Julia McLeod, School of Applied Sciences, Abertay University

An on-line survey of counselling and psychotherapy practitioners who identified themselves as using, or influenced by, a pluralistic framework for practice, was conducted in April 2020. Invitations to complete the survey were circulated by email to a wide range of individuals who had either participated in pluralistic training and research, or had indicated an interest in the approach. A preliminary analysis of findings is available below. A longer, more detailed version will be submitted for journal publication, early in the new year.

We would be really grateful if you could share your thoughts, feedback, and questions about where we have got to so far with the analysis of the survey data, using the blog discussion form. Your contributions will be enormously helpful in ensuring that the final paper is as clear and informative as possible.

The survey was designed by a ‘pluralistic practice expert group’, to collect information on the characteristics of therapists influenced by pluralistic ideas, the settings within which they worked, experience of training and supervision, use of pluralistic ideas and techniques, evaluation of the utility of a pluralistic approach, and views regarding its further development. 

Participants were provided with consent information explaining the purpose of the study before indicating their consent and proceeding to take part. Ethical approval for the study was granted by the Research Ethics Committee, Abertay University.

Respondents

Responses were received from 186 participants:

• 48 male, 134 female, 4 gender not specified
• Average age was 49.37 years (SD 11.90 years)
• 92% were white/Caucasian
• Place of residence: Scotland (33%), England (27%), Ireland (12%), Norway (6%); other nationalities included Germany, New Zealand, USA, and Argentina
• Working area: urban (64%), rural (28%), mixed (8%)
• Average of 10.95 years practicing as a therapist (SD = 11.51 years)
• Self-described professional discipline: counselling (35%), counselling/psychotherapy (30%), psychotherapy (13%), clinical psychology (10%), other categories (12%)
• Primary work setting: private/independent practice (46%), voluntary sector counselling (19%), health service community health centre/GP practice/primary care centre (7%), university/college student counselling service (6%), health service outpatient clinic (5%), other categories (19%); 54% also reported a second practice setting
• The majority had another occupational background prior to training as a therapist: education (15%), community work (10%), management (10%), administration (10%), none (9%), social work (8%), artist/creative (6%), and other categories (32%)
• 63% did not have a psychology degree
• General therapy training: completed (or were working toward) therapist training at postgraduate or Master’s level (53%), Doctoral level (21%), Undergraduate/BA/BSc (13%), Undergraduate certificate/diploma (11%), and other (3%)
• Training in pluralistic therapy was primarily via independent study (40%), specific pluralistic training programme (e.g., Abertay, IICP) (37%), other (23%)
• Of those who had completed training as a counsellor or psychotherapist (86% of sample), training was primarily part-time (78% versus 22% full-time), and lasted 40.75 months on average (SD = 16.95 months)
• 82% were members of at least one professional organization
• 5% were members of the Society for the Exploration of Psychotherapy Integration
• 96% had some form of personal therapy before (50%), during, or after their training; from an average of 3.40 therapists (SD = 3.21), of whom 20% were pluralistic in their orientation
• 55% identified their approach as ‘pluralistic’; ‘Integrative’ (32%), single-orientation label (6%), ‘eclectic’ (1%), other (5%).

Characteristics of Practice

• The respondents had worked with an average of 6.01 formal supervisors at the time of report (SD = 12.52), of whom 34% were pluralistic in their orientation
• All participants were engaged in client work at some level (20% full-time)
• Other work roles: clinical supervision (43%), trainer/lecturer (47%), managing a service (25%), research (18%)
• Respondents worked with around twice as many female as male clients; 1% of participants reported working with non-binary clients
• 74% worked entirely or predominantly with adult clients; other categories of clients: children (reported in caseloads of 5% of participants), adolescents (10%), older adults (6%)
• Clients of black/minority ethnicity were a significant proportion in 2% of caseloads
• At least half of clients were receiving medication (in 47% of caseloads)
• At least half of clients were: experiencing poverty (in 15% of caseloads), low income (32%), middle income (50%), affluent (11%)
• Regularly encountered client presenting problems: anxiety (in 78% of workloads), depression (60%), trauma (51%), bereavement and loss (30%), work stress (30%), couple/relationship/marital (28%), sexual violence (23%), social/family problems (23%), long-term health conditions (19%), suicide (15%), poverty/housing (13%)
• Less commonly encountered client presenting problems: sexual (8%), personality disorder (7%), violence (7%), racism (7%), disability (6%), eating disorders (5%), personal therapy for other therapists (4%), psychosis (3%), OCD (3%), refugees (0%)
• Mode of therapy: individual (75%), on-line (8%), joint work with colleague from another discipline (4%), couples (4%), families (4%), groups (4%)
• Short-term work (1-6 sessions) (10%), Medium term (7-20 sessions) (58%), Long-term (>21 sessions) (36%)
• Significant theoretical influence on practice: humanistic (76%), psychodynamic (27%), systemic (22%), CBT (17%) (many other influences also written in).

Pluralistic Skills Regularly Used With Clients

• Shared decision-making (around goals, tasks, methods and practical aspects of therapy such as duration and scheduling of sessions, etc.):  82%
• Shared decision-making and planning around the ending of therapy: 82%
• Explicit agreement over goals for therapy: 80%
• Using client feedback to inform therapist learning and development: 71%
• Therapeutic metacommunication to clarify client or therapist intentions and reactions: 68%
• Collecting information on client strengths and cultural resources: 64%
• Collecting information on client preferences: 63%
• Collaborative case formulation: 56%
• Case formulation offering alternative ways of thinking about the client’s problem: 53%
• Collecting and discussing feedback on symptom change, gathered through regular completion of a scale such as CORE, OQ, ORS etc.: 51%
• Using methods/activities devised or suggested by the client: 51%
• Exploring the pros and cons of different methods (techniques, interventions, activities) for tackling specific tasks: 46%
• Using a timeline or other type of visual diagram for case formulation and planning: 45%
• Therapist outline of what they can offer (therapist’s ‘menu’): 44%
• Using a scale or form to monitor goal attainment on a weekly or other regular basis: 34%
• Breaking down goals into step-by-step tasks: 35%
• Collecting and discussing feedback on client preferences for therapist style and way of relating (e.g., using Cooper-Norcross Inventory of Preferences): 22%.

Innovative Therapy Methods Used/Encouraged with Clients (Not Necessarily Regularly)

• Client writing (poems, journals, letters): 84%
• Client reading/bibliotherapy (client reads books, articles): 81%
• Meditation, mindfulness, prayer: 75%
• On-line therapy (text, email, apps, video [e.g., Zoom, Skype]): 70%
• Art-based expressive techniques (visual arts, drama, music): 58%
• Physical exercise (walking, swimming): 56%
• Yoga: 36%
• Therapy sessions conducted out of doors: 32%
• Craft work (knitting, tapestry, quilt-making, woodworking): 30%
• Therapeutic interaction with animals (dogs, horses): 27%
• Horticultural (tending a garden): 13%
• Participation in environmental activism: 12%.

Views about Pluralistic Therapy

Responses to how ‘pluralistic therapy has contributed to the development of your practice (in relation to your own personal experience with your own clients, as well as more broadly within the agency or clinic within which you work)’. Percentage ‘agree’ or ‘strongly agree’:

• Client understanding of their own role in therapy: 90%
• My capacity to work collaboratively with clients: 90%
• Client outcomes (how much my clients have been helped by therapy): 89%
• The extent to which I engage in shared decision-making with clients: 88%
• The capacity of clients to make use of their own strengths and resources: 87%
• My openness to, and capacity to use, feedback from clients: 87%
• Client active involvement in therapy: 86%
• My ability to work effectively with clients who have complex problems: 70%
• Client retention in therapy (i.e., has reduced the proportion of clients who drop out of therapy/unplanned endings): 63%
• The effectiveness of therapy with clients whose cultural, ethnic, and social backgrounds are different from my own: 60%
• My capacity to use research to inform my practice: 60%
• The capacity of the clinic or service that I work in to adopt innovative ideas and practices: 54%
• The capacity of the clinic or service that I work in to flexibly adapt to changing demands (e.g., coronavirus): 53%
• The way that the clinic or service that I work in organizes and delivers its services: 44%
• The capacity of the clinic or service that I work in to reach out to new groups of clients: 29%.

Level of Satisfaction with the Way that Pluralistic Therapy has Developed and is Currently Organised

Percentage ‘satisfied’ or ‘highly satisfied’:

• Practice-based books and articles: 71%                                           
• Research evidence to support practice: 57%
• Providing a ‘home’ for people already involved in pluralistic practice: 55%
• Pluralistic practice website: 53%    
• Annual conferences: 47%                                                                     
• Possibilities for exchange of information among pluralistic practitioners: 39%
• Social media presence: 36%          
• Availability of clinical/professional training in a pluralistic approach: 35%
• Encouraging dialogue with professionals not necessarily committed to or aware of a pluralistic perspective: 30%
• Advocating for pluralistic therapy with professional organizations and in the public arena: 27%
• Agreed standards/competencies statements, to support recognition by professional bodies and employers: 26%
• Opportunities for taking part in:
  • Training workshops: 67%
  • Webinars on pluralistic therapy: 40%
  • Networking with people in my locality: 29%
  • Research on pluralistic therapy: 27%                                                   
  • Development of resources for clients: 25%                                  
  • Publishing my ideas: 23%                                         
  • Pluralistic supervision: 18%                                   
  • Pluralistic personal therapy: 17%.                                   

Conclusions

Some tentative themes emerged from this preliminary analysis of data:

1. There was limited overlap between the characteristics of respondents in the present survey and those who have completed other therapist surveys. Pluralistic practitioners are more likely to have had a previous career before entering therapy training, are unlikely to have a psychology degree, and are more likely to work in community settings rather than in medical contexts (e.g., NHS settings).
2. Client profile (types of problems and high level of social adversity) is consistent with front-line community practice.
3. There was limited connection with BAME clients or therapists.
4. At the present time, pluralistic practice is mainly conducted close to regional centres of training in Scotland, Ireland, and England.
5. A significant minority of pluralistic practitioners learned about the approach through independent study, rather than accredited training.
6. There was a lack of overlap with SEPI membership.
7. Humanistic theory had a significant influence on respondents’ practice.
8. There was substantial agreement on key elements of pluralistic practice: particularly shared decision-making, goal oriented practice, use of feedback, and attention to client strengths.
9. There was substantial agreement on the value of a pluralistic approach: client active involvement, collaboration, and client outcomes/benefit.
10. Practitioners indicated an openness to innovative forms of practice.
11. There was a lack of satisfaction with current organisational support for practice; and opportunities for pluralistic training, supervision, and personal therapy.

The survey included additional open-ended response boxes regarding several of these issues. Although participants offered a range of valuable observations and suggestions (e.g., around research into pluralistic practice that they would like to see), these have not been included in the present summary for reasons of space, and will be reported later in a separate blog.

Acknowledgements

Invaluable contributions to the design, distribution, and analysis of the survey study were made by many colleagues, including Chris Watkins, Mick Cooper, Clare Cunningham, Marcella Finnerty, John McLeod, Kate Smith, Rolf Sundet, Jay Beichman, Frankie Brown, John Hills, Triona Kearns, Lynne Gabriel, and Mhairi Thurston.