about therapy) are likely to have around only being willing to commit themselves to therapeutic experiences that make sense to them.

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Practice principle 2: client preferences are complex and multidimensional Practice principle 2.1 Client preferences do not readily map on to the concepts and methods of established theories of therapy: therapist engagement with client preferences needs to be open to uncovering a range of possibilities. Practice principle 2.2 A preference for non-psychotherapeutic strategies for coping with problems is likely to have a degree of credibility for many clients: therapist exploration of client preferences needs to be willing to take account of the existence of ambivalence about the utility of therapy. There have been many studies that confirm the existence of preferences in relation to how to deal with problems in living. It is clear that many people prefer to deal with problems on living without recourse to professional help. This deep-rooted resistance to the potential benefits of psychotherapy is reflected in the findings of a large-scale survey of attitudes to emotional support of a large sample of the UK population (Anderson & Brownlie, 2011; Brownlie, 2011), which reported that more than 30% of respondents preferred not to make use of any professional help for psychological issues. Among the sample of the population that does acknowledge the value of professional help, around one in four prefer to consult a medical practitioner (Anderson & Brownlie, 2011) or other source (Barker, Pistrang, Shapiro, & Shaw, 1990), or make use of a pharmacological intervention (Kocsis et al., 2009; Kwan, Dimidjian, & Rizvi, 2010; van Schaik et al., 2004) rather than engage in any form of talking cure. There is also evidence that many people believe in the efficacy of a wide range of activities, such as diet, exercise and complementary therapies as means of dealing with psychological issues (Jorm et al., 2000). Alongside these preferences for non-psychological source of help, respondents in surveys also indicate that they differentiate between forms of therapy, in terms of the perceived efficacy and credibility of these approaches (Bragesjo, Clinton, & Sandell, 2004; King et al., 2000; Lang, 2005; Lin et al., 2005; Pistrang & Barker, 1992; Sobel, 1979; Sweeting & McLeod, 2010; Tarrier, Liversidge, & Gregg, 2006). In surveys of public preferences for different therapy approaches (e.g. psychodynamic, CBT, person-centred), respondents generally regard all approaches as having some credibility and value, while expressing preferences for one approach over others. Taken as a whole, these studies suggest that members of Western societies are exposed to a range of

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discourses and practices around how to make sense of, and resolve, emotional, behavioural and relationship difficulties. It is probable, therefore, that when a person enters therapy, he or she is likely to be influenced by several of these discourses and practices, in relation to his or her general sense of what will be helpful in therapy. In addition, he or she is likely to hold some preferences around the value of certain therapy ideas and methods and will regard other approaches as lacking in credibility. In relation to principles of therapy practice, these factors suggest that it is necessary for therapists to be sensitive to the existence of client ambivalence around the likely efficacy of any form of therapy that is offered, on the grounds that the client will be aware of alternative models of cure. There are various ways in which this general principle might inform the approach taken by a therapist during the early stages of therapy. One strategy, adopted in the pluralistic approach (Cooper & McLeod, 2011) is to facilitate collaborative discussion around preferences, with the aim of harnessing the views of the client in designing an individually tailored therapeutic experience. Another approach is to use the intake and assessment phase of therapy to match the client with the therapist or therapy model that most closely corresponds to their preferences (van Audenhove & Vertommen, 2000). A third strategy is to reduce ambivalence and enhance commitment to one model, by persuading the client of the merits of a specific approach (Ahmed & Westra, 2009). A significant area of challenge for any counsellor or psychotherapist seeking to engage with the treatment preferences of clients is associated with the issue of the structure or dimensionality of client preferences. It may be valuable, as proposed by Duncan and Miller (2000) to be guided by the clients theory of change. But what does a client theory of change look like? Research into client preferences indicates that, beyond a general awareness of the strengths and limitations of broad categories of intervention, such as psychodynamic therapy, CBT or antidepressant medication, clients are also able to draw on ideas about the personal relevance of specific interventions or methods. Dimensions of preference for concrete therapeutic techniques that have been identified in research studies include: approaching emotional difficulties and painful experiences (Philips et al., 2007), defining concrete goals and getting support (Berg, Sandahl, & Clinton, 2008), exploring spiritual experiences (Rose, Westefeld, & Ansley, 2008) and working with dreams (Hill, 2004). On each of these dimensions, some clients will actively seek that specific activity, while other will actively avoid it. A further set of micro-preferences, such as the therapist being more or less directive, or more or less self-disclosing, have been identified by Bowens and Cooper (2012). Beyond these preferences for in-therapy activities, there is also evidence that clients have preferences around practical arrangements and the frame of therapy, in respect of factors, such as the frequency and location of sessions (Mohr et al., 2006). Qualitative studies have used in-depth interviews to enable therapy clients to express the broader meaning of attitudes to therapy in the context of their life as a whole. The findings of these studies suggest that the ideas of clients of what will help are organised around an overarching biographical narrative the story that the person tells about who they are, why they have encountered difficulties in their

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lives and the kinds of curative processes that will help to get their life back on track (Kuhnlein, 1999; Valkonen, Hanninen, & Lindfors, 2011). These studies of the structure and content of client preferences suggest that preferences are complex and multidimensional. The implication for practice that can be derived from this particular area of work is that at present there is no single model or dimension of client preferences for therapeutic experiences that can serve as a basis for counsellor or psychotherapist exploration of this issue. Instead, it seems important to be willing to be sensitive to multiple facets of potential preference.

Practice principle 3: attention to client preferences supports core therapeutic processes: meaning-making and the development of a therapeutic alliance It is clear that competent therapists are highly responsive to clients, for example in monitoring the acceptability of interventions, and are therefore able to take account of client preferences in a constructive manner (Stiles, Honos-Webb, & Surko, 1998). But there is an absence of research into the detailed ways in which effective therapists work with their clients around exploring and making practical use of the clients preferences for specific types of therapeutic activity There appear to be three main ways in which mis-match between client and therapist views about what is helpful can undermine the process of therapy. First, there is evidence that differences in ideas about what is helpful create a barrier to the development of an effective working alliance (Constantino et al., 2007; Goates-Jones, & Hill, 2008; Iacoviello et al., 2007; Patterson et al., 2008). One of the central factors is that at the start of therapy, clients actively assess their therapist around his or her capacity to accept, understand and appreciate the clients life experience (Ward, 2005). It would appear that failure on the part of the therapist explicitly to demonstrate such appreciation contributes to a decision on the part of the client to quit therapy. A second process through which fulfilment of client preferences seems to lead in the direction of good outcomes, and lack of fulfilment to poor outcomes, is associated with the experience of choice. Each occasion on which the practitioner invites the client to express a preference creates an episode characterised by choice and reflection. A study by Handelzalts and Keinan (2010) directly addressed this issue. Individuals who were seeking counselling for anxiety problems were offered two contrasting forms of therapy. All of the clients were asked to indicate their preference for which type of therapy they preferred. However, one group of clients were told that they were receiving their preferred intervention, while a comparison group were told that they had been randomly allocated to whichever therapist was available. In fact, all clients received their preferred therapy. The outcome at the end of therapy was that those clients who believed that they had actively chosen the therapy they had received, reported significantly more improvement than the control clients who believed that their own preference had not been a factor, yet had actually received the therapy they had chosen. The practical implications of this study, if confirmed by other research, are that conversations between therapists and

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clients around preferences for different types of therapeutic experience, may have the potential to reinforce the clients sense of control over the course of therapy. A third process that is relevant to the role of client preferences is that clients have a fairly good sense of what they like and what works and does not work for them. Clients may have a sense of what has been helpful in the past, and which they want to try again. Or it may be that the client believes that all or some of their existing strategies have failed, and they want to try something different. In either case, if the person does not get what he or she is looking for, they are less likely to stay in therapy or commit to the work of therapy. Studies by Kuhnlein (1999) and Valkonen, Hanninen, and Lindfors (2011), and the extensive literature on client aptitude (i.e. personality factors and cognitive styles that are associated with good or poor outcomes in different therapy approaches see Cooper, 2008 for a review) provide strong support for the notion that clients are mainly looking for more of what has worked for them in the past. An important practical implication of these research findings is that attention to client preferences, in terms of previous coping styles and learning experiences, can usefully be incorporated into aspects of therapy such as assessment, history-taking, case formulation and progress reviews.

The influence of client preferences on the process of therapy: a case example Some of the ways in which client preference can exert an influence on the process of therapy are illustrated in my work with Alan, a young man who arrived at our counselling centre in a state of desperation. For some time he had lived with intense anxiety around participation in social situations in which he felt isolated, exposed to a group of unknown people who he believed were judging him, or where he did not know the rules. More recently, this anxiety had begun to spread into other areas of his life. He attended for 16 sessions of counselling, and reported a good outcome in terms of both his scores on symptom measures and in a range of constructive shifts in his way of being in the world and acceptance of self. In our initial meeting, and during the assessment and contracting phase at the start of therapy, I emphasised to Alan that I took a flexible approach to therapy. I suggested that different people benefit from different therapeutic activities, and provided examples of these activities for him to think about. I encouraged him to read about therapy, as way of helping him to decide on the type of therapeutic process that would be most helpful for him. I asked him about his ways of coping with anxiety and other difficult emotions, and his previous involvement in therapy. I consistently asked for his feedback around the value of various ideas and techniques that we explored during sessions. What I learned was that Alan held a range of ideas about what might be helpful for him. His GP had suggested antidepressants, which he rejected. His girlfriend appeared to be sceptical about the value of any form of

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professional help. He himself believed that therapy was potentially useful, because his earlier therapy had made a difference to him. In the light of these discussions, we agreed to pursue three main therapeutic tasks: (i) developing an understanding of the anxiety; (ii) learning concrete strategies for controlling his anxiety; (iii) constructing sources of positive meaning and satisfaction in his life, as a counter-weight to his tendency to be self-critical in ways that heightened his sense of not being in control in anxiety-evoking situations. A key moment emerged in session 10, when Alan was describing an occasion in the past week when he had started to have panic feelings at his place of employment. I suggested to him that it would be helpful for me, as a means of appreciating his experience, if he could describe in as much detail as possible what he had been thinking and feeling during this episode of panic. He recounted that he had felt utterly alone, despite the presence of other people. He did not know what to do, in respect of the job he had been asked by his boss to carry out. He imagined that this would be the end of his career there was no future for him in that organisation. He then added that he recalled a situation in his childhood where he had experienced the same thoughts and feelings. His parents had divorced when he was very young, and he then lived alone with his mother in a remote rural setting. His mother suffered from a medical condition that caused her to lose consciousness, and there had been several occasions when he had woken in the middle of the night to find his mother passed out on the living room floor, apparently dead. As a four yearold, he had no capacity to assist his mother in any way. In a highly emotional and moving episode in the therapy, he vividly described the depth of terror that he had experienced during these events. My response to this disclosure was to assume that the key to Alans anxiety lay in these awful childhood experiences. I believed, and my supervisor believed, that current situations that evoked anxiety in Alan could be understood as in some sense triggering that very raw four year-old terror, and that if he could come to realise that he was now a grown-up adult who in fact knew what to do, he would be able to assimilate these traumatic childhood memories into his overall sense of himself, and move on. In the next two sessions I therefore supported Alan to map out in more detail what had happened in these childhood episodes, and to make connections with his present-day anxiety attacks. However, at an early point in session 12, as we were pursuing this line of inquiry, Alan stopped and said to me, I know where you are going with this, but it is not helping me what I really need is to concentrate on what I can do differently in scary situations now, like the breathing and relaxation exercises I have learned. Following this conversation, Alan was much more actively in charge of the therapy process. It was as though he had decided for himself what he needed to do (practical strategies) and what was not so useful (understanding how and why his anxiety had emerged and what made it so powerful). In the final session of therapy, when invited to review what he had learned in therapy, Alan provided a detailed account of how he was now able to anticipate and manage

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the sequence of events that led him to feel anxious in certain situations. He also acknowledged the importance of learning about the value of friendships, and the significance of choices he had made about his future career directions. He said nothing about his understanding of the effect of childhood traumatic experiences on his life. How are we to understand the role of client preferences in Alans therapy? In my work with Alan, I sought to create an environment that allowed him to explore the utility of a range of ways of making sense of his problem, and a number of change strategies, with an explicit message that he would know what was right for him. What this did was build a supportive scaffolding within which Alan could become an active-self-healer (Bohart & Tallmann, 1999) and purposefully make use of the resources available, to him to take charge of his own life.

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Conclusions The aim of this article has been to provide a practice-friendly introduction to research into client preferences for therapy, and to offer some suggestions about the implications of that literature for the way that counselling and psychotherapy is carried out. The analysis of the research literature that has been presented is inevitably partial and incomplete. There are certainly further practical lessons that can be drawn from this area of research. In addition, ongoing programmes of research are likely to generate new insights around this topic in future years. Despite these limitations, it is clear that research into client preferences has a great deal to offer any practitioner who seeks to work with clients in a flexible, pluralistic manner. The research suggests that clients arrive in therapy with a capacity to make reference to a complex set of ideas around what will be helpful for them. Some of these ideas may be lightly held, in reflecting images of therapy that have been acquired through the media, but other ideas are likely to be embedded in core self-narratives. While clients may have some difficulty in articulating their preferences, for example in intake and assessment sessions, many research studies have demonstrated that clients are able to respond to preference items in questionnaires, or interview questions, in ways that have a bearing on the eventual outcomes of their therapy. It is possible brief self-report instruments may have an important role to play, as conversational tools (Sundet, 2009) in supporting clients in giving voice to implicit choices and values around the conduct of therapy. The indications from research are that active therapist engagement with client preferences has the effect of strengthening the client-therapist relationship, enhancing client commitment to change, and creating opportunities for reflection and construction of shared meaning through a process of collaborative choicemaking. From a practitioner perspective it would be valuable if further research could be carried out into how these processes happen, and into the factors that contribute to successful and less successful negotiations across the divide between what a therapist has to offer, and what their client wants and needs.

European Journal of Psychotherapy and Counselling Notes on contributor

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John McLeod is Emeritus Professor of Counselling at University of Abertay Dundee. He is author of many books and articles, including An introduction to counselling (Open University Press, 4th edition, 2009), Counselling skills (with Julia McLeod, Open University Press, 2nd edition, 2011), and Pluralistic counselling and psychotherapy (with Mick Cooper, Sage, 2011) and was the founding editor of the Counselling and Psychotherapy Research journal.

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