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Pluralistic Therapy: Presentation slides

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Abstract

Slides on pluralistic therapy, covering the beginnings and basis of the approach, its relationship to integrative therapies, and the evidence for a pluralistic stance. The presentation then goes on to look at the need for, and methods of, facilitating communication about the process of therapy.
1
Mick Cooper
Professor of Counselling Psychology
University of Roehampton
mick.cooper@roehampton.ac.uk
www.pluralistictherapy.com
With thanks to John McLeod and all
the clients, therapists and researchers
who contributed data and analysis
Pluralistic Therapy
Models of
integration
Integration
Putting together different theories
Theory
A
Theory
B
Theory
C
2
Theoretical integration
Selecting concepts and methods from
existing approaches to create a new
approach
Approach
A
Approach
B
Assimilative integration
Starts with core model, with other
approaches gradually integrated into it to
develop a unique individual style
Approach
A
Approach
B
Approach
C
Common factors
Assumption that therapeutic change
determined by similar factors across
orientations
40%
30%
15%
15% Client factors
Relationship
Hope
Model
3
Eclecticism
Selecting techniques from a number of
different orientations irrespective of the
underlying philosophies
Practice
A
Technique
B
Technique
C
Pluralistic
attitude
Metather-
apeutic
communication
Multi-
orientation
practice
Pluralism
1900 1950 2000
Pure form
therapies
Integrative
therapies
Eclectic
therapies
Pluralistic
approach
4
History
2006
John
McLeod,
with Mick
Cooper,
Julia
McLeod
and
colleagues,
set up
Tayside
Centre for
Counselling
2007
First paper
on
‘pluralistic’
framework
5
2007- Development of
training courses:
Abertay, Glasgow
Caledonian, UEL,
Manchester, IICP
2011
2013-2015
Pluralistic
therapy for
depression
study,
funded by
BPS
6
2016
Influences
7
Humanistic/Existential Psychology
Client-centred approach
Uniqueness of each client
Client as agentic and
purpose-oriented
Collaborative focus
Dialogue: openness
Empathy and acceptance to
other approaches
A person-centred
metatherapeutic stance
Postmodern/Narrative Therapy
• Transcending monism
• Co-existence of multiple
‘truths’
• Openness to otherness
• Social justice
A postmodern
appreciation of
multiple therapeutic
possibilities
• Centrality of ethics
Ethics of
diversity
8
An openness to
Otherness (Levinas)
An ethical relationship is one in
which we are willing to
encounter, and prize, the Other
in all their Otherness, their:
• complexity
• heterogeneity
Irreducibility to finite laws,
characteristics and
assumptions
To meet the face of the other
The
evidence
base
Different clients want
different things
Do depressed clients in primary care want
non-directive counselling or cognitive-
behaviour therapy (King et al 2000)?
NDC
CBT
40%
60%
9
Research indicates wide variations in client preferences
e.g., Level of structure
‘I would like the therapist to…’
(
n
= 225, Cooper & Norcross, 2015)
Give
structure
to the
therapy
Allow the
therapy to be
unstructured
Research indicates wide variations in client preferences
e.g., Temporal focus
‘I would like the therapist to…’
(
n
= 226, Cooper & Norcross, 2015)
Focus on my
past
Focus on my
future
Clients do better in their
preferred therapies
Clients who receive their preferred treatment:
Small increase in outcomes (ES = .31)
33%-50% less likely to drop out of therapy
(Swift et al., 2012)
National audit of psychological therapies
findings
10
Different clients do better
in different therapies
• Most clients do best when levels of
empathy are high…
…but some clients do not: highly
sensitive, suspicious, poorly
motivated
• Clients who do best in non-directive
therapies vs. CBT:
– high levels of resistance
– internalizing coping style
Shared decision making
in the
medical encounters can…
Reduce drop out
Increase people’s satisfaction with care
Increase people’s active involvement in care
Increase people’s self-efficacy, self-confidence and
self-management
Improve people’s knowledge about their condition
and treatment options
Improve professionals’ communication with
patients
Possibly improve outcomes
The pluralistic
approach:
An
introduction
11
Aim
An attempt to transcend schoolism in all its
forms (including a ‘pluralistic schoolism’)
and re-orientate therapy around clients’
wants and client benefit
Maintaining a critical, self-reflective stance
towards our own theoretical and personal
assumptions
The pluralistic approach strives to
transcend ‘black-and-white’
dichotomies in the psychotherapy
and counselling field, so that we
can most fully engage with our
clients in all their complexity and
individuality
From either/or to both/and
Practice A
Practice B
12
Theory A
Theory B
Relationship
Techniques
Single-
orientation
Integrative/
eclectic
13
Basic assumption 1
Lots of
different things
can be helpful
to clients
Pluralism across practices
Basic assumption 2
If we want to know
what is going to
help clients, let’s
discuss it with them
Pluralism across therapeutic dyad
Pluralistic
attitude
Metatherapeutic
communication
Multi-
orientation
practice
Pluralism
Three elements
14
Pluralistic attitude
Metatherapeutic
communication
Multi-orientation
practice
Distinction
between three
domains is
important, as
may hold a
pluralistic
attitude,
without
drawing on
multiple
orientations
Person-centred
practice
Psychodynamic
practice
But isn’t
pluralism just
the same as
integrative/
eclectic therapy?
Pluralistic
attitude
Metatherapeutic
communication
Multi-orientation
practice
Pluralistic practice =
collaborative integrative
practice, but…
Pluralism can also be an
attitude and way of
communicating to clients,
without involving multi-
orientation practices
Some integrative practices
do not emphasise
metatherapeutic
communication, or a
pluralistic attitude Integrative and
eclectic practices
Multi-orientation
practice
15
Meta-
therapeutic
communication
…starts with
being clear
about what we
can offer clients
My therapy (in 100 words)
I offer clients an opportunity to talk through their
experiences, emotions, behaviours and thoughts; and to
find ways of acting and thinking that are more rewarding
and satisfying. I aim to facilitate this process by listening
and feeding back to clients what they are saying; and
through inviting clients to talk about – and stay focused
on – the issues that are key to them. Through talking
about their feelings and experiences – particularly ones
that they may feel bad about – and through challenging
negative ways of seeing themselves, clients can also come
to feel better about who they are.
16
Metatherapeutic
dialogue
Going
beyond
intuition
17
Can we just trust our intuitive
sense of what clients need?
A. Research indicates that
therapists are generally poor
judges of what clients want
or experience
Why can we miss so much of what clients
experience/want?
Clients frequently
defer
to their therapists (David
Rennie):
– Withhold critical, challenging, negative comments
– Agree when they disagree
65% of clients leave at least one thing unsaid during
sessions (Hill et al., 1993)
Why do clients defer:
– want to be seen as ‘good clients’
– out of a fear that therapists will retaliate
– because therapists are experts
– to save therapist’s ‘face’
Given how much
we can miss…
Important that
we
explicitly
explore with our
clients their
wants and goals
18
Doing whatever a client initially asks for,
and then sticking to it regardless!
=
Subtle, complex, on-going process
Draws on expertise of both client and therapist
Collaboration is not
about the uncritical
acceptance of the
client’s viewpoint -- it is
about moving beyond its
uncritical negation
Co-constructing therapeutic
methods I
Following dialogue comes from a first session of therapy
between Mick and Saskia (from Cooper and McLeod, 2011,
p.111)
Mick asked Saskia what she thought might be helpful to her
in the therapy/what she had found helpful or unhelpful with
previous therapists
Saskia replied that she had found it unhelpful when there is
‘just a man sitting behind you’ not giving you any feedback -
- she said that she wanted lots of input and guidance
Mick was fairly happy to work in this way, but also sensed
that Saskia had a relatively ‘externalised locus of evaluation’
and had some concerns about reinforcing this
19
Co-constructing therapeutic
methods II
Mick: So it sounds like feedback will be useful ?
Saskia: Yeah, Yeah.
Mick: OK.
Saskia: Yes, definitely, because….no matter who we are in the world,
wherever we are in life, there is always going to be something that
we’ve missed, either because we don’t want to s ee it, or because
we just didn’t see it. Even if someone is 90% ‘ actualised’…they’re
not going to see everything. [So] you [can] turn around and s ay:
‘You could have said this, you could have done that.’ And they’r e:
‘Oh, really, thanks Mick, I never-- I never saw that.’
Mick: I guess the important thing for me, in giving feedback, is that you
can say ‘That’s not right’ [Saskia: Sure.] And you can say, ‘ No, that
doesn’t fit,’ or ‘That’s not helpful’ [Saskia: Sure, sure.]. I mean,
one of the ways that I like to work is-- is very much with
feedback…and that needs you to say to me, ‘ No, don’t like that…’
‘That’s good…’
Opportunities
for meta-
therapeutic
dialogue
• Goals
• Method
• Content
• Understanding
• Progress
• Experience
Subject matter:
What?
20
Goals: Possible prompts
‘Do you have a sense
of what you want
from our work
together?’
‘What do you hope to
get out of
counselling?’
‘So I wonder what’s
brought you here?’
‘Where would you like
to be by the end of
counselling?’
Methods: Possible prompts
‘What would you want
from me as a
counsellor?’
‘If you’ve had
counselling in the
past, what sort of
things have been
helpful?’
‘How do you think we
can best help you get
that?’
Content: Possible prompts
‘What would you like
to talk about today?’
‘What do you want to
focus on?’
‘What’s been on your
mind that might be
useful to talk
through?’
21
Understandings: Possible prompts
‘How do you make sense of
what you’ve been going
through?’
‘How would you
understand why you’re
experiencing these
difficulties?’
‘Here are some different
ways of understanding
your difficulties, do any of
them fit for you?’
‘Would you find it useful to
think about this in terms of
a diagnosis, or not?’
• Previous session(s)
• Current session
• Next session
• Therapeutic work as
whole
• Extra-therapeutic
activity/homework
• Ending
Temporal focus:
About when?
Temporal period:
When?
Start of sessions
Within sessions
End of sessions
Review points
Final sessions
22
Evolving principles of
metatherapeutic communication
1. Address metatherapeutic issues from the start
2. Actively
invite clients to share their views
3. See MTC as an
ongoing
process
4. Uncertainty is a predict of when to MTC
5. Be part of the dialogue
6. Describe what the options might be
7. Tailor levels of MTC to the particular client
8. Adopt a whole service approach
9. Use measures
Using
systematic
feedback to
facilitate
meta-
therapeutic
dialogue
Systematic feedback
• The
integration
into therapy of
validated
methods that invite clients, on a
regular
basis, to assess their wellbeing (
outcome
feedback
), or experience of therapy and the
therapeutic relationship (
process feedback
)
23
Two main types of
measures
Outcome measures
: feedback
on changes in mental wellbeing
(e.g., PHQ, CORE)
Process measures
: feedback on
clients’ experiences in therapy
(e.g., Session Rating Scale,
Helpful Aspects of Therapy)
Pluralistic specific measures…
Goals
Form
Personalised outcome
measure
Invites clients to focus
on what they want
Discussed and agreed
in assessment session
Rated every
subsequent week
24
Clients’ ratings of feedback forms
(n = 18, Cooper et al., 2015)
Very helpful
Neither
1
2
3
4
5
Helpful
Unhelpful
Very
Unhelpful
I would like a/my therapist to:
(
n
= 224)
Mean = 1.43
Decide the
goals for
therapy
themselves
Include me in
setting the
goals for
therapy
Using the Goals Form
1. Client and therapist discuss the client’s goals for
therapy (normally at assessment)
2. Wording is agreed a written down on the Goals Form
3. Clients are asked to rate how much they feel each
goal is currently achieved
4. Clients are asked which goals they would like to
prioritise
5. The client’s goals are transposed to an electronic
copy of the form and copies of the personalised form
is printed off
6. Clients are asked to rate their goals at the start of
every session
7. Clients can add to, delete or modify their goals as the
work progresses
25
Qualitative data
‘I really liked the goals, for
example, I really liked that
element of it, and knowing that
you have this-- and focusing your
thoughts and saying, “Ok, What do
I need to do to achieve that and
that and that?” I think,
probably, this task [of completing
the Goals Form] was probably one
of the most helpful [aspects of
therapy]-- in the sense of,
actually, you know, going through
“What is it that I want to
achieve, what is it that is making
my life difficult, and I want to
improve?”…. We didn’t have goals
in the previous counselling
experience that I had and I can
say that it is something that
helps me for some reason. It
focuses. It’s like a task, and
this is how my mind works….
Definitely very useful, to
crystallise and put things down.’
Basic principles
1. Clients should not be
required
to set
goals
2. Goals can normally be established in a
first, or assessment, session
3. But, goal-setting is a process across
therapy, and not a one-off event
4. Clients should be allowed to add to,
remove and modify goals as
appropriate
5. Goals should be determined by clients,
in dialogue with their therapists
Goals on the Goals Form should be…
Concise: Not
more than one
sentence long
Single goals
‘Absolute’: Not
relative (e.g.,
‘less
depressed’), as
difficult to rate
from week to
week
26
Ideally, goals on the Goals Form should be…
Synergetic: or
at least not in
conflict
Intrinsic
Approach
goals
Achievable
(i.e.,
supportable by
specific plans)
Research also suggests goals should be…
Relatively
challenging
Specific
Important/rele
vant/committed
to by the person
Supported by
ongoing
feedback: i.e.,
keep measuring
regularly
27
Inventory of Preferences (C-NIP)
18 item process measure (free to use) that
invites clients to say how they would like
therapy to be
Can be used at assessment and in ongoing
therapeutic work/at review
Four dimensions: directiveness, emotional
intensity, past orientation, support
Additional preference items (e.g., gender of
therapist)
Key issue is strong preferences
The Cooper-Norcross Inventory of Preferences (C-NIP)
(download and use for free from pluralistictherapy.com)
Online survey composed of 40 therapy
preference items
Completed by 860 respondents,
primarily female (
n
= 699), British (
n
=
699), White (
n
= 761), and mental
health professionals themselves (
n
=
615)
Method
28
Four principal components identified,
accounting for 39% of variance:
Therapist Directiveness vs. Client
Directiveness (5 items, α = .84)
Emotional Intensity vs. Emotional Reserve
(5 items, α = .67)
Past Orientation vs. Present Orientation
(3 items, α = .73)
Warm Support vs. Focused Challenge
(5 items, α = .60)
Components analysis and interpretation
Supervision Personalisation Form
11 scale tool
that invites
supervisees to
say what they
would like from
supervision
(Wallace &
Cooper, 2015)
Debates and
challenges
29
Implicit needs and processes
Clients may not be
able to say what
they want or need
Implicit, unconscious
desires may be very
different to explicitly
stated wants
Danger of colluding
with clients
maladaptive
interpersonal
dynamics
‘Maybe I am
getting…my kind of
demands, just
because I put down
something on those
papers…. And I
questioned whether,
whether I should
have been giving the
opportunity to be
kind of designing.
Because I am the one
who is unwell, who
has been unwell, so
giving me to the
choice may be…’
(PfD client)
Implicit needs and processes
Being pluralistic about pluralism
Collaboration, MTC, systematic feedback,
etc. may not be desirable or helpful for all
clients – pluralism invites us to be
critical/pluralistic about tools too
‘As a client, I felt like she would ask me how
the session had been for me at the end of every
session as a kind of mini-review and I just felt
totally, like, put on the spot, and still trying
to process whatever we had been talking about.
So it kind of took me out of what I had been
thinking about and I lost touch with the
process, rather than become absorbed in it. And
then I do the sort of people pleaser thing of
trying to be like “Yeah, yeah, it was really
good, really helpful”, and really want to answer
her question as I do not want to say anything
was unhelpful as that feels really
uncomfortable. I would never say anything
unhelpful.’
(from client experience research by Keri Andrews, counselling
psychologist)
30
Therapist
inauthenticity
‘I think it was an
unfair situation on
the therapist that I-
- that somebody just
walks in from the
street and gets into
the project and says
“So I want you to
behave like this,
this, this and this
with me”…. He is not
behaving in a way he
would naturally would
behave.’
(PfD client)
Towards a
wikitherapy
An evidence-
informed
resource for
therapists and
clients on the
different methods
that can help
clients achieve
different goals
Thank
you
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