Developing a Pluralistic Framework for Counselling and Psychotherapy Research – BACP workshop
What is Pluralistic Research? Mick Cooper
- A pluralistic approach to research challenges any assumption that there is one, right, best way of conducting research. Rather, it starts from the principal that different research questions are best answered in different ways at different points in time.
- This means a ‘lightness’ in methodological decision-making: we can use different methods, try different things, get some purchase on some possible answers. But it’s a tentative walking-towards-different-possibilities, from multiple directions: no absolute pathways towards absolute truths
- Not trying to establish universal laws: pluralistic research recognises that, at the deepest possible levels, there will be differences across individuals. Inferential research, in particular, is not seen as establishing laws that are true for everyone. Averages give us averages—not generalizable, trans-individual laws.
- Epistemologically, pluralism sits somewhere close-ish to critical realism, if a bit further towards constructionism. It doesn’t reject the idea of a ‘real’, but is also open to the possibility that there is no ‘real’; and if there is a real then it can only ever be seen through particular individual or cultural perspectives and experiences.
- There is an emphasis on recognising our own position (transparency), both personally and culturally: our biases, assumptions, directions. We can recognise these and be explicit about these; put them to one side when we report out findings; enter into dialogue with them and with others in the rich amalgam of beliefs-findings-personal wants. From a pluralistic standpoint, we want to both hold a position but also have some distance, see things in multiple ways. Not ‘objectivity’ and ‘neutrality’ but multi-perspectivism!
- Pluralism is pragmatism: pluralistic research wants to ask questions that are of importance to real world difficulties and challenges.
- There’s an openness to what participants say and how they describe their experiences: we’re not always looking ‘behind’ them for some absolute or objective truths, but trusting that their subjective experience is an important (albeit fallible) source of knowledge. This means that, ideally, research is co-produced in dialogue with participants and stakeholders.
- Pluralistic research should be culturally sensitive: taking on board the diversity of cultural tools, interests, and ways of asking questions.
- There is an openness to ‘what is out there’: whether inductive or hypothetico-deductive. We’re not interested in proving a particular point or assumption, but in finding out, more closely, what might be going on.
- Pluralistic research is welcoming: it welcomes different studies into different questions, open to new explorations and new methods. It welcomes researchers: both those new to research, and those who are very experienced. It deeply values the efforts that even the most novice researchers can make towards learning and discovery. Pluralism sees research as a democratic field in which everyone can contribute.
Adherence scale from three perspectives – Marie-Clare Murphie
I am developing an adherence scale for pluralistic therapy for my thesis. In order to develop any therapy and research it, you need to know that those counsellors in the study are delivering that therapy. This is what you use and adherence scale for.
Traditionally, adherence scales are only used by independent observers. In studies which test the scale, usually ‘raters’ are trained to find specific things in a given section of a therapy session. They do this so that they can find the interrater reliability and if that is high, the scale is taken to be reliable. They also use this method in RCTs. They will use manuals to train independent observers to find techniques that therapists should be using if they are delivering the therapy as it’s set out in the manual. These observers or raters are independent from the study, they have no relation to the therapists or the clients whose sessions are being rated.
However, as we heard, pluralistic research requires an openness to what is out there, to listen to what lots of different people from different backgrounds are saying. Using a multi-perspectivism, rather than trying to get one objective truth. By having only one point of view (the point of view of the observers) you are missing out on the perspectives of those involved in the session. In an attempt to find the objective truth, the independent observers’ understanding and experience is privileged.
A pluralistic research methodology and philosophy would advocate for inclusivity, taking a step back and looking at who could be involved in this. In this example, the counsellor and the client have not been considered. An adherence scale using ratings from observers, clients (in this case caregivers who were in therapy with the child), and therapists has actually been developed in a study by Herschel and colleagues in 2020. All three sets of raters were asked the same question, worded differently for it to be understood by every level of experience and education.
There’s quite a lot of variety in results of studies and reviews which test adherence, but mostly there is no correlation between adhering to the therapy and client outcomes. One reason that Herschel suggests is that the counsellors might be adhering to the therapy more than the observers are objectively witnessing. In their results they certainly found that there was very little agreement between the ratings of the therapist, observers and the caregivers. Generally, the caregiver gave the highest adherence rating, and the observer the lowest, with the therapist somewhere in the middle. This is similar to the few other studies which have attempted something similar (e.g. Chapman et al., 2013).
Who is to say which of these should be privileged over any others? There are obviously good points and issues with each of them and the point here wouldn’t be to distil all of it down to an average, but rather look at each one to see the similarities and differences.
Taking into account the ideas of all participants and stakeholders gains a much more rounded and nuanced data set. Similarly, it’s not about distilling it down into one truth to take away, but rather looking at the differences between the ratings and holding all the points of view.
Chapman, J.E., McCart, M.R., Letourneau, E.J., & Sheidow, A.J., (2013) Comparison of Youth, Caregiver, Therapist, Trained, and Treatment Expert Raters of Therapist Adherence to a Substance Abuse Treatment Protocol. Journal of Consulting and Clinical Psychology, 81(4): 674-680.
Herschel, A.D., Quetsch, L.B., & Kolko, D.J., (2020) Measuring Adherence to Key Teaching Techniques in an Evidence-Based Treatment: A comparison of Caregiver, Therapist, and Behaviour Observation Ratings Journal of Emotional and Behavioural Disorders 28(2): 92-103.
Pluralism across one subject area (Sight Loss) – Mhairi Thurston
I’m going to explain (in 5 minutes!) a programme of research, which spanned around 10 years and resulted in the development of a pluralistic model of counselling for sight loss. This has been developed into a training course, in collaboration with RNIB. It’s offered free of charge to qualified counsellors, who can then apply to become accredited by and within the sight loss sector. This has led to an increase in the number of counsellors with specialist training in UK and in Ireland.
I’m using a Pluralistic perspective to articulate my research programme. I identify goals, tasks, methods and points of collaboration (all of which are distinctive aspects of a Pluralistic Framework). I had two main goals starting out, both of which emerged out of my personal experience of losing my sight:
- To understand the social and emotional effects of sight loss
- To improve specialist counselling provision for people with sight loss in the UK
These were pretty huge goals and no single research question could address them. So I broke them down into more focussed areas of interest (Tasks):
- How do blind and partially sighted people experience different aspects society such as health, education, accessibility and inclusion? (creating a social context)
- How does sight loss impact on mental health?
- How do people with sight loss experience counselling?
I conducted a number of research studies addressing each of these tasks. E.g. For task 1 there were five studies (a literature review, a survey, an IPA study, a swot analysis and a pilot study for an app development). I didn’t hold onto any methodological hierarchy. I chose what I considered to be the best method for each study.
For task 2, I did one study using a grounded theory method. I chose that specifically to create a theoretical model to inform the development of the research. The model explained the process of ‘going blind’. It was a key theoretical development.
For Task 3, to find out what clients with sight loss found helpful in counselling, I chose systematic case study research as my method. I conducted a few of these case studies, in the counselling research centre at Abertay, but I only ever wrote up one for publication. The client data informed the model of counselling for sight loss.
Finally, to understand what emotional support/counselling services in the UK existed for people with sight loss, I co-designed a UK based scoping survey. The results of this survey were hugely significant. They highlighted that, in some case, people without any counselling training were offering support to people with sight loss in issues such as anxiety, depression, addiction etc. It highlighted a need for improved quality standards. This increased our understanding of how to improve service provision for this client group and was an impetus behind creating the training course to upskill counsellors to understand specific issues around sight loss.
Throughout the research programme, collaboration was important (another pluralistic principle). I collaborated with Royal National Institute for Blind People (RNIB) in a number of research studies and in the development of the training course. It was important to take my research into the real world and to reach people with sight loss, viewing them as collaborators in research and co constructors in a model of counselling. (Nothing about me without me).
Detailed breakdown of projects and references.
1. To understand the social and emotional effects of acquired sight loss
2. To improve specialist counselling provision for people with sight loss in UK
|Tasks||Methods||Collaboration and preferences||(Results)|
|Q. How do blind and partially sighted people experience different aspects of society such as health, education, accessibility and inclusion? (creating a social context)||Three studies: (a) Literature review of the impact of undiagnosed refractive errors on reading attainment in school (b) IPA study of the lived experience of visually impaired children in mainstream education (c) Survey (n=228) about access to health information in Scotland Two supporting studies examined how inclusion in healthcare might be increased through nurse education (swot analysis) and how accessible games might aid inclusion in entertainment (product development).||Collaboration with RNIB Scotland about design of survey and recruitment of participants Survey was offered in a range of accessible formats (Large print, braille, audio, telephone, face to face) Blind participants were collaborators in designing a tablet game app for leisure||Results – Difficulties were evident across the lifespan, starting with undiagnosed refractive errors in early childhood, moving to perceptions of inclusion in high school and on to experiences of exclusion in health care and engagement with leisure activities in adulthood. Social context better understood.|
|Q How does sight loss impact on mental health?||1 mixed methods study. Sample defined by using items from NEI VFQ tool (subsection on mental health). Semi structured interviews with 18 participants to deep dive into their lived experiences. Grounded theory informed analysis.||Range of interview formats offered to suit participant preference – face to face, preferred venue/location, on line or telephone||Led to the development of a theoretical model which captured the process of “Going blind” Identified different support needed at different points in the process|
|Q How do people with sight loss experience counselling?||Systematic case studies and data from clients at Uni Research Clinic- 1.Hermeneutic Single Case Efficacy Design analysis (HSCED) 2.Ward method (Creative consensual analysis) 3.Change interviews from clients at university research clinic 4. Survey- 182 responses across UK helped answer questions about what was being delivered, where it was being delivered, who was delivering it and what issues service users were bringing.||Task list verified in collaboration with participants Survey co -designed by a range of sight loss stakeholders and BACP representative||Therapeutic task list identified from HAT Highlighted a need for specialist training.|
Real world changes
This programme of research led to the development of a free pluralistic training package, designed and delivered in collaboration with RNIB and accredited by Vision UK. Aim of training – to upskill qualified counsellors to work specifically with the needs of blind and partially sighted people UK. The pluralistic model gave space for counsellors of all modalities to find a way of working that best suited them. More specialist counsellors for sight loss now practicing in UK and Ireland
Thurston, M. (2010). An enquiry into the emotional impact of sight loss and the counselling experiences and needs of blind and partially sighted adults. Counselling and Psychotherapy Research, 10(1) 3-12. doi:10.1177/0264619609359304
Thurston, M., Thurston, A. & McLeod, J. (2010). Socio-emotional effect of the transition from sight to blindness. The British Journal of Visual Impairment, 28(2) 90- 112. doi: 10.1080/14733140903492139
Thurston, M., McLeod J. & Thurston, A. (2013). Counselling for sight loss: Using systematic case study research to build a client informed practice model. British Journal of Visual Impairment, 31(2) 102-122. doi:10.1177/0264619613481777
Thurston, M., McLeod, J., & Thurston A. (2012). Counselling for sight loss. Using Hermeneutic Single Case Efficacy Design methods to explore outcome and common factors. Counselling Psychology Review, 27(4) 56-70
Thurston, M. & Thurston, A. (2013). Risks to client confidentiality when communicating health information to blind and partially sighted patients. Disability, CBR &Inclusive Development, 24(1) 22-39. doi: 10.5463/dcid.v24i1.182
Willis, D. & Thurston, M. (2014). Working with the disabled patient: Exploring student nurse views for curriculum development using a swot analysis. Nursing Education Today, 35(2) 383-387. doi:10.1016/j.nedt.2014.10.013
Scott-Brown, K. C., Harris, J., Simmers, A., Thurston, M., Abbas, M. deMajo, T., Reynolds, I. Robinson, G. Mitchell, I, Gilmour, D. Martinez, S., & Isaacs, J. (2014). Tapology: A game-based platform to facilitate e-health and e-inclusion. In Stephanidis, C. & Antona, M. (Eds) Lecture Notes in Computer Science: Universal Access in Human-Computer Interaction. Part III, 8515, pp. 368-377
Thurston, M. (2014). ‘They think they know what’s best for me’. An interpretative phenomenological analysis of the experience of inclusion and support in high school for vision impaired students with albinism. International Journal of Disability, Development and Education, 61(2) 108-118. doi:10.1080/1034912X.2014.905054
Thurston, A. & Thurston, M. J. (2013). A literature review of refractive error and its potential effect on reading attainment in the early years of school. Optometry and Visual Performance, 1(1) 44-56.
Pybis, J., Thurston, M., Dennison, C., Broom, M. & Miller, A. (2016). The nature of emotional support and counselling provision for people with sight loss in the United Kingdom. British Journal of Visual Impairment, 34(2) 169-178. doi:10.1177/0264619616633884
To book a place on a Counselling for Sight Loss course, contact firstname.lastname@example.org
Find an accredited sight loss counsellor: https://www.rnib.org.uk/sight-loss-advice/sight-loss-and-wellbeing/sight-loss-counselling/find-accredited-sight-loss-counsellor#:~:text=The%20accreditation%20process,for%20a%20two%2Dday%20course.
Counselling for sight loss online training: https://visionary.org.uk/courses-for-mental-health-and-emotional-wellbeing/
Coproducing Pluralistic Research – Nicola Blunden
One distinctive aspect of a pluralistic approach to research is its emphasis on coproduction. Coproduction is a form of deep collaboration that goes beyond consultation or involvement, into partnership. I will talk about my experience of coproducing case study research with a person who is also my client, as well as being a therapist herself. Her pseudonym is Billie.
Billie experiences herself as plural. She has distinct inner parts of self with separate identities, personalities, memories and values. Billie and her parts of self and I developed a person-centred pluralist model of working together, that we carefully and methodically devised as we went along, and which didn’t fit the sometimes brutal clinical practices that we saw represented in the literature. We felt that writing up and sharing this work might counter some of the stigmatising accounts of plural identity experience, add her voices to the discourse, and offer an alternative model that centres the humanity of the person, and of her parts of self.
We agreed that a case study approach seemed most appropriate as a way of telling the story of the work, and that we would begin by recording a few sessions, and mutually adding commentary. Billie would select three extracts that we could use to illustrate our developing model, and all of Billie’s parts of self would be involved in that selection process.
In this way, we devised a case study approach that firstly contextualised the research within the existing literature, secondly took an analytic approach to significant moments in the therapy, and thirdly related this analysis reflexively back to practice, drawing out thematic learning from our analysis that may be useful to other clients and therapists working with plural identity. Politically, we chose the term ‘plural identity’ as an alternative to dissociative identity or multiple identity discourses. It was important to all of us (Billie, myself, and the parts of Billie) that we deliberately undermined the existing pathologising language around inner plurality.
So, to what extent did our approach utilise the principles of coproduction? Firstly, we brought diverse forms of knowledge together. Not only did Billie and I collaborate, but Billie’s parts of self also co-authored the work, contributing commentary and ideas for theory. To my knowledge, this is the first time that parts of self have been published in this way.
Secondly, we innovated the approach, and resisted homogeneity. We had many discussions about the effect of the research on the therapy, of the therapy on the research, and metacommunications about the effect of our discussions on the therapy and the research. This helped us to keep critiquing our approach and refining it, until it took its true shape.
Thirdly, our effort was reciprocal, if not identical. Billie’s work was in part the work of a client, painstakingly piecing together her experience, and fearlessly moving towards understanding her own difficulty and pain, as well as her own thriving. My effort was to be a reliable presence alongside her, wholeheartedly figuring it out with her. Our writing work, too, was about equal.
Finally, benefit was reciprocal, if not identical. Billie used her previously silenced voice and joined the scientific discussion about her experience, from which she had been previously excluded. I benefitted from publishing a piece of work that I can be forever proud of. We received an email recently from someone who thanked us for showing that there can be hope in living with plural identity, and an alternative way to view it. That gave us both joy.
I feel that the coproduction of this research led to a result that is effectively unique. When you coproduce research, you open up the possibility of telling a truly multi-vocal story.
John McLeod – A pluralistic perspective on how we use the research literature
A pluralistic perspective opens up new ways of thinking about what happens to studies after they are completed and published. There are many thousands of therapy research studies that have been published, using a wide range of methodologies and theoretical perspectives. Even if the idea of pluralistic inquiry were to be widely adopted, it is certain that a high proportion of researchers would continue to publish studies based on conventional approaches. A major challenge for therapy research is how we make use of the knowledge that already exists.
In relation to the publication, dissemination, review and practical utilisation of research knowledge, implications of pluralistic perspective include:
- Opening up articles to discussion and dialogue from multiple perspectives. This can be achieved by publishing reviews alongside articles or providing a discussion forum where readers could comment on articles (and authors could respond to comments). Some journals have already started to experiment with this kind of approach. Conference presentations and panels could be based on pre-reading of a paper, allowing as much time as possible for discussion. These initiatives would more connections to be made across studies, more connections to be made between research and practice, and critique of research from a much wider range of readers.
- In recent years there has been an explosion of published systematic reviews or meta-syntheses that bring together the findings from published studies on a topic. The majority of these reviews focus on either qualitative or quantitative studies – seldom both together, and virtually never including autoethnographic or case study evidence. Generally, review papers aim to condense the headline findings of studies into a narrow set of conclusions. This is problematic from a pluralistic perspective: within any empirical study, there are almost always minor themes, outliers, discrepant and unexpected results etc. Although authors of studies generally acknowledge these observations, current review methods do not take them into account. In addition, reviews are usually carried out by small teams that share a particular set of assumptions – there is no expectation that the review process should accommodate a diversity of positions. Finally, reviews strive to arrive at a single answer, rather than acknowledging that there may exist credible alternative interpretations of the meaning and implications of a body of research. Taken as a whole, these aspects of the process of conducting systematic reviews of research have the effect of producing over-simplified knowledge that does not do justice to the diversity of all relevant evidence.
- A pluralistic perspective invites attention to the act of reading a research paper. Typically, a paper is read quite quickly – the reader is guided by the APA structure to look for certain sections that highlight key findings, and then moves on. By contrast, intensive reading, particularly within a group, can open up many further hidden and implicit insights. Also, it is rarely possible for readers to engage in dialogue with researchers/authors. Both the reader and the researcher are losing the opportunity to deepen their understanding through such a dialogue. In addition, there are very few critical/appreciative guides to reading a research paper. Compare this with the production of an art exhibition, theatre play, movie, novel, book of poetry etc. These are often accompanied by: (a) intensive engagement by the consumer/ reader/audience; (b) dialogue with the artist (sometimes in person but more often through being interviewed in a magazine; (c) an exhibition guide, or similar. Of course, not all art, movies etc get this degree of attention. But the fact that some do, creates a platform of understanding that can be transferred to other art works.
An appreciation of these aspects of a pluralistic perspective on the published literature already exists within the research community. Some examples are summarised below.
Nosek, B.A. & Bar-Anan, Y. (2012). Scientific Utopia: I. Opening Scientific Communication. Psychological Inquiry: An International Journal for the Advancement of Psychological Theory, 23(3), 217-243 (can be accessed through Google Scholar). Useful discussion of some of the changes that are taking place in the academic publishing industry. The section of the paper from page 236 (Stage 6: Open, Continuous Peer Review) to the end is particularly relevant.
Wakeling, S., Willett, P., Creaser, C. et al. (2019). ‘No comment’? : a study of commenting on PLOS articles. Journal of Information Science. (can be accessed through Google). The vision of continuous peer review outlined by Nosek & Bar-Anan (2012) has proved to be hard to actualise. Wakeling and colleagues discuss the reasons for the lack of progress. Their conclusion is that traditional academic/scientific communities are resistant to culture change. It may be that therapy professional communities, where there are relatively few researchers and many more practitioners, could be a more fertile ground for such initiatives.
Pomerville, A., Burrage, R. L., & Gone, J. P. (2016). Empirical findings from psychotherapy research with indigenous populations: A systematic review. Journal of Consulting and Clinical Psychology, 84(12), 1023-1038. (can be accessed through Google Scholar). This is a review published in a high status journal. From a pluralistic perspective it exhibits two notable features: (i) range of material included in review (qualitative studies, quantitative studies and unpublished Doctoral dissertations), and (b) discussion that acknowledges that the evidence can be understood from different positions.
Greenhalgh, J., Gooding, K., Gibbons, E., Dalkin, S., Wright, J., Valderas, J., & Black, N. (2018). How do patient reported outcome measures (PROMs) support clinician-patient communication and patient care? A realist synthesis. Journal of Patient-Reported Outcomes, 2(1), 1-28. (published in an open access journal). Realist synthesis is a review approach that makes use of all available sources of evidence, which are used to develop and test a ‘theory’ of the intervention/programme being evaluated. Although the remit of this particular review is broader that psychotherapy (although it considers evidence from therapy studies), it provides a powerful demonstration of what can be achieved.
Granek, L., & Nakash, O. (2016). The impact of qualitative research on the “real world” knowledge translation as education, policy, clinical training, and clinical practice. Journal of Humanistic Psychology, 56(4), 414-435. (not open access). This paper reports on how two researchers actively promoted dialogue and debate around the findings of their studies, by direct engagement with relevant professional groups.
Råbu, M., McLeod, J., Tønnessen, T. B., & Moltu, C. (2020). Creating art from research: a theatre play based on research interviews with senior therapists. British Journal of Guidance & Counselling, 1-13. (Open access paper). Describes an extended process of dissemination and dialogue following the publication (in Psychotherapy Research) of a qualitative study in which retired therapists were interviewed about the ways that their lives had been affected by a career as a therapist.