Pluralism: towards a new paradigm for therapy

by
Mick Cooper and
John McLeod
to be read in conjunction with their article from
http://www.therapytoday.net/article/show/2142/

There are fears that CBT will become the predominant therapy in the health service
– with other well established traditions marginalised unless a client actively chooses
an approach other than CBT.

Yet the has been a history of ‘splitting and dividing’ of schools of counselling and
psychotherapy over the last century, with an estimate of over 400 different
approaches, with most therapists identifying with one of these schools.

This encourages diversity, creativity and growth, with the refinement of interventions
that benefit the client. However, on the other hand there is the potential for
schoolism, where one approach thinks it is superior to others. There is the potential
for a rigid adherence to what is thought to be the ‘right approach’, with a closed
attitude to the ‘skills and wisdom’ of other approaches. Thus the therapist, but more
importantly, the client can be ‘severely disadvantaged’.

Research;

• Clients tend to do better if they get the therapy they want

• Drop out less
• Some types of client do better in some types of therapy than others
• ‘For instance, clients with high levels of resistance and an internalising coping
style tend to do better in non-directive therapies; while those who are judged
to be non-defensive and who have a predominantly externalising coping style
tend to benefit from more technique-orientated approaches’

Development of integrative and eclectic schools

Since the 1930s therapists have tried to overcome the problems of their own
therapies by developing integrative and eclectic approaches. Since the 1970s it is
claimed that 25-50% of Americans identify with this approach, making it the most
common approach. On top of this, research suggests most therapists from single
schools as well ‘tend to integrate into their practice methods from other orientations’.

‘For instance, a US-based study found that psychodynamic therapists, on average,

strongly endorsed the CBT practice of challenging maladaptive beliefs, while the vast
majority of CBT therapists prioritised the person-centred stance of empathy.’

Integrative and eclectic therapists believe no one school had all the answers, and
that different clients may benefit from different interventions. What is right for the
individual is at the heart of the approach with a personal and individually tailored
approach. (Lazaras- multimodal therapy).

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However, even these developments often sit within a body of theory (Multimodal
therapy identifies with social-cognitive learning theory) or tends to replicate
something quite similar (ie Egan’s approach to helping clients to overcome their
difficulties), and then to find a structure and keep a distance from other approaches.

Within an Integrative or eclectic approach, the theory and interventions are very
much chosen by the therapist, with little consultation with the client. Thus there may
be the same issues as with single schools (ie Gestalt), that the interventions chosen
may be tailored to the therapist more than to the individual client.

Introduction to a pluralistic approach

Mcleod and Cooper Have worked to develop a pluralistic approach, underpinned by
humanistic values. This aims

‘to be a way of practising, researching and thinking about therapy which can
embrace, as fully as possible, the whole range of effective therapeutic methods and
concepts’.

The assumption is there is no ‘best’ way of practising therapy as different people are
helped by different things at different times. Ie different schools of therapy can
compliment each other – ‘both/and’ rather than ‘either/or.

Another assumption is that the therapist should not decide what the focus and
interventions of therapy should be, but that this should come out of close
collaboration with the client.

Two ‘ basic principles underlying this approach can be summarised as follows: (1)
Lots of different things can be helpful to clients; (2) If we want to know what is most
likely to help clients, we should talk to them about it’.

Pluralism means there are a lot of potential and possibly mutually conflicting
responses to an individual situation. Monism is the belief that for each question there
is one specific answer. Pluralism rejects the idea of a single truth or superior
perspective ‘from which the ‘truth’ can be known’.

You can have a pluralistic viewpoint which is the above belief, but without having to
have clear guidelines about how to put this into clinical practice.

In contrast, ‘pluralistic practice’ or ‘pluralistic therapy’ refers to a specific form of

therapeutic practice which draws on methods from a range of orientations, and which
is characterised by dialogue and negotiation over the goals, tasks and methods of
therapy’.

A pluralist approach does not see itself as superior to a single school approach or
prevent you from adopting a single school approach. The difference is that this would
be if it was the right thing at the right time, and negotiated with the client.
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The pluralistic framework: goals, tasks and methods
How can a pluralistic avoid ‘ the haphazard, uncritical and unsystematic combination of theories and
practices?’

By some kind of structure and framework for practice, focussing on what the client
wants from therapy. (This is in place of diagnosis or therapist assessment or core
training). This is the basis for considering the focus, strategy and methods for the
work- suggesting ‘concrete activities’.

Collaborative dialogue

The ‘goal-task-method framework is useful to the therapist re considering what

interventions may be useful for a particular client and whether they themselves have
the appropriate methods [and training..(Sheila)]

Example student with a goal of being able to speak in seminars. To meet the goal,
tasks of understanding his problem to stop it reoccurring, learning to control the
panic, and moving beyond just coping to a positive experience were identified.

Each task was looked at in a separate session and methods considered, ie

relaxation and what strategies worked for the client in other situations. The therapist
asked permission to suggest other strategies that might work, saying that these
could be rejected if not useful –(ie information on panic, 2 chair work to explore
internal self talk and a self help booklet on working with symptoms). These were
accepted and worked with in the sessions and evaluated in his wider experience. Ie
was the goal achieved?

Conclusion
The vision of pluralism is to provide a research based, open source of therapeutic
interventions tailored to a client’s needs. The vast range of methods that can help a
client meet his needs can be identified, whilst acknowledging that some methods are
more appropriate than others for some clients.

‘We hope that a pluralistic outlook can help us move beyond the many false
dichotomies that plague our field: ‘Is it the relationship that heals?’ ‘Does CBT just
provide a short-term “fix”?’ ‘Do antidepressants work? From a pluralistic standpoint,
these are just the wrong questions to be asking: it depends on the particular client at
the particular point in time.’

Lots of therapists are integrative or eclectic in their practice but more is written about
single modes of practice, as if this is the norm. There is need for a greater need for
articulation of a pluralistic approach and its application to clinical practice, training
and supervision and research.
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Pluralism is limited by a trend to a unitary approach. It is important to maintain
an open approach ‘and to resist such forces, to ensure that diversity, mutual
respect and an appreciation of each person’s uniqueness can continue to
flourish’.