What’s the difference between pluralism and integrative (or eclectic) therapy?
Three things. First, pluralism can be an outlook as well as a practice. So you could be a pure person-centred or CBT therapist and still hold a pluralistic outlook. By contrast, it wouldn’t really make sense to say you were ‘a pure CBT therapist and also integrative’—because ‘integration’ means a specific way of practising. Second, pluralism is about an openness to all different forms of therapy, whereas ‘integration’ can refer to specific combinations of therapies, such as cognitive analytic therapy (CAT). Practising integrative therapies like CAT can be very helpful and, of course, it can be done from a pluralistic standpoint; but such therapies are not pluralistic, per se. Indeed, it’s possible that integrative therapies can end up promoting the same kind of schoolist attitudes that pluralism specifically challenges. Third, while lots of integrative therapies do promote a collaborative attitude to client work, it’s not intrinsic to integration, per se. So you could practice integratively but from a very strongly therapist-led perspective—and that wouldn’t be pluralistic. As a practice, though, pluralism could be described as an integrative approach to therapy which particularly emphasises client–therapist dialogue on the goals and methods to be adopted.
Does a pluralistic approach mean that I have to be skilled in every therapeutic method going?
No. it is quite possible to adopt a pluralistic perspective on therapy and still practice within a single orientation. What makes someone pluralistic in their outlook is an appreciation of the many different ways that therapy can be helpful (and unhelpful) for different clients, an awareness of one’s own limitations, and a willingness to refer on if a client’s wants do not match one’s own resources. Even for therapists who are working in a specifically pluralistic way, there is no expectation that they will be able to do everything. No-one can learn all 450+ types of therapeutic practice. Again, what is important is that they are aware of what they can, and cannot offer, clients, and are able to discuss and negotiate this with the people that they work with.
Most of my clients can’t say what they want from therapy, so what is the point of asking them?
Discussion and negotiation around the goals of therapy does not simply involve asking a client, in a first session, what they want, and expecting an immediate and definitive answer. In general, it takes time for people to identify their goals for therapy (and for life), so it is probably more useful to think about this as an invitation to clients to start thinking about, and talking about, what they want; and as part of creating a culture of feedback. As it is, though, clients may begin to get a much better clarity about their goals just by talking about them and feeling safe enough to communicate them.
What happens if a client does not want a pluralistic approach – if they just want the therapist to decide what to do and to take the lead?
It is a paradox of a pluralistic approach that, sometimes, a pluralistic perspective on therapy means delivering therapy in a non-pluralistic way! There is no doubt that, for some clients, metacommunication and discussion over the goals, tasks and methods of therapy are the last thing they will want. As Elizabeth Freire, one of Mick’s person-centred colleagues put it, ‘If you are down a hole, the last thing you might find useful is someone saying to you, “Now… How can I help you? Would you like a ladder… or some rope… or shall we talk more about what might help you get out?” Rather, you just want someone to haul you out.’ So working pluralistically means being sensitive to the appropriateness and helpfulness of pluralistic therapist activity, itself, and adjusting accordingly.
It is also important to note that, for some clients, the offer of choices and alternatives and metacommunication around the processes of therapy may be interpreted as a sign that the therapist ‘does not know what they are doing.’ Given the importance of hope, expectation and confidence in the therapist to positive outcomes, this has the potential to have quite detrimental effects. In working pluralistically with clients, therefore, it is important that therapists find a balance between flexibility and conveying a confidence in their ability to help (if that is what they feel). This means that statements like, ‘I’ve got some good ideas about what might be useful for you, but let’s see what you think…’ may be much more helpful than, ‘I really don’t know what is going to help you… you decide?’
Does working pluralistically mean that I have to do whatever a client wants?
No. Clients, like all of us, get things wrong some of the time; or want things that, ultimately, will not be of help to them. And, as individuals with an in-depth understanding of human psychological functioning, therapists may have much to offer in terms of helping clients identify what will be of benefit in the long-run. So a pluralistic approach does not require therapists to put their own understandings, perceptions or expertise to one side — these may be a very valuable part of the collaborative therapeutic dialogue. What it does do, though, is to ask therapists to treat clients’ wants with respect and understanding, and to put these at the heart of the therapeutic work.
The pluralistic framework feels very task-orientated, with its focus on goals and outcomes – whatever happened to just ‘being with’ a client?
From a pluralistic standpoint, it is undoubtedly the case that some clients will want a therapist who just strives to be ‘alongside them’, without any expectations of achieving particular goals. So terms in the pluralistic framework like ‘goals,’ ‘tasks’ and ‘methods’ should not be taken too literally, or as meaning to imply that clients should be pressurised to achieve particular outcomes. Rather, the terms are used in the loosest sense to simply refer to what clients want, how they hope to get there, and what they might do to make that happen. In this sense, ‘just being with a client’ can be seen as one type of therapeutic task, which might be undertaken to achieve a range of therapeutic goals, such as ‘feeling more comfortable about being myself.’ Hence, although the terms ‘method,’ ‘task’ and ‘goal’ tends to imply something that is consciously and deliberately chosen, they do not need to be; rather, they are intended to be inclusive of much more subtle, non-conscious, and organismic processes.
What difference will adopting a pluralistic approach actually make to my practice?
For therapists who work within a single orientation, thinking pluralistically, at least initially, may not make an enormous difference to practice. But it should lead to an increased amount of discussion and metacommunication with clients about what they want from therapy, and how they might achieve it. For those of us who have gone down this route, one consequence of this is a greater sense of confidence and a feeling of ‘I know what I am doing now,’ rather than a sometimes vague sensation of ‘I’m not quite sure what I’m doing with this client and it doesn’t seem to be making much difference.’ Our experience has also been of an increased sense of engagement and enjoyment in the therapeutic practice: of working alongside the client, and feeling more free to start drawing on other therapeutic knowledge and skills. For therapists who go down the route of developing a fully pluralistic practice, there will be much more noticeable changes in the work: in particular, the use of an increasing range of therapeutic methods.
Does a pluralistic approach means that any therapeutic method goes?
No. A pluralistic approach means appreciating the potential value that any therapeutic method may have, but it is also open to the possibility that some methods, for some clients (and maybe for most clients), for some of the time (and perhaps for much of the time), can be harmful, and that it is very important to find out when this might be the case. Unfortunately, at present, we know very little about which ‘therapeutic’ methods may be unhelpful, above and beyond the macro-level question-marks that hang over particular therapies. This is why the research agenda may be so important: helping to establish the particular contexts in which particular methods might be actively harmful.
Isn’t pluralistic therapy just a bit superficial: a mish-mash of lots of different techniques without any underlying coherence?
Although pluralistic therapy draws on a range of different ideas and methods, it is orientated around one very clear focal point: clients’ goals. So while it does incorporate a great deal of diversity, it is a diversity in the service of a focused and coherent objective. Moreover, a pluralistic approach to therapy is rooted in a cohesive—albeit complex—set of philosophical and ethical principles.
Surely all the different therapeutic orientations are based on different philosophical and psychological assumptions, so how can you just clump then together?
It only becomes problematic to combine different worldviews when they are held as fixed and mutually-exclusive truths, rather than as offerings that may or may not be of use to a client. In other words, for instance, a person-centred belief that people are actualising beings is difficult to integrate with a cognitive-behavioural belief that people do think in dysfunctional ways. But if both of these viewpoints are ‘held lightly’ – in other words, that it can sometimes be useful to see people as moving towards growth, and that people can sometimes be seen as making errors in their thinking – then there is no problem in holding them concurrently. Furthermore, until there is really good evidence to suggest that any one set of these underlying assumptions is more ‘true’ than another, we think that holding them in this light way is the most ethical stance to take.
Aren’t many of us pluralistic therapists any way, so what’s the big deal?
Yes. As the research indicates, it is undoubtedly true that many therapists already think, and practice, in a way that is consistent with the pluralistic approach described here; but we think this text is the first book to try to really articulate this perspective and practice. It is also true that some of the established integrative and eclectic approaches, particularly multimodal therapy, approximate pluralistic practice, but we think there are certain features of this pluralistic approach that make it uniquely inclusive and collaborative.
It’s one thing to say that we should value all the different therapeutic orientations, but is it really that easy to be so open-minded?
If our own experiences are anything to go by, it almost certainly is not. Mick, for instance, has variously aligned himself with existential, person-centred and relational approaches to therapy, and more than once has been accused of being dismissive or overly-critical towards other schools of thought. Given the powerful psychological forces that pull us towards schoolism an in-group favouritism, however, such biases should come as no surprise; and might be best thought of as the rule rather than the exception. From this perspective, then, an ‘us and them’ attitude towards methods from other counselling and psychotherapy fields is something that we will always need to watch out for. However, just as professional training, for many of us, involved acknowledging our biases and prejudices and learning to put them to one side; so we can learn to acknowledge, and bracket, our biases and prejudices towards other methods and practices.
One of the best strategies for opening ourselves up to diversity across groups is by acknowledging the diversity within. That is, the more we can see that our own orientation is heterogeneous, fluid and with amorphously-defined internal boundaries, the less rigid our boundaries to the ‘outside’ world are likely to feel. This could certainly be argued to be the case, for instance, in the person-centred field, where a growing acknowledgement of different ‘tribes’ has coincided with the development of more integrative person-centred perspectives. Also, in terms of overcoming in-group/out-group barriers, this is not just about thinking things through at an intellectual level, but working on the gut feelings sedimented within. It is about noticing those times when our shoulders start to hunch, our lips start to purse, and our skin starts to tighten in response to alternative perspectives, and finding a way of standing back and retaining an open-mind.
Isn’t pluralism, itself, a monism, in that it holds a core set of values (e.g., acceptance of diversity is a good thing) and says, effectively, that there is a better way of doing therapy (i.e., a pluralistic practice)?
Yes and no – it is a paradox of all pluralistic and relativistic thinking that, in many respects, it presents another set of truths; and these always have the potential to congeal into yet one more fixed and dogmatic -ism. That is why, in the pluralistic perspective, we have tried very hard to develop it in a way that is inclusive of non-pluralistic, single orientation practices; and have also not argued that a pluralistic way of working is necessarily more effective than a single orientation specialism. It also means that, for us, it is essential to hold the theory of pluralism lightly; and not to assume that it is a given or unquestionable truth. It may turn out that pluralism is not the best way of taking the counselling and psychotherapy field forward, and this is something we would want to stay open to.
Having said that, we do put forward a set of core underlying value for the pluralistic approach – a deep appreciation of Others and of difference – that is unapologetically monist in intent. Is this hypocritical? One answer to this is that pluralism can exist at different levels, and we can distinguish between the most radical ‘foundational pluralism,’ which holds that there are no given values whatsoever; and a more moderate ‘normative pluralism’, which roots a pluralistic perspective in a monist set of assumptions and values. In this respect, the pluralistic approach can be seen as an example of the latter: a prizing of diversity and difference which emerges from a set of fairly specific humanistic values and assumptions which, to a large extent, are not considered negotiable.
Closely related to this, if pluralism is about accepting the full range of perspectives and overcoming binary thinking, how can it take such a strong stand against schoolism? Surely that is a valid viewpoint too? This is an issue that has taxed pluralists in all fields: How do you accept an Other that does not accept you? William E. Connolly is particularly clear on this. He argues that, while modesty, negotiation and adjustment are all cardinal virtues of pluralism, ‘The limit point is reached when pluralism itself is threatened by powerful unitarian forces that demand the end of pluralism.’ Here, he argues, there is a need for a ‘militant assemblage of pluralists,’ that can resist the onslaught of monist repression and its drive for uniformity. In other words, from a pluralistic standpoint, it is quite legitimate to resist those that seek to annihilate otherness and difference – though this is not to say that they can not still be understood, empathised with and valued – whether in the field of politics or psychological therapies.