Adapted from: Cooper, M., & Dryden, W. (2016). Introduction to pluralistic counselling and psychotherapy. In M. Cooper & W. Dryden (Eds.), Handbook of pluralistic counselling and psychotherapy. London: Sage.

Development of the Pluralistic Approach

The origins of the pluralistic approach to therapy were developed by Mick Cooper and John McLeod in 2006, and stemmed from the idea that all therapeutic approaches offered useful insights into how to help people therapeutically.  Cooper and McLeod views, in particular, were a reaction to what they saw as dogmatism within the counselling and psychotherapy field, and the lines that were being drawn between different therapeutic orientations.  Their goal was to create and develop an approach to therapy that was flexible and suited to the needs of each individual client.

An original paper on the pluralistic approach was published in 2007, entitled ‘A pluralistic framework for counselling and psychotherapy: Implications for research’ (Cooper & McLeod, 2007).  This article laid out the basic principles of a pluralistic approach within a research-informed context.  At the same time, McLeod and Cooper developed two courses oriented around pluralistic principles: The Postgraduate Diploma in Counselling at the University of Abertay and the Doctorate in Counselling Psychology at Glasgow Caledonian University and the University of Strathclyde.  Pluralistic research clinics were also established at both Abertay and Strathclyde universities.  McLeod and Cooper, together and separately, began to deliver workshops on pluralistic therapy around the UK and at training events and conferences.

In early 2011, Cooper and McLeod published Pluralistic counselling and psychotherapy, which provided a coherent and comprehensive introduction to the core principles and practices of a pluralistic approach.  Since its publication, the book has had over 300 citations on Google Scholar, and has become the standard text for pluralistic therapy.  Later in 2011, the Universities Psychotherapy and Counselling Association, in association with the Research Centre for Therapeutic Education at Roehampton University, held an international conference on ‘A pluralistic approach to practice? — Implications for the psychological therapies.’  The papers for this conference were later published in a special issue of the European Journal of Psychotherapy and Counselling (vol. 14: 1) (Bowens & Cooper, 2012; Cooper & McLeod, 2012; Dryden, 2012; Mcleod, 2012; Miller & Willig, 2012; Ross, 2012; Thompson & Cooper, 2012; Watson, Cooper, McArthur, & McLeod, 2012).  Windy Dryden, who attended the conference and authored a commentary on the main papers for this special issue, began to develop an interest in the interface between the pluralistic approach and cognitive-behavioural therapy (CBT).  He started to work more closely with Cooper and McLeod on developing a pluralistic approach in Britain.  The handbook of pluralistic counselling and psychotherapy was published in 2015, co-edited by Cooper and Dryden.

Since the publication of Pluralistic counselling and psychotherapy in 2011, a number of pluralistic trainings in counselling, psychotherapy and counselling psychology have developed in the UK.  In addition, several introductions to the approach have been published in counselling and psychotherapy textbooks (McLeod & Cooper, 2012, 2015; McLeod, McLeod, Cooper, & Dryden, 2014). 

In the UK, the field of counselling psychology has been particularly receptive to pluralistic ideas and practices.  Applications of the approach have been discussed in the British Psychological Society’s (BPS) Division of Counselling Psychology (DCoP) journal, Counselling Psychology Review (Scott, 2014; Scott & Hanley, 2012; Wilk, 2014); and pluralistic concepts and practices have featured extensively in two recent texts: one on counselling psychology work with adolescents (Hanley, Humphrey, & Lennie, 2012), and the other on counselling psychology’s contribution to therapeutic and social issues (Milton, 2010).  In addition, in 2013, the BPS DCoP provided funding support for a pilot study of pluralistic therapy for depression (Cooper et al., 2015).  The study, based at three research clinics in the UK — the University of the West of England, the Metanoia Institute, and the University of Strathclyde — assessed the outcomes, acceptability and helpful aspects of a pluralistic therapeutic intervention for depression (see below).  The pluralistic therapy for this study was delivered by trainee and qualified counselling psychologists, trained and supervised by John McLeod at the University of Abertay.

Internationally, training and talks on pluralistic practice have been delivered by McLeod and Cooper around the world, and a Master’s-level training in pluralistic practice has now been established in Ireland.  Although dissemination in the US is more sparse, the feedback-informed approach of Duncan, Miller, Sparks and colleagues bears many similarities to the pluralistic model. 

Pillars and Principles

Pluralism can be defined as the philosophical belief that ‘any substantial question admits of a variety of plausible but mutually conflicting responses’ (Rescher, 1993, p. 79).  More than that, it is an ethical commitment to valuing diversity; and a wariness towards monolithic, all-consuming ‘truths’, because of the way that they can suppress individuality and difference.  In respect to counselling and psychotherapy, this pluralistic standpoint implies that there are a variety of views that can be taken on a wide range of therapeutic issues, and that there is no inherent right or wrong way.  This forms the grounds for three pillars that underpin a pluralistic approach to counselling and psychotherapy. 

The first pillar is pluralism across orientations.  This means that a pluralistic practitioner is open to considering a variety of different ways in which clients get distressed and, correspondingly, a variety of different ways of helping them.  Taking this stance poses a direct challenge to the schoolism that has been endemic in the field of counselling and psychotherapy. 

The second pillar is pluralism across clients.  This is marked by the emphasis that is placed on recognising and celebrating diversity across clients.  What follows from this is that pluralistic practitioners are keen to offer each client a bespoke approach to counselling and psychotherapy rather than one that is ‘off the peg’. 

This relates to closely to the third pillar of a pluralistic approach: pluralism across perspectives.  A pluralistic therapeutic approach advocates that both participants in the therapeutic relationship — clients as well as practitioners — have much to offer when it comes to making decisions concerning therapeutic goals and the selection of therapy tasks and methods.  This means that a pluralistic approach emphasises shared decision-makingand feedback across clients and therapists.

These three pillars of the pluralistic approach can be summarised in the following principles:

• There is no one right way of conceptualising clients’ problems — different understandings are useful for different clients at different points in time
• There is no one right way of practising therapy — different clients need different things at different points in time
• Many disputes and disagreements in the therapeutic field can be resolved by taking a ‘both/and’ perspective, rather than an ‘either/or’ one
• It is important that counsellors and psychotherapists respect each others’ work and recognise the value that it can have
• Counsellors and psychotherapists should acknowledge and celebrate clients’ diversity and uniqueness
• Clients should be involved fully at every stage of the therapeutic process
• Clients should be understood in terms of their strengths and resources, as well as areas of difficulty
• Counsellors and psychotherapists should have an openness to multiple sources of knowledge on how to practice therapy: including research, personal experience, and theory
• It is important that counsellors and psychotherapists take a critical perspective on their own theory and practice: being willing to look at their own investment in a particular position and having the ability to stand back from it.

Research Evidence

As a relatively new development in the field of counselling and psychotherapy, the evidence base for pluralistic counselling and psychotherapy is still at a nascent stage.  Nevertheless, there are several lines of evidence in the psychotherapy research field that provide initial support for a pluralistic approach to counselling and psychotherapy. 

First, clients do seem to do better in therapy when it matches their preferences (Swift, Callahan, & Vollmer, 2011).  More specifically, clients who receive a preferred intervention are ‘between a half and a third less likely to drop out of therapy prematurely compared with clients who did not receive their preferred therapy conditions’ (Swift et al., 2011, p. 307); and also show a small but significant increase in outcomes (d = 0.31).  This is consistent with the research in the field of shared decision-making, which shows that patients are more satisfied with their medical treatment and less likely to drop out if they are involved in making decision about their health care (Joosten et al., 2008; The Health Foundation, 2014). 

Second, there is strong relationship between client-therapist agreement on the tasks and goals of therapy, and therapeutic outcomes (Horvath, Del Re, Fluckinger, & Symonds, 2012; Tryon & Winograd, 2012).  That is, clients do best in therapy when they feel that their therapists are striving for the same therapeutic goals as they are, and are in agreement about the best therapeutic methods to be used.

Third, there is research to suggest that flexible practice, tailored the needs of individual clients, is experienced by clients as a helpful and important aspect of therapy (Cooper et al., 2015; Perren, Godfrey, & Rowland, 2009).  This is supported by quantitative research suggesting that flexibly tailored practice can, in certain instances, lead to improved outcomes and greater engagement with therapy (e.g., Jacobson et al., 1989). 

Fourth, randomised controlled studies indicate that the use of systematic client feedback — which is integral to the pluralistic approach — can lead to significantly enhanced therapeutic outcomes, particularly for clients who might otherwise deteriorate in therapy (Lambert & Shimokawa, 2011).  Indeed, feedback-informed treatments are now recognised as evidence-based programs by the US government’s Substance Abuse and Mental Health Services Administration (SAMHSA). 

            In addition, UK-based studies of a specifically pluralistic practice — both for clients with depression (Cooper et al., 2015, see above) and for a more heterogeneous sample (Cooper, 2014) — have shown that it has relatively positive outcomes, as well as good rates of engagement and retention.  As indicated above, these studies have also found that most clients value the flexibility and collaborative approach that is at the core of pluralistic practice. 

References

Bowens, M., & Cooper, M. (2012). Development of a client feedback tool: a qualitative study of therapists’ experiences of using the Therapy Personalisation Forms. European Journal of Psychotherapy and Counselling, 14, 47-62.

Cooper, M. (2014). Strathclyde pluralistic protocol. Glasgow: University of Strathclyde.

Cooper, M., & McLeod, J. (2007). A pluralistic framework for counselling and psychotherapy: Implications for research. Counselling and Psychotherapy Research, 7(3), 135-143. doi: 10.1080/14733140701566282

Cooper, M., & McLeod, J. (2012). From either/or to both/and: Developing a pluralistic approach to counselling and psychotherapy. European Journal of Psychotherapy and Counselling, 14(1), 5-18.

Cooper, M., Wild, C., van Rijn, B., Ward, T., McLeod, J., Cassar, S., . . . Sreenath, S. (2015). Pluralistic therapy for depression: Acceptability, outcomes and helpful aspects in a multisite study. Counselling Psychology Review, 30(1), 6-20.

Dryden, W. (2012). Pluralism in counselling and psychotherapy: Personal reflections on an important development. European Journal of Psychotherapy & Counselling, 14(1), 103-111.

Hanley, T., Humphrey, N., & Lennie, C. (Eds.). (2012). Adolescent Counselling Psychology: Theory, Research and Practice. London: Routledge.

Horvath, A. O., Del Re, A. C., Fluckinger, C., & Symonds, D. (2012). Alliance in individual psychotherapy. In J. C. Norcross (Ed.), Psychotherapy Relationships that Work: Evidence-based responsiveness (pp. 25-69). New York: Oxford University Press.

Jacobson, N. S., Schmaling, K. B., Holtzworth-Munroe, A., Katt, J. L., Wood, L. F., & Follette, V. M. (1989). Research-structured vs clinically flexible versions of social learning-based marital therapy. Behaviour Research and Therapy, 27(2), 173-180.

Joosten, E. A., DeFuentes-Merillas, L., De Weert, G., Sensky, T., Van Der Staak, C., & de Jong, C. A. (2008). Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychotherapy and psychosomatics, 77(4), 219-226.

Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed., pp. 203-223). New York: Oxford University.

Mcleod, J. (2012). What do clients want from therapy? A practice-friendly review of research into client preferences. European Journal of Psychotherapy and Counselling, 14(1), 19-32.

McLeod, J., & Cooper, M. (2012). Pluralistic counselling and psychotherapy. In C. Feltham & I. Horton (Eds.), The Sage handbook of counselling and psychotherapy (pp. 368-371). London: Sage.

McLeod, J., & Cooper, M. (2015). Pluralistic counselling and psychotherapy. In S. Palmer (Ed.), The beginner’s guide to counselling and psychotherapy (2nd ed., pp. 322-332). London: Sage.

McLeod, J., McLeod, J., Cooper, M., & Dryden, W. (2014). Pluralistic therapy. In W. Dryden & A. Reeves (Eds.), Handbook of individual therapy (6th ed., pp. 547-573). London: Sage.

Miller, E., & Willig, C. (2012). Pluralistic counselling and HIV-positive clients: the importance of shared understanding. European Journal of Psychotherapy and Counselling, 14(1), 33-46.

Milton, M. (2010). Therapy and Beyond: Counselling Psychology Contributions to Therapeutic and Social Issues. London: Wiley-Blackwell.

Perren, S., Godfrey, M., & Rowland, N. (2009). The long-term effects of counselling: The process and mechanisms that contribute to ongoing change from a user perspective. Counselling and Psychotherapy Research, 9(4), 241 – 249.

Rescher, N. (1993). Pluralism: Against the Demand for Consensus. Oxford: Oxford University.

Ross, A. (2012). The new pluralism–a paradigm of pluralisms. European Journal of Psychotherapy & Counselling, 14(1), 113-119.

Scott, A. J. (2014). How to skin a cat: A case for and against the use of mindfulness-based cognitive therapy in pluralistic therapy. Counselling Psychology Review, 28(1), 81-90.

Scott, A. J., & Hanley, T. (2012). On becoming a pluralistic therapist: A case study of a student’s reflexive journal. Counselling Psychology Review, 27(4), 29.

Swift, J. K., Callahan, J. L., & Vollmer, B. M. (2011). Preferences. In J. C. Norcross (Ed.), Psychotherapy relationships that work (2nd ed., pp. 301-315). NY: Oxford University.

The Health Foundation. (2014). Person-centred care: From ideas to action. London: The Health Foundation.

Thompson, A., & Cooper, M. (2012). Therapists’ experiences of pluralistic practice. European Journal of Psychotherapy and Counselling, 14(1), 63-76. doi: 10.1080/13642537.2012.652393

Tryon, G. S., & Winograd, G. (2012). Goal consensus and collaboration. In J. C. Norcross (Ed.), Psychotherapy Relationships that Work: Evidence-based responsiveness (2nd ed., pp. 153-167). New York: Oxford University Press.

Watson, V., Cooper, M., McArthur, K., & McLeod, J. (2012). Helpful therapeutic processes: A pluralistic analysis of client activities, therapist activities and helpful effects. European Journal of Psychotherapy and Counselling, 14(1), 77-90.

Wilk, K. (2014). Using a pluralistic apporach in counselling psychology and psychotherapy practice with diverse clients: Explorations in clutural and religious responsiveness within a Western paradigm. Counselling Psychology Review, 29(1), 16-28.