Psychotherapy © 2013 American Psychological Association

2013, Vol. 50, No. 3, 279 –283 0033-3204/13/$12.00 DOI: 10.1037/a0032031

Working With Clients by Incorporating Their Preferences

Kelley A. Tompkins and Joshua K. Swift Jennifer L. Callahan

University of Alaska, Anchorage University of North Texas

Working with clients by integrating their therapy preferences into the treatment decision-making process
has been identified as an important part of evidence-based practice in psychology. Accommodating client
preferences has also been demonstrated to lead to fewer treatment dropouts and improved therapy
outcomes. In this article, we present a number of clinical interventions or techniques for addressing client
preferences in psychotherapy. Clinical examples demonstrating the techniques are also provided.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Keywords: client choice, preferences, psychotherapy, process

A Theory for Preference Inclusion
Although stereotypes sometimes display therapists as stoic ex-
perts who offer interpretations to their passive clients, in reality,
many therapists work collaboratively with their clients by using
client preferences and choice to guide treatment decisions. In fact,
current guidelines for evidence-based practice in psychology even
recommend that treatment decisions should be made in the context
of client preferences (APA Presidential Task Force on Evidence-
Based Practice, 2006). Preferences are defined as the specific
variables or attributes that clients desire to have in a therapy
setting, including three main types: role, therapist, and treatment-
type preferences (Swift, Callahan, & Vollmer, 2011). Role pref-
erences are the behaviors that clients expect both themselves and
their therapists to engage in during therapy (therapist to offer
advice, client to talk during the majority of the session, etc.),
whereas therapist preferences consist of characteristics that clients
desire in an ideal therapist, such as being empathetic, belonging to
a specific ethnic group, or having a high level of clinical experi-
ence. Treatment-type preferences refer to the kind of intervention
hoped for, whether it be psychotherapy versus another treatment
option (medication, religious counseling, etc.) or a preference for
a specific treatment orientation (behavioral, psychodynamic, etc.).
Although preferences and expectancies may be related, they are
two distinct constructs (Tracey & Dundon, 1988), with preferences
representing hoped-for conditions and expectancies representing
anticipated conditions (Swift et al., 2011).
The importance of honoring client preferences as a mechanism
of therapeutic change can be grounded both in recognizing the
client’s role as an expert and in the power of choice. Clients often
seek therapy feeling stuck or lost with regard to how to fix the
problems that they are experiencing. It can thus be easy for
Kelley A. Tompkins and Joshua K. Swift, Department of Psychology,
University of Alaska, Anchorage; Jennifer L. Callahan, Department of
Psychology, University of North Texas.
Correspondence concerning this article should be addressed to Joshua K.
Swift, Department of Psychology, University of Alaska, Anchorage, 3211
Providence Drive SSB214, Anchorage, AK 99508. E-mail: joshua.keith
.swift@gmail.com
therapists to assume responsibility in helping their clients get
unstuck by providing solutions. After all, therapists are experts in
human behavior, with specialized knowledge and training in psy-
chopathology and treatment techniques. However, therapists are
not the only experts in the relationship. Although they may feel
stuck or lost, clients are still experts in their own lives. Most of the
time they have some idea about how their problems developed, and
when the treatment matches their conceptualization, it is more
likely to succeed (Addis & Carpenter, 1999; Addis & Jacobson,
1996; Meyer & Garcia-Roberts, 2007). Additionally, clients know
which interventions have or have not worked in the past, and they
know which interventions they are willing and motivated to try
now. Thus, preference accommodation as a clinical process has an
early influence on engagement in therapy. Additionally, preference
accommodation in the form of incorporating client choice can have
a continued impact on the therapy process. According to cognitive
dissonance theory (Cooper, 2012; Draycott & Dabbs, 1998; Fest-
inger, 1957), when an individual makes a choice between options,
the chosen option becomes valued more strongly and the individ-
ual becomes more committed to and invested in making that option
become the right choice. Likewise, allowing clients to choose
between treatment options would theoretically result in a greater
level of therapeutic investment. Finally, including client choice in
therapy allows therapists to express confidence in their clients,
thus increasing client hope, and allows clients to practice this type
of behavior.
Research Support for Preference Integration
A number of studies and reviews support the accommodation of
preferences as an important clinical process for therapy. The most
recent and comprehensive review of the topic was completed by
Swift, Callahan, and Vollmer (2011), which was a meta-analysis
with data from 35 studies that compared preference-matched and
nonmatched clients. They found both a significant outcome (d ⫽
0.31) and dropout (OR ⫽ 0.59) advantage in favor of matched
clients. In their review, the improved outcomes and decreased
dropout rates for clients whose preferences were accommodated
were consistent across preference types (role, therapist, or treat-
ment type) and client disorder. In a follow-up meta-regression
analysis that included the same studies, Swift, Callahan, Ivanovic,

279
 280 TOMPKINS, SWIFT, AND CALLAHAN
and Kominiak (2013) found that the preference outcome and
dropout effects were also consistent across client age, gender,
ethnicity, education level, and marital status. In other words,
clients of all types did better in treatment (showed greater outcome
improvements and were less likely to drop out) when their therapy
preferences were matched.
Interventions for Incorporating Client Preferences
Incorporating client preferences is an important clinical process
that can occur at many different times throughout therapy. Here we
provide a number of recommendations for integrating client pref-
erences in therapy within three general areas, including assessing
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
client preferences at the start of treatment, working with clients
This document is copyrighted by the American Psychological Association or one of its allied publishers.
when preferences cannot be met, and revisiting preferences
throughout therapy. Clinical examples are provided for each tech-
nique.1
Assessing Client Preferences
A variety of methods are used to assess client preferences during
treatment. The simplest of these is to directly ask clients which
therapy conditions they would prefer. However, questionnaires for
assessing client preferences also exist. For example, to assess
preferred therapy roles, therapists can use the preference version of
the Psychotherapy Expectancy Inventory—Revised (Berzins, Her-
ron, & Seidman, 1971; Rickers-Ovsiankina, Geller, Berzins, &
Rogers, 1971), which measures preferences for approval-seeking,
advice-seeking, audience-seeking, and relationship-seeking, or the
preference version of the Treatment Preferences and Experience
questionnaire (Berg, Sandahl, & Clinton, 2008), which measures
preferences for outward- versus inward-oriented treatments, sup-
port, and catharsis. Rather than simply asking which treatment
option is preferred, these two measures, as well as others, use
Likert-type scale ratings, which allows for an additional assess-
ment of preference strength for the given options. Another exam-
ple of a preference measure is the Treatment Preference Interview
(Vollmer, Grote, Lange & Walker, 2009), which allows clients to
express preferences across multiple domains (role, therapist, and
treatment type).
Whether choosing to inquire about preferences in person or
through an existing measure, a number of recommendations can be
made for preference assessment. First, we recommend that each of
the three preference domains (role, therapist, and treatment type)
be assessed. Second, for some therapy options, such as preferences
concerning the therapist characteristics, the assessment can occur
very early on, perhaps even over the phone. For others, such as
treatment-type preferences, therapists may want to wait until the
end of an intake so that they can have a better idea about which
options are most appropriate for the client, given their presenting
problems. Third, as some clients might not have a general under-
standing of what choices are available, preference assessment
should be preceded by a thorough description of the options.
Fourth, therapists should also only offer the options that they are
prepared to meet. For example, some therapists may be willing to
allow their clients to choose between different types of treatments,
whereas other therapists may want to only provide services under
one specific orientation. Those therapists who desire to stick to a
specific orientation may want to offer some options within that
treatment to allow clients to have an active role in at least part of
the decision-making process.
Clinical example 1: A general inquiry of preferences.
Megan sought behavioral health services at a primary care medical
center after a car accident in which she was pinned under her car.
She reported symptoms meeting criteria for post-traumatic stress
disorder (PTSD) from the accident as well as a return of trauma
symptoms related to being sexually abused by her father when she
was a child. During the intake appointment, she did report previous
therapy experience. The therapist then stated:
“People who have participated in therapy before sometimes have
preferences for how they would like their current therapy experience
to look like. For example, they may have worked with their previous
therapist on a specific approach that they found helpful or they want
a therapist of a certain gender. It would be helpful to hear a little bit
about what you liked and didn’t like about that experience so that I am
better equipped to work with you and honor the way you would like
your therapy experience to proceed. So Megan, tell me about what
you found helpful from the last time you were involved in therapy.”
Megan reported that her previous therapist helped her work
through an exposure-based PTSD workbook, which she found
helpful and which she still kept and read through when she felt
anxious or triggered. She specifically elaborated on how helpful it
was for her to have a therapist read and work through the book
with her, as she occasionally had difficulty reading and compre-
hending certain passages. After listening to Megan, the therapist
then said:
“So, it seems like you found worksheets that you can review when you
need to at home to be an important part of your previous therapeutic
work. On top of that, it appears as if it was helpful for you to have
support in session to review those worksheets. Would you like our
work together to follow a similar approach, or do you have a different
idea for what you would like therapy to look like?”
Megan indicated that it was indeed her preference to follow a
similar approach as before. The therapist and Megan worked
through another PTSD workbook, and in a matter of weeks, she
had demonstrated a clinically significant decrease on a measure of
PTSD symptoms.
Clinical example 2: Providing treatment options. Sam was
referred for therapy after endorsing suicidal ideation in an appoint-
ment with his primary care physician. In the initial appointment
with his therapist, he reported a significant number of depressive
symptoms and increased isolation from others. He also stated that
although he did not have a suicidal plan, he frequently thought
about death and felt like he wanted to die. Given Sam’s frequent
suicidal ideation, the first two sessions were spent doing crisis
management and safety planning work as well as discussing goals
for therapy. At the end of the second session, the therapist explored
Sam’s preferences for therapy. The therapist stated:
“Sometimes people begin therapy and have set ideas for the way they
want therapy to go. They may have ideas for ways they want to tackle
1
Clinical examples are disguised, in that client names have been
changed and identifying information is not presented. Although the ther-
apist dialogue that is presented matches actual session content, it is not a
verbatim transcript.
 INCORPORATING CLIENT PREFERENCES
their problems, or they may have a preference for how therapy will go
based on previous therapy experience, reports they have heard from
other people or educational material they have come across. Sam, tell
me about how you would prefer therapy to look like in order to best
reach your goals of reducing your depression and learning skills to
deal with anger.”
Sam explained that he had never been in therapy before and thus
had no idea what to expect or want from treatment, although he
knew that he did not want to take any medication. His therapist
then said:
“There are various therapy approaches that can be effective with
individuals who experience depression. I have experience with
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
cognitive– behavioral and process-oriented approaches and have seen
clients experience benefits from both of them. Let me briefly describe
This document is copyrighted by the American Psychological Association or one of its allied publishers.
them to you to give you a better sense of how each approach looks.”
The therapist briefly described a cognitive– behavioral and a
process-oriented approach and explained that both have research
support indicating their effectiveness in treating depression. Sam
immediately stated that he wanted a cognitive– behavioral ap-
proach because he “is very concrete” and “does better with visual
things.” Therapy proceeded with behavioral activation and cogni-
tive restructuring techniques. By the end of 3 months of treatment,
Sam reported a significant decrease in his depression and the
absence of any suicidal ideation.
Clinical example 3: Providing options within a treatment.
Mark sought treatment for the depression he was experiencing
after his girlfriend ended their 2-year relationship. His therapist
typically used a process-experiential approach to treatment and felt
like it would be appropriate for Mark’s problems. Instead of
offering treatment options, in the initial session, the therapist
simply provided Mark with a treatment rationale for the process-
experiential approach and asked Mark if he felt like this would be
a good fit for him. Recognizing the importance of preferences and
choice, the therapist still wanted to give Mark the opportunity to
tailor his treatment. With this desire in mind, the therapist said:
“Now there is never one right way for treatment to proceed for all
clients and I find that clients often know best about what is going to
be most helpful for them. Typically, I will meet with clients once a
week for an hour at a time. But, we do have a couple of options. If you
feel like it would be of more benefit, we could meet twice a week for
an hour at a time or we could meet once a week with 90 minute
sessions, or we could just keep it at the normal once per week 60
minute session schedule. Typically someone would choose longer or
more frequent sessions if they are facing a crisis or feeling a lot of
distress. Or sometimes someone just needs a little bit longer to get
through everything that needs to be covered in a session. What would
you prefer?”
Mark ended up choosing the twice-per-week sessions and ex-
pressed his appreciation for having been given the choice.
Working With Clients When Preferences
Cannot Be Met
Although preference integration is an important clinical process
for therapy, there may be times when a client’s preferences cannot
or should not be met. For example, a client may seek services from
a clinic and may strongly desire an African American therapist.
281
However, if no African American therapists work at the clinic,
how should this client’s preferences be addressed? Or a client may
express a desire for advice, but the therapist has strong beliefs
against offering advice in treatment. Does preference integration
mean that the therapist should just offer advice anyway? One
solution for situations when preferences cannot be met is to refer
the client to another provider who might be able to better accom-
modate his or her preferences. However, this solution is not always
possible and may frequently not be the best course of action. It is
important for therapists to be able to listen to, validate, and try
work with clients even if they cannot perfectly match their pref-
erences.
In situations when a client’s initial preferences cannot or should
not be met, the therapist should first attempt to gain a better
understanding of the reason for the client’s preference. Once the
reasons behind the preferences are understood, the therapist may
be able to provide the client with education about therapy. This
education may include other available options that may fit the
reasons behind the unavailable preference condition or may in-
clude education about why the original preferences are actually
counterindicated for the client’s problems. The therapist and client
can then decide together if they want to try one of the other therapy
options or if a referral to another provider or clinic is needed. The
goal throughout this process is to help clients feel like they have a
legitimate opinion and voice in deciding what is included in their
treatment.
Clinical example 4: Accommodating an unaccommodatable
preference. Gregory sought treatment in a psychology depart-
ment clinic for his experience of panic disorder. While he had
experienced occasional panic attacks for at least the past 10 years,
he started having daily attacks midway through his first year of
college and after discontinuing his antidepressant medication. In
the initial appointment, he specifically asked for Eye Movement
Desensitization and Reprocessing (EMDR) for the treatment of his
panic. Gregory’s therapist had not been trained in this specific
treatment and thus was not able to accommodate his preference.
Rather than simply informing Gregory that his preference could
not be matched or providing an immediate referral to an EMDR
provider, the therapist inquired further about Gregory’s preference
for EMDR. Gregory stated that he did not know much about
EMDR, but he read about it online and it seemed to have a lot of
empirical support. The therapist then said:
“I hear you saying that you like EMDR because you have read some
good things about it on the Internet and it seems to have a lot of
research that supports its use. Although I do not offer EMDR per-
sonally, I am familiar with the treatment. Studies have found it to be
one effective option for PTSD. For those types of problems, EMDR
primarily includes the pairing of eye movements with exposure in the
form of cognitive processing of the traumatic events. In working with
anxiety of any type, particularly panic disorder, I typically like to use
a cognitive– behavioral approach. Although cognitive– behavioral
therapy [CBT] for panic disorder does not include the eye movements,
it does include the same principles of exposure as well as identifying
and challenging some of the thoughts that contribute to the continued
panic attacks. Personally, I have seen a lot of success with CBT when
working with clients to overcome their panic attacks. There is also a
large body of research that supports the use of CBT for panic
disorder. If you feel like you are dead set on EMDR, I can give you a
 282 TOMPKINS, SWIFT, AND CALLAHAN
referral for an EMDR provider. Or, if you want, we can give the CBT
approach a try. What do you think?”
Gregory asked to hear a little more about the nature of CBT for
panic, and after hearing a more detailed treatment rationale, he
expressed his desire to use CBT rather than being referred to an
EMDR provider. Twice-weekly sessions using a CBT approach
were held, and by the end of 2 months, Gregory was able to start
his second year of college with a significant reduction in panic
attacks and little fear or impairment from the infrequent attacks
that he did have.
Revisiting Preferences Throughout Therapy
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Although integrating client preferences largely occurs early on
in therapy during the initial decision-making process, therapists
should seek to revisit their clients’ preferences occasionally
throughout the therapy encounter. The process of revisiting pref-
erences is helpful for several reasons. First, client preferences for
treatment can change over time. As life is constantly in fluctuation,
new life circumstances or experiences may change current prefer-
ences. Additionally, preferences may shift as clients gain experi-
ence with a therapist and a more trusting relationship is developed.
Second, despite the therapist’s best attempts, the client’s prefer-
ences might not be met. Clients sometimes have difficulty articu-
lating what they want early on in treatment, and therapists some-
times have difficulty understanding exactly what their clients’
preferences are. 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 ther-
apy. Checking in on preferences fits nicely with outcome moni-
toring and client/therapist discussions of treatment progress.
Clinical example 5: Revisiting preferences. Sarah, an over-
weight individual, was referred to therapy by her primary care
physician for chronic depression and low self-esteem related to
longstanding issues with her weight. When asked about her goals
for therapy during an intake appointment, Sarah expressed a desire
to first work on developing and maintaining an exercise plan to
help her lose weight, believing that that would be the best way for
her to improve her self-esteem and, in turn, reduce her feelings of
depression. Given this goal preference, the therapist started treat-
ment by providing Sarah with education about healthy exercise
habits and helping her implement a simple exercise plan. However,
despite her agreement with and excitement about her exercise plan,
Sarah repeatedly failed to complete her homework assignments.
After a couple of sessions of homework noncompliance, Sarah’s
therapist inquired about whether the treatment approach was still
meeting her preferences. The therapist stated:
“Sarah, when we first met together we talked about the way you
wanted therapy to go. Over the past few weeks, we have worked
together to try and honor your preferences by addressing your self-
esteem and weight goals by doing exercise related homework assign-
ments. Each week, it seems as if it has been a bit of a struggle for you
to complete these assignments. Does that match with your
experience?”
Sarah agreed she struggled with completing the homework
assignments. The therapist continued:
“I wonder if these difficulties relate to the way we have been design-
ing your homework assignments or if they might be occurring for
some other reason. Perhaps we have been taking the wrong approach.
What do you think? Is this still the direction that you want therapy to
go?”
Sarah reported that the first few sessions of therapy helped her
realize that maybe focusing on exercise and activity levels was not
the best approach for her right now. Instead, she now felt like she
might be better served by addressing her use of food as a coping
mechanism for her depression. She indicated a shift in preference
from focusing on an exercise plan to wanting to explore the link
between her eating and her feelings, as well as develop an ability
to express her emotions rather than turn to food. With a shift in
focus to match these new preferences, Sarah became more com-
pliant with her homework assignments and she started to make
progress in reducing her depression and changing her eating habits.
Conclusions
Working with clients by integrating their therapy preferences
into the treatment decision-making process is an important part of
evidence-based practice in psychology. Further, preferences ac-
commodation has also been found to lead to fewer treatment
dropouts and improved therapy outcomes. Future research should
continue to identify the preferences that clients hold for therapy as
well as identify the effects of providing clients with their preferred
treatment conditions, particularly in the area of preferences about
the therapist. Given the research evidence that does exist, thera-
pists should seek to incorporate their clients’ preferences into
treatment whenever possible. In this article, a number of clinical
techniques for addressing client preferences in psychotherapy were
presented. These techniques can help therapists demonstrate an
overall attitude of being equal partners with their clients in psy-
chotherapy.
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Received January 9, 2013
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analysis. Journal of Psychotherapy Integration. Advanced online pub-

lication. doi:10.1037/a0031423 Accepted January 17, 2013 䡲
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Call for Papers: Personality and Psychotherapy

In 2004 as a guest Editor of Journal of Personality Assessment I helped organize a special issue on
the relationship between personality assessment and psychotherapy. A decade later I believe it
would be fruitful to ascertain how this area of research has progressed. Therefore, Psychotherapy
invites manuscripts for a special issue on Personality and Psychotherapy. Specifically, identifying
personality characteristics of patients and therapists that potentially impact treatment process and
outcome (i.e. moderators, mediators, etc). We welcome papers empirically examining complex
aspects of personality across a range of different theories, orientations, measures and perspectives.
Studies using quantitative or qualitative methods, as well as those demonstrating null or negative
results, are welcomed. In addition, meta-analyses on different patient or therapists characteristics
that both synthesize the existing empirical literature as well as offer direction for future training,
research and practice of psychotherapy are encouraged. Studies examining simple personality
variables such as demographic, diagnostic group or global pathology are not the focus of this special
issue.
While this call is for empirically based studies on the impact of personality on psychotherapy
process and outcome, manuscripts submitted to this Journal must also have a very clear statement
and implications for applied clinical practice.
Manuscripts can be submitted through the Journal’s submission portal, under the Instructions to
Authors at: http://www.apa.org/pubs/journals/pst/. Please note in your cover letter that you are
submitting for this special issue. Deadline for submitting manuscripts in this special issue is
January 15, 2014. Any inquiries or questions regarding topic or scope for the special issue can be
sent to the Editor, Mark J. Hilsenroth, at: Psychotherapy@adelphi.edu.