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Pluralism in counselling and psychotherapy: An introduction to theory and implications for practice

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Mark Pearson, M.Ed(BEM), PhD., Senior Lecturer in Counselling, University of the Sunshine Coast, and Marc de Bruin, B.Law, Grad.DipMBCT, Dip.C., Post-graduate student at University of the Sunshine Coast 

 

Introduction

There is a vast array of approaches to counselling and psychotherapy. Nearly 15 years ago, Norcross (2005) estimated that there were more than 400 types of therapy, all with differing practices, techniques, foundations, and perspectives on responding to psychological distress. Miller, Duncan, and Hubble (2004) provided an even higher estimate, suggesting that they may have been up to 1000 different treatment models and techniques. Over the last 10 years, counselling research has refocused on the impact of attending to individual client preferences by considering a wide range of approaches (e.g., Swift & Callahan, 2009; Swift, Callahan, Ivanovic, & Kominiak, 2013). This article provides an overview of the pluralistic approach: its foundations, tenets, and applications, and identifies challenges and implications for practice.

Historically, counselling and psychotherapy practice has been structured around separate sets of ideas and models, each with their own manuals, teaching schools, and professional associations (McLeod, 2013a). The existence of so many distinct therapeutic schools can lead to what has been labelled “schoolism,” an assumed monopoly of truth regarding causes and treatments, that may reduce client options (Cooper & McLeod, 2011). Adhering to one particular school can lead to closing off to the clinical activities of other therapeutic approaches and the significance of the therapeutic alliance (e.g., Crawford et al., 2002; Gershefski, Arnkoff, Glass, & Elkin, 1996), and may incline a therapist to prize adherence to method over sensitivity to client preferences and needs. However, diversification can foster growth and creativity in counselling and psychotherapy (Cooper & McLeod, 2010, 2011). Miller et al. (2004) reported that therapists working from an eclectic philosophy may use as few as four of the many available techniques. 

Since the 1930s, and increasingly since the 1970s, theorists and practitioners have been working on finding ways to combine different theories and techniques to overcome limitations perceived when using a single or small number of therapies (e.g., Cooper & McLeod, 2007; Hansen, 2000; Ward, 1983). This has involved looking for parallels and connection between various methods (Cooper & McLeod, 2011, 2012; McLeod, 2013a) and has provided a number of different pathways towards integration (Norcross & Goldfried, 2005). Such pathways include Lambert’s (1992) common factors approach (i.e., “Common factors refer to the commonalities between therapeutic approaches and experiences that seem to account for change in service recipient outcomes” [Surette & Shier, 2017, p. 113]), as well as specific integrationist perspectives, such as theoretical integration, technical eclecticism, and assimilative integration (e.g., Norcross & Grencavage, 1989; Palmer & Woolfe, 1999).

More recently, the developers of pluralism (Cooper & McLeod, 2007, 2010, 2011) have attempted to construct a framework for therapy that could overcome some of the restrictions of schoolism and the perceptions of “rightness” of one model over another. These authors have identified the necessity of responding to client diversity using an appropriate range of methods.

From Eclecticism to Pluralism

Eclecticism is defined as “the knowledge and ability to employ many psychological theories” (Larsen, 1999, p. 69). It has been developing for over 80 years (Lampropoulos, 2000), and has been used to describe informal and more systematic ways counsellors and psychotherapists apply theories and methods that are considered a best fit for specific client needs (Hollanders & McLeod, 1999; Lampropoulos, 2000; Lazarus, Beutler, & Norcross, 1992). Lazarus et al. (1992) stated that therapists have realised “that one true path to formulating and treating human problems does not exist” (p. 11). A survey of British counsellors indicated that 87% applied some form of eclecticism in their daily practice (Hollanders & McLeod, 1999). Past studies in the United States of America found therapy integration through eclecticism in action (e.g. Cooper, 1987; Jensen, Bergin, & Greaves, 1990; Patterson, 1997). More recently, in an Australian survey of clinical psychologists, Poznanski and McLennan (2004) found that almost all participants described using CBT (as required by Medicare) alongside additional theoretical approaches.

Lampropoulos (2000) identified a need to focus on developing systematic treatment selection methods and organisational schemes to guide therapists. He also called for more research on developing “aptitude by treatment interactions” (p. 286) where different interventions are matched to client variables, and what he termed “personality-matched eclecticism” (p. 288). He appears to have been moving towards aspects of the pluralism concept although maintaining the assumption that therapists would decide the direction of therapy.

The term “integrative” has also been used widely to indicate a more formal, intentional, and theoretically coherent way of combining psychological treatments (e.g., Hollanders & McLeod, 1999; Lazarus, et al., 1992; Long & Young, 2007). In Hollanders and McLeod (1999), the counsellors and psychotherapists based their combination of approaches on personal choice or intuitive preferences, not on an organised or theoretically coherent foundation. Lazarus et al. (1992) suggested that the blending of concepts and methods from the various psychotherapy schools has been conducted in an arbitrary, subjective, even capricious way. They argue that haphazard eclecticism should be replaced by specific organising principles.

A significant theme to emerge from the Poznanski and McLennan (2004) study of Australian clinical psychologists was that theoretical orientation to practice was connected to the individual practitioner, with underlying theoretical beliefs emerging from the personal development background of practitioners; in other words, the therapists’ choice of treatments was potentially based on their personal constructs. Reasons for choice of orientation/decisions about treatments did not appear to include the preferences of clients, with one exception being the broadly named category of “experiential practitioners” (18.4% of participants) who believed it was important to validate clients’ personal experience.

All of the attempts to find ways to integrate different practices and ideas into one over-arching paradigm seem to represent a somewhat monistic strategy: an assumption that there is one right answer or a single truth (McLeod, 2013b). Pluralism developed as an alternative to monism, and refers to the notion that a number of valid responses or answers can be found to significant questions and “different things are likely to help different people at different points in time” (Cooper & McLeod, 2010, p. 3).

Recent research has indicated that client retention and therapeutic outcomes are enhanced through responding to client preferences (Swift et al. 2013), and this endorses the pluralistic practice of involving clients in discussions of treatment (Cooper & McLeod, 2012). It could be argued that one outcome from therapy for clients is learning skills in reflectivity, cognition, and behaviour (Willner, Jones, Tams, & Green, 2002). Individuals have varying attributes that lead to preferred styles of learning (Rolfe & Cheek, 2012). Indeed, over 70 different types of learning styles have been identified (Coffield, Moseley, Hall, & Ecclestone, 2004). It was originally thought that individuals develop preferences for specific modes of learning (e.g., Kolb & Kolb, 2005).  However, recent research (An & Car, 2017) has suggested that differences in verbal and visual skills, expertise and domain knowledge, self-regulation, and inhibition, should be used to focus learning. Consequently, therapists should be open to an investigation into the best fit for each therapeutic mode for each client.

An approach to counselling that incorporates multiple intelligence theory and practice (Pearson, 2011; Pearson, O’Brien, & Bulsara, 2015) suggests that an assessment of client strengths or preferred intelligences can provide a platform for collaboration. This, in turn, assists selection of client-specific therapy methods, specifically in the early stages of alliance formation. This contribution towards pluralistic practice has been referred to by McLeod (2018) as providing “epistemic fluidity” (p. 27), or support for identifying client ”ways of knowing”. He described counsellors and clients as having five contrasting sources of knowledge (i.e., theoretical, practical, cultural, personal, and scientific) and the multiple intelligences approach can use all these. He further suggested that “the most effective problem-solving occurs when dialogue takes place between different ways of knowing” (p. 26).

Assumptions of Pluralism

Pluralism, as a basis for psychological theory and practice, was first introduced as a philosophical viewpoint by William James in his 1909 lectures A Pluralistic Universe (James, 1909/2004). James argued that if an absolute singular truth underpins a theory, this would mean the theory cannot be changed or improved. As all theories are constantly evolving and changing, he concluded that the monist idea that there is a single truth cannot be supported.

The pluralistic rationale is an ethical one: to strive for a humanistic, respectful agenda in which clients are most valued (Cooper & McLeod, 2012). Its psychotherapeutic standpoint has two core tenets: 1) a number of different models of psychological distress may be “true”, and it is not necessary to bring them together in one unified model; and, 2) therapists should be closely working together with clients to discover what clients want from therapy and how to achieve their objectives (Cooper & McLeod, 2007, 2012). The increasing interest in, and success emerging from, collaboration in therapy (e.g., Anderson, 2012; Anderson & Gehart, 2007; Murphy & Sparks, 2018; Long & Young, 2007) increasingly justifies the pluralistic way of engaging with clients.

Two further basic principles, while not exclusive to pluralism, underlying the pluralistic approach are: 1) many different approaches can be helpful for clients; and 2) therapists should talk to clients to determine and agree on the best treatment (Cooper & McLeod, 2011; Loewenthal, 2012; Murphy & Sparks, 2018). Clients who present for therapy are considered to be the experts in their lives who have an implicit understanding of what they need, when they need it, and how to achieve that result in the best possible way, yet it is recognised that they may need support to access this knowledge (McLeod, 2018). The pluralistic approach leads to a collaborative style of working; joint decision making and problem solving between counsellor and client based on transparency of ideas and varying viewpoints. Pluralism invites a “both/and” strategy rather than an “either/or” approach (McLeod, 2013, 2018). The counsellor and client may each have strong ideas about what may be most effective, but must remain open to dialogue and try to understand each other’s viewpoint (McLeod, 2013). This dynamic relationship could be considered as the evolution of the respectful humanistic (Rogerian) viewpoint, and can also be found in several other approaches, for example in some strength-based approaches and dialectical behaviour therapy.

Critique of Pluralism

If the pluralistic approach acknowledges that many different approaches and activities can be helpful to clients, and that therapist and client need to work together to determine the most appropriate treatment, is it then similar to integrative or eclectic approaches? Cooper and McLeod (2011), referring to a comprehensive article by Downing (2004), point out that although many eclectic and integrationist approaches attempt to transcend monist models of theory and practice, they end up “replicating something quite similar” (p. 6). Integrative and eclectic approaches tend to be less restricted by specific methods and theories than monist approaches (Cooper & McLeod, 2011). The obvious risk is that practitioners of pluralism, in their enthusiasm to make a case for the pluralistic approach, create a new schoolism dichotomy (Dryden, 2012).

Another risk Dryden (2012) identified was that, although pluralism advocates an inclusive both/and approach over an exclusive either/or approach, this may not be particularly evident in its practitioners’ work. Ross (2012) considered that pluralism, which by its nature should accept other forms of pluralism, can become a “pluralism of pluralisms” (p. 113). The danger of this is that pluralism turns into an implicit meta-narrative, leading to overlap with the one thing it wishes to avoid: monism. To this, Cooper and McLeod (2012) write: “A pluralistic stance, therefore, also needs to be pluralistic about pluralism” (p. 14).

Pluralism in Practice

The pluralistic perspective has the potential to accommodate an infinite variety of counselling and psychotherapy models of change, techniques, practices, and theories (Cooper & McLeod, 2011). Additionally, pluralism also draws on “therapeutic possibilities that exist within the wider culture” within which clients live (McLeod, 2013b, p. 52). There is evidence that a wide range of everyday activities, including spiritual practices, physical exercise and travel (McLeod, 2015) and cultural resources have an ameliorating impact on psychological difficulties. McLeod (2013b) explained this process:

Effective therapy involves collaboration between therapist and client to identify and then implement the ideas and methods that are acceptable and make sense to the client and that make a practical difference in relation to the resolution of the client’s difficulties (p. 52).

A detailed analysis of three cases where pluralistic Transactional Analysis was used to treat clients with long-term health problems (McLeod, 2013) found high levels of client satisfaction with achieving their goals. The author attributed effectiveness to the use of a flexible, integrative approach; counselling that “encouraged clients to acknowledge their strengths, and to find ways to channel these strengths in the form of activities that would be meaningful and satisfying” (p. 42).

A study of client perspectives on being supported through a pluralistic approach in their quest to reduce depression (Antoniou, Cooper, Tempier, & Holliday, 2017) revealed three factors that clients felt were helpful: providing a positive perspective on therapy, supporting their efforts to change, and contributing to the decision-making process. Therapists were perceived by clients as accepting and respectful, empathic, responding to their needs, appropriately challenging, and flexible. The helpful treatment outcomes were identified as changes in positive perspectives, improved behaviour and response to problems, as well as increased insight. Overall the study suggested that clients in pluralistic therapy are active agents of change. It could be argued that these factors, perceptions, and outcomes may also appear as the result of all good therapy. There may be many therapists who through evolution of their personal style have moved towards a more inclusive, pluralistic practice, without specifically intending to do so. Further exploration of intentional and/or accidental adoption of a pluralistic style is recommended.

Facilitation of collaborative conversations between client and therapist is a core element of pluralistic practice (e.g., in solution-focused and strengths-based therapies). Non-judgmental collaboration allows the exploration of the client’s understanding of what might help and what might hinder therapeutic success, as well as the communication of the many therapeutic possibilities known to the therapist (McLeod, 2013b). Four questions should be the focus of the client/therapist conversations:

  1. What is it that the client wants from therapy: what are his/her goals?
  2. What tasks need to be accomplished in a step-by-step manner in order to achieve the defined goals?
  3. What practical strategies and methods can be utilised to carry out these tasks?
  4. How can we create a shared understanding of what happened in the client’s life, and how can the client facilitate improvements in their condition (McLeod, 2013b. p. 2).

There are challenges in commencing the therapeutic relationship without a clear plan. O’Hara and Schofield (2008) found that a number of theory/practice gaps were identified in their participants’ practices of therapy when attempting to use an integrative approach, and these lead to dynamic tensions. An experienced therapist seems more able to stay engaged with the tension created by different therapeutic paradigms, able to “value cognitive complexity and ambiguity” (Jennings & Skovholt, 1999, p. 3), and may be more able and willing to work in a pluralistic way.

McLeod (2013b) wrote that the exploration of the full implications of a pluralistic stance in counselling, counselling psychology, and psychotherapy training, practice, and research is still underway. Six years later, that comment is still relevant, despite further research and the commencement of international conferences on pluralistic counselling and psychotherapy.

One challenge has been recognised with regard to the emerging value dilemmas for those aiming to provide a pluralistic practice (Tilley, McLeod, & McLeod, 2015). Tilley et al. (2015) also described value dilemmas for therapists in their attempts to adopt a non-expert role. Interestingly, Carl Rogers (1951) noted something similar when observing therapists endeavouring to use the client-centered approach:

. . . the development of the way of looking upon people which underlies this therapy is a continuing process, closely related to the therapist’s own struggle for personal growth and integration. He can be only as “nondirective” as he has achieved respect for others in his own personality organisation (p. 21).

When dealing with this dilemma, some therapists discussed it with their clients, and others addressed it within supervision sessions (Tilley, et al., 2015). All reported that adjusting to the pluralistic moral and value stance had not received extended or experiential exploration during their training. A willingness to continually make discoveries about how clients deal with their lives is essential for a career as a pluralistic practitioner (McLeod, 2015b), and an expansion of personal development within counsellor training is recommended.

A survey of therapists who identified as pluralistic (Thompson & Cooper, 2012) revealed a fit between the pluralistic approach and participants’ personal beliefs, and this fit lead to the positive experience of “a great deal of creativity and flexibility” (p. 68). However, a tension between theory and practice was identified, particularly early in training. Another challenge emerged when clients expected therapists to behave as experts. The study revealed that participants felt that the lack of efficacy studies initially impacted on confidence. Despite these issues, the freedom and creativity associated with pluralistic practice lead to a level of professional satisfaction, and an intent to continue to work pluralistically.

Pluralistic supervision is often influenced by what the counsellor learns during a particular session or case (Miller & Willig, 2012). Pluralistic supervision is often used to explore dilemmas relating to differences in counsellor and client values (Tilley et al. 2015). Furthermore, pluralistic supervision is distinctive in that sessions are structured and facilitated in accordance with pluralistic principles, and supervisees are encouraged to focus on aspects of pluralistic practice such as goal clarification, collaboration, and use of feedback (McLeod, 2018).

Conclusion

While attending the 1st International Conference on Pluralistic Counselling and Psychotherapy at the University of Abertay in Scotland, in March 2018, the first author noted that every conversation and most presentations included a narrative of relief and excitement in discovering pluralism. This discovery was described as providing a fuller framework for the journey towards becoming a humanistic practitioner, and seen as the logical and ethical evolution of the Rogers’ (1951) person-centred approach.

In order to educate pluralistic therapists, there are specific capabilities, knowledge, and expertise required. An inclusive and flexible meta-theoretical framework that includes an understanding of a number of therapeutic approaches is required. Given the breadth of the underpinning philosophy of the approach, it could be suggested that developing expertise in pluralistic practice may be most relevant for post-graduate students for whom cognitive flexibility may be most possible. Palladino et al. (2013) found evidence supporting the validity of the construct of psychological flexibility, and as this is a central concept underlying self-awareness, it may have important implications for clinical training and practice. A specific challenge may be developing ways client knowledge can be taken seriously (McLeod, 2013), which would incorporate the development of abilities to assist clients in reflection and communication on their needs, goals, and therapeutic preferences.

Overall, adopting pluralistic practice more widely in Australia requires an increase in the educational opportunities for counselling and psychotherapy students so that they can experience pluralistic theory and practice, as well as a wider acceptance of evidence-based methods by funding providers. This will demand the students’ personal development of cognitive flexibility and a willingness to constantly make discoveries about the many ways in which clients deal with the negative and positive aspects of their lives.

McLeod (2018a) identified the need for outcome research and challenged pluralism enthusiasts to contribute to the evidence base. The evolution of psychological therapy has moved through stages of inventing, formulating, mastering, proving, and then, in some cases, protecting specific methods, theories, and schools. For some time, the following stages have included eclectic adventures, integrative practices, and increasingly respectful relating with, and to, the differences between clients. These more recent stages lead logically and ethically towards pluralism.

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