Integrating Counselling & Psychotherapy

Directionality, Synergy and Social Change

Mick Cooper

• Publisher: SAGE Publications Ltd
• Year: 2019
• Print ISBN: 9781526440037, 9781526440020
• eBook ISBN: 9781526481160
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

How can therapists integrate theories and practices from across the psychological therapies?  

This book presents a framework for understanding distress and change that can unite different orientations, along with sociopolitical perspectives.

Its starting point is that therapy aims to help clients move towards the things they most deeply want.  It shows how the actualisation of these 'directions' leads to greater well-being, and how this can be brought about through the development of internal and external synergies. 

Using in-depth cases, the book provides detailed guidance on how this framework can be applied. After reading this book, you'll feel better equipped to understand, and work with, your clients' directions—tailoring the therapy to their unique wants.

1 Introduction Towards a common framework for counselling and psychotherapy

This chapter discusses:

• The rationale for writing this book.
• The development of integrative, eclectic, and pluralistic perspectives in counselling and psychotherapy and their relationship to the present book.
• The desire to develop a common framework for understanding distress and change, inclusive of both psychological and sociopolitical factors.
• Ethics as a starting point for developing a common framework for counselling and psychotherapy.
• The structure of this book.

It’s Wednesday afternoon, quarter past three. The therapy session was supposed to start at three o’clock, but Mei has still not turned up. I’m beginning to worry that she’ll miss the session entirely. Then I remember that I thought that last week, and the week before, and then actually she did turn up – just, it seems, later and later each week. I hear footsteps past the door to our university-based therapy centre… they go on; no Mei. I sit in my chair, trying to do what I know I should do: use the time to reflect on Mei and what might be going on for her. But I’m distracted, agitated – a bit annoyed, although I can never feel too annoyed with Mei. Then a knock, Mei’s at the door, smiling apologetically. She rushes in, apologises again, backpack down, handbag down, Sainsbury’s bag to the side, sits, asks if she can go to the bathroom, rushes out, rushes back, sits, smiles. It’s nice to see her.

Mei and I have been working together for just over two months. A housing officer in her late-thirties, Mei came to therapy saying that she wanted to work out what to do in her marriage and to find some satisfaction in her life. ‘It’s a question,’ she said, smiling wryly, ‘of whether I should “dump the lump”.’ The ‘lump’ that she was referring to was her husband, Rob, whom Mei had known from college and married in her mid-twenties. ‘He’s a good man,’ she said, ‘a really good man; and a loving dad to Olivia [their 12-year old daughter]. But… Oh my G… he– we’ve just got so… boring.’ With a half-grimace/half-smile, Mei told me that she and Rob had not had sex for over two years, and that they had both acknowledged the relationship as ‘pretty much over’. In addition, for the last three years, Mei had had a ‘thing’ for a younger colleague at work, Saul. ‘We did– kind of– something happened one drink’s night,’ she said, ‘but it was really nothing. I just wish he’d– he’s so ambivalent, so anxious; you see his lovely face for a few seconds and then he just scurries back under his blanket.’

In our assessment session, Mei also said that she hoped therapy would help her cut back on her ‘spendaholism’. ‘Rob and I are terrible with money,’ she said. ‘When we first met, we were both really into punk music, and we’ve always spent far too much buying old vinyl records that we never bother listening too.’ And then there was her mother. ‘God knows, she should have been put down years ago,’ said Mei. ‘But I just don’t want her to die and feel that, really, I could have been a better person to her. She did– I suppose– she did do her best. It wasn’t easy for her getting disowned by her middle-class, home counties family for marrying someone Taiwanese.’

So how can I, as a therapist, be of greatest value to Mei? How can I help her make sense of her difficulties and move towards the things that she wants in life? With over 500 different varieties of counselling and psychotherapy now available (Lillienfeld & Arkowitz, 2012), our field offers a plethora of different understandings and methods that may be of use. From a person-centred perspective, for instance, I might support Mei to connect with her ‘true’ feelings towards Rob; behaviourally, I might help Mei develop her assertiveness skills; or, from a psychodynamic perspective, I might encourage Mei to notice how her behaviours towards me – such as arriving later and later for each session – mirror past and present patterns of relating.

This diversity of understandings and methods makes the counselling and psychotherapy field a treasure trove of possibilities. But it also means our field can tend towards the fragmentary, disjointed, and disconnected: a ‘Babel’ of different models, languages, and beliefs (Miller, Duncan, & Hubble, 1997). This can make it difficult for therapists to draw on understandings and methods from other orientations – even if they may seem particularly appropriate for particular clients at particular times. For instance, it might seem helpful to encourage Mei to explore ‘transference’ issues around her lateness, but how do you do that if you are only trained in CBT or humanistic therapies? The diversity of approaches in our field can also increase the likelihood of an unproductive schoolism (Clarkson, 2000), in which advocates of different orientations ‘defend passionately the “truth” of their own school and attack with vigour the “error” of rival schools’ (Hollanders, 2003, pp. 277–278). Clients, too, may find this diversity and heterogeneity of therapies and therapeutic languages confusing or overwhelming. They may be left wondering, for instance, ‘Which therapy is best for helping me with my problem?’ and ‘How do these different approaches fit together?’

The Development of Integrative and Eclectic Approaches

From the 1930s onwards, therapists have attempted to overcome these challenges through the development of integrative and eclectic approaches to counselling and psychotherapy (Goldfried, Pachanakis, & Bell, 2005). Here, ‘pure form’ therapies have been combined in four main ways (Norcross, 2005; Stricker & Gold, 2003). First is theoretical integration, in which aspects of two or more approaches are synthesised together to form a new therapy. A classic example of this is ‘cognitive analytic therapy’ (Ryle, 1990). Second is assimilative integration, in which therapists introduce new understandings and methods into their pre-existing orientation. In contrast to theoretical integration, this is often on an individual basis (for instance, a person-centred therapist drawing in psychodynamic and Gestalt understandings and methods) and is likely to proceed over the course of a professional career. Third are common factors approaches, which attempt to identify active ingredients across a range of therapies. This approach is based on the assumption that, ‘Therapies work not because of their unique explanatory schemes of specialized language; on the contrary … their success is based on what they have in common’ (Miller et al., 1997, pp. 22–23). For instance, Miller et al., drawing on the psychotherapy research evidence, argue that all forms of therapy have four common curative elements: (1) client factors and the clients’ environment; (2) the therapy relationship; (3) the therapy technique; and (4) expectancy and hope. Finally, there is technical eclecticism, such as Lazarus’s (1981) multimodal therapy, in which the therapist draws on a wide range of therapeutic methods, without any single theoretical model underlying their practice.

By combining two or more pure form therapies in these ways, integrative and eclectic approaches help to create more common languages in the counselling and psychotherapy field, and reduce the likelihood of schoolism. However, they still have their limitations. Theoretical and assimilative forms of integration combine just a small handful of different orientations, leaving the vast majority outside their scope. In addition, theoretically integrative forms of therapy, as specific combinations of different pure form therapies, can become schools of therapy in themselves. At the other extreme, while eclectic therapies offer a more inclusive framework, their lack of unifying, underlying theory may mean that they tend towards syncretism: the haphazard, uncritical, and unsystematic combination of theories and practices (Hollanders, 2003). This means that, as with common factors models, practitioners may struggle to know which methods to adopt when. As Mei’s therapist, for instance, I may know that change is dependent on her engagement with therapy, the quality of our relationship, the particular methods I use, and her levels of hope – but what do I actually do with her?

The Development of Pluralistic Perspectives

In an attempt to overcome some of these issues, John McLeod and I – along with other colleagues, such as Windy Dryden – have articulated a pluralistic approach to counselling and psychotherapy integration (Cooper & Dryden, 2016; Cooper & McLeod, 2007, 2011; McLeod, 2018b). This is based on two fundamental premises: (a) ‘Lots of different things can be helpful to clients’; and (b) ‘If we want to know what is most likely to help clients, we should talk to them about it’ (Cooper & McLeod, 2011, p. 6). In our work, we have distinguished between a pluralistic perspective and a pluralistic practice. The former refers to a general sensibility: an inclusive attitude towards the whole scope of therapeutic understandings and methods, including pure form, integrative, and eclectic ones. By contrast, the latter ‘refers to a specific form of therapeutic practice which draws on methods from a range of orientation, and which is characterised by dialogue and negotiation over the goals, tasks and methods of therapy’ (Cooper & McLeod, 2011, p. 8).

The inclusivity of the pluralistic approach comes from its grounding in a pluralistic philosophical outlook (e.g., Berlin, 2003; James, 1996), which holds that ‘any substantial question admits of a variety of plausible but mutually conflicting responses’ (Rescher, 1993, p. 79). This means that a pluralistic approach to therapy can embrace a multiplicity of seemingly contradictory truths. For instance, from a pluralistic standpoint, one might understand Mei’s problems with her mother in psychodynamic terms (that her mother was neglectful when she was a child) and also in behavioural terms (that her problems with her mother fester because she is not, at the present time, sufficiently assertive with her). Hence, psychodynamic and/or behavioural approaches may both be considered suitable for working with this client, depending on the client’s own personal preferences. As with eclectic and common factors approaches, however, the downside of a pluralistic framework is that it may not provide strong guidance on how different understandings or methods should be drawn together, or what should be used when – particularly in the absence of client preferences. And, indeed, research shows that trainees in a pluralistic approach can struggle with knowing how the different orientations can be fitted together (Thompson & Cooper, 2012).

Towards a Unifying Theoretical Framework

From a common factors perspective, a fitting parable for the therapeutic field may be that of the blind men and an elephant. In this tale, originally from India, one blind man feels the elephant’s trunk and says that the entity in front of them is a snake. Another feels its ear and says it is a fan. A third feels the elephant’s side and says it is a wall, etc. Eventually, in some versions of this story, the blind men come to blows, never realising that they are all, actually, describing facets of the same thing. Similarly, it could be claimed, each of the different therapy orientations ‘see’ people’s problems, and their solutions, in different ways and miss out on the common principles and processes behind them all.

Without wanting to mix metaphors, this is, perhaps, the ‘elephant in the room’ and the basis for the present text: that behind all our different theories and concepts, there is, actually, a great deal of commonality in how we understand clients and how we try to help them. So the aim of this book is to try to describe something of what that elephant might be like: to articulate a common framework – and vocabulary – for counselling and psychotherapy that can:

• support the integration of understandings and methods from across orientations;
• help to improve communication and collaboration between the schools;
• bring greater clarity and cohesion to the field.

As with common factors and pluralistic approaches, this is not about creating a ‘new’ and ‘improved’ brand of therapy (Miller et al., 1997). Rather, the aim is to try to show how the present orientations might be brought together to better effect.

Although the framework developed in this book, and its ethical foundations, are highly consistent with Miller et al.’s (1997) common factors approach, it adopts a somewhat different starting point (see Chapter 2, Directionality). In contrast to other common factors models, it also tries to identify – and describe – the specific, ‘pantheoretical’ (i.e., across orientation) pathways by which change can happen in therapy. In this respect, it might be termed a ‘common functions’ framework, rather than a‘common factors’ one (Caspar, 1995).

Probably, the therapeutic approach that comes closest to the present framework is Grawe’s (2004) psychological therapy. Grawe, based at the University of Bern in Switzerland, was a brilliant psychotherapy theorist and researcher, who developed a comprehensive model for understanding psychological distress and change. Unfortunately, along with his untimely death (in 2005, at the age of 62), little of Grawe’s work has been translated into English, and what there is – his magnum opus, Psychological therapy (Grawe, 2004) – is a dense, somewhat cacophonic mix of perspectives and voices. Fortunately, many of his ideas and interests have been developed by members of his school, including Caspar, Grosse Holtforth, and Michalak, who are now among the leading lights of the psychotherapy research world. In addition, the present framework shares many features with a range of contemporary psychotherapeutic and psychological approaches: Snyder’s ‘hope therapy’ (Lopez, Floyd, Ulven, & Snyder, 2000), ‘motivational counseling’ (Cox & Klinger, 2011c, 2011d), and ‘Motivational Systems Theory’ (Ford, 1992).

In relation to the pluralistic approach, the framework and practices developed in this book can be considered both a step forwards and a step back. In terms of moving forward, the present text strives to go beyond the pluralistic approach by providing specific ideas on which understandings and methods should be used with which clients, and when. The present book also strives to refine, and extend, a key premise underlying the pluralistic approach: that human beings are oriented towards ‘goals’, and that these should be a principal focal point for the therapeutic work (Cooper & McLeod, 2011, Chapter 3). This focus on ‘goals’ has been a key criticism of thepluralistic approach and, to be honest, neither John McLeod nor I were entirely happy with the term when we adopted it. In our pluralistic approach, we focused on ‘goals’ because we wanted to emphasise the active, future-oriented nature of human being, and to put the client’s own agenda at the centre of the therapeutic work. However, we also knew that this term had a somewhat mechanistic feel to it and could be seen as over-emphasising outcomes over processes, as well as conscious deliberations over unconscious desires. In the present book, therefore, the concept of directionality is used to describe this forward-moving, active quality of humanbeing – in the hope that this provides a more encompassing, less mechanistic, conceptual foundation (see Chapter 2).

The framework developed in this book, however, is also a step back from a pluralistic approach, in the sense that it presents one particular understanding of how psychological difficulties emerge and how they can be addressed in counselling and psychotherapy. That is, the model aims to be all-inclusive – to account for all change across all orientations – and this striving for totalisation might be seen as contradicting the basic pluralistic principle of differentiation: that different people change i...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Acknowledgements
• Contents
• Acknowledgements
• Web Resources
• About the author
• 1 Introduction Towards a common framework for counselling and psychotherapy
• Part I A Common Framework For Counselling, Psychotherapy, And Social Change Describing the elephant
• 2 Directionality Philosophical foundations
• 3 A Phase Model of Directionality From fantasy to action
• 4 Wellbeing and Emotions A life ‘on track’
• 5 Goal Dimensions What we strive for counts
• 6 A Structural Model of Directionality What we really, really want
• 7 Effectiveness Better ways of getting to where we want to be
• 8 Synergies Are Good
• 9 From Intrapersonal To Interpersonal Levels of Organisation Playing to win–win
• Part II Resources for an Integrative Practice Putting the elephant back together
• 10 Psychodynamic Approaches within A Directional Framework Change through awareness
• 11 Humanistic Approaches within a Directional Framework Helping directions unfurl
• 12 Existential Approaches within a Directional Framework Choosing to choose
• 13 Cognitive-Behavioural Approaches within a Directional Framework Effective strategies for life
• Part III DIRECTIONAL Practices Riding the elephant
• 14 Goal-Oriented Practices
• 15 Working With Directions in Counselling and Psychotherapy
• 16 Developing Interpersonal Synergies
• 17 Conclusion Towards better
• References
• Index