Sarah Cantwell, @cantwels1

For better or worse, I’ve always had a drive towards trying to comprehend the fundamental structure of things. Unsurprisingly then, I majored in philosophy for my undergraduate degree, and I took my curiosity about underlying causes with me, through my studies in psychology and into my counselling training. I was astounded when I read the reviews of common factors research in psychotherapy in Norcross’s 2011 edited book (Psychotherapy relationships that work: Evidence-based responsiveness). It seemed that the therapeutic theories and approaches around which counselling and psychotherapy courses were organised might be contributing very little to what actually helps the client feel better in therapy. By far, the majority of known common factors that predict therapeutic outcomes are actually derived from the client alone: Factors like their current motivation and interests and the various types of psycho-social and economic resources available to them. After that, the next most substantial variable is the client’s perception of the therapeutic relationship—do they feel heard and understood and do they feel the therapist is on the same page as them when it comes to what might be helpful in therapy?

These research findings blew my mind. The therapy sector invests most of its resources in training students in particular approaches, when the research is clearly telling us that we need to be creating empathic and collaborative relationships with clients and continually adapting the therapy to their particular context. As you can imagine, I was then very happy to come across Mick Cooper and John McLeod’s 2011 book on pluralistic therapy. They articulated an innovative structure for collaborating with clients to tailor the therapy to fit each individual’s needs and values. I really appreciated this as an ethical and pragmatic response to the findings from common factors research. Ethical because it was saying we need to be collaborative and open with clients about what the research tells us, and pragmatic, since it’s saying ‘Let’s get started and put what we know into practice in a common-sense manner.’

Trying to tackle the theory-research gap

Another thing I was intrigued by was the gap between the input I was getting on my training and then the ‘wide-open space’ left for me to put this into practice with clients. It was one thing to read about how to do therapy and listen to my trainers and supervisors and have discussions with my peers and to do role plays. And it’s another thing to be faced with a real-life client and all the complexities that can arise as two people start working together. Good supervision (and especially, bringing recordings to supervision) gets at some of the complexities, but due to time limitations, it still only scratches the surface. I became fascinated by the worlds upon worlds of interactions and processes in therapy that we never get to articulate.

I considered the effectiveness of various research methods in getting at this complexity. Both quantitative methods and conventional process research aim to reduce the complexities to artificially constructed variables. And a lot of qualitative research assumes that participants can, first of all, notice, and then, after, accurately recall with sufficient detail what goes on in therapy sessions.

Happily, the pluralistic approach is pluralistic about research methods too (see here). So, I proposed a PhD research project where I would use conversation analysis. This is a method that stays very close to the actual moment-by-moment interactions between clients and therapists while also trying to elucidate and describe reoccurring interactions across participants. The research aimed to elaborate the pluralistic therapy programme by describing how real-life clients and therapists actually do one of the basic features of pluralistic therapy: opening up conversations about what might be helpful for a particular individual.

I first found out about conversation analysis during my training at the University of Roehampton. (Shout out to Paul Dickerson and John Rae for an inspirational introduction!) It was originally developed in the field of sociology as a radical attempt to move beyond abstract theories and variables: to more adequately confront the complexity of how society is (re-)created, moment-by-moment, as people simultaneously refresh and uphold—or don’t uphold—social conventions and values whilst speaking and interacting with each other. It is a very rigorous discursive methodology, since any claim about what participants are doing in the conversation needs to be transparently evidenced by showing how the participants themselves are positioning themselves regards that conversational action. For example, in conversation analysis, I can’t conclude that someone is complaining unless I can point to (a) the features of that person’s talk, and (b) features of how other participants in the conversation respond, which show them both treating that bit of talk as complaining about something.

I was excited to try to apply conversation analysis to recordings of pluralistic therapy since I thought it could contribute towards decreasing the theory–practice gap by providing an independent window into what people are actually doing in therapy sessions. The perspective given by conversation analysis can be considered ‘independent’ in the sense that it does not use the concepts of pluralistic theory to describe what participants are doing in therapy sessions. 

Drawing it all Together: Our Recent Publication

In a just-published article in Counselling Psychology Quarterly, based on my PhD research project (‘Therapists’ questions to clients about what might be helpful can be supportive without being directive: a conversation analysis’), we describe how therapists can start a conversation about what might be helpful with various different conversational practices; and that each of these practices have distinct advantages and disadvantages for managing the various (and, at times, conflicting) aims of pluralistic therapy. The article is behind a paywall but you can find the full thesis here.

We found that open questions with no ‘scaffolding’ material (i.e., support/input from the therapist to guide the client’s response) helped clients respond with their own ideas. However clients can initially treat such questions as ‘problematic’, finding it difficult to know how to answer. An example of this is from Line 6 onwards in Figure 1. (You’ll notice that the transcript has a lot of extra symbols. Click here for an accessible and entertaining introduction as to what they mean. And you can find the full transcription key by scrolling down the conversation analysis wiki page here.) You can see in this extract that the therapist asks the client, ‘Do you have a sense of what would be really helpful for you?’ This is a really open question, but the client is a bit bemused and answers, ‘If I knew that I could go and get it myself’, before going on to say they’d like to be a millionaire and spend thousands in therapy.

On the other hand, we found that questions with scaffolding support the client to cooperatively respond, but do so at the cost of lowering the likelihood of the client responding with their own ideas.

One way we found that psychotherapists can resolve this dilemma is by supportively modelling an answer (i.e., scaffolding), whilst not presenting it as the answer. Lines 7-15 in Figure 2 exemplify this practice. We called it a de-specifying practice. Here the therapist performs a delicate conversational manoeuvre of balancing the need to scaffold clients in answering these questions, with being non-directive and opening up the conversational floor. This de-specifying practice has the potential to preserve a genuinely collaborative opportunity for the client to volunteer their own ideas about what might helpful. In this example, you can see that the therapist asks the client if they have ever had any previous therapy, and what they might have learnt from their friend. But they also ask the client if there is ‘anything in mind you want to give me’.

So de-specifying involves providing a structure and guidance to help clients talk about their preferences, but then making sure it is not so rigid or directive that it leads a client down any particular path.

The great distinguishing feature of pluralistic therapy is its eminently reasonable principle that different methods can work for different folks at different times and that we need to have collaborative discussion with clients to figure out what will be helpful for this person at this time. And I think the value of our recent paper lies in constraining this principle slightly—in having such conversations, we must also be sensitive to existing social expectations and conventions and reoccurring patterns in our interactions across clients. Similar to the example in Figure 1, most of the clients in our study tended to balk at wide-open questions asking them what they thought might be helpful. There is evidence they treated these questions as something they should not be expected to know. Of course, there will always be a few clients who won’t be thrown by such a question, but our findings show that a safer bet is the practice of delicately manoeuvring between the two extremes as shown in Figure 2—asking an open question, then providing some supportive scaffolding and then finish by opening up the space again and invite the client’s own ideas.

I think our research findings give a small taste of the practical complexities of putting pluralistic therapy (and, indeed, all psychotherapies!) into action. Having an inspirational and rational theoretical structure is one thing, but it’s another thing altogether for a multitude of different therapists and clients to go about trying to implement it in real-life interactions. These findings can be used as training materials as one means of helping to bridge that theory-practice gap.

I like how the conversation analysis research has shown up a wealth of nuance in starting just one conversation in pluralistic therapy. Who knows what unexpected practical and procedural intricacies may surround other important conversations in pluralistic therapy?

And, zooming back out to my original preoccupation with the fundamental structure of things… like the field of particle physics, it appears that the more we dig into therapeutic conversations, the more meaning and complexity we unearth!