Jacobsen, C. F., Falkenström, F., Karstoft, K.-I., Igra, L., Lunn, S., Nielsen, J., Lauritzen, L., & Poulsen, S. (2025). Exploring the matching effect: The association between preference accommodation, the working alliance, and outcome in psychotherapy. Journal of Consulting and Clinical Psychology, 93(6), 443–456. https://doi.org/10.1037/ccp0000955
Key Takeaways
- Focus: The study explores the impact of aligning psychotherapy activities with client preferences on therapeutic outcomes.
- Aims: The research aimed to investigate whether accommodating client preferences directly influences therapeutic outcomes or indirectly affects outcomes through the therapeutic alliance. It also examined variations based on the phase and types of therapy activities.
- Method: The study used dynamic panel modeling with 366 adults (75% female, average age 43.2) undergoing individual psychotherapy with 50 therapists. Therapy preferences, experiences, therapeutic alliance, and symptoms were measured at multiple points.
- Findings: Matching client preferences with therapy experiences robustly improved therapeutic alliance but had inconsistent direct effects on symptom improvement.
- Implications: Preference accommodation primarily enhances psychotherapy through improved therapeutic alliances rather than direct symptom reduction, suggesting a nuanced approach to therapy personalization.
Focus
This study looks at how closely therapy session activities follow what clients say they prefer, and how that matching affects both the client-therapist bond and changes in clients’ symptoms.
Aims
- Primary aim: Find out whether giving clients more of the activities they want leads directly to symptom improvement or works indirectly by strengthening the alliance.
- Secondary aim: See if these effects differ depending on the type of activity (e.g., emotional exploration vs. practical support) or the stage of therapy (early vs. later sessions).
Rationale
Research shows that when clients get treatments they prefer, they stay in therapy longer (Swift et al., 2018) and sometimes improve more (Lindhiem et al., 2014), but results are mixed (Windle et al., 2020).
Most past studies looked only at big choices—like “skills training” versus “talk therapy”—and only before therapy began (Chui et al., 2020; Sandell et al., 2011).
We still don’t know whether adjusting the specific activities therapists use, week by week, really helps clients feel heard and eases symptoms.
It could be that matching works directly—clients feel better because they get what they asked for—or indirectly—clients feel a stronger bond, which leads to better outcomes (Norcross & Cooper, 2021).
To clarify this, we need a study that checks both session-by-session preferences and later symptom measures in the same real-world therapy courses.
Method
- Design: Followed 366 adults in individual therapy over ten sessions; measured their activity preferences, what actually happened in sessions, their sense of alliance, and weekly symptom levels.
- Analysis: Used statistical models that track changes over time within each person, comparing how “preference gaps” at one point predict alliance and symptoms later on.
Procedure
- Before session 1: Clients filled out a questionnaire rating 25 possible therapy activities (e.g., “I want to talk through my feelings,” “I want concrete advice”).
- After every session: Clients rated how close they felt to their therapist and how clear the goals/tasks felt.
- Sessions 4, 7, 10: Clients rated which of those same 25 activities actually happened.
- Weekly: Clients completed an 11-item checklist of anxiety and depression symptoms.
- Modeling: We calculated “preference gaps” (what they wanted minus what they got) and looked at how those gaps forecast alliance and symptoms in the next phase.
Sample
- Clients (N=366): Average age 43; 3 out of 4 were women; most had at least a bachelor’s degree; many worked full-time.
- Therapists (N=50): Average 17 years of experience; mix of psychodynamic, humanistic, and CBT orientations.
Measures
- Preference & Experience Questionnaire (PEX): 25 items, five domains (e.g., inward reflection, outward focus, emotional expression, emotional restraint, support).
- Session Alliance Inventory (SAI): Six items on bond and agreement about tasks/goals each session.
- Symptom Checklist-11 (SCL-11): Weekly ratings of anxiety and depression symptoms.
Statistical Approach
- Dynamic panel models: Tracked how changes within each person over time predicted later changes, while holding constant each person’s average level.
- Key paths tested:
- Direct effect: Preference gaps → symptom change
- Indirect effect: Preference gaps → alliance → symptom change
Results
- Alliance boost: Smaller preference gaps (i.e., more matching) reliably predicted stronger alliance scores in the next measurement period.
- Symptoms: Matching had inconsistent effects on symptoms:
- Early sessions: too much emotional expression predicted slight symptom increases.
- Later sessions: extra practical support predicted symptom decreases.
- Mediation: Alliance consistently grew with better matching, but alliance did not always translate into symptom improvement on its own.
Insight
Giving clients more of what they ask for makes them feel closer to their therapist, but it isn’t a magic bullet for reducing anxiety or depression.
Timing and type of activity matter: hands-on support helps more as therapy progresses, whereas deep emotional work may be overwhelming too soon.
These findings push us to personalize not just the “big picture” of therapy, but each session’s activities in response to client feedback.
Key Takeaways
- Clients want more active involvement than they usually get. When people began therapy, they had clear ideas about what kinds of activities (like talking through feelings or getting practical support) they wanted—but sessions often didn’t match those wishes.
- Matching activities to preferences builds trust. When therapists adjusted what they did in session to fit what clients said they liked, clients felt the therapist-client bond grow stronger.
- Better bond doesn’t always equal faster symptom relief. Although matching helped people feel understood and supported, it didn’t always lead to quicker drops in anxiety or depression.
- Timing matters. Getting practical support later in therapy did help reduce symptoms; diving straight into deep emotional work too early sometimes increased distress.
- Alliance is the main pathway. The client-therapist bond (alliance) seems to be the key reason why matching preferences matters—especially around deciding on goals and tasks together.
Clinical Implications
Implement Brief Preference Check-Ins:
- Use a 2–3 item survey at the start of each session to ask clients what they most want to focus on—practical solutions, emotional exploration, or support.
- Benefits: Keeps therapy client-centered and responsive; reduces risk of misalignment.
- Challenge: Adds a few minutes to each session; requires simple digital or paper tools.
Phase-Sensitive Treatment Planning:
- Early sessions (1–3): Emphasize concrete, problem-solving tasks (e.g., coping skills, action plans) to establish safety and competence.
- Middle to late sessions (4+): Gradually integrate deeper emotional work (e.g., exploring attachment wounds) once alliance ratings are high.
- Benefits: Balances structure and depth; tailors intensity to client readiness.
- Challenge: Therapists need training to gauge alliance strength accurately and adjust pacing.
Incorporate Alliance Monitoring:
- After each session, include a quick alliance rating (e.g., “On a scale from 1–5, how clear were our session goals today?”).
- If ratings dip below a threshold, immediately revisit preferences and adapt activities.
- Benefits: Early detection of alliance fractures; promotes continuous collaboration.
- Challenge: Therapists must be comfortable with transparent feedback and iterative change.
Train Therapists in Preference-Based Flexibility:
- Develop workshops or supervision modules focused on detecting and responding to client preferences in real time.
- Include role-plays where therapists practice shifting from one activity type to another (e.g., moving from skill-building to emotional processing).
- Benefits: Builds therapist agility; improves client satisfaction and engagement.
- Challenge: Requires organizational support and time for training.
Policy & Service Design:
- Clinics and healthcare systems should allow session structures that accommodate preference assessments (e.g., allotting extra 5 minutes).
- Outcome metrics could include both symptom change and alliance trajectories.
- Benefits: Encourages evidence-based personalization; may reduce dropout and improve cost-effectiveness.
- Challenge: Shifting administrative norms and billing practices to support flexible session formats.
Strengths
- Real-world setting with many therapists and clients.
- Repeated, session-by-session data on preferences, experiences, alliance, and symptoms.
- Advanced models that separate within-person change from overall differences between people.
Limitations
- Preferences only measured at the start—clients’ wishes may have shifted over time.
- Experience ratings every three sessions may miss nuances in between.
- Dropout reduced sample size at later points, which may bias findings.
- All participants from Denmark; may not generalize to other cultures.
Socratic Questions
- Preference shifts: How might clients’ activity preferences evolve during therapy, and how could you measure that?
- Overmatching risks: When could giving someone exactly what they ask for backfire?
- Cultural context: How might cultural background shape what clients want from therapy?
- Intentional mismatch: Can deviating from a client’s stated preference ever lead to growth, and under what circumstances?
- Integration with feedback: How could you combine qualitative session feedback with the PEX scores to deepen understanding of what truly helps clients?
References
Jacobsen, C. F., Falkenström, F., Karstoft, K.-I., Igra, L., Lunn, S., Nielsen, J., Lauritzen, L., & Poulsen, S. (2025). Exploring the matching effect: The association between preference accommodation, the working alliance, and outcome in psychotherapy. Journal of Consulting and Clinical Psychology, 93(6), 443–456. https://doi.org/10.1037/ccp0000955
Chui, H., Palma, B., Jackson, J. L., & Hill, C. E. (2020). Therapist–client agreement on helpful and wished-for experiences in psychotherapy: Associations with outcome. Journal of Counseling Psychology, 67(3), 349–360. https://doi.org/10.1037/cou0000393
Lindhiem, O., Bennett, C. B., Trentacosta, C. J., & McLear, C. (2014). Client preferences affect treatment satisfaction, completion, and clinical outcome: A meta-analysis. Clinical Psychology Review, 34(6), 506–517. https://doi.org/10.1016/j.cpr.2014.06.002
Norcross, J. C., & Cooper, M. (2021). Personalizing psychotherapy: Assessing and accommodating patient preferences. American Psychological Association. https://doi.org/10.1037/0000225-000
Sandell, R., Clinton, D., Frövenholt, J., & Bragesjö, M. (2011). Credibility clusters, preferences, and helpfulness beliefs for specific forms of psychotherapy. Psychology and Psychotherapy: Theory, Research and Practice, 84(4), 425–441. https://doi.org/10.1111/j.2044-8341.2010.02010.x
Swift, J. K., Callahan, J. L., Cooper, M., & Parkin, S. R. (2018). The impact of accommodating client preference in psychotherapy: A meta-analysis. Journal of Clinical Psychology, 74(11), 1924–1937. https://doi.org/10.1002/jclp.22680
Windle, E., Tee, H., Sabitova, A., Jovanovic, N., Priebe, S., & Carr, C. (2020). Association of patient treatment preference with dropout and clinical outcomes in adult psychosocial mental health interventions: A systematic review and meta-analysis. JAMA Psychiatry, 77(3), 294–302. https://doi.org/10.1001/jamapsychiatry.2019.3750
