Pluralistic Counselling

---

Hi, I'm Mick Cooper and I'll be doing this presentation on Pluralistic Counseling and Psychotherapy. The aim of the presentation is to introduce you to the pluralistic approach, both as a perspective on counseling and psychotherapy and also as a way of working with clients. By the end of the presentation you should have an understanding of what pluralistic therapy is all about and also be able to apply it to your own supervision and practice.

A bit of background about the pluralistic approach. It really started when John McCleod was developing a research clinic up at the University of Abertay and thinking about what kind of therapy he wanted to offer.

John and I both came from person-centered backgrounds but we felt that sometimes a person-centered approach could be a bit restrictive and we were aware that for some clients, they did want some different things. They wanted more techniques or more guidance or more advice, and we wanted to be able to offer a therapy but that was really genuinely person-centered in the sense that it was responding to the different things that clients might want, including person-centered, but also open to other ways of working as well.

We came up with the term pluralistic as a way of trying to describe this integrative way of thinking and working with clients and we started writing about it in 2007 when we published our first paper in counseling and psychotherapy research. Since we've started writing about the pluralistic approach, various different courses have come on board at Universities like Glasgow Caledonian University, where I was teaching, University Strathclyde, University East London, Manchester and in Dublin, the IICP, and there's been quite a groundswell of people interested in this pluralistic perspective.

John and I published our first book on the pluralistic approach in 2011 called 'Pluralistic Counseling and Psychotherapy', which is really still the best summary of what it means to think and practice in a pluralistic way. We joined up with a number of research clinics including Metanoia University and University West of England and we looked at the outcomes of pluralistic therapy with clients who were depressed, which seemed to be pretty good and clients certainly seemed to stick with the therapy. We published that in 2015.­­­­­­

We had a number of people who came on board and we were delighted to have Wendy Dryden, who edited the Handbook of Pluralistic Counselling and Psychotherapy, which presented a more detailed understanding and analysis of pluralistic therapy with a lot of different contributors. We had our first International conference on Pluralistic Counselling and Psychotherapy in 2018, where we had people from all over the world coming to discuss pluralistic therapy, and the second conference in London in 2019. So, up to present, we've had about 40 book chapters and journal articles about Pluralistic Therapy and you can find out much more about it on the website www.pluralistictherapy.com.

In many ways, Pluralism emerged as a way of trying to go beyond 'schoolism'. What John and I felt in the person-centred field as well as in many other therapies, was that there was a tendency to think that that particular approach was the best and the right way of doing therapy. Of course, schools have always emerged in the psychotherapy field from Freud and they've been enormously important in helping us develop our theory and our practice, but there's always a danger that schools can Segway into 'schoolism', which is a much more dogmatic assumption about 'this is the best way or that it's the truth', that a particular understanding of why people have come to develop problems is the answer rather than one answer amongst many different possibilities.

As well as in the therapy field, people feel that there are sometimes best ways of doing things. Also, in our health care system in the UK, there's been an increasing pressure towards what we might call a therapeutic monoculture, a particular emphasis on CBT being seen as the solution to many different problems rather than recognizing that different clients may need different kinds of therapies.

In the field, there can be a tendency towards 'schoolism' and we have also seen that in policy and commissioning, but the idea that there's one therapy that is right for all people really doesn't stand up to the evidence base.

For instance, if we look at what clients want. What you can see in this pie chart is that when clients are offered the options between non-directive counselling from cognitive behavioural therapy, there's differences. Some clients want a non-directive approach where some clients want a more directive CBT approach.

Some of the research that I've been doing has been looking at client's preferences along various different dimensions, like would you like more goals in your therapy or not have goals? Would you like therapy to be unstructured or more structured? What you can see in this graph here is that some clients want a very structured approach to therapy, whereas other clients want a really unstructured approach and would really like the therapy to be much more open ended. The idea that there is one right therapy that's going to suit both the client who wants as strongly structured approach and a strongly unstructured approach really doesn't make that much sense.

Of course, you might say that clients say that they want more structure or more goals, but I know what they need. I'm their therapist and I know that they need a CBT approach or I know that they need a Psycho dynamic approach or they need non-directive therapy, even though they don't know themselves, but what the evidence shows is that clients preferences, their state preferences are an important predictor, a good predictor of how they'll actually do in a therapy. So, they're associated with slight improvement in outcomes and particularly when clients get a therapy that matches what they're saying that they want, they're much less likely to drop out so we can't ignore what the difference is in what clients are saying they think will work for them.

Just to give you one example of that. We did a study where clients were either randomly allocated to person-centred counselling or online CBT, and at the beginning of that we asked them how much they thought they would want each of those different kinds of therapies. What you can see in this graph is the plot between how positive they worked towards CBT at running along the bottom and then how much improvement they showed at the end of therapy with lower down, meaning more improvement.

What you can see here on the green line is that as they became more positive towards CBT, those who got person-centred counselling did worse and worse and worse. Right to the left, the ones who weren't very positive to CBT did pretty well in person-centred counselling, but then as they got more and more positive to CBT at the start, they did worse and worse in person-centred counselling. Whereas the ones in CBT, if they weren't positive about CBT at the beginning but then got it, they didn't do so well. In fact, they didn't show any improvement at all, but then the amount of improvement increased as their attitudes towards CBT improved.

This is one example showing how clients stated preferences at the beginning of the therapy do have a relationship to how well they end up doing in the end.

What are the core principles of a pluralistic approach? Let's get onto the core principles of the pluralistic approach and as I've been trying to say in many ways, the aim is to really get away from 'schoolism' and in all its forms, including a pluralistic 'schoolism'.

It's not waving a flag saying pluralism is now the best therapy and everyone should be integrative and do a lot of different things. It's really about trying to maintain a critical, self-reflective stance towards our own theoretical assumptions, our own personal assumptions, but more than that, our own emotional needs and agendas to show that a particular therapy is best and to really try and bracket that and to put it to one side so that we can be there as much as possible for our clients and really listen and respond to what might be best for that individual person.

The pluralistic approach then is trying to get away from black and white dichotomies in the psychotherapy and counselling field around 'this is best or that's best' and really trying to engage with our clients in their complexity and their unique individuality.

Rather than saying is practice A or practice B better, it's about acknowledging that for some clients at some point in time practice A, person-centered therapy may be most suitable, but for other clients at another point in time it might be a psychodynamic or cognitive behavioural or an emotion focused approach is the most helpful and appropriate.

It's also about trying to get away from dichotomies like is therapy about the relationship or is it about technique? Some people would say, it's all about the relationship, but a pluralistic approach would say yes, a good relationship might be really important for a lot of clients for a lot of points in time, but we can't reduce everything that happens down to all clients to just being about the relationship. It may be that for some clients, particular techniques would be really helpful and really important.

It's also, and I'll explain this later, about trying to get away from a dichotomy between single orientation approaches, pure form therapies like classic person-centred therapy or psychodynamic therapy and integrative approaches, and getting away from the idea that it's better to be integrative or draw on a lot of different things rather than one particular orientation.

Again, from a pluralistic standpoint, we would want to hold that different approaches, sometimes pure form, sometimes integrative can be really helpful for different clients at different points in time.

There are two basic assumptions to this pluralistic approach, and the first one is that a lot of different things can be helpful to clients. We're talking about a pluralism across practices but there's many different things that can be of benefit. The second basic assumption within the pluralistic approach is that if we want to know what's going to help the client let's talk to them about it.

This is about a pluralism across the therapeutic dyad that the client as well as a therapist is likely to have a lot to contribute about how best to work with them. Of course, that's not to say and I'll come back to this, that we just say to the client "okay right which one do you want" and then we do it. A lot of clients don't know what they want. Sometimes they want things that we can't do. Sometimes they want things that may not necessarily be helpful, but it's about having a collaborative relationship where we can talk and work with clients to try and find out the best way of helping them and supporting their therapeutic journey.

One of the important things we talk about in pluralism is that it can be both a general attitude, a pluralistic philosophy, as well as a specific practice. A pluralistic philosophy is the belief that different clients are likely to benefit from different things at different points in time and that there's no one right therapy. We developed an inventory to help people assess how much they agree or disagree with this standpoint.

Things like; I believe that a lot of different therapeutic approaches have much to offer.

I don't believe that there's any one 'best' therapeutic orientation. The opposite of this would be I think there is one approach that suits most clients. You can download the therapy pluralism inventory from the pluralistic therapy website.

Then we have the specific pluralistic practice, which is about adopting a personally tailored approach with each client, where we're talking with the client about what might be most helpful and most suitable for their perspective.

On this pluralism inventory there is things like; I explore with my client the various ways we could work towards their goals; I tailor the way that I work with each individual client and I work collaboratively with my clients to agree the direction for therapy.

Why is this distinction important? We know that these things from research are independent dimensions is because it's quite possible for someone to hold a pluralistic philosophy without necessarily practicing in a pluralistic way. If you practice in a pluralistic way, you have to hold those pluralistic beliefs, but you can also hold those pluralistic beliefs and practice in a very specific pure form way.

You could have a person-centred practitioner who says, "I want to do person-centred practice, that's what I love and that's what I'm best at. I know and I can appreciate that there's many different things out there that can be very helpful to clients and if I have a client who comes to me and they want a lot of techniques and guidance and advice, then I may well refer them on. I can appreciate these different approaches but what I do is something very specific".

That kind of person-centred practice embedded within a pluralistic philosophy would be differentiated from a more dogmatic or 'schoolism' person-centred approach, which is saying "I do non-directive counselling and I think that is the best approach for all clients at all times", or holding that view implicitly rather than explicitly.

One of the questions we get asked a lot is, "isn't pluralism just the same as integration eclecticism? What's actually the difference?" I think one of the first things to say is that it does come from a different starting point in the sense that it's embedded in humanistic person-centred ways of thinking rather than coming out of integration, a classicism per say but there are also some very specific differences.

First of all, if we think about integration, there's some forms of integration, for instance, cognitive analytic therapy or dialectical behaviour therapy, which essentially are schools of therapy in themselves, or specific approaches that we would call integrative because they combine different approaches, but are much more specific than a much broader pluralistic framework and a way of thinking about practice. Secondly, and that leads onto the second point, as I was saying earlier, that pluralism can really be thought of as a general attitude as well as a particular form of practice. We might say "I practice in a person-centred way but I hold a general pluralistic attitude towards the field."

It wouldn't make sense to say "I practice in a person-centred way and I'm integrative". Those two things aren't consistent because integration by definition is about practice.

The third thing is that although in a lot of integrative an eclectic approach, there is an emphasis on working collaboratively with clients but that collaborative discussion about what clients want is at the heart of a pluralistic approach and really defines it. It could be there in an integrative approach, but it isn't necessarily there by definition.

That shared decision making, that thinking together about how do we work here is a really defining feature of pluralism as a form of practice.

What does pluralism actually look like in practice? One of the first things is that it means being really clear for ourselves in a reflective way about what it is that we can offer clients so we can have conversations with them around whether we can provide them and help them on the kind of journey that they want to go on, rather than perhaps assuming that we can help all clients all of the time.

What is it, for instance, that you can really help clients do? It's a question that we don't often think about as counsellors or psychotherapists. Sometimes we think about what we don't do. Counsellors will say things like, "I don't give advice, I don't tell you what to do", but what is it we do? What can we help our clients with? When I think of that for myself, I think that what I probably do is I provide clients with the space to reflect on their emotions and their psychological processes and their experiences and who they are as a person. I do that in different ways by reflecting, by listening, by inviting them to talk, by focusing and by making suggestions. I think through doing that, I can help them identify potentially more rewarding acts or ways of thinking which they can then test out in the real world. A lot of my work with clients I think, is trying to identify these better ways of doing things for them that they can perhaps then try out and then we look at whether that has been helpful or not.

Something else I think I also do with clients is that through that reflective process, I can maybe help them challenge negative thoughts about themselves and develop a more positive sense of self so that they can feel better. Of course, that's just me reflecting on my practices as a therapist, but by doing that, I can think more about where I can help clients and where I can't help clients. So, for instance, if a client comes to me and says that they just want answers to their problems, well, that might be more difficult for me. If they want a lot of guidance and advice, then maybe that's not something that I can offer.

We know from the research that where clients have a sense of what they're going to get out of therapy, they can make better use of it.

Thinking about how we inform clients about that and how we tell them about that, maybe from an information sheet, maybe through a video where they can see what our work might look like, is the beginning of introducing pluralism into therapy in the sense of introducing that transparency and clarity with the clients about the ways we can help them, about what we can offer them.

One of the core practices in a pluralistic approach is what we might call Meta-therapeutic communication or Meta communication and this involves really talking to clients about the process of therapy, about their goals, about the methods we might use and working with clients to find the most helpful and appropriate approach for that particular unique individual.

Why do we actually need to talk to clients about these things? Don't we often have an intuitive sense of what it is that clients want?

Well, certainly we can do and that can be enormously important in guiding us in how best to help clients, but what the research also shows is that therapist can often be pretty poor judges of what clients might want or experience.

For instance, if you ask therapists what the most important event in the session was, often, it's very different from what clients say. If you ask therapists to rate how helpful sessions are, it can be very different from how clients rate them. If you ask therapists which client is most likely to drop out? Is a client likely to end therapy, then therapists can be incredibly poor judges of that?

Although intuitively we can know a lot, relying only on our intuitive sense rather than having explicit conversations with our clients can lead to us misunderstanding and making assessments based on our biases rather than reality of what clients are experiencing.

One particular danger is that we assume that what clients want from therapy is the same as what we want. It's a very well-known bias of generalising out from our own experience to the experience of others. We did some research on this. We asked clients how much they wanted goals in therapy or not using the same dimensions as I was talking about earlier. Some of these clients were also mental health professionals themselves, and some of them weren't. They were laypeople. What we found was that the clients who were therapists themselves were much less likely to want goals in therapy than the laypeople.

Most of the laypeople wanted to have goals and to have a focus for the therapy, whereas most of the mental health professionals, who was clients themselves, didn't. There are differences. There are clear differences in what mental health professionals want as clients and what laypeople want as clients and we need to be careful not to generalise out on dimensions like these, our own preferences and experiences on to our clients.

There's a lot that we can then miss. That means that sometimes not all the time, but sometimes it can be important that we do explicitly explore with our clients what their wants or their goals are and how they'd like therapy to be.

Just to really emphasize this point, explore doesn't mean doing whatever clients want and then sticking with it regardless. It is about a dialogue and with any dialogue, it's a subtle, complex, ongoing process that draws on the expertise of both the client and the therapist. It's really not about just giving the client a menu and saying "right, which one of these do you want? Do you want some chair work? Would you want to talk about your past or do you want some behavioural exercises?"

It's about having a conversation with clients and often bringing in our own expertise into that dialogue to help shape how the therapeutic work happens, but making that transparent and collaborative rather than just going ahead with it without discussing that with the client.

When we're talking about collaboration, we're not talking about the uncritical acceptance of the client's viewpoint, but it's also about moving beyond its uncritical negation and just not considering it at all.

If somebody was having a medical procedure, of course we'd want to think about consent and informed consent and the person having a view on that and having a view on what they want. In the same way in therapy, we're talking about listening to and considering the client's viewpoint, explicitly and transparently, even if through dialogue, we end up deciding to do something else.

Just to give you an example of that, this comes from my work with a client called Saskia and in the first session of therapy, I was asking her about what she thought might be helpful to her and what she'd found helpful or unhelpful with previous therapies. She was saying that she didn't find it very helpful when it was, as she described it, just a man sitting behind you and not giving you any feedback. She said that she wanted a lot of input and guidance in our therapeutic work.

I was fairly happy to work in that way and I can work in a more active way but I was also sensing through our initial discussions, that she had quite a strong external locus of evaluations, she was looking for other people to tell her what to do. That was something that I was concerned about and didn't want to reinforce. I said to her "It sounds like feedback will be useful" just acknowledging and reflecting back what she's saying what she wants.

Saskia says "Yeah, definitely, because no matter who we are in the world, wherever we are in life, there's always going to be something that we've missed, either because we don't want to see it or because we just didn't see it. Even if somebody is 90 percent actualized, they're not going to see everything. So, you can turn around and say, you could have said this or you could have done that. They can say thanks Mick, I never saw that". I think what's interesting there is that she's not just saying "oh tell me what to do, I'm useless here". There is an informed understanding of why it might be helpful for her to have some guidance and advice.

That's been my experience very much. When the clients talk about wanting more input, it is often in the former when there's reasons why they want it. Still in this dialogue to her, I also share my viewpoint and my perception so that we can talk about these things. I say "well, I guess the important thing for me giving you feedback is that you can say that's not right. You can say, no, that doesn't fit or that's not helpful. Saskia's says "sure, sure". I mean, one of the things I like to work with very much is feedback and that needs you to say to me "no I don't like that or that's good".

When is it possible then to have these dialogues with clients about what happens in therapy and what kind of things can we talk to them about?

That's something that we've done some research on. Led by Fani Papayianni are Meta-therapeutic communication published in the British Journal of Guidance and Counselling.

We found three main dimensions based on an analysis of therapist's notes. The first thing was when does this conversation actually take place? It might be something that happens before therapy, in an initial phone call with a client about what kind of therapy they're looking for. It can very much happen in an assessment session. Certainly, if you look at my own practice.

I mean, my work tends to be quite person-centred, some elements of existential but I think the difference that you see in my work and maybe more classic person-centred approaches, particularly in that assessment session, talking to the client about past experiences in therapy, what they found helpful, what they didn't find helpful, how they'd like the therapist to work, what particular goals they might have for our work together.

It can also be something at the start of sessions. When I'm talking to clients and beginning sessions, I'll often say to them "how would you like to use today?", as I'm sure many of you would do as well.

Might be something that happens within sessions. Maybe if we're not quite clear what we're doing or if something's breaking down and it seems a bit of a rupture to have that conversation with clients about where they'd like to go.

End of the sessions can be another very useful point to talk about how the therapeutic work is going and what was helpful, what wasn't helpful.

Review points, sometimes useful to build into the beginning of fourth sessions or a tenth session, or every six sessions where we review the work. I generally encourage people to have explicit review points so it's something that you make sure you do, even if they're very brief. The final session can also be a chance to talk to the client about what worked, what didn't work. Maybe less so for that episode of therapy, but for future episodes of therapy. A lot of our clients will then go on and have more therapy and knowing what worked for them with us can be very useful for them in the future.

Then there's the question of what it is that we actually talk to our clients about? We found that there were many different things that therapists were talking about.

One might be goals. What do you want to get at this work? Where do you want to go in your life? Second one might be the methods that we use. What would be most helpful to explore this problem with you? For instance, should we talk about it and talk about your childhood? Would it be more helpful to think about what you do in the future and maybe looking at meanings and purposes in your life? Looking at how you deal with everyday situations?

Then there is content. We might talk about things, but would it be more helpful to look at your relationship with your mother or your relationship with your partner? Understandings where we can work with clients to talk about how do we make sense of their problems so we can present clients with different understandings. Here's a cognitive understanding, which would be in terms of the way that you're thinking about it. Here's a more existential understanding, which is about how you have a sense of meaning and purpose in life or not, which of those makes more sense?

Which of those resonates with your own sense of what's going on for you? We can talk to clients about progress. How did they feel that they're getting on in the therapeutic work? Is it helpful for them? We can also talk about their general experiences in therapy. How they are feeling about the therapeutic work.

Then there's the question of when you are talking about, what period you are referring to. It could be about the previous session and about what was helpful in the last session. It could be about the current session. What you want to do in this session. What should we do in the next session? You might talk about the end session.

You might have a conversation about the therapeutic work as a whole. Where should we take this over the next six to twelve sessions. You might talk about homework, things that are done outside of the session or it might be about how we end in the ending period. We've got these three dimensions that gives a lot of different configurations about conversations about the therapeutic work itself.

Over the time we've been doing research and practice, a number of principles have evolved for us around how best to have these kinds of conversations with clients. First one is to really try and introduce an openness and an opportunity to talk about these things from the start. It may be that if it's the first thing that you say to clients, it's going to be a bit overwhelming and it's something that maybe needs to be gradually introduced.

Clients sometimes don't know what they want, particularly if they haven't had the experience of previous therapy so you don't want to be saying to the client the moment they come in "What should we talk about? Where you want to go?", but creating an opening and letting clients know that they can talk about these things means that even if there and then they don't have strong ideas or strong preferences that it allows them to feel later on in the therapy that they their voice can be heard and they can introduce their own views and ideas into it.

Second thing is about actively advising clients to share their views. So, not assuming that clients will feel that they can talk about what they want. What we know from the research is that clients can often be very deferential to therapists. There is a power difference and clients can find it very difficult to say what it is that they want so clients need to be actively invited in to share their views and particularly more negative or more critical views about what's going on in therapy so that they feel that it's okay to say that.

Third thing is seeing this meta-therapeutic communication as an ongoing process, so it might be something that we introduce earlier on, but really not thinking that because a client says in session one, that they want a particular method or that they have the goal, that is then fixed for the rest of the therapy. Clients preferences evolve. They may have different ones at different points in time and we need to be flexible and fluent and have an ongoing discussion about these things.

Fourth thing is to just notice when we're uncertain about where to go with the client and to use that as a marker when it might be possible to go back to client to say, "well, what would you like to do here?" So often as therapists where we're uncertain about what to do or we don't know how to work, what we do is we take that to supervision and we think "should I be more directive with the client here? Should I maybe set some exercises?" Sometimes it can also be helpful to think about "should I be asking the client this?" Can I say to the client, for instance, "would you like or would it be helpful if I was more directive, would it be helpful if we had more exercise?"

Supervision can be fantastic and of course, it\'s an incredibly important response resource, but drawing on the views and having that dialogue with clients themselves is something that we shouldn't forget about and it\'s often more possible than we think.

Fifth is being part of the dialogue ourselves. Meta-therapeutic communication means bringing in our own skills, our wisdoms, our understanding, all the things that we know and that we think that might be best to inform the work. From our research, clients really aren't saying "I want to control everything, I just want to do it my way". We've heard many clients say that "I want a therapist to be informed. I want them to have ideas. I want to be able to make choices". Clients generally say that they like being asked about what they want, but as I'm sure you know, being presented with a blank sheet of paper can be pretty overwhelming at times. Having different options, "would you like this or would you like that?" Sometimes saying, "would you like me to lead the way and then we can see how that goes", can be very useful.

That leads to point six, which is about describing what the options might be. We see that in shared decision making when you look at in medical settings and we've also seen that in our own research. Clients often really value where the therapist provides or outlines different options rather than leaving it entirely unstructured.

Point seven is about tailoring the levels of meta-therapeutic communication to the particular client.

Being pluralistic means being pluralistic about pluralism itself and recognising that some clients want more tailoring, more dialogue, and some clients don't. Some clients in our research have literally said, "I just want my therapist to lead the way and know what's going on". Of course, that doesn't mean that every client wants that. A lot of other clients said, "I really like being asked and I like being able to say what I want to happen" and "that's something I hadn't been asked before and I really appreciate it".

We need to be sensitive to the different levels of communication, a conversation that clients want about the different methods and goals. Generally, what we're finding in our research is that the more experienced clients are as clients, the more likely they are to have views on what they want. The more they are novice clients, the more they may want the therapist to kick things off and not feel like they have to say where they want things to go.

Point eight is if you're working in a service. It's about using the whole service approach. That meta-therapeutic communication really starts from the moment somebody comes into the services and is presented with different options about how a therapist might work with them, what kind of therapist they might have.

The last one here is about using measures which can be a way of facilitating, deepening the dialogue with clients about how they'd like things to work.

When we're talking about measures, then we're talking about using what's called systematic feedback as a means of facilitating meta-therapeutic dialogue. Systematic feedback is the integration into therapy of validated methods and measures that invite clients on a regular basis to assess how they're feeling, which is what we call outcome feedback, or to rate or give quality descriptions of their experience of the therapy and therapy process and a therapeutic relationship, which is what we call process feedback.

There are two main types of measures. There're the outcome measures which give us this feedback on changes in mental well-being and that measures you might be familiar with like the Core, the PHQ9 which is for depression, the GAD7, which is for anxiety. There are many measures out there for all kinds of different things around levels of eating disorder symptoms, phobia. Then there's the process measures, which from a pluralist standpoint is in many ways more interesting and these give feedback on the clients' experiences in the therapy itself.

The most common one is called the Session Rating Scale from the Partners for Change Outcome Monitoring System, which is a short four item measure, which invites clients, at the end of the session, to rate how they found the session. Did they talk about what they wanted to do? Did they feel understood? That's something that can then be discussed with the therapist to look at how the therapy is actually going. There are other measures like the Helpful Aspects of Therapy, which looks at asking the clients to rate the session at the end and to describe what was helpful or not.

In the pluralistic field, we've developed both a specific outcome measure and a specific process measure, which could be used as part of the therapeutic processes.

As an outcome measure we've developed something called the goals form, which is a way of very much having a tailored, individualised outcome rather than something which is the same for all clients as with the Core or the PHQ9, so this is a personalised outcome measure and it invites clients to focus on their specific goals for therapy.

The way that it works is that in an assessment or first few sessions, I would talk with a client about what brought them to therapy and where they would like to go to, and then we would write down and agree to some goals, if they wanted to. Some clients do want goals and some clients don't. I wouldn't use it if a client didn't want to use it. If they did, we would write down some shared goals together and then those would be typed up and then they could be rated every session or every other session if client would prefer so that the client can see how they're progressing and whether they're making the progress that they want to.

Clients generally say that they find something like this helpful because it reminds them of what they come to therapy for and it helps them focus. We're also finding that for some clients, if it's brought in too early, they can feel that they're not really sure what they want and sometimes clients need a bit of time to really get their heads around where they'd like to go in therapy.

What is clear is that when we ask clients, "would you like the therapist to set the goals for therapy themselves or would you like to be included in the goal setting", the clients do absolutely say or at least most clients say that they want to be involved in the setting of the goals. Having this conversation with clients seems relevant and helpful for many clients who come into therapy about where it is that they want to go and then being able to monitor that.

If you're interested, you can download the goals form and use it for free. You can also see a video of using the goals form which illustrates how it can be used in an assessment session which demonstrates my own practice.

I think what you can see there is that it's not simply a question asking clients "right, what are your goals? What do you want to do?" It's very much an evolving dialogue over time, just gaining some sense and some focus for the therapeutic work.

As a process measure, the main one that we've developed is called the Cooping Norcross Inventory of Preferences, developed by the very well-known American psychologist John Norcross and myself.

This is one that I mentioned before and it\'s a very interesting measure. What we do is we invite clients to say how they would like therapy to be. It's based along four dimensions and each one has a few items to it. One of the dimensions is would they like the therapy to be more directive or less directive? The second one is around emotional intensity. Would they like the therapist to focus more on emotions or less so? The third one is past orientation. Do they want to talk more about their past or about the present or the future? The fourth one is around do they want the therapist to be warmer and more supportive or more focused and challenging?

Then there's also additional items which ask them questions around, for instance, the gender, the therapist. Do they have a preference for a particular gender? What we're particularly looking for on this form is around strong preferences. From what the research suggests is that for a lot of clients, it doesn't matter too much how the therapy goes and they don't have strong opinions, but in some cases, clients do have strong preferences. For instance, they really do want it to be a kind of non-directive therapy where the therapist isn't giving them much guidance and advice or they really want some emotional intensity. It's where the therapist is matching strong preferences that seems to be particularly important.

You can see on the measure itself how it works. The idea is that you give the client the form and you invite them to complete the 18 lines, like focus on specific goals, not focus on specific goals and then you can very easily add up the total for each subset of questions. That allows you then to discuss with the client what their strong preferences might be.

Again, it's important that it's not a menu. It's not about saying to the clients "here's what I can do. Just tell me what to do". It's about eliciting from the client their particular preferences and then having a conversation about it.

It might be, for instance, that if a client indicates that they really want goals, they really want a therapist to take a lead, and that you as the therapist work in a very classic, non-directive way that you have a conversation with them which says that maybe you're not the best therapist for them and that maybe someone who does take a more directive stance or a more CBT stance might be more suited.

The idea is to make these conversations transparent. To involve clients, to empower clients in these conversations so that rather than the client just starting and not really knowing what they're getting and just thinking, oh, I have to go with this because this is what the therapist does, being informed about what the therapist is trying to do, understanding why they work in that way, sharing their opinions and their voices about what it is that they would want themselves.

We've used this in our work quite a lot and it does bring out some very interesting dynamics and preferences and clients generally say that they're happy to fill it in and that they appreciate being asked these kinds of questions. Some clients say it feels very early to be asking because they didn't know what to say and that means that it's not appropriate for all clients. Clients really need to be asked first about whether they are happy to fill it or not. Where clients are, it can bring in a lot of information for the therapist that can then be used, for instance, in supervision.

If a client has indicated that they want an emotionally intense experience, then that might guide therapists and supervise how they talk about working with that client as well as going back to the client and discussing it with themselves.

If you're interested in using the C-NIP, you can work with your clients to complete it online at www.c-nip.com and that will allow clients to actually complete it online and then it will give them the output, the reading of where there's any strong preferences.

That also includes a set of instructions that you can download. All of this is free for use. The instructions will tell more about the measure and answer some frequently asked questions about it.

Let's discuss some of the debate, issues, challenges and criticisms of a pluralistic stance, because it's important to look at the weaknesses and the limitations as well as what it can contribute. What then are some of the limitations, challenges and criticisms of a pluralistic approach?

Well, perhaps one of the main limitations is that the emphasis on explicit communication, dialogue means that sometimes more implicit needs and processes could be overlooked. As I was saying before, clients aren't always able to say what they want, and even clients themselves say that sometimes there are things that at the beginning of therapy they just felt that they couldn't talk about or weren't aware that they wanted.

Just relying on explicit communication could miss that. That kind of implicit, unconscious desires may also be very different to what clients are explicitly stating they're wanting. In some cases, clients may really need something or at some deep level want something, but at a surface level might say that they want something else.

When clients are saying what they want in the beginning it could be part of an unhelpful dynamic, a client who is saying, for instance, I want a lot of advice, I want a lot of guidance, that might be part of their problem, they're always looking for others. You giving them guidance, advice, telling them what to do and actually, they haven't really developed that internal locus of evaluation, which allows them to take control of their own lives. These are things that as practitioners, as therapists we need to be sensitive to. From a pluralistic standpoint, we need to acknowledge that not everything for all clients is able to be stated explicitly, but also that what is explicit can be an important part of the dialogue.

One client, for instance, said "maybe I'm getting my kinds of demands just because I put down something on those papers and I questioned whether I should have been given the opportunity to kind of be designing because I'm the one who's unwell, who's been unwell. So, giving me the choice maybe…." That's the client really saying themselves "I'm not sure if the therapist tailoring things to me is the most helpful thing for me".

Of course, that doesn't mean that that's not true for all clients. Again, getting away from black and white that the clients do know what they want or clients don't know what they want, from a pluralistic standpoint. Some clients sometimes really know what they want, other clients at other points at times, maybe really don't know what they want or want things that aren't helpful for them. As pluralistic therapists, what we need to do is to be sensitive to all those possibilities and to try and work with a client to find out what's going to be most helpful for them.

That means then, as I was saying before, being pluralistic about pluralism itself, not waving a pluralistic flag, but recognizing that this communication that we can have with clients is likely to be helpful to some clients at some points in time and for other clients at other points in time may really not be helpful.

For instance, one client said, "as a client, I felt like she would ask me how the session had been for me at the end of every session as a kind of mini review and I just felt totally like put on the spot and still trying to process whatever we've been talking about. It took me out of what I've been thinking about and lost touch with the process rather than become absorbed in it. And then I do this sort of people pleasing thing of trying to be like, "yeah, yeah, it was really good, really helpful" and really want to answer her questions as I don't want to say anything was unhelpful as that feels really uncomfortable. I would never say anything unhelpful".

Here's a client saying it really wasn't useful for me being asked at the end of the session how that session was. That doesn't mean that therefore no clients find that helpful. What we know from our research is that some clients do really like that and we value some clients don't, and therefore we need to individually tailor the pluralism itself.

The third limitation we can talk about is the danger that a therapist feels that they have to tailor themselves to each client that walks in the door and rather them being the consistent, solid person that they are becoming a different person for every different client.

Also, does pluralism mean that we then have to go beyond what we're skilled at and what we're trained in to be able to offer everything? Absolutely not. Pluralism is not, as I was saying before, about being able to offer everything to everyone but it is about being clear about what we can offer because clients often don't appreciate or don't recognise that therapists have their limits.

One client we hear saying, I think it was an unfair situation on the therapist got somebody that just walked in from the street and gets into the project. That's a pluralistic project saying I want you to behave like this, this and this with me. It's not behaving in a way he would naturally behave.

Clients want us to be authentic and to be genuine and not to just bend at everything that they are asking for. At the same time, as in any relationship, we want a mixture, often of flexibility and also consistency, so pluralism is about trying to be responsive to that in different measures for different people.

When John and I first developed the pluralistic approach, we used to talk about this idea of Wikitherapy, which would be a resource where therapies and clients could find out about many different methods and approaches that were out there and what would be most appropriate. What were the different possibilities?

I think we still like to think of this idea that one day there could be this resource, this great resource, where all of us as therapists and with our clients could think about the different ways to work. Of course, we can't be trained in everything and we can't do everything for everyone at every point in time, but rather than having these boundaries, which are often artificial between this method and that method, because this one comes from this tradition and that comes from that tradition, that we can all dip into this amazing pool of resources that are out there in the therapy field and really use what is best for our individual clients at individual points in time.

I hope that in listening to this presentation, you've developed a deeper understanding of the pluralistic approach, both as a way of thinking about therapy as a whole and really valuing the enormous diversity of approaches that are out there, even though we can only do a small fraction of them. Then also as a particular practice, which is particularly based around meta-therapeutic communication and the value for some clients at some point in time in talking openly, transparently, honestly about what they want from therapy and how we can work with them to try and make therapy as tailored specifically and as helpful for them as possible.

If you're interested in the pluralistic approach, I'd encourage you to go to pluralisticpractice.com and there you can find out a lot of different resources about conferences, about tools for measures, about research initiatives, blogs, and a lot of different publications there in the field.

Thank you very much for listening to this presentation.

Don't forget to collect your CPD certificate.