Book Review: Pluralistic Counselling and Psychotherapy

Pluralistic Counselling and Psychotherapy

Mick Cooper and John McLeod. (2011). London: Sage Publications Ltd.

This is an important book for therapists, partly because it looks to the future of psychotherapy, particularly within the NHS. The view presented is that therapists who only offer one modality of treatment, for example CBT or psychodynamic counselling, are unlikely to satisfy the NHS requirement that the client receives what he needs, rather than what the therapist offers. The requirement to provide what the client needs might seem obvious, but regretfully clients report that therapy is not always delivered like that. For example, some clients require direction, yet some therapists are reluctant to be directive because of their training.

Pluralism is the flexibility to consider any method or modality, and to be innovative where required, having negotiated agreement with the client. This could be good news for existential therapists, whose training covers a range of modalities and ongoing Continuing Professional Development (CPD). The assertion (p132) that 10 hours training can turn any therapist pluralistic means to me that after reading this book an existential therapist can claim to be pluralistic, and as such potentially acceptable to the NHS.

Chapter 1 covers the rationale for a pluralistic approach and the limitations of one-flavour counselling, discusses integrative and eclectic approaches, and lays out the assumptions basic to the pluralistic approach. It is a call to take full account of the complexity, diversity and variability of the human response to the world. Pluralism takes a philosophical approach in order to free itself from particular psychological models, and advocates remaining firmly in contact and collaboration with the client's view of what might help towards achieving their goals. 'If we want to know what is best for clients, we should start by asking them' (p13). Both for practical and ethical reasons, the therapist needs to stay flexible, regularly reviewing the goals, tasks and methods that have been agreed with the client, and generating possible alternatives.

Chapter 2 provides more detail about the philosophy, which is rooted in ethics rather than epistemology (theories of knowledge). By recognising and respecting that different people give importance and meaning to different things, it becomes an ethical decision as to whether to exercise the therapist's beliefs and values, or to what extent. It might not be right to choose a theory and method for the client, but it might be right to choose to clarify the client's worldview and preferences, a 'humanistic ethic of deeply valuing and respecting the client's individual way of being' (p17). This requires familiarity with various cultural assumptions, values and concepts as well as theoretical and ethical models. For example, the idea of an autonomous, bounded self – an individual – is not necessarily familial in all cultures.

The authors claim that such an approach is fully in line with recent developments in health and social policy. Pluralism's assumptions that there is not a 'best therapy' that suits everyone, and that the client should be fully consulted, are supported by research findings such as:

• clients improve more if offered what they prefer
• goal consensus and collaboration fuel improvements
• clients do in fact choose most of the changes made in therapy
• therapists with a broad and flexible perspective are more successful.

They cite recent health and medical care directives such as the DoH's (2009) 'New Horizons' programme, and social care directives such as Putting People First (HM Government 2007). These directives emphasise the user's strengths and resources, his right to choose and to be supported in his choices, and the provider's obligation to personalise their services. Therapeutic relationships should provide equality of respect, the client being seen as an expert on himself collaborating with an expert in the field of psychological therapies. The shift is towards the client being more in control, and therefore being more responsible for his therapy and for how he lives his life.

Chapters 3–6 show how to implement pluralistic principles in practice. Throughout these four chapters, the authors' style includes bullet points and checklists, exercises and questions to provoke thought and consolidate learning, snippets of verbatim to illustrate and validate the concepts, sample interventions, varied page layouts, handy metaphors, recommended reading lists, research evidence and statistics, and a summary at the end of each chapter. The language is straightforward, and technical terms are explained as they are used. It feels like a helpful, friendly and respectful textbook.

Chapter 3 sketches how a collaborative relationship can be created to include the client in the decision-making – from asking the client where he would like to sit, to offering a range of ways of addressing what the client feels is important. The therapist's activities can include information-giving, negotiating when, where and how contact can take place, 'metacommunication' such as telling the client the purpose of what the therapist might say, reviewing the work, and listening and watching for the variety of ways the client might express himself, in order to maintain a flexibility of response. Secrets, the unsayable, might be coded as tone or posture or different personality modes. The therapist should stay interested, observant, and respectful.

Chapter 4 is about finding out early on in the process of therapy what the client really wants. Practical ways of identifying and monitoring goals are discussed, and two forms are presented in Appendices B and C. The assumption is that people do mind about what happens, and can make a difference in their own lives. The authors stress the importance of dialogue, of therapist flexibility, and of offering the client choices. They claim that goals are a starting point for pluralistic therapy because this is an ethical, respectful, practical, positive position to take, which supports the client's perception of being helped, and puts the therapist's agenda aside. Client's goals are key causes of their emotions, thoughts, behaviours and diagnoses, all of which must therefore take second place. We are then shown what all of this might look like in practice, what sorts of goals can lead to therapeutic outcomes, and which goals might be best dealt with by a different professional. Yet we are warned against being goal-driven, or dogmatic in any way, the overriding concern being to make the client feel welcomed and understood. The phrases 'hold open the possibility that...' and 'it might be useful to...' recur in the text, which sounds like good existential advice to me.

Having distinguished between goals, tasks and methods in Chapter 4, Chapter 5 looks at identifying specific tasks that might constitute a plan for 'the work' of therapy. 'Research shows that a well-formulated action-plan is a key factor in helping people to achieve the goals that they set for themselves' (p82). One example is Worden's 'tasks for mourning'. Another example given is about a binge-eating client. Complex issues presented by suicidal clients require knowledge of what is known to have been useful to other people, and might point to further reading and CPD for the therapist. Having negotiated tasks, it then makes sense to set priorities, and to discuss methods tailored to the client's strengths and preferences. Tasks are best addressed one by one. Pluralism frees the therapist to consider including any task or activity found by research or personal experience to be useful. They list nine common tasks (p84).

Pluralism requires ongoing collaborative case formulation. The idea of 'task' is so commonplace that it makes it easy for pluralistic counsellors to explain to the client, and to the world at large, what is on offer in their consulting room, rather like the way a menu makes it clear to the diner what choices are available to him to meet his requirements. A sample information sheet for prospective clients is shown on pages 182-185.

Chapter 6 acknowledges the vast choice of methods for consideration in therapy, and the sources of these activities – cultural and personal as well as in the therapeutic literature. If the sheer volume of methods seems daunting, we are reassured as to what the minimum requirement is to stimulate a process of reflection in the client and to have the basic skills to create and maintain a collaborative process.

Five categories of method are described:

• Conversation
• Structured problem-solving
• Creating new experiences
• Making use of existing strengths
• Directly intervening to alter information processing

and the 'top 20' forms of these methods used by experienced therapists are listed. It is important to make a collaborative choice, to monitor the effectiveness of the choice, and to check out whether what is happening and the way it is happening in the session is OK for the client. Therapists should limit their suggestions for methods to three, and at the same time ask the client for their own suggestions. This is to facilitate dialogue, collaboration, reflection, and the client's confidence in his own ability to make a difference. Giving choices is about informed consent, without which the therapy fails ethically, and is likely to fail practically as well. Clients usually neglect their homework unless there is a joint, detailed understanding of how the homework task is supposed to help.

Chapter 7 outlines the principles of pluralistic research and how this can overcome previous difficulties of using an evidence-based approach. The principles are clear:

• research is not the only guide to practice
• user perspectives are needed to balance the profession's concerns and questions
• research identifies possibilities, not universal truths, about what methods lead to what outcomes
• a focus on micro-processes is more useful than the usual research briefs and leads to identifying potential change pathways.

And here's my only criticism of the whole book, which is also a worry with evidence-based practice generally: surely research into micro-processes is just as likely to be used incorrectly as 'X tends to cause Y so I'll try X with my client', rather than 'X might lead to Y for my client so I'll check the idea out with my client' as any other research. We have already been led to this when X = 'negotiating goals' and Y = 'successful outcome'. Yet the conditions under which X might lead to Y for the client in front of us is initially unknown. I wonder if therapists really do understand that diverse populations such as humans make statistical analysis meaningless for the individual, and that correlation never can imply causality. However, the type of research being called for here does have the potential to produce a 'treasure-house of hopefulness' (p127) for clients, provided that the interpretation of research is that of uncovering possibilities rather than prejudicing criteria for practice.

Chapter 8 re-iterates the key pluralistic principles such as collaboration and avoiding negativity, and considers the consequences of these principles in the areas of training, supervision, CPD, and service delivery. There are examples of what a supervisor might say, what a training programme might consist of, how CPD can be implemented, and what features might be included in service delivery programmes. Training would start with pluralistic orientation, and generic counselling skills, progress into particular theories, and then to specialisations. Then students could for example analyse case material from a number of different theoretical perspectives. The stance is that therapists, trainers and supervisors do not have universal truths to impart, but can offer possible truths to a particular client. A modality is a hypothesis, one potential way of helping clients, and we can locate our primary modality within a pluralistic framework. CPD is required to enrich a pluralistic attitude with concrete possibilities for interventions. Pluralistic CPD would show us, via the basic principles, how to integrate a new approach into our practice, for example by linking it to clients' goals and strengths and by asking the client if the new approach makes sense for him. Pluralistic service-provision would aim to introduce flexibility and choice for the client, for example by allowing the client to specify the frequency and length of his appointments. They recommend front-line pluralistic workers backed up by specialists.

Chapter 9 summarises the key pluralistic ideas and addresses some frequently asked questions and criticisms, such as whether to resist those who resist pluralism. They sketch a vision for a pluralistic future for therapy, free from both inter-modality wrangling and from anything-goes relativism. Research is needed to identify and assess the risk of harm that therapies can present, such as single-session debriefing for trauma victims.

Conclusion

The writing style is plain and clear. The structure of each chapter is evident, rather like a textbook with handy bullet points at the beginning indicating the chapter's content, a summary at the end, and questions and exercises to test the reader's critical understanding. There is recommended reading so that you can follow up on particular points, and no particularly difficult or obscure language to grapple with. I found the text totally accessible.

The authors' call for service-providers to think carefully about the risks involved in only offering a limited range of therapeutic modalities / brands such as CBT, psychodynamic, person-centred, existentialism, and so forth, that is, to consider the risks of not providing the therapy that would be optimal for the client and the society around him. There are also risks associated with rigid service structures – for example only offering weekly one-hour face-to-face sessions.

As existentialists, we are free to explore how the client's experience of himself and his life can be generated by his intentionalities – his values, beliefs, expectations, memories, assumptions, hopes, concepts, goals, and so on. We can imagine and experiment with how these experiences might be different were he to choose his intentionalities differently. We are free to ask the client to assess for himself the risks and benefits of what he might want to achieve and the way he might go about achieving it. We are trained in a range of modalities usually including the medical model (used by psychiatrists), developmental theories (used by psychologists), CBT (used by NHS practitioners), and psychoanalysis (used by psychodynamic counsellors), and are committed to CPD. I think an existential therapist can reasonably claim to be pluralistic, and as such potentially employable in the NHS.

Paula Smith