In a research paper published today (see here for journal version, and here for author final version), we found that a majority of clients wanted a more directive approach to therapy. Our data shows, for instance, that over 70% of clients wanted their therapist to focus on specific goals in therapy, to give structure to the therapy, and to take the lead. Clients expressed a particularly strong preference for therapists to teach them skills to deal with their problems. By contrast, only around 15% of clients wanted a more non-directive approach.
What we also did in our paper was to compare these preferences against therapists’ preferences, themselves. Not surprisingly, perhaps, we found that counsellors and psychotherapists—mainly of a person-centred orientation—wanted a lot less direction. So if we’ve used our own preferences as a guide to what clients are likely to want, it may come as something of a shock to see that, in fact, clients tend to want a lot more structure and leading. But that’s what we found, in two pretty rigorous surveys, and it’s matched by previous findings in the field (see, for instance, here).
These findings may be pretty challenging to those of us, from person-centred, humanistic, and relational orientations, that tend to work in more non-directive and unstructured ways. It suggests that what clients want is sometimes (perhaps often) different from what we tend to offer.
We could try and dismiss these findings by arguing that what clients want is not necessarily what they need. And, indeed, there’s good evidence that people don’t always know what is best for themselves (see, for instance, here). Two problems though. First, the evidence shows that there is quite a good association between what clients say they want from therapy, and how well they end up doing in it (see, for instance, here). So clients’ explicitly-stated preferences do indicate, on average, what works better for them, and also the kind of therapy that they are more likely to stick with. Second, if we start saying that clients don’t really know what they need (and we do), then we’re moving dangerously close to an ‘expert-driven’ perspective which holds that, as therapists, we know what’s best for clients. Not a good place for person-centred therapists to find themselves at!
Maybe it’s a case that clients’ preferences change over time. That is, they start off wanting more therapist direction but, once they get into therapy, they get more used to taking control for themselves. That may also be true in certain instances; but our data suggests that, across therapy, clients’ preferences don’t change too much. Certainly, in my own experience of using a preference inventory, I’ve found that what clients want stay pretty consistent. That is, at the start of therapy, clients are often saying things like, ‘Mick, I’d like this therapy to be fairly task-oriented,’ and after a few sessions they are saying, ‘So come on, when are we going to start on tasks!’
Perhaps clients’ desires for goals, tasks, and CBT is a consequence of neoliberalism, with the promise of an easy fix around every corner: someone who can always sort you out. Maybe. But, in my experience, when clients are asked why they want direction they come out with pretty cogent rationales: for instance, ‘Goals give me a sense of what I can focus on,’ or ‘I’d like to see things from a different perspective.’ And it’s a bit patronising, too, to assume that, because clients may want things different from us, it’s because they’ve been socialised into ‘faulty’ ways of thinking. Again, if we’re coming from a person-centred perspective, and trusting in the client’s own wisdom, surely we should be valuing how they see things from the start.
Does this mean that clients don’t want empathy, or acceptance, or an intense relational encounter as well? Not at all. In fact, we didn’t even ask about those relational qualities because we figured that, for most clients, the choice between an ‘empathic’ or a ‘non-empathic’ relationship would just be a no brainer.
And does this research suggest we should all re-train as CBT therapists? No, of course not. For a start, there are clearly some clients who do want a less directive approach, or who have tried CBT and are now wanting something different.
More importantly, perhaps, I think that the kinds of qualities that clients are asking for are all things that can be incorporated into a person-centred, humanistic, or relational practice. What, I think, a lot of clients are saying is something like this, ‘I want a therapist who is going to be active, who is going to do things, who is going to “sit forward” rather than “sit back”’. It’s like what I’ve wanted when I’ve been for a massage. It may feel less painful if the masseur is soft and gentle, but what I really want is someone who is going to be digging their knuckles in, making things happen. Clients invest a lot in therapy—time, emotionally, and financially often—and I think what many of them are saying is, ‘I want you, as a therapist, to be really involved here. To do things. Not just to sit back and let me do all the work.’
So I do think these findings challenge some ways of being a person-centred, humanistic, or relational therapist (or psychoanalytic, for that matter). I think they challenge a fairly ‘passive’, non-involved, ‘neutral’ style—or one where the therapist sticks mainly just to reflecting the client, and doesn’t add too much beyond that. The limitations of such a style are also very evident from research we’ve done with young people, as well as findings from adult clients: that a passive, non-involved stance can really ‘freak’ some clients out. They want to feel that the therapist is a ‘real person’, with real thoughts and ideas. And if everything is just focused on them, it can feel very unnatural.
More than that, from a pluralistic person-centred stance, goals, structure, and skills training can all be part of our therapeutic work—if that’s what clients are wanting, we’re appropriately trained in it, and we’re happy to work in that way. So while we can’t ever be everything to every client, a pluralistic PCA always tries to put the needs and wants of the individual client before any rigidity or dogma of method. If a client wants it, and we can do it, and we can both see how it might be helpful, then why not!
One of the nice things about a pluralistic person-centred stance is also that we can be really open to whatever the research says, and not having to reinterpret it to fit our own needs and agendas. As Carl Rogers so beautifully puts it (and there’s a great book of this title :-) ):
…[T]he facts are always friendly. Every bit of evidence one can acquire, in any area, leads one that much closer to what is true. And being closer to the truth can never be a harmful or dangerous or unsatisfying thing. So while I still hate to readjust my thinking, still hate to give up old ways of perceiving and conceptualizing, yet at some deeper level I have, to a considerable degree, come to realize that these painful reorganizations are what is known as learning, and that though painful they always lead to a more satisfying because somewhat more accurate way of seeing life.
Finally, just to say, the whole point of this blog isn’t to argue that we should all, now, work in more active and directive ways with every client. From a pluralistic standpoint, different clients need different things at different points in time; so there’s undoubtedly some clients out there who really want—and need—us to be quieter and more sitting back. Rather, the point of this blog is to say that we should always try and stay open to each individual client, and not prefigure what they want or need. In fact, if I think about myself, I tend to prefer a therapeutic style that gives me lots and lots and lots of space. But then, I’m a therapist.