Pluralistic Counselling and Pressures in healthcare systems towards therapeutic monoculture : Psychotherapy: One size fits all Contemporary Developments Joint PACFA/CCAA/SCAPE/APECA Conference, Melbourne 2016 Mick Cooper Professor of Counselling Psychology University of Roehampton mick.cooper@roehampton.ac.uk www.pluralistictherapy.com With thanks to John McLeod and all the clients, therapists and researchers who contributed data and analysis Pluralism: A celebration of diversity in therapy Content of Talk • History • Background: History, evidence and ethics • Core principles • Metatherapeutic communication • Using measures 2006 John McLeod, with Mick Background Cooper, Julia McLeod and colleagues, set up Tayside Centre for Counselling 1
Development of 2007 2007- training courses: Abertay, Glasgow First paper Caledonian, UEL, on Manchester, IICP ‘pluralistic’ framework 2011 2013-2015 Pluralistic therapy for depression study, funded by BPS 2016 2
Beyond ‘Schoolism’ Research shows • History of therapy characterised by that clients do not emergence of ‘schools’ all want, or benefit • Often segue into ‘schoolism’ and from, the same dogmatism: assumed monopoly of truth on aetiology thing and treatment of problems for all Different clients want Research indicates wide variations in client preferences e.g., Level of structure different things ‘I would like the therapist to…’ ( n = 225, Cooper & Norcross, 2015) Do depressed clients in primary care want non-directive counselling or cognitive- behaviour therapy (King et al 2000)? 40% NDC CBT 60% Allow the Give structure therapy to be to the unstructured therapy Clients do better in their Research indicates wide variations in client preferences e.g., Temporal focus preferred therapies ‘I would like the therapist to…’ • Clients who receive their preferred treatment: ( n = 226, Cooper & Norcross, 2015) • Small increase in outcomes (ES = .31) • 33%-50% less likely to drop out of therapy (Swift et al., 2012) • National audit of psychological therapies findings Focus on my Focus on my future past 3
Ethics of Different clients do better in different therapies • Most clients do best when levels of diversity empathy are high… …but some clients do not: highly sensitive, suspicious, poorly motivated • Clients who do best in non-directive therapies vs. CBT: – high levels of resistance – internalizing coping style An openness to Otherness Links to pluralism as a social and political philosophy An ethical relationship is one in which we are willing to encounter, and prize, the Other in all their Otherness (Levinas), their: • complexity • heterogeneity • Irreducibility to finite laws, characteristics and assumptions To meet the face of the other Aim Core An attempt to transcend schoolism in all its • forms (including a ‘pluralistic schoolism’) and re-orientate therapy around clients’ wants and client benefit principles Maintaining a critical, self-reflective stance • towards our own theoretical and personal assumptions 4
From either/or to both/and Practice A The pluralistic approach strives to transcend ‘black-and-white’ dichotomies in the psychotherapy and counselling field, so that we can most fully engage with our Practice B clients in all their complexity and individuality Theory A Relationship Techniques Theory B Basic assumption 1 Single- Lots of orientation different things can be helpful Integrative/ to clients eclectic Pluralism across practices 5
Basic assumption 2 Pluralistic attitude Three elements If we want to know Pluralism what is going to Metatherapeutic communication help clients, let’s discuss it with them Multi- orientation practice Pluralism across therapeutic dyad Pluralistic attitude Metatherapeutic communication The belief that different clients are Exploring with clients what they want from therapy ( goals ), and how they may likely to benefit from different be most likely to achieve it ( methods ) things at different points in time Example items from the Therapeutic Orientation Inventory Example items from the Therapeutic Orientation Inventory (Thompson, 2013) (Thompson, 2013) • I believe that lots of different therapeutic approaches have much • I work collaboratively with my clients to agree the direction for to offer therapy • I do not believe that there is any one, “best” therapeutic • I ask clients for feedback about the therapeutic process orientation throughout our work together • I think that there are lots of different ways to help clients get what • I talk to my clients about what I feel I can offer them they want from therapy Distinction Multi-orientation practice between three Psychodynamic practice Drawing on understandings and methods domains is Person-centred Pluralistic attitude from a range of different orientations in practice important, as one’s therapeutic practice may hold a Metatherapeutic pluralistic communication Example items from the Therapeutic Orientation Inventory attitude, (Thompson, 2013) without • My practice is drawn from a wide variety of therapeutic approaches drawing on • I tailor the way that I work to each individual client Multi-orientation practice • My therapeutic work is based on one specific therapeutic multiple approach (reversed) orientations 6
Pluralistic practice = Pluralistic But isn’t collaborative integrative attitude practice, but… pluralism just Metatherapeutic Pluralism can also be an communication attitude and way of communicating to clients, the same as without involving multi- orientation practices Multi-orientation Multi-orientation integrative/ practice practice Some integrative practices do not emphasise metatherapeutic eclectic therapy? communication, or a Integrative and pluralistic attitude eclectic practices Humanistic/Existential Psychology Pluralism is an • Client-centred focus integrative approach • Uniqueness of each client • Client as agentic and grounded in purpose-oriented humanistic, • Collaborative focus • Dialogue: openness postmodern and • Empathy and acceptance to politically progressive other approaches • A person-centred principles metatherapeutic stance Politically progressive Postmodern/Narrative Therapy • Transcending monism • Challenging powerful, dominating discourses • Co-existence of multiple ‘truths’ • Equity in the therapeutic relationship • Openness to otherness • Shared decision making • A postmodern appreciation of • Multiculturalism multiple therapeutic • Celebrating diversity possibilities • Centrality of ethics 7
Meta- Going therapeutic beyond communication intuition Can we just trust our intuitive sense of what clients need? Given how much we can miss… Important that A. Research indicates that we explicitly therapists are generally poor explore with our judges of what clients want clients their or experience wants and goals Collaboration is not about the uncritical ≠ acceptance of the Doing whatever a client initially asks for, and then sticking to it regardless! client’s viewpoint -- it is = about moving beyond its uncritical negation Subtle, complex, on-going process Draws on expertise of both client and therapist 8
Co-constructing therapeutic Co-constructing therapeutic methods I methods II • Following dialogue comes from a first session of therapy Mick: So it sounds like feedback will be useful? between Mick and Saskia (from Cooper and McLeod, 2011, Saskia: Yeah, Yeah. p.111) Mick: OK. Saskia: Yes, definitely, because….no matter who we are in the world, • Mick asked Saskia what she thought might be helpful to her wherever we are in life, there is always going to be something that in the therapy/what she had found helpful or unhelpful with we’ve missed, either because we don’t want to see it, or because previous therapists we just didn’t see it. Even if someone is 90% ‘actualised’…they’re not going to see everything. [So] you [can] turn around and say: • Saskia replied that she had found it unhelpful when there is ‘You could have said this, you could have done that.’ And they’re: ‘just a man sitting behind you’ not giving you any feedback - ‘Oh, really, thanks Mick, I never-- I never saw that.’ - she said that she wanted lots of input and guidance Mick: I guess the important thing for me, in giving feedback, is that you • Mick was fairly happy to work in this way, but also sensed can say ‘That’s not right’ [Saskia: Sure.] And you can say, ‘No, that doesn’t fit,’ or ‘That’s not helpful’ [Saskia: Sure, sure.]. I mean, that Saskia had a relatively ‘externalised locus of evaluation’ one of the ways that I like to work is-- is very much with and had some concerns about reinforcing this feedback…and that needs you to say to me, ‘No, don’t like that…’ ‘That’s good…’ Opportunities Subject matter: What? for meta- • Goals • Method therapeutic • Content • Understanding dialogue • Progress • Experience Temporal period: When? Temporal focus: About when? • Before therapy • Previous session(s) • Assessment sessions • Current session • Start of sessions • Next session • Within sessions • Therapeutic work as • End of sessions whole • Review points • Extra-therapeutic • Final sessions activity/homework • Ending 9
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