Pluralistic Therapy

Distinctive Features

John McLeod

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781138202894
• eBook ISBN: 9781315398242
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Pluralistic Therapy: Distinctive Features offers an introduction to what is distinctive about this increasingly popular method. Written by one of the co-founders of pluralistic therapy, and a leading UK figure in counselling and psychotherapy, this book describes 15 theoretical features and 15 practical techniques for practitioners. Pluralistic therapy is a flexible, integrative approach to counselling and psychotherapy, which has also found applications in fields such as mental health, life coaching and careers guidance.

Pluralistic Therapy: Distinctive Features will provide an essential guide to students and practitioners of psychotherapy, or an allied area of practice, who are open to learning about new ideas and techniques from current interdisciplinary research.

Distinctive Aspects of the Practice of Pluralistic Therapy

16

Beginning

That was different. I’d been for counselling before, when I was at school. Then, I just met the counsellor and we got started. This time, they sent me a booklet and asked me to answer questions about I want from the counselling, what would be helpful to me, what my strengths are and how many counselling sessions I thought I might need. Certainly made me think. The booklet kept going on about how the counsellor would really want to know about my ideas. And that’s what it was like when I met her. She was a nice enough woman. Seemed genuinely interested in what I thought about all that stuff.

These words are Darren talking to his university tutor, in response to a question about whether he had been to see a counsellor yet. Although Darren was clearly interested in his degree studies, and his assignments had shown a lot of potential, it was clear that he was in trouble – missing classes and labs and visibly shaking with fear if at any stage during a seminar he thought he might be called to speak. The tutor had made a point of talking to Darren after a class, and suggested that he make an appointment at a local community counselling service.

Most therapy is predicated on an assumption that the therapist is highly trained, knowledgeable and skilful in relation to managing the process of therapy, while the client is a person in crisis and in need of assistance who has few, if any, ideas about how to take the therapy process forward. A pluralistic stance invites reconsideration of this core assumption: both client and therapist have important contributions to make. Pluralistic therapy aims to help the client be the best client they can be. This requires consistent attention to engaging the client as an active participant throughout the process of therapy (Bohart and Tallman, 2001; Bohart, 2006).

What happens before the client meets the therapist has an impact on the therapy process, by setting the scene for what might happen in terms of appropriate expectations. On the whole, clients tend to be influenced by cultural images of doctor–patient or teacher–pupil relationships, and do not expect therapy to be a collaborative process that involves their participation in shared decision-making and providing feedback. In addition, at the point of entering therapy, clients may be in a state of personal crisis and emotional exhaustion in which they do not regard themselves as possessing personal strengths and resources. It is therefore valuable to ensure, as far as possible, that the information provided to prospective clients (through websites, leaflets, conversations with receptionists, material in waiting rooms, etc.) conveys the key message that therapy is most likely to be helpful if the client is an active participant. For example, the pre-therapy leaflet provided to Darren at the pluralistically oriented counselling centre he attended included the following statement:

At our service, there are many different ways in which we can help you. We like to think of ourselves as providing you with options, so that you can decide, with our support, the best way to tackle your problem. Some of the issues that clients often choose to focus on are:

• Talking through an issue in order to make sense of what has happened, and to put things in perspective;
• Making sense of a specific problematic event that sticks in your mind;
• Problem-solving, planning and decision-making;
• Changing behaviour patterns that are getting in the way of living the life you want to lead;
• Acquiring new strategies and coping skills;
• Negotiating your way through a life transition or developmental crisis;
• Dealing with difficult feelings and emotions;
• Finding, analysing and acting on information;
• Undoing self-criticism and enhancing self-care; and
• Dealing with difficult or painful relationships.

Other sections of the leaflet invited Darren to think about what he wanted from counselling, and how many sessions he thought he might need. The leaflet included a link to the counselling centre website, which provided brief sections on each of the therapists, and links to further reading on mental health issues and testimonies from previous clients.

The use of language in that leaflet, for example the use of doing words, positions the client as active and purposeful, rather than as passive or helpless. This type of constructive positioning also takes place in conversational interaction once therapy is underway. For example, therapeutic metacommunication (discussed in more detail in Chapter 19) is a way of talking in which the therapist comments on what has been said, on what they are thinking about saying or about similar processes occurring in the other person. In effect, this involves standing outside the ongoing flow of conversation, and drawing attention to the intentions that underpin these interactions. Each time this happens, the client receives an implicit message that ‘you have something important to offer here.’ Although a pluralistic therapist may also straightforwardly tell the client that he or she has something important to offer, the use of metacommunication is a micro-conversational strategy that has a powerful effect through not merely telling, but actively showing, this way of relating. Positioning the client as knowledgeable and resourceful is further reinforced during conversations arising from completion of feedback measures (see Chapter 24).

Engaging the client as an active participant requires being responsive to subtle suggestions and initiatives presented by the client. It is unlikely that a client would explicitly say something along the lines of ‘I have been thinking about how I deal with my anxiety, and realise that talking to my wife about it seems to be helpful … could we explore the implications of this a bit more in our therapy today?’ A useful perspective on this process can be found in the innovative moments model developed by Gonçalves, Matos and Santos (2008). Influenced by the narrative therapy tradition, these researchers suggest that much of what clients say in sessions consists of reports on their problems and difficulties. However, it is possible to detect, embedded in the client’s talk, moments when the person mentions an exception to their predominantly problem-saturated way of describing their life. These ‘innovative moments’ can take the form of new actions or behaviours in which the person has resisted their problem, ‘protest’ against self-defeating behaviour patterns, periods of reflection, reconceptualising their problem and genuinely new personal experiences. This research group has conducted several studies that have demonstrated that therapist responsiveness to innovative moments is associated with positive therapy outcomes (Cardoso et al., 2014; Gonçalves et al., 2016; Matos et al., 2009).

A final approach to supporting client active involvement is through physical props – objects and artefacts that are available to the client. An appropriately written pre-therapy leaflet, or similar information available on a website, is an example of this strategy. Providing clients about information about how to complain, lists of alternative therapy providers and other community resources, and self-help books, articles and websites, represent further ways of reinforcing the idea that the client is making active choices around whether to remain in therapy and how to use it. Such information can be located in a waiting area, on a website or offered to a client at a suitable stage within therapy.

17

Therapist style

As I said before, my name is Sally, and I am one of the counsellors here. I appreciate how open you have been about how scared you feel a lot of the time. It was good to hear a bit about the things you have been able to do to keep that under control. I mentioned earlier that I would like to say a little bit about myself. If it’s OK with you, I’d like to take a couple of minutes to do that now. For me, as a counsellor, there are two big things. The first is about being flexible. Different people find different things helpful. For example, some people who come to me for counselling want to work out an answer to their problems, in a logical way. Other people find that it helps to use counselling to let go of their feelings. The same person might want one thing at one session, and then a different thing the next week. Some people just need a couple of meetings to get themselves back on track. Other people are looking for a counsellor who will support them over a much longer period, months maybe, to make changes in their life. I could give other examples. The point is that it’s important to be flexible, and find the right thing for each person. That’s why I am interested in your ideas – you are the only person who can judge what works for you. Does that make sense? The other big factor is that you need to feel safe with me. You need to be able to trust me, so that you can talk about anything at all that is bothering you. Maybe it will turn out that I am not the right counsellor for you – that even if I am a great counsellor for other people who see me, there just isn’t a good fit between us, or there is something that gets in the way. For example, I’m probably old enough to be your mum – maybe that’s a good thing or maybe it’s not. If you have any concerns at all that I’m not the right person, then it’s really important to let me know. I really mean that. Maybe we can find a way to sort it out, or maybe we decide that it would be best for you to try another counsellor in the centre. That is a perfectly OK thing to do. Not a problem. I’ve gone on for long enough. The last thing is – it’s good to ask me any questions that you might have, about who I am, how I see you, or the approach I am taking in our counsellor. Are there any questions at the moment?

Pluralistic therapists tend to be people who have displayed an enduring lifetime interest around the issue of how to cope with personal problems and challenges and how to grow and develop as a person. This interest may have its origins in a specific personal ‘wound’, for example a traumatic event in childhood such as abuse or loss. Alternatively, such an interest may arise from a more diffuse range of influences, such as the experience of repeated geographical dislocation or having family members with health or emotional difficulties. Whatever the root cause, the individual becomes someone who experiments with different ‘therapies’, builds up a first-hand personal knowledge of what they have to offer and is always curious to learn more.

Pluralistic therapists also tend to be people who have had experiences, within their own lives, that have led them to adopt a sceptical, pragmatic and open approach to issues, and willingness to learn about new ideas. For example, they may have grown up in a farming family that was not impressed by fancy theories but only in ‘what worked’. Or they may have had a pivotal life experience of training in social work and being exposed to human diversity.

These types of experience connect with current research-based knowledge around the attributes of effective therapists. The ‘wounded healer’ hypothesis proposes that many therapists are individuals whose early trauma has enabled them to be particularly sensitive to the ‘wounds’ of others (Zerubavel and Wright, 2012). If such people have been able to resolve their own issues to a sufficient extent, they are able to draw on their personal awareness in helpful ways in their work with clients. On the other hand, if the original trauma has not been resolved, a wounded therapist may be someone who has the potential to harm their clients, by using the client to buttress their own insecurity. The pattern found in many pluralistic therapists can be seen as an extension of the wounded healer model. Pluralistic therapists have not only been able to heal their own wounds (in so far as this is ever possible), but have done so in a manner that has left them with an abiding curiosity around the nature of the change process and how helping interventions work in practice. Life experiences that encourage scepticism and openness to learning also appear to be consistent with studies that have shown that professional self-doubt (Nissen-Lie, Monsen and Ronnestad, 2010) is a key element in therapist effectiveness, and therapist belief that no single theory of therapy offers a sufficient basis for understanding the complexity of human development (Jennings and Skovholt, 1999).

A further aspect of being a pluralistic therapist is learning from the client. If a therapist is committed to working collaboratively with a client, engaging in person-to-person dialogue and being curious about the cultural resources available to the client, then it is inevitable that he or she will learn from the client. Where appropriate, pluralistic therapists may invite their client to teach them about what they know about anxiety, depression or whatever their main problem might be. Pluralistic therapists expect to be surprised by the change process undertaken by clients, and accept that their clients may evaluate therapy in ways that differ from their professional judgement. Pluralistic therapy theory assumes that effective work depends on the ongoing commitment of the therapist to personal learning and development, as outlined in the ‘deliberate practice’ model (Rousmaniere, 2017). Such commitment gives expression to a positive life attitude that may be of value to the client. It may also contribute to conveying to the client a sense that their therapist is coming to them ‘fresh’, and regards them as a unique challenge and opportunity. At the same time, commitment to deliberate practice serves to avoid therapist stagnation and burnout.

18

The menu

You have talked a lot about how you feel safe when you’re in your room, and pretty safe when you’re with your mum and dad and your sister. But meeting with strangers is always hard for you, and situations where you feel you are being judged, such as a university seminar, are really, really awful. We have agreed that the first priority for the counselling is to get to grips with this – in particular to make it easier to deal with situations at uni so you can finish your degree. I was wondering if we could talk for a bit now about how you could deal with these fears – what would make a difference. Do you have any thoughts, yourself? [No, not really.] All right, if it’s OK with you, I’d like to make some suggestions, based on things that I think might work. Would that be OK, to do that now? [Yes, definitely.] I’m going to suggest a few possibilities, and I’d like you to tell me whether any of them seem like they could be helpful to you. I don’t want you to agree to anything that isn’t right for you. If these ideas seem daft, just tell me, and we’ll keep looking. In the end, I’m really sure that there is something that will work. Also – and I mean this – it could be that my suggestions trigger your own thoughts about other stuff that might help. Just chip in if that happens. Right, let’s start. I’m going to begin by talking you through four ways of dealing with fear. Maybe all of them could help you, or none of them. One thing that you could do is to learn how to reduce fear when it happens, using a technique that I could show you, to breathe in a particular way. That’s one possibility, which I think we have touched on already. A second thing would be that many people have messages in their head that wind up their fear levels. Like saying to yourself ‘I can’t cope’, or ‘these people are all going to think I’m stupid’. So a second possibility is to look at what is happening in your head, and learn new ways of thinking. A third approach is that situations that terrify you are because something has happened in the past to make you really sensitive to these scenarios. If that is the case it can be helpful to revisit what happened in the past, so that you can get to a point of accepting that you are a different person now. The final option, for the moment, is to find examples of social situations where you don’t feel terrified, that are sort of exceptions to the rule, and to figure out how it is that you are able to cope in these situations and whether these skills can be applied in other situations such as seminar presentations. So, four possibilities to start with. What do you think? Are any of these worth talking about some more? Or even worth trying out?

To work together in a collaborative manner, then the client needs to know what the therapist has to offer. Here, Sally is initiating a conversation about what she has to offer in relation to Darren’s fearfulness in social situations.

In Functional Analytic Psychotherapy (Tsai et al., 2012), the therapist assembles and rehearses a treatment rationale or ‘rap’ that can be tailored to different clients and situations. Similar strategies exist in narrative therapy (Sween, 1999) and no doubt in other therapy approaches as well. The pluralistic equivalent is conceptualised as a therapist ‘menu’. The metaphor of a menu evokes various meanings that can be helpful: the client chooses from the menu; items on the menu can be adapted to meet dietary needs and tastes; tasters and various portion sizes are available; the waiter can explain menu items if the customer is unsure of what they refer to; information can be organised in terms of starters, mains and desserts. As with all aspects of pluralistic therapy, language can be personalised and nuanced. Other possible metaphors include repertoire, palette, toolkit, toy box, playground, skill-set and catalogue. Each of these terms highlights some aspects of the process and downplays other aspects. What is important is to ground what is being talked about in a domain of experience that is familiar to the client.

A therapist menu is likely to incorporate the following ingredients:

• Micro-skills or counselling skills. For example, if an important task for a client is to talk about an issue in order to make sense of something that has happened and find meaning, the therapist can offer a repertoire of micro-skills that might be helpful in facilitating this process:
  Usually what I do is listen, maybe occasionally ask questions to clarify details and then try to sum up what you have been talking about … maybe also reflect back my own feelings that are triggered by what you are saying … does that seem OK for you? … Maybe we can look at this at the end of the session and see whether its working for you, or whether we need to try a different approach.
• Ideas, explanatory narratives and ways of conceptualising. A central aspect of pluralistic therapy is to be able to offer the client alternative perspectives on a problem, usually based on ideas from theories of therapy presented in accessible language and tailored to the individual circumstances of the client.
• Information. There are many types of information that may be valuable for clients. This can include research evidence around the effectiveness of various interventions, where the client can find other sources of help in the community, and how different diagnostic terms are de...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Acknowledgements
• Introduction
• Distinctive theoretical / conceptual features of pluralistic therapy
• Distinctive aspects of the practice of pluralistic therapy
• References
• Index