4. Choice Framework

At the beginning of the Choice appointment, all clinicians ensure that service users are informed about what will happen. All clinicians work in a Choice framework. Clinicians complete appropriate tasks for clinical governance and risk management.

Choice framework

  • Curiosity about the service user’s view
  • and our reflected opinion;
  • evolving a Joint Formulation followed by a
  • Discussion of Alternatives (not all involving mental health services) ending in
  • The Choice point
  • Maximised by their engagement tasks.

We know that outcomes are better with strengths-based, personalised approaches that use evidence based interventions. Building a relationship that is truly respectful of the client is very important (Kurtz & James, 2004).


Engaging and motivating service users is key to CAPA. From the initial Choice appointment everything should feel personalised, collaborative, useful and focused. This works through a stance of the clinician being a ‘facilitator with expertise’. We help the person make sense of their experiences, motivating them to change things and offering them alternatives that may help them reach those goals. It helps to explore things they have already done so that they can build on these. It is also worth being open about the possible consequences of not changing things.

Joint Formulation

Reaching a shared understanding of the problem (i.e. a joint formulation) enhances task and therapeutic alliance (see later) and thus the outcome for the person coming to you for help.

For the client to engage in change they need to know what interventions may help and what these involve. How often are we explicit with people about what a particular therapy is like or how long it may take for things to improve? They need warning that things may seem to get worse before they get better (e.g. a ‘compliant’ daughter who now has anorexia nervosa may turn into a ‘stroppy’ teenager as they recover). Only after we have had these explicit conversations can clients truly make an informed choice about what they want to happen.

There is likely to be a range of interventions that may help them. Rarely are the problems we see pure and present in isolation. Furthermore, some people are more practical and prefer a problem solving approach; others are more relational and may prefer a systemic approach. A blended combination may be most suitable for others. Discuss the options, what they are like, and any evidence base. Help them interpret these options in relation to their circumstances.

Agreeing things they can do to help themselves further engages them in the change process and builds on their self-efficacy.

What happens if you don’t use a Choice framework?

Service users are likely to feel less involved and passive in front of an expert. This is likely to lead to their experience being worse and their engagement, therapeutic and task alliance and motivation will be lessened. Change will definitely take longer. Your assessment may identify needs that they are not interested in, nor would they consent to if you were explicit. So fruitless work may be begun. Hard to engage service users will be even less likely to engage…