Mick Cooper's Blog

Amanda McGuinness ( amandanbentley3@outlook.com ) completed a Sexual Health degree at the University of Central Lancashire in 2024, and is commencing a Master’s in Mental Health Nursing at Manchester Metropolitan University in Feb 2025. A previous urology nurse, she has always had an interest in sexual health and psychology and, more recently, the pluralistic approach to therapy.

John McLeod once gave a simple response in an interview with trainees. When asked about what qualities he felt are needed for someone wanting to use the pluralistic approach, the answer resonated. He simply stated that one quality was the basic desire to help others.

Another pluralistic narrative of how simply viewing what we have in our own lives to help also made me reflect that our therapeutic support needn’t be complex. My mum used to tell my siblings and I to ‘look up’ (if possible, at the sky), when life felt tough. The simplicity of those words has felt very powerful and helpful to me. I knew what she was conveying, even if I couldn’t tell you as a child. The simple ritual of my daily running has also helped me process a difficult time, or equally, a joyous time in my life. These mindfulness examples making me reflect that, as a trainee therapist, I might have more tools than I think I do.

I hear the debate about how complicated the concept of pluralism can feel, but I don’t agree. It feels very uncomplicated to me if we keep the client at the core of our conversation.

I attribute this understanding to a recent safeguarding situation I was involved with. At the heart of the situation were young people. The adults around them felt unsure of what to do and were worried about upsetting others and the consequences of that. They felt it was too hard, too complex to navigate. I, however, didn’t see the complexity, I just saw the young people wanting to be deeply listened to. This ultimately meant a simple resolution for all concerned, because I was clear on the accountability, clear on what needed to be said.

We all have our language, from the cheffing world to the world of sport, or nursing, or art, or teaching. We all have our terminology, the stuff that becomes safe and familiar. I get it. But I think the language we use in therapy needn’t worry us as practitioners. Asking the simple question of what pronouns a client likes to use demonstrates inclusivity and that this is a safe space. It takes less than 30 seconds to simply say but also non-verbally, speak volumes to my client about what perhaps I can offer as a therapist.

I for one, hope that this debate about the simplicity, and the complexity, of the pluralistic approach continues. It can keep us curious about where our therapeutic journey takes us as professionals. It also keeps us mindful, present, and diverse in our thinking–inclusive rather than exclusive. It keeps us, simply, human.

David Hansen, https://davehansentherapy.co.uk/

There is a lot of debate among person-centred therapists over whether Carl Rogers could be described as ‘pluralistic’ if he was alive today. This writing offers my perspective on the topic.

Freud: A scientist of his age?

Freud gets a lot of stick nowadays for being unscientific or, at least, for developing elaborate theories that were arguably out of proportion with the data available to him. ‘Over-reaching’, one might call it. I think though, in fairness to him, his approach is about in line with the scientific attitude of the time.

Back in the 19th century, there was a prevailing attitude in science that any particular area of enquiry can be mapped out in its entirety and fully understood if only we take the time to explore it enough. There is a famous quote often attributed (wrongly, apparently) to prominent 19th century physicist Lord Kelvin that captures the attitude: ‘There is nothing new to be discovered in physics now. All that remains is more and more precise measurement.’

I see Freud as essentially trying to get our understanding of human beings to the level described above: to establish the fundamental truths, leaving nothing left to do but become more precise in our measurements of them. And fair play to him for that. I find Freud’s ideas fascinating although I find this ‘mapping out how everyone works in its entirety’ attitude quite jarring.

Conversely, when I discovered the writings of Carl Rogers before I became a therapist, I resonated not only with his ideas but also his attitude towards his ideas. While navigating uncertain terrain we do best to tread carefully, and I find in his writing a tentativeness which attempts to capture the complexity of the topic at hand. I believe he held a deep suspicion for the comfort of fixed ideas, especially if those ideas get in the way of engaging with the ‘unknown other’ of the person in front of us.

Changes in Attitude

Both Freud and Rogers’ attitudes towards science were representative of the time in which they were writing.

I read John Higgs’ book Stranger Than We Can Imagine recently, which explores changes in the world that give rise to these changes in attitude. The title of the book is a variant of the 1927 quote by another Physicist, J.B.S. Haldane: ‘The universe is not only queerer than we suppose, but queerer than we can suppose.’

Higgs argues that in the 19th century the world was understandable. In the UK, at least, there existed various existential touchstones for the culture as a whole: some of these were King/Queen and Country, Empire, God…along with other fixed and unquestioning ideas about gender roles, sexuality, and the structure of society. Higgs uses the word omphalos to describe these things, which he explains as ‘the centre of the world’ or, more accurately, what was culturally thought to be the centre of the world: an all-encompassing frame of reference around which a person can orientate themselves entirely and find meaning in their life.

The 20th century, he argues, destroyed the possibility of an omphalos. While all these touchstones could previously be experienced as fixed and intractable, there is now a debate to be had about each and all of them. A person might still believe the same things as a 19th century person, but that isn’t the point. The point is that it is only with the biggest blinkers on that a person can nowadays settle into their personal meaning without at least a dim awareness of the fact that other people out there see things differently. 

To ground this in an example, imagine you’re a Christian in the 19th century. At that time, you could feasibly settle into your life engaging only with other Christians. With this kind of uniformity around you, Christianity can become truthful to you in the same way that ‘the sky is blue’ is truthful. The ‘other’ need not be engaged with—they are simply wrong, heretical, bad. And for the purposes of living your life meaningfully, you might not need to think about it any more than that.

Today, many Christians need to account for the fact that not everyone believes in God, and that others deeply believe in different Gods entirely. There is an implicit challenge in this, especially when a person engages with these ‘others’ on a regular basis, and it forces a person to engage with their own belief a little differently. ‘The truth’ perhaps becomes ‘my truth’ or ‘the truth to me’—a change which enables the person to cope with difference and complexity. While the truth may well be a truth ‘out there’, there is a form of truth ‘in here’ too.

I use Christianity merely as a relatable example. The point is that this has happened, or is happening, across numerous different areas, and this change in our attitude towards knowledge and truth has embedded itself deep in our culture. There are a few words associated with this new development: one is ‘postmodernism’, another is ‘pluralism’.

Do We Need ‘A’ Reality?

The above is the title of a chapter in Carl Rogers’s book A Way of Being. In the chapter, he reflects explicitly on his ideas around truth and what ‘reality’ means. I find it to be the most explicit expression of an attitude which I find throughout all of his writing.

I see Rogers as the forefront of this pluralistic, postmodern attitude towards truth and the scientific process. Science becomes less an attempt to explain things with finality but more a way of continually exploring things; about asking questions, rather than finding fixed answers; as an ongoing interplay between experience, measurement, and drawing tentative conclusions, whilst making sure we are still open to further experience.

If we are too firm in our conclusions, of course, they may become dogmatic and may get in the way of our ability to listen openly. We can develop an understanding of things, but we need to own the fact that it is our understanding, and we need to wear it loosely. Science here becomes less about attaining all the answers, but about accepting and being comfortable with the fact that we don’t.

I’m not sure whether Rogers would be pluralistic in his practice nowadays—by which I mean bringing in other approaches if a client wants it, etc. I’ve not read anything of his to convince me that he definitely would, but equally I can’t rule it out either. (I should say, I’m a bit suspicious of any rhetoric that suggests that ‘what Rogers would do’ is the ultimate barometer of what I should do. That feels cultish to me.)

While Rogers’ attitude towards pluralistic practice might be up for debate though, I don’t think him having a pluralistic attitude is. A pluralistic attitude is baked into the centre of the person-centred approach, and I don’t understand how the approach could possibly exist without a pluralistic attitude towards people.

I am Pluralistic and Person-Centred

I have a pluralistic attitude towards both people and also towards the person-centred approach itself.

Philosopher Alfred Korzybski’s mantra ‘the map is not the territory’ is something I always come back to when thinking about this.

Imagine some maps of London. One might give you a photographic view, so you can see lots of specific details as though you’re hovering above it all in real life. Another might be an infrared map, showing which parts of the city are warmer than others. Another still might highlight the different levels of elevation…and so on. My point is that they all look at the same area, but in a different way. Which is the ‘right’ way of looking at the territory? Well, I suppose it depends on what you are looking for, what your purpose is and what kind of data you prioritise.

In my practice I am person-centred, but I am aware that it is only one way of looking at things—it is a map. It is a map that I love very much, that resonates deeply with me and I feel I am well suited to using. It is only a map though, and I know there are other maps too which some people might find useful.

I find this all perfectly acceptable, so long as people don’t forget that all they have is a map. If we ever confuse the map for the territory itself (i.e., how people actually work) then the map becomes dogmatic, and problematic. I think Rogers wrote the way he did to try and protect against this, yet the risk always remains.

I’m not sure if Rogers wrote much about that map metaphor or ever mentioned Korzybski directly, but I imagine him quite liking it. If he didn’t like it though, that doesn’t mean that I can’t!

Ani de la Prida, Association for Person-Centred Creative Arts

Grief

Bereavement and loss are an integral part of life. There are common, universal aspects of the grieving process such as sadness, depression, and cognitive disorganisation. But the grieving process itself is individual, it can be different with each person, and it can be different with each loss. Grief is a holistic experience, it involves body, mind, and spirit. Emotional distress is often accompanied by physical symptoms such as such pain, fatigue, headaches, and even illness. Grief is a natural response, and it isn’t something we can avoid.

Some clients come to therapy after a bereavement with the idea that grief is something to work through and get over, so they can return to ‘normal’. The experience of grief can be complex. Although it can become persistent and debilitating, for example unresolved arguments, or a sudden unexpected death can be traumatic and give rise to a more complex experience of grief. Experiencing grief doesn’t mean that something is wrong, and generally its associated symptoms are a natural and unescapable part of life.

Over the years I have learned that grief isn’t necessarily a linear journey, it can come and go, often in a cyclical pattern. Emotional distress, and even physical symptoms, can reoccur at significant times of the year such as a birthday, or when triggered by a seemingly insignificant event, for example smelling a particular perfume. For me, every spring the sight and scent of lilac trees in bloom, my mother’s favourite flower, triggers memories of her death and another cycle of grief.

Art

Throughout recorded history, people have used art, stories, song, and dance as healing rituals. A pluralistic perspective recognises the value of personal and cultural resources such as art which ‘may function as a means of incorporating spaces into the everyday life of the person that operate as touchstones or reminders of transcendent and aesthetic aspects of being human’

Whilst simply engaging in art can be therapeutic in itself, using creative arts methods in therapy can be a useful way to work with the grieving process. Art can help to express and process experiences and emotions at conscious and unconscious levels, particularly those that are stored non-verbally and may be difficult to put into words.

The creative arts can also touch our psyche in deeply personal, meaningful, and unexpected ways. According to Natalie Rogers the expressive arts process can expand our awareness and ‘deepen our experience…our connection…to our inner source…the world and the universe’.  

My mother died in November 2009, and each year I have unexplained aches and pains, feel very tired, and find myself in tears over small things in the weeks leading up to the anniversary date. My body remembers and expresses the distress I experienced in the weeks leading up to her death, long before I make a conscious connection.

Last autumn I had an unexpected and meaningful experience with art in my own grieving process. I’d had an intense headache for days, which I thought was due to eye strain, so I decided to take a break and go for a walk. It was a beautiful autumnal blue-sky day. I absorbed the vibrant reds and browns of the leaves, watching the colourful seasonal cycle of death as they fell to the ground, the trees seeming to sigh as they let go.

When I got home, I became fascinated with the leaves in my garden. I was doing a 21-day red dot art challenge with a group of students where each day you draw red dots on paper, one dot on day one, two on day two, and so forth. Then each day you use the dots to create a picture. It’s a simple exercise designed to engage the imagination and creative process with no particular therapeutic intention. I was on Day 14 and thought it would be fun to create an autumnal leaf as part of the challenge.

I imported a photo, and using my iPad digitally painted 14 red autumnal dots onto a green  leaf (see blog image). I became immersed and lost track of time as I painted in an experience of flow, a state of intense focus where the conscious experience of time and the self becomes distorted which can generate feelings of wellbeing and clarity.

As I became absorbed in painting the experience expanded into a dynamic interchange between myself and the art, in an unexpected interactive process. Bullen, Fox & Lyon’s (2016) study explores this process and the intense experience of ‘being present … with a quality of engagement, immediacy and acuity of perception… maintaining and sustaining the artists’ receptivity as the drawing unfolds’. (p.129)

 As I painted, I found myself connecting with the universal ‘life-death-life cycle’, the art bringing it into my conscious awareness in a reciprocal process. My sense and awareness of the nature of how things are, not in an intellectual sense but as a felt, embodied sense, deepened. A transpersonal experience where a perceptual shift of awareness expands beyond our individual sense of identity, accompanied by feelings of awe, joy, and peace.

Pluralistic Practice

Pluralistic practice involves being open to the wide variety of experiences and meanings attached of grief. Clients in therapy might not recognise that their symptoms may relate to grief, even many years after bereavement. So, I find it helpful to pay attention to physical symptoms, low energy, or mood that seems unexplained, and I often ask about significant times of year or dates to explore any potential connection.

Pluralistic practice involves asking clients about their beliefs, their experience of loss, accepting all truths and experience as equally valid whilst prioritising the beliefs and perspective of the client over those of the therapist. This ‘curiosity and a genuine interest in the client, their life …paying attention to and actively seeking to identify their knowledge and resources, but also initiating exploration into aspects of experience that neither of you understand’ (Smith & de la Prida, p.29) is crucial. Inviting exploration helps client and therapist learn about personal resources, strengths, activities and methods that have helped the grieving process, harnessing the insights of both the client and therapist.

The use of rituals can be a helpful resource and touchstone which may help to create space to experience and process grief emotions.. Rituals around death have ancient roots: they are varied and intrinsically linked to culture and to personal beliefs. Rituals can be collective as in memorial services and laying flowers on a grave, or they can be deeply personal and unique. Asking a client how they mark an anniversary, can bring to light personal and cultural rituals.  One client, whose father died, takes her son to a local ice-cream parlour on the anniversary of her father’s death. They eat his favourite ice cream, drink his favourite brand of beer, and laugh and cry as they share memories of him with each other. Their personal ritual creates a space and becomes a container for processing their feelings.

From a pluralistic perspective curiosity and openness to each individual experience of grief, and of the personal resources of client and therapist is a key principle of practice. In therapy I may invite clients to engage in art, drawing on my personal knowledge and experience of its therapeutic value, explaining how art can act as a container for grief and can help to process feelings. Being able to draw on my clients’ personal knowledge and draw on my own experience helps me tailor therapy to each client and foster the processing of grief in therapy in deeply personalised and meaningful ways.

Further Resources

Useful further resources on understanding stages of grief include Elizabeth Kubler Ross.  From a pluralistic perspective John Wilson offers a comprehensive view of models and helpful resources for practice.  

Jackson,C. (2022) The big issue: Navigating complex grief. Therapy Today. BACP. Available at https://www.bacp.co.uk/bacp-journals/therapy-today/2022/july-august-2022/the-big-issue/McLeod, John. (2017) Pluralistic Therapy Distinctive Features (p. 35). Taylor and Francis. Available at https://www.taylorfrancis.com/books/mono/10.4324/9781315398266/pluralistic-therapy-john-mcleodWeiskittle,R., Gramling,S. (2018) The therapeutic effectiveness of using visual art modalities with the bereaved: a systematic review. Psychology Research and Behavior Management. Vol 11. Pp 9-24). Available at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5798551/David Harris. (2009)The Paradox of Expressing Speechless Terror: Ritual Liminality in The Creative Arts Therapies’ Treatment of Posttraumatic Distress, in The Arts in Psychotherapy Vol 36(2) Pp 94-104. Available at:  https://www.researchgate.net/publication/222511492_The_paradox_of_expressing_speechless_terror_Ritual_liminality_in_the_creative_arts_therapies’_treatment_of_posttraumatic_distressRogers,N. (1993) The Creative Connection : Expressive Arts as Healing. (Page 4) Science and Behavior Books. Available at : https://www.amazon.co.uk/Creative-Connection-Expressive-Arts-Healing/dp/0831400803Red Dot Art Challenge. Association of Person Centred Creative Arts. Available at: https://www.apcca.org.uk/red-dot-page. [Accessed 16.01.24].What is a flow state and what are its benefits? Headspace.  Available at: https://positivepsychology.com/mihaly-csikszentmihalyi-father-of-flow/ [Accessed 14.09.23].Bullen,D., Fox,J., Lyon,P. (2016)  Practice-infused drawing research: ‘Being present’ and ‘making present. (p129) in Drawing: Research, Theory, Practice. Vol 2.1.Pp 129-142. Available at: https://research.brighton.ac.uk/en/publications/practice-infused-drawing-research-being-present-and-making-present.Nash.J. (2023) What is Transpersonal Psychology? 9 Examples and Theories. Positive Psychology. Available at: https://positivepsychology.com/transpersonal-psychology/Smith, K., de la Prida, A. (2021) The Pluralistic Therapy Primer. PCCS Books. Available at: https://www.pccs-books.co.uk/products/the-pluralistic-therapy-primerWojtkowiak J, Lind J, Smid GE. (2021) Ritual in Therapy for Prolonged Grief: A Scoping Review of Ritual Elements in Evidence-Informed Grief Interventions. Front Psychiatry. 2021 Feb 3;11. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887294/#ref-list-a.p.btitle

We are delighted to invite submissions for the seventh international conference on pluralistic counselling and psychotherapy.

Click here for more information, and to submit a paper, panel discussion, workshop or poster

Conference Title: A Pluralistic Approach to Trauma – Multiple Perspectives

Friday 15th November 2024 (6:00 pm – 8:45pm pm / Social event from 8:00 pm)
Saturday 16th November 2024 (9.15 am – 6:00 pm)
Online via Zoom, hosted by Online Events
Questions for the Conference: pluralisticpractice@gmail.com
Questions for the Event Team: help@onlinevents.co.uk

Here’s the google form link to share with colleagues interested in submitting a paper; https://forms.gle/E7URMVaSbZkktF7N9

We are seeking submissions of abstracts for:

Papers of 30 or 60 minutes (20 or 45-minutes presentation/10 or 15-minute questions)Panel dialogues (60 minutes)Workshops (60 or 90 minutes)Poster presentations to the full conference (2 minutes per presentation, again with a focus on one of the two strands)

The next International Conference on Pluralistic Counselling and Psychotherapy will be held on the 15th & 16th November 2024!

More exciting details to follow….

Dr Gina Di Malta, Senior Lecturer in Psychotherapy and Counselling, Open University

The field of mental health and psychotherapy has seen significant advancements over the years with a constant quest to improve therapeutic outcomes. One critical aspect of this quest, and particularly from a pluralistic standpoint, is understanding the client’s perspective. At the heart of our programme of research—comprising four separate studies—lays the question: How do patients perceive the helpfulness of the outcome measures used in their treatment? We’re delighted that the results of our research have now been published in one of the leading international journals in the field, Assessment (see Open Access article here).

The journey of the development and validation of a unique self-report measure, the Patient-Perceived Helpfulness of Measures Scale (ppHMS), started back in 2016 at the CREST Clinic, University of Roehampton, which offered up to 24 weeks of pluralistic therapy. The scale was designed to gauge patients’ perspectives on the helpfulness of the measures used in psychological treatment. An endeavour that promised to transform the way psychotherapy is personalised and delivered.

The Birth of the ppHMS

The journey begins with the realisation that understanding the client’s perspective is essential to enhancing therapeutic outcomes. But how do you start measuring something as subjective as the patient’s perception of helpfulness of measures in psychological treatment?

We started by asking our patients about their experiences of using measures. In the first study, qualitative interviews with patients paved the way for item development. Patients’ experiences and insights provided a foundational understanding of the construct of ‘patient-perceived helpfulness of measures’. This approach revealed the nuances and intricacies of the patients’ perspective, guiding the development of items that accurately represented this perspective.

From an extensive item pool, a 10-item scale emerged. The goal was to make the scale as concise and comprehensive as possible, keeping the patient’s experience at the forefront. Further psychometric exploration in both clinical and online samples of psychotherapy patients led to the creation of a more streamlined six-item scale.

Stability Across Nations

The following steps in this journey were to test the ppHMS on diverse and representative groups of clients. A stratified sample of UK patients participated, providing insights into the usefulness of the scale. At this stage a five-item model emerged. The model was confirmed in a new US stratified sample, showcasing the stability of the ppHMS across the two nations. The ppHMS proved itself to be a generic scale capable of assessing the helpfulness of psychotherapy measures in different settings.

Reliability and Validity

Any measurement tool needs to meet certain criteria based around reliability and validity. The ppHMS excelled in this regard. It displayed excellent internal consistency (i.e., the different items aligned with each other) and test-retest reliability (people gave similar answers at a subsequent time point), reinforcing its reliability as a measurement tool. Furthermore, it demonstrated convergent and divergent validity (showing that it was statistically related to similar measures, and different from measures of other things). Convergence with the ‘Delighted-Terrible scale of product satisfaction’ was particularly strong, underlining the ppHMS’s ability to capture the patient’s perception of form helpfulness effectively. However, satisfaction with psychotherapy showed lower convergence, emphasizing the unique nature of the ppHMS in assessing the helpfulness of measures.

Invariance Across Measures

An essential aspect of any measurement tool is its invariance, which shows the stability of an instrument across different uses and contexts. In our studies, the ppHMS demonstrated invariance over time periods and countries.

A unique feature of the ppHMS was for the scale to be used to assess the helpfulness of a range of therapy measures, and demonstrate invariance across all measures. In our studies we used the ppHMS with the most commonly used outcome and feedback measures in the UK and US. Invariance was observed in all cases. This adds to the scale’s versatility and robustness as a tool that can be used to assess helpfulness across outcome and feedback measures.

Limitations and Future Directions

As with any research, there are limitations to consider. The studies that led to the development and validation of the ppHMS had their own unique constraints. For instance, the initial qualitative interviews were limited to patients without any serious mental health conditions, which may have created a positively biased representation of patients’ experiences of using measures. Additionally, the studies focused on Western samples and would benefit from further validation in diverse and non-Western cultures. Future research can also explore the predictive validity of the scale on psychotherapy outcomes.

Unlocking the Potential of the ppHMS

The development and validation of the Patient-Perceived Helpfulness of Measures Scale offer a transformative tool for the field of psychotherapy. The ppHMS can be applied in four ways to benefit patients.

Service-Level Decision-Making: The ppHMS can provide patient-centric evidence to inform the selection of measures as part of Routine Outcome Monitoring (ROM) and Clinical Feedback (CF) systems in services. It supports the decision-making process around choosing the most helpful measures.Research with Patient Groups: The ppHMS can be used in research to identify which measures are most helpful for specific patient groups. This data can be used to tailor ROM and CF systems for different demographics or diagnoses, enhancing the quality of care.Individual Patient Level: Clinicians can use the ppHMS to identify the most helpful measures for individual patients. This personalised approach can enhance patient engagement and improve outcomes by selecting measures that align with a patient’s specific issues.Enhanced Dialogue: The ppHMS can also prompt dialogue between patients and psychotherapists, encouraging shared decision-making and discussions about psychotherapy processes.Looking Ahead

As we continue on this journey to harness the power of patient feedback to inform evidence-based practice, it seems the ppHMS has the potential to revolutionise the way in which routine outcome monitoring in psychotherapy is personalised and delivered. It emphasizes the importance of understanding and respecting the patient’s perspective, leading to more effective and meaningful therapeutic experiences.

The ppHMS, with its reliability, validity, and versatility, stands as a beacon of hope in the ever-evolving field of psychotherapy. It is a reminder of the pluralistic principle that progress is made when we listen to the voices of those at the heart of it all—the clients. This scale has the potential to change the landscape of mental health treatment and usher in a new era of personalised care, where each client’s unique needs are at the forefront of their therapeutic journey.

Reference

Di Malta, G., Cooper, M., Bond, J., Raymond-Barker, B., Oza, M., & Pauli, R. (2023). The Patient-Perceived Helpfulness of Measures Scale: Development and validation of a scale to assess the helpfulness of using measures in psychological treatment. Assessment. https://doi.org/10.1177/1073191123119...

Measure

The ppHMS items can be seen below, with PDF and Word versions for download. The measure is free to use under Creative Commons License CC-BY-NC-ND 4.0 . Please do let us know how you get on with it and any findings.

P-PHMS-v.1 Download ppHMS Word Version1 DownloadPatient-Perceived Helpfulness of Measures Scale (ppHMS)

For form ____________, please select a box to indicate how much you agree or disagree with the statements below. There are no right or wrong answers.

I got something out of using this form1 Strongly disagree2 Disagree3 Neutral4 Agree5 Strongly agree

2. The form was a useful addition to what we did in therapy

1 Strongly disagree2 Disagree3 Neutral4 Agree5 Strongly agree

3. This form got me thinking about what matters to me in therapy

1 Strongly disagree2 Disagree3 Neutral4 Agree5 Strongly agree

4. Using this form made the therapy better

1 Strongly disagree2 Disagree3 Neutral4 Agree5 Strongly agree

5. I learnt something from using the form in therapy

1 Strongly disagree2 Disagree3 Neutral4 Agree5 Strongly agree

Mick Cooper, Professor of Counselling Psychology, University of Roehampton

Over the past few years, a team of us have been working together to bring together all the datasets on the Cooper-Norcross Inventory of Preferences (C-NIP). The tool was developed by John Norcross and myself to support the assessment of clients’ preferences for therapy–a key part of pluralistic practice. The C-NIP consists of 18 ‘bipolar’ items scored on seven-point scales ranging from 3 (strong preference in one direction) to −3 (strong preference in the opposite direction), with 0 indicating no or equal preference. There are four scales measuring preference for (a) therapist directiveness versus client directiveness, (b) emotional intensity versus emotional reserve, (c) past orientation versus present orientation, and (d) warm support versus focused challenge. The measure also contains several open-ended items regarding clients other preferences (e.g., therapists’ gender, theoretical orientation, and length of therapy). The measure has been translated into over ten different languages now and is freely available at c-nip.net , where there’s also an option of completing an extended version online.

Our project was led by Tomáš Řiháček at Masaryk University, Brno, with Hynek Cígler, Gina di Malta, and Zhuang She also involved, along with John and myself. We wanted to see if the measure was consistent across different countries, and also whether the different scales would stand up to rigorous statistical analysis. In particular, as a measure, it is important that the scales are consistent across different items, indicating that the scales are robustly measuring the dimensions they are supposed to.

We managed to collect 15 datasets with over 10,000 observations in total (thanks to everyone who provided datasets). This include analysis of data from the English, German, Chinese, Czech, French, Spanish, Italian, Turkish, and Portuguese translations of the measure.

What did we find? Generally, the C-NIP did pretty well, across different countries and datasets. The main issue was that a couple of the items did not fit so well, and there seemed to be a split on the Emotional Intensity versus Emotional Reserve dimension, with some items showing a better fit with a new dimension of Immediacy versus Nonimmediacy. That is, clients’ preferences for talking about the therapeutic relationship or not was a somewhat different dimension from whether or not they wanted emotional intensity in their work.

The C-NIP was originally, and most importantly, developed as a tool to facilitate conversations with clients about their preferences in therapy. As such, each of the items, and the scales that they are located within, provides a useful basis for commencing–and reviewing–clinical work. The findings of this study, though, suggest that the C-NIP also does pretty well as a research tool, and as a robust and reliable quantitative indicator of clients’ preferences. Excitingly, though, there’s some valuable opportunities arising from this research for developing and refining our understanding of what clients want from therapy and the best means for assessing this.

Our published paper can be found here . Reference is:

Řiháček, T., Cooper, M., Cígler, H., She, Z., Di Malta, G., & Norcross, J. C. (2023). The Cooper-Norcross Inventory of Preferences: Measurement invariance across & international datasets and languages. Psychotherapy Research, 1-13. https://doi.org/10.1080/10503307.2023...

Kerry-Jayne Lambert, University of Roehampton (lambertk@roehampton.ac.uk)

Deliberate practice (DP) is argued to be at the ‘cutting edge’ of counselling and psychotherapy. It is a set of training methods aimed to support therapists to improve their clinical performance by isolating and focusing on specific skill subsets. This is considered similar to other fields promoting high levels of performance training such as premier football teams, where a football coach or ‘expert’ will work closely with players on specific skills, such as ‘dribbling’ or ‘marking an opponent’ as separate activities during practice sessions. Specific practice skills might be more necessary for certain players than others and therefore targeted accordingly during practice by repeatedly using specific methods, aimed to increase improvement. DP, similar to pluralistic therapy, is argued to emphasise working beyond any one ideology about how best to support clients to achieve change, emphasising learning through opportunities for therapist feedback including therapeutic role-play or an audio-recording from a therapeutic session, to help develop and improve effective outcomes.

It is argued therapists benefit from methods of DP training to help improve clinical effectiveness that aim to ‘break through’ the potential for a ‘competency plateau’ by engaging in continuous, gradual, skill-based processes that aim to develop standards of ‘psychotherapeutic expertise’ (Vaz & Rousmaniere, 2022). This requires the opportunity for therapists to be able to observe and reflect on work undertaken at the same time as receiving ‘expert feedback’ from an ‘expert coach’. Opportunities for repetitive behavioural rehearsal using both expert guidance as well as solo practice are considered important, alongside continuous assessment of performance based on client outcome measures.

Research into the effectiveness of DP in the field of counselling and psychotherapy has highlighted that therapists who achieve effective client outcomes are reported to have engaged in DP almost three times as often as other therapists in the sample (Chow et al., 2015) identifying a potential pathway for improving therapists’ performance that keeps practice ‘live’ and ‘relevant’ to identified training needs/goals. Despite decades of studies identifying DP to be associated with high standards of performance across a variety of professions, it is in the last decade that its potential for improving therapeutic performance has been considered with outcome data largely based in the USA and parts of Europe. Despite large number of counselling and psychotherapy-based training programmes within the UK, opportunities to train using DP are not widely employed, with skill-building tasks often incorporated as part of a specific teaching models, for example skill-building role plays, rather than a specific DP training culture. Even though professional bodies stipulate the requirement for ongoing professional development post-training there are few opportunities for therapists to continue to practice and refine clinical skills in an organised or professionally ‘meaningful’ way. 

A recent mixed-method study by Julia McLeod (2021) explored the use of DP during the initial stages of counsellor training, having acknowledged current literature speaks mostly to the challenging and complex nature of the process of acquiring therapeutic competencies rather than specifically to the learning strategies used or sustained by trainees to develop competence. The study identified a number of important areas for additional insights to be gained into DP including differences between individual learner’s multi-cultural competencies, and the influence of DP exposure on later phases of a therapist’s career. Given that DP continues to remain largely unknown or, at best, in early stages of infancy in the UK, further opportunities to understand the attitudes and opinions of counsellors and psychotherapists towards its methods, from a post-training perspective feel important, particularly given its emphasis on working to standards of clinical ‘expertise’. Currently there is limited research to generate a deeper, richer understanding of DP from qualified and experienced practitioners working in the field.

Registration bodies in the UK set high standards for practice based on agreed criteria, in order for trainees to reach required levels of clinical competency, which most would agree are both rigorous and demanding. Given more recent initiatives such as the SCoPEd framework (Scope of Practice and Education), that aims to categorise practitioners into three ‘skill-based’ columns of practice, questions have been raised, for example about what constitutes differences between ‘practice standards’ of counsellors and psychotherapists at each corresponding level of ‘expertise’ identified, generating active and ongoing debates about what constitutes therapeutic experience, expertise, and opportunities for ongoing skill-development. Currently expectations for ongoing continued professional development is largely ambiguous within the field and equally working environments, which are not necessarily specifically related to clinical outcomes.

My name is Kerry-Jayne, and I am currently a third-year counselling psychology student at the University of Roehampton and in the process of recruiting participants to take part in my research. I am aware that this is not the first blog shared in this forum on DP, with many of you having probably read Alexander Vaz overview on 7th November 2019. I initially became interested as part of my PsychD training in the process of how counsellors, psychotherapists, and psychologists develop and maintain required standards of clinical practice post-training, given years of therapeutic outcome research data telling us that therapists’ ‘years of experience’ is not a good predictor of clinical outcomes.

I would value the opportunity to meet with experienced pluralistic practitioners working with a minimum of five clients in the field, who are accredited with a registering body, including BACP, BPC, UKCP, and who have not yet experienced methods of DP. I will provide additional information in the form of a short video (25-30min) which will initially provide an overview of DP, including its implementation within the field of counselling and psychotherapy, key principles considered necessary to train as an ‘expert’, and examples of what a session might look like between an ‘expert/therapist’ in practice. We can then explore together what training in methods of DP might elicit for you as a pluralistic practitioner from both a practitioner and supervisory perspective when considering working to levels of ‘clinical expertise’.

If you are an experienced pluralistic practitioner and willing to offer some time to share your thoughts with me…

PLEASE EMAIL ME, KERRY-JAYNE LAMBERT, AT lambertk@roehampton.ac.uk  to contribute to this research

Please also find below the participant information form which explains more about the project and contact details.

Appendix.-A.-V6-Participant-Information-FormDownload

Darren Hopgood, Counsellor and supervisor in private practice, Darren Hopgood Counselling

I have been a pluralistic counsellor for five years now, so not long. I have been a supervisor for just over a year, so not long at all. This is a short reflection on some things I have learned and discovered that have helped me and I hope, my supervision clients.

For me, pluralistic supervision supports pluralistic counselling and reflects most, if not all, the principles within this practice. For me this means working with, respecting, and accepting the difference and diversity of the practice of those that come to me, and working collaboratively to build a tailor-made supervision experience that is designed to get the best from our sessions and the supervisees’ practice.

I see my role as a qualified supervisor as one of guidance, oversight, and often as a restorative mentor helping supervisees both get the best from their practice. It is also one of personal development, working with them to develop professionally in the future by goal setting for their continue professional development (CPD): aiding future growth and achieving the vision they have for their practice.

My practice integrates multiple modalities and theories, many developed from post qualification CPD. I have a focused development plan for myself at present, I am working to develop online group counselling, supervision, and personal encounter groups. However, I am also reflective to the supervisee’s needs. I am quite early into my counselling journey, and often clients bring to their sessions things I have little experience or knowledge working within my ‘zone of competence’, but there is a need for development. This means there is a need for focused and responsive CPD which I work towards developing with supervisees.

A thing I have learned is not to just to take part in CPD because it sounds interesting, but to find focus. I have limited knowledge, and my supervisees and I can spend time learning together in a cooperative manner to develop skills. Personally, once we get to a point of trust and respect for each other’s work, I see nothing wrong with us going down parallel training road. So, all my clients have enjoyed and respected me saying ‘I don’t know, let’s work it out together.’

Another aspect of my practice is to encourage reflective practises that examines a supervisee’s own assumptions, biases, and reactions to their clients. We create a safe and supportive environment that encourages discourse around issues that may affect practice that may be sensitive in any other environment. We can reflect of the rationale behind decisions made in the here and now, and explore ethical considerations around actions. We look at alternatives ways to work with clients, and I may play ‘devil’s advocate’ whilst we explore this by offering alternatives and conflicting points of view. I may do this even though I 100% agree with the counsellor’s actions, as doing so helps explore angles to practice that might not have been considered before.

Reflective practice helps the supervisee to deepen self-development and to develop a more nuanced understanding of their clients and professional practice.

Due to the nature of our work, a good percentage of supervision can focus on the supervisee’s self-care and wellbeing, which sadly can fall by the wayside with many counsellors. At times a greater part of the supervision sessions is around this need for the supervisees to look after themselves, before burnout becomes a big part of their lives. It is easier to work with preventing burnout than it is working with someone that is in the middle of a potentially practice-ending burnt out state. We look at strategies that can build and maintain a healthy balance between practice and homelife so that the work of counsellors and clients are not negatively affected. This includes maintaining personal and professional boundaries to promote a sustainable practice.

Overall, pluralistic supervision builds on collaborative and developmental practices, enhances skills, expand on theoretical knowledge, and foster personal and professional practice that promotes healthy growth and balance. It facilitates a safe space to navigate the complexities of working with new skills and practices whilst maintaining high ethical standards and ensuring both counsellor and client care.

This has been a personal reflection on my first year as a supervisor and has not covered many aspects of pluralistic supervision. I would recommend those reading this to read Supervision from a pluralistic perspective by Mick Cooper. This work inspired me to write this personal perspective from my first year as a pluralistic supervisor.

Dr Paul Galbally & Dr Fevronia Christodoulidi, BSc (Hons) Counselling, University of East London

In our exciting new article in Teaching in Higher Education, we take a pluralistic perspective to demonstrate how academics at the University of East London—working with a diverse cohort of students in a collaborative, reflexive, and dynamic way—has led to a vibrant pedagogical culture that has resulted in better than average outcomes and an embedded reflective teaching style. We advocate and provide pragmatic recommendations for interacting with students in a way that allows a personalised pedagogy for each learner and allows them to meaningfully contribute to a shared and phenomenological learning encounter in every type of educational activity they take part in. In this blog, we will introduce the idea of pluralism within teaching; showcase our collaborative research project with a cohort of final-year BSc Counselling students; and highlight the types of practices that have contributed to a truly diverse group of learners outperforming national averages in attainment, retention, and inclusivity.

Pluralistic practice is a term that we are borrowing from the domain of psychotherapy and applying it to a higher education setting. As a teaching team of psychotherapists, counsellors, and psychologists, we naturally occupy a hybrid role of academic practitioners and in some ways have embedded the concept of pluralism in our professional lives. We wear multiple hats as practitioners, clinical and research supervisors, teachers and pastoral care tutors which we occupy carefully when interacting with students within the boundaries of our academic role. Pluralism is a branch of psychotherapy that is gathering increasing momentum and is spearheaded by several esteemed proponents including Mick Cooper, Windy Dryden, and John and Julia McLeod. The central tenet of this postmodern perspective is a worldview that accepts and values all approaches to psychotherapy in a way that opposes the traditionalist monoculturalism that some refer to as ‘purist’ forms of training. The main difference is that pluralism is accepting and appreciative of other ways of working: ways that some traditional practitioners would view as inferior, ineffective, wrong, or unscientific when compared to their chosen approach. When this philosophy is applied, the client is centralised as a valuable agentive resource and is consulted by the therapist on what they need from therapy in a collaborative dialogue that is termed metatherapeutic communication. Such pluralistic ideas translate in the context of our specific training institution in the following ways: we are teaching at the heart of East London which is a hub of cultural, ethnic, religious, and racial diversity—also reflected in our cohorts of students who embody intersectional identities in more, than usually, visible ways. As educators, we are inevitably called to adpopt a pluralistic stance when interacting with students, given that each of them presents with often different needs and therefore may need different ways of engaging with their studies and the learning community. This is quite different to other experiences we have had when teaching in non-urban and often less diverse areas in the UK when we would address cohorts where the student(s) of a minoritized background would stand out amongst their peers, with all the ensuing dynamics at play.

Within academia, forms of pluralism are argued to already exist in research paradigms such as mixed methods and can also be seen when academics cross philosophical boundaries to produce interdisciplinary research and theory. Our paper seeks to further the field of pluralism via applying this concept to our training programme. It does this by taking a pedagogical stance that incorporates a student-centred approach that personalises learning, connects biography to a lived curriculum, and offers access to intimate parts of the tutors’ experiences. This is accompanied with pastoral care that is empathetic, supportive, and tailored to the needs of the student, contextualised within their development, identity, life narrative, and educational challenges.

Our research began as a way of distilling the unique approach to training we offer, and evidencing this with the voice of the students on our course by setting up a focus group that focussed on addressing the following key questions:

How do we facilitate personalised learning on such a programme that considers learners’ ongoing professional identity development?How do we enhance the student experience and support academic progression that is congruent to the development of a new role where the ‘use of self’ is the main tool?

Our focus group revealed that students can engage in processes of self-reflection and self-direction when facilitated by staff expertly straddling boundaries of empathy for when things go wrong alongside fostering maturity and conscience that enable the student to make appropriate ethical and professional decisions that elevate their practice, critical thinking, and interpersonal relationships.

Our focus group revealed that students—when participating in a group setting which is facilitated by staff who can expertly hold boundaries and foster empathy when conflict arises—can more easily engage in processes of self-reflection around challenging topics. This stance is supported by fostering maturity and cultivating professional conscience that enable students to make appropriate ethical and professional decisions which elevate their practice, promote critical thinking, and improve interpersonal relationships.

The whole course was for me because a kind of lesson for setting boundaries in my life. We had lots of discussions and lectures and behind the personal development groups we had personal therapy and our relationship with an academic advisor. All of them had different boundaries and showed me how I can set boundaries in my personal life with different people … And yeah, now when I reflect, I can see that it’s impacted my personal life as well.

Niloufar

The positioning of staff as the instrument of teaching was also found to help students become immersed in their learning through the human connection to their lecturers:

But, uh, I think you know the knowledge, of course was good, but definitely looking back was the human interactions. Because the knowledge made more sense through the human interactions (Abedi)

We also found that this aligned and relational mode of teaching provided a sense of containment that allowed students to engage with the course during times of personal struggle:

Who do I go to? What am I going to do? What’s the next step? How do I go about even getting help? So having that opportunity to ask it just made all the difference and that to me is the difference between someone continuing and someone dropping out.

Chantelle

As well as these anecdotal experiences provided by our students, we couched our training ethos within an empirical framework that showcased the diversity of our student body, with over a third identifying as having a minority ethnic background. We also highlighted that these students have closed the award gap of performance disparities between white and black students by reporting that all of our students massively outperformed national averages in terms of ’good’ honours awarded (1st class and higher 2nd class degree classifications). If we were to draw from Carl Rogers’s famous quote ‘What is most personal is most general’, these achievements are an optimistic movement towards social change in the field of psychology that provides an opportunity for increasing humility and equality within higher education.

As we conclude, we are also reflecting on the possibility of allegiance bias that can occur when researchers conduct qualitative explorations within their context; worth noting that a core principle in adopting a pluralistic stance has been remaining open to equally hear the less positive accounts from students; we facilitate that by adopting a ‘pedagogy of vulnerability’, where we may risk revealing our struggles in the interactions permeating our role and such practice has proven to model the possibilities of ‘repair’ and collaborating with students towards a shared goal to develop and succeed. In the true spirit of reflective pedagogy and pluralism, we attempt to incorporate any critique in a way that promotes students to become stakeholders of our course rather than position them as consumers of education where staff are always holding expertise. Taking this stance, we not only recentre the learning experience to the student need but also acknowledge their lived experience and retain a professional curiosity to encourage academics to become aware of and address their developmental edges. An example of this is reworking our previously undefined personal development groups around Julia Mcleod’s pluralistic model which is more structural and facilitator-led, after students struggled to understand the function of these groups. Before this change, students would often use the space to inappropriately voice concerns on course logistics or bring established, uncritical, and rigid political topics that typically resulted in a polarised debate that marginalised some student voices, avoided deep relational introspection, and left little space for meaningful development. This student-informed change has not only been well received but also led to students having a better understanding of the group purpose, greater engagement, and positive interrelational experiences following attendance.

We hope that you enjoy reading our paper as much as we enjoyed writing it.

Acknowledgements

Photo by Ricardo Resende on Unsplash