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The identity of counselling and psychotherapy and the quest for a common metatheory

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Denis J. O’Hara, Australian College of Applied Psychology, Brisbane, Australia and E. Fiona O’Hara, University of the Sunshine Coast, Sippy Downs, Australia.  

Introduction

Counselling and psychotherapy has enjoyed over a century of explosive development which has seen it emerge from a nonspecific pastoral practice to a professional entity that has played a significant role in the transformation of modern culture. Today counselling and psychotherapy is an integral feature of society, demanding attention from government, health and legal systems, and community groups. One of the curious aspects of counselling and psychotherapy is that it is a professional enterprise which is not owned by any one professional group yet its practitioners, at heart, acknowledge a collective identity. One example of this collective identity is the designated title of one of the profession’s peak bodies, the “Psychotherapy and Counselling Federation of Australia”.  This sense of identity is by no means unified or free from splits. We note, for example, definitional debates about the distinctiveness of counselling and psychotherapy and while we acknowledge the importance of these debates, we do not address them in this paper. However, in recognition of these concerns we have used the inclusive term “counselling and psychotherapy” throughout this paper.

In reflecting on the development and progression of counselling and psychotherapy we are of the view that the field is now at the dawn of a new stage. This stage might come under many names – terms such as non-dualism, integral, and unification being examples. The aim of this article is to briefly outline the current state of psychotherapy as seen through the lens of counselling and psychotherapy integration and metatheory and to comment on what might be the next developmental stage for the profession.

The development of theories

The founding of counselling and psychotherapy as a profession required the establishment of a solid theoretical base. This was provided in the twentieth century through the development of an impressive array of counselling theories, each adding something unique to the disciplinary corpus. From its early modern beginnings until now, the field has weathered a number of stormy challenges. One of the earliest of these was Esenicks (1952) assertion that psychotherapy was not particularly effective. Thankfully the research on psychotherapy effectiveness spurred on by this challenge, resulted in the provision of overwhelming evidence for the collective effectiveness of psychotherapy (Cooper, 2008). While the matter of effectiveness was largely settled, the related question of why counselling and psychotherapy is effective had also to be asked. Research seeking to explore why therapies are effective has provided some of the answers but there remains much that is still not understood. This has resulted in claims by proponents of different therapies that certain therapies have more evidence of effectiveness than others (Barlow, 2004, Chambless, Baker, Baucom, Beutler, Calhoun, Crits-Cristoph, 1998). Of course, evidence for effectiveness and actual effectiveness are not the same thing. The consistent finding, known humourously as the Dodo Bird Effect, that all bona fide therapies provide very similar therapeutic outcomes, suggested that the active ingredients in therapy are common across therapies (Luborsky, Rosenthal, Diguer, Andrusyna, Berman, Boston, et al. 2002). The debate over what factors are considered the active ingredients in therapeutic change, common factors, or specific ingredients, continues.

Psychotherapy integration

The proliferation of therapeutic approaches in the twentieth century and the Dodo Bird Verdict led many in the field to explore what was common across theories and to begin to consider the possibility of counselling and psychotherapy integration. By the nineteen eighties this movement had grown to such an extent that it gave rise to the establishment of a professional society whose purpose was the investigation of the forms and benefits of integration – the Society for Psychotherapy Integration (SEPI) (Norcross & Goldfried, 2005).

The integration movement was a refreshing change of emphasis away from the defensive positions often held by single schools, where therapists from different counselling and psychotherapy traditions argued over the strengths of their own theories and the limitation of others’ theories, and to a much more inclusive attitude of inquiry and appreciation. Integrationists, in seeking to find ways of integrating different theories and practices of counselling and psychotherapy, developed a number of approaches to integration. In broad terms, there are two main aims in integration: one, to incorporate bona fide theories into a whole metatheory or at least a collection of common theories and; two, to organise a system which identifies techniques that have been verified as effective in the treatment of psychosocial problems. Since the nineteen nineties, four main types or categories of integration have been delineated: Theoretical Integration, Assimilative Integration, Technical Eclecticism, and Common Factors.

Theoretical Integration is an approach which seeks to combine either a couple or many different theories into one new coherent theory (Hollanders, 2001). The aim here is to merge the essence of the respective theories into an organic whole. The resultant new theory reflects the respective theories from which it draws, but also transforms them into something more than the sum of the individual theories. Theoretical integration draws attention to the need for a metatheory of psychotherapy. The hope is that, in combining even only a few theories together, a way to draw all theories into an overarching metatheory will eventually be found.

Assimilative Integration, like theoretical integration combines existing theories but does so differently (Messer, 1992). This approach to integration recognises that therapists tend to have a preferred, primary or default theory which provides a philosophical as well as a theoretical base for their practice. One of the important aspects of theory is that it provides an organising foundation or set of principles to help the practitioner make sense of humanness. Whether we are fully aware of it or not, psychotherapy is very much about defining the nature of humanness, including such features as personality, health, illness, exceptionality, and the nature of the change process. To varying degrees, theories provide therapists with frameworks of understanding from which to practice. Assimilative integration pays attention to this reality and asks the therapist to take note of the theory(ies) which most influence them. The most influential theory is acknowledged as the base theory into which other theories can be integrated. Hence, one therapist may begin with psychodynamic theory and integrate existential therapy or emotion focused therapy. Another therapist might begin with cognitive behaviour theory and integrate mindfulness theory. However, assimilative integration is not simply adding a dash of other theories into the base theory. By adding other theories into the base theory in a considered way, the whole theoretical structure and system is fundamentally changed. The base theory still provides a strong set of philosophical principles which help clarify such issues as the nature of humanness, but the other theories extend the comprehensiveness of this base theory and in so doing provide for the emergence of a new integrative framework.

Both Theoretical Integration and Assimilative Integration focus on the importance of theoretical sophistication and frameworks of understanding. Technical Eclecticism and Common Factors approaches place greater focus on the techniques of psychotherapy (O’Hara & Schofield, 2008, O’Hara, 2012). The primary issue in these approaches is identifying what works in therapy, hence, integration is seen as way of combining practices from the various theories which have demonstrated utility and benefit in facilitating therapeutic change.

Technical Eclecticism is an approach which seeks to acknowledge that research has the capacity to demonstrate and even prove which techniques are effective in the therapeutic process (Lazarus, (1992). It is therefore not an “anything goes” approach to eclecticism in which therapists choose what feels good in the moment. Techniques and interventions are chosen on the basis of their proven effectiveness. A good example of this is behavioural activation. This approach is drawn from Behaviour Therapy and has proven effective in the treatment of depression and anxiety conditions (Hopko, Lejuez, Ruggiero, & Eifert, 2003). A therapist using this intervention may also draw on techniques from Gestalt Therapy, like two chair work, if such techniques have proven benefit. Thus technical integration is used by therapists as a means of drawing on the wide range of interventions available from all theories that provide a recognised therapeutic benefit. An important parenthetical note should be offered here. The notion of “proven effectiveness” has attached to it its own set of philosophical assumptions that often go unchallenged. We are of the view that the default philosophical position in Technical Eclecticism is positivism – a position which itself is now under serious critique as an insufficient philosophy of science (Slife, 2003).   

Finally the Common Factors approach highlights the fact that while there is an enormous array of theories with very different sets of assumptions and practices, when applied well, all produce similar results in terms of client outcomes. This fascinating observation was first made by Saul Rosenzweig in 1936 (Duncan, Miller, Wampold, & Hubble, 2010) and it forced therapists and researchers to realise that there must be a set of factors common across therapies which are the active ingredients of therapeutic change. These ingredients, or common factors as they have become known, have been the focus of research over the past thirty years, with the result that we have some clearer, although not final, insight into what these factors are (Lambert, 1992; Norcross, 2011; O’Hara, 2012).  

Metatheory and psychotherapy

One of the great challenges of any approach to integration is that different theories arise from different philosophical assumptions. These different assumptions are based on very different views about fundamental issues like the nature of humanness, the nature and cause of mental illness, human capacity, and the therapeutic change process, to name a few.  In more philosophical terms we are speaking of the impact of different ontologies. Ontology is the study of reality and how it is constructed. For example, for the realist, the world is an entity which actually exists whether humans exist or not. For the constructivist, reality is defined by human beings and so can be constructed in many forms. Philosophers like Kuhn (1982), Feyerabend (1962), and Pepper (1942) argue that different ontological assumptions or worldviews make it difficult to compare theories. Based on these differences Kuhn suggested there is an “incommensurability of paradigms” (p.669) which means that while it is not impossible for there to be dialogue between worldviews it is unlikely that worldviews can be merged or integrated.

It should be noted that not all theories arise from separate worldviews or metatheories. However, whatever designations are used, there are only a few metatheories from which individual theories of counselling and psychotherapy emerge. In Pepper’s (1942) view there are four main worldviews or metatheories: Formism, Mechanism (Positivism), Organicism (Developmentalism), and Contextualism. To provide an explanation of how different theories of counselling and psychotherapy can share a common metatheoretical base, the following few examples are provided. Behaviour Therapy and Cognitive Therapy both share the metatheory of mechanism. Mechanism or positivism asserts the view that reality is based on cause/effect relationships and that life can be broken down into its component parts and that these parts can be studied in isolation to the whole (Pepper, 1942). The knowledge gained from the study of these atomized parts can then be generalised (Goldhaber, 2000). Similarly, while Person-Centered Therapy and Psychodynamic Therapy are quite different in many ways, they both share the common metatheory of Organicism. Organicism uses the metaphor of organic life, which is understood to proceed and develop through phases and stages of growth. When growth is nurtured the organism flourishes, but when it is disrupted or traumatized, growth is stunted (Goldhaber, 2000). While Psychodynamic Therapy tends to focus more on the elements which stunt growth with the aim of reanimating growth, Person-Centred Therapy focuses on the conditions for growth and the organism’s own growth potential. Those of a contextualist metatheoretical orientation agree that the individual develops over time but do not focus on organismic growth, seeing development to be more directly related to the influence of changing contexts. For the contextualist, life is about the meaning we draw from our family, historical, social, and economic settings (Pepper, 1942). Solution-Focused and Narrative therapies both share a contextualist worldview and thus have much in common. Their focus is not on the mechanism or the organism but on the contextually situated narrative (McLeod, 2009).

One of the interesting observations that can be made when examining psychotherapy integration is that it is often easier to integrate theories which share a common metatheoretical underpinning. This is obvious in the case of CBT which is really a merger of Cognitive Therapy and Behaviour Therapy both of which reside within a mechanistic metatheoretical framework. The common metatheoretical underpinnings of Person-Centred and Psychodynamic Therapy may be a little less obvious, but at heart they both share a view of humanness which focuses on growth and ongoing change. The contextualist theories of Solution-Focused Therapy and Narrative Therapy seek to work with the individual and family system on the basis of context specific meaning and therefore have no need to promote generalisable principles, or developmental trajectories.   

The existence of discrete and foundational assumptions inherent within worldviews, like those outlined by Pepper, suggests that ultimately any attempt at meaningful theoretical integration is limited. While it might be possible to combine different theories of counselling and psychotherapy at some level, it is unlikely that a meta-framework which is capable of subsuming all theories will be found. If this is true, it implies that the paradigm wars we see between different schools and sub-disciplines (e.g., clinical psychology, and counselling and psychotherapy) will continue, usually with the group whose metatheoretical framework has wider social ascendency in the given period of history, holding the greatest advantage. A current example of the paradigm wars within our field is the debate around the philosophical foundations and ultimate utility of the Diagnostic and Statistical Manual of Mental Disorders (DSM V) (BPS, 2011). 

Like various forms of theoretical integration, technical eclecticism and common factors approaches fall short of providing a comprehensive approach to integration. As mentioned earlier, technical eclecticism, at best, can only provide an array of “approved” evidenced-based interventions. While there is certainly benefit in appreciating the efficacy of specific interventions, the problem remains that the arbiter of such “approvals” is positivism (Slife, 1987). The Common Factors argument is also problematic because it provides a limited ground on which to base coherent theory. While a focus on client and therapists factors is of great importance, counselling and psychotherapy needs a foundational paradigm upon which to cohere all of its various dimensions.

In recognising the dilemma of the “incommensurability of paradigms” authors like Cooper and McLeod (2007, 2011) have argued for what may be regarded as a different approach to integration which does not seek to integrate different paradigms directly but which holds them in a loose détente. They argue that the way forward through the difficulties of integration is to take a pluralistic stance. Theirs is not a general pluralism but a specific framework which has as at its base a pluralistic philosophy. This approach is founded on the view asserted by the philosopher Rescher (1993) “…that any substantial question admits of a variety of plausible but mutually conflicting responses” (p.79). Cooper and McLeod (2007) clarify the basis of their approach by stating, “It is a philosophical standpoint closely aligned with postmodern thinking (e.g. Lyotard, 1984) that maintains that the desire for consensus, a key aim of modernist, scientistic discourse, is doomed to fail” (p. 136). They agree with Rescher that the normal human condition is dissensus rather than consensus.

A pluralistic framework as recommended by Cooper and McLeod solves the problems of integration by at least indirectly asserting that integration is not possible; it however, has its own problems. While it may be true that any substantial question in counselling and psychotherapy elicits a variety of conflicting positions, it does not mean that there is no overarching integrative paradigm or possibility of holding the various perspectives together. Another issue and the one that we see as most problematic, is that the pluralistic framework as developed by Cooper and McLeod is fundamentally based on contextualism. While there are many benefits of a contextualist worldview, much of the counselling and psychotherapy world cannot ascribe to it as their singular metatheoretical foundation. Some other meta-framework is required.

International priorities and differences

Before turning to yet another philosophical and hopefully practical solution to the problem of multiple paradigms and the lack of professional coherence this evidences, it is worth pausing to examine the implications of the current state of affairs in terms of how psychotherapy education and practice is conducted. Different countries and jurisdictions have handled the proliferation of theories and the paradigm wars differently. There is no doubt that the United States has been at the forefront of the integration movement both in terms of debate and research (Castonguay, 2006; Messer, 2001; Norcross & Goldfried, 2005; Stricker, 2010; Stricker & Gold, 2006; Wachtel, 2014). Early discussions between Marvin Goldfried, George Stricker, Jeanne Phillips, Paul Wachtel, Barry Wolfe and others resulted in the establishment of the Society for the Exploration of Psychotherapy Integration (SEPI) in 1983. Later in 1991, SEPI established the Journal of Psychotherapy Integration. While there remain very strong schoolist interests which promote their cause to governments and health insurance funds on the grounds of being the most evidenced-based (this logic itself being founded on particular metatheoretical assumptions) there is also a large movement within academia which acknowledges that no one paradigm alone is sufficient to answer all the questions and problems of the human condition. In many schools and universities within the States there is a genuine attempt to raise awareness of the influence of worldviews on the theory and practice of psychotherapy. This said, the evidence-based juggernaut, the most vigorous offspring of positivism, still largely rules the day (Slife, Wiggins, & Graham, 2005).  

Historically, the British approach paid less attention to psychotherapy integration although with notable exceptions (Hollanders, 2001; Holmes & Bateman, 2002; Horton, 2001; Palmer & Woolfe, 2000). While there have been commentators and institutional pockets which have sought to explore and promote integration, the collective emphasis has tended to remain schoolist in nature (Cooper & MCLeod, 2011; Faris & van Ooijens, 2011; Lapworth & Sills, 2009). Cooper and McLeod (2011) agree stating, “Within the United Kingdom, most practitioners adhere to one or other of these schools, and single orientation approaches remain the predominant way of practising, commissioning and thinking about the therapeutic field” (p. 1).  The humanistic and experiential school, for example, has always maintained a strong voice within Britain even in the midst of an equally forceful cognitive and behavioural school which, as is common across the West, has gained more ground in government sponsored health care (NICE, 2010). Of course, having strong schools of psychotherapy has also been an advantage as it has provided the theoretical base for ongoing research and development. The strength of the humanistic and experiential school in Britain, represented by developments in Emotion-Focused Therapy and Existential Therapy, are good examples of the benefits of maintaining strong schools (McLeod, Elliott, & Rodgers, 2012). Interestingly, there is more recently a move toward pluralism within Britain although this move is still in its infancy (Cooper & McLeod, 2011).

The Australian experience is different again to both that of the United States and Britain. Unlike Britain, Australia has provided much less support for individual schools of counselling and psychotherapy. While there is definitely support for different schools as evidenced in the strength of specific professional societies and centres of practice, (e.g., Gestalt Australia and New Zealand; Centre for Existential Practice; the Australian Centre for Psychoanalysis) among others, these schools are not typically strongly represented in the universities and colleges. The highly pragmatic nature of the Australian culture tends to focus on the utilitarian (Monsma & Soper, 2009). In terms of counselling and psychotherapy education, this has translated into a more survey-based approach to theory, with minor theoretical emphases within different programs.  Underlying this approach is an assumption of counselling and psychotherapy integration. In other words, while an institution may give more space in the curriculum to a particular theory, it is rarely so devoted that the graduate can claim a schoolist specialisation. In reality, the expectation is that the graduate will, more likely than not, practice some form of integrative psychotherapy with a little more knowledge about one or two theoretical approaches. While counselling and psychotherapy integration is a highly valued approach to practice, training in integration has its own challenges and needs to be well conceptualised, especially pedagogically (Boswell, Nelson, Nordberg, McAleavey, & Castonguay (2010).

We argue that in Australia, counselling and psychotherapy integration is typically the default position but one which has no real self-conscious theoretical grounding. It has little grounding in theory because there is often within training programs little attempt at developing the actual meaning of integration at a deep level. The culture of pragmatism allows for an assumption of integration without really exploring it. The main exceptions to this rule are found in faith-based institutions which are more invested in clarifying their philosophical and theological understandings and how counselling and psychotherapy relates to them (Meteyard, 2009). Most counselling and psychotherapy programs in Australia, while teaching a range of theories, ultimately assume a superficial form of integration theory as a largely unconscious default.

We argue that understanding one’s theoretical assumptions both at theoretical and metatheoretical levels is important for several reasons. The first is that being aware of our philosophical base more ably informs our approach to research and practice. A second benefit of theoretical self-awareness is that it affords us more tolerance of different positions. The final argument for understanding our philosophical assumptions is that we ultimately practice what we actually believe and not what we say we believe; our assumptions, whether conscious or not, win out (O’Hara & Schofield, 2008). In this respect, it is better to be aware of one’s assumptions than not. This point is well articulated by Jaspers (1954) when he states, “There is no escape from philosophy. The question is only whether a philosophy is conscious or not, whether it is good or bad, muddled or clear. Anyone who rejects philosophy is himself unconsciously practicing a philosophy” (p. 12).

As well as the challenge of philosophically robust integration, the profession of counselling and psychotherapy faces the challenge of self-definition. While we know that counselling and psychotherapy is effective and beneficial, we have not clarified its boundaries and points of differentiation from other professions. This is a more nuanced challenge than many professions have faced because there are multiple pathways into the practice of counselling and psychotherapy. Is counselling and psychotherapy, for example, an art or a science? Should it define itself on a science-practitioner model like much of psychology, or a reflective-practitioner model (see Strawbridge & Woolfe, (1996) for a discussion on the distinction between these two models)? Are these positions mutually exclusive? In our view, counselling and psychotherapy is both an art and a science and any quest to separate these is doomed to fail. While it is at first glance more persuasive to argue for science as the principal base, with Medicare and health insurance rebates being easier to procure on this basis, this would ultimately do violence to the very nature of counselling and psychotherapy. This is not because it is principally an art, but because it is principally an art and a science. It is in looking squarely at this reality that the path to professional definition can be found.

A new paradigm – Non-Dualism and Critical Realism

It is our contention that the underlying root to the limitations of schoolist thinking, seemingly unsolvable integration attempts, and the problem of professional identity, lies in philosophical dualism. At every turn we are dealing with the challenge of trying to reconcile seeming opposites. This is true at every level whether at the metatheoretical level, theoretical level, or at the level of professional practice. How can we pay attention to the parts while not losing the whole and vice versa? The only way forward is to take a non-dualistic stance. A non-dualistic philosophy promotes the holding of opposites, the holding of contradictions. This is different from a general pluralism which switches between different theoretical positions and does not seek an integration of positions or a dynamic holding of opposites or differences. A non-dualistic philosophy deems that there is an underlying unity in existence at its foundations even though this unity is not always evident in our everyday experience.

It is outside the scope of this paper to develop a comprehensive philosophical treatise, but some sense of how a non-dualistic stance benefits counselling and psychotherapy does need to be outlined. A preliminary comment needs to be made and that is, defining non-dualism is difficult to do because to speak of the possibility of non-dualism is in itself dualistic as an opposite is automatically posited, “dualism’”. Hence, any definition, while necessary, is problematic. This is also evidenced in the fact that different writers espousing non-dualism, approach it differently. However, a metatheoretical approach which we believe does provide a very powerful explanatory foundation is Critical Realism (Bhaskar, 1979; 2012). Critical Realism goes beyond positivism and contextualism (constructivism) while enjoying the strengths of both. One of the key principles of Critical Realism is a careful distinction between ontology (view of reality) and epistemology (avenues of knowing). For the Critical Realist, reality is objectively real in the natural world and has inferred objective structures in the social world. Like the positivist, the Critical Realist holds that there is an objective reality apart from the human, but unlike the positivist sees that there is much more to reality than we can ever grasp through empirical means. It identifies a difference between the natural and social worlds in terms of objective existence, asserting that social structures and relationships only exist in terms of their effects (Bhaskar, 1979). This means that we are able to induct principles of the social world but, unlike the natural world, these principles are not independent of our conceptions of them. One of the benefits of this philosophy is that it allows for the existence of universal principles, but acknowledges that human apprehension of these principles is limited by epistemology. This means that if there is an objective reality separate from human awareness, our capacity to apprehend that reality and, for that matter, any constructed reality, is always limited by our subjective awareness.

Critical Realists understand reality to be stratified or to be composed of different domains – the empirical, the actual, and the real (Danermask, Ekström, Jacobson, & Karlsson, 2002). The empirical consists of that which we can observe and experience and is the domain that positivists seek to understand. The actual is the domain which is beyond human perception and which functions beyond the researcher’s capacity to observe. The domain of the real includes those mechanisms that function to produce events on the plane of what Critical Realists call “surface phenomena”. Surface phenomena exist in both the physical and social worlds; respective examples being gravity and social and economic status. The focus of the real is to explain the mechanisms underlying reality and to relate these to the other two domains of the empirical and the actual. The domain of the real includes the other two domains and therefore all levels of reality.

The stratification of reality has many implications. One benefit of these different layers that is immediately relevant to counselling and psychotherapy is that those of different metatheoretical persuasions all find room for their priorities within this philosophical scheme. For example, researchers and theorists who are more mechanistically inclined find warrant for their focus on cause/effect relationships. Equally, those who are interested in the mechanisms that explain the operations and relationships in the social world are provided the philosophical rationale to do so. Note here that Critical Realists in using the term “mechanism” are not referring to mechanistic principles but principles which underly reality and explain processes on both the empirical and actual domains (see Danermask, et al., 2002, for a more detailed explanation of the domains of reality). For the purposes of our discussion, the main points are that reality is more than the physical world and is constituted of three strata or domains and that this ontology should not be confused with epistemology. Critical Realists, like constructivists, assert the existence of a large array of epistemologies which inform our knowledge of the world but unlike constructivists, argue that reality exists beyond our knowledge or construction of it.

There is much more that could be said about Critical Realism and how it explains reality both in the natural and the social worlds, but even within this very brief outline are the foundation stones of a non-dualistic rapprochement between different schools of therapy and their foundational worldviews. Theories founded on more mechanistic principles like Cognitive and Behavioural Therapies find space for their realist assumptions, while constructivist therapies like Narrative Therapy and Solution-Focused Therapy find acknowledgement of their claims that reality is also constructed. The great benefit of Critical Realism is that it provides a means for a holding of seeming opposites. Counsellors and psychotherapists are both scientist-practitioners and reflective-practitioners – one does not exclude the other.

The implications of this are extensive. It means for example, that what is allowed as “evidence” and therefore that which informs policy and practice, is not constrained by a narrow philosophy of science, that is, positivism. As reality is deemed to be both a feature of the natural (scientific) world and also of the social world (human and social sciences), then both domains should be seen as sources of evidence. In this scheme it is less viable to position counselling and psychotherapy a rung down from clinical psychology or psychiatry as “evidence” is not divided. It also means that our education of counsellors and psychotherapists should be much more inclusive of both the scientist-practitioner model and the reflective-practitioner model, a position that currently is hard to find. 

A non-dualistic stance has important implications at the level of practice. Like pluralism, non-dualism seeks to provide a theoretical inclusiveness of practice. In this respect, practitioners would be encouraged to use techniques from different theoretical paradigms if they were deemed to be appropriate for the client at any given moment. The question here is not whether to be inclusive or not rather, it is on what basis should we include and use a particular theoretical intervention? As mentioned earlier, Technical Eclecticism determines this ultimately on the basis of research grounded in a positivist worldview. Pluralism encourages inclusivity on the basis of contextualism, that is, a social constructivist worldview. From this stance, different theoretical approaches are all possible because there is no single truth rather a multiplicity of truths. The choice of approach is then largely determined on the basis of collaboration between the therapist and client (Cooper & McLeod, 2011). Client choice and therapist responsiveness are free to be promoted within pluralism because the issue of the supremacy of one theory over another has ceased to be an issue. The criterion for theoretical inclusiveness in a non-dualistic framework, like Critical Realism, is based on the holding of opposites. Unlike pluralism, non-dualism does not simply move from one single theory to the next in any given moment but rather seeks to hold the tension between different possibilities. An example of this is already seen in the inclusion of mindfulness within CBT. CBT largely functions on the basis that change occurs through “right thinking” – rational argument and logic. Mindfulness focuses much more on a non-rational engagement in the moment and an acceptance of “what is”. At first glance these positions appear irreconcilable but in holding the tension between the two, which is not a direct attempt at integration, the contradictory positions work.

There are many other examples of non-dualism which already exist in counselling and psychotherapy. Probably the best examples of this in terms of identified therapies are found in Acceptance and Commitment Therapy (Hayes, Masuda, & De Mey, 2003), Dialectical Behaviour Therapy (Lineham, 1998), and Compassion-Focused Therapy (Gilbert, 2009). However, opposites are everywhere and the challenge to hold them in dynamic tension through non-dualistic attention is always present. A small sample of opposites pertinent to counselling and psychotherapy is listed in Table 1 below.

Table 1. Seeming opposites

Client knowledge

Therapist expertise

Developmental blockage

Self-actualisation tendency and choice

Systemic determinants of personality, social interaction, and  therapeutic change

Intrapsychic determinants of personality, social interaction, and therapeutic change

Emotions as change variables

Cognition as change variable

Acceptance

Agency

Despair

Hope

Imagination

Groundedness and reality testing

Interpretive/Subjective knowledge

Empirical/Objective knowledge

 Conclusion

We began this paper asserting the need for further development in the professional identity of counselling and psychotherapy. Our lens focused on the growth of theory through the twentieth century and then the realisation that all serious theories offer important knowledge to the discipline, requiring an examination of how theories may be integrated. We concluded that the integration enterprise while beneficial, has not delivered the necessary platform to stabilise the profession and to provide a common ground of understanding. This is because each theory is based in a set of metatheoretical assumptions which themselves have not been reconciled. In recognising the fundamental value of theories and their capacity to inform the researcher and practitioner, it remains important to find a means of holding and valuing theoretical difference while also providing a common meta-framework of understanding. We believe the only way forward in this regard is a non-dualistic worldview which seeks unity within diversity and does so by holding the tension between opposites. Theoretically, Critical Realism is one such comprehensive, non-dualistic, metatheoretical framework where everything belongs.

Our purpose in this paper is to highlight some of the key philosophical developments in counselling and psychotherapy and to introduce an argument for a potentially new metatheoretical foundation for the ongoing development of the field. Based on the foundations of Critical Realism and non-dualism, counselling and psychotherapy may be in a position to value objective and subjective realities so fundamental to the practice of therapy. If we can step into this view of reality and assert its claims, counselling and psychotherapy will be even more effective in practice, be humbly self-confident in its professional identity, and become situated comfortably within society and social policy.

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