Mick Cooper's Blog, page 3

What do Clients Really Make of Working with Preferences?

Mick Cooper, Professor of Counselling Psychology, University of Roehampton

Asking clients about their preferences, and trying to accommodate them, is right at the heart of pluralistic practice. But what is that actually like for clients? Do clients want us to ask them about their preferences? Do they find it helpful? And what if they don’t know what their preferences actually are? We know from the evidence that assessing and accommodating preferences is, overall, helpful, but so little is known about how or why this might happen, and how things are seen from the client’s side of the room.

Several years ago, when I was working with Joshua Swift (Idaho State University) on his meta-analysis chapter of the quantitative research on preferences, he said that it would be great if, one day, we could also do a qualitative study to see how clients experienced preference work. I agreed, and some time later a funding opportunity came up from the Division of Counselling Psychology (BPS) to bid for some money to do this work. We were fortunate to win the funding, and appointed Gina di Malta to work as our Researcher on the project; with Hanne Oddli (University of Norway), a world-leading qualitative researcher on clients’ experiences, also involved.

What about the qualitative method to use? ‘Thematic analysis’, ‘interpretative phenomenological analysis’, ‘grounded theory’? I love most of these methods, but one approach I’d never used, but had always been really drawn to, was consensual qualitative research (CQR), developed by the brilliant psychotherapy researcher Clara Hill and her colleagues in the United States. CQR had always impressed me because, uniquely, the coding and analysis process is all done as a team, so that there’s a constant triangulation between different researchers’ viewpoints. It sounded very ambitious, but I was keen to try it, and we were amazingly lucky to have one of its founders, Sarah Knox (Marquette University) join our research team to guide us through the method.

At our therapy research clinic at the University of Roehampton, we were offering clients with symptoms of depression up to 24 sessions of pluralistic therapy (for those of you who don’t know, this is a collaboration integrative form of therapy). So we used that as the context to conduct the study, interviewing 13 clients in total. We started interviewing clients, at the end of their therapy, about how they found the preference work: Did they find it helpful? If so, in what ways did it help? And also questions about the kinds of preferences they had and where their preferences had come from? Rather than asking generally, we’d start the semi-structured interviews by asking the clients about one particular preference and then focus on that — then another preference if there was one, etc. And then, as the data came in, we’d meet weekly (for about a year or so, either as a whole team or in pairs) and analyse it. First we broke the transcribed interview data into different ‘domains’, depending on what the client was talking about. Then, for each client, we summarised the core of what they were saying in each domain. After that, we brought all the ‘cores’ together to summarise the responses across clients. As per CPR methodology, Joshua worked as ‘auditor’, meaning that we’d send him the analyses at particular points and he’d given us feedback on where he thought we could improve it. All this checking and cross-checking meant that the analysis wasn’t any one individual’s interpretation of the data, but a collective, multi-perspective understanding. One thing I really learnt during this process was how different two people’s interpretations of the data could be — sometimes, we’d spend a whole hour arguing about what a client had been trying to say! It made me realised how ‘subjective’ any individual analysis was going to be: not wrong, but less representative of how most people might understand the data as compared with having a team working together. The team work was also a lot of fun and a chance to really thrash out understandings with informed and experienced colleagues.

So what did we find? The write-up of the results and the rest of the paper are now available here, published open access (i.e., available to everyone, which is great) in the highly-respected journal Psychotherapy Research.

Did the clients like being asked about the preferences?

Generally, we found that they did, though we needed to be really careful about introducing our own biases here. What was particularly interesting was why the preference work was helpful. John Norcross and myself, in our book Personalizing psychotherapy: Assessing and accommodating patient preferences, had suggested three possible reasons: 1. Because it gives clients what they know is best for them, 2. Because it helps client feel empowered, 3. Because it helps to develop the alliance. In fact, we found most evidence for the third of these reasons: that being asked about their preferences helped clients feel safer, more trusting, and more listened to by the therapist. At the same time, we found some clients didn’t find it helpful being asked about their preferences; and, also, some clients found it was helpful when the therapist did things that was counter to their preferences. So it was a nuanced picture here, and clearly one that suggests a need for ongoing communication between therapist and client as the work unfolds.

What kinds of preferences did clients have?

There’s quite a bit of quantitative work, to date, on what clients want to happen in the therapy room (particularly using our new C-NIP measure, see for instance here), and our qualitative data triangulated well with these findings. Typically, clients wanted quite an active style of therapist, with the therapist leading the way rather than being passive or disengaged. But they also wanted the therapist to be warm, to listen, and to give them space to explore.

Where did clients’ preferences come from?

A really interesting question we explored, which hasn’t been investigated in the literature at all to date, was the origins of clients’ preferences. Clients indicated three sources. First, their preferences were a result of things about themselves or their current circumstances: for instance, they knew they were someone who liked a lot of space to talk. What I found particularly interesting here was that, sometimes, clients wanted the thing they knew really matched their personality (e.g., ‘I like talking about the past, so let’s do that’) and sometimes they wanted the thing that was opposite of how they typically did things (e.g., ‘I like talking about the past, so I know, in therapy, I need to focus on the present’). Second, their preferences emerged from the current therapy: for instance, the therapist did something, like ask them about their childhood, and then they realised that was really helpful. Third, their preferences came from their previous episodes of therapy, and particularly unhelpful experiences: like being pushed to talk about something they really didn’t want to.

Did client preferences change over time?

This was another really interesting and new question, and generally we found a mixed picture: some preferences changed, but some didn’t. So, for instance, some clients would come in wanting direction and guidance, and still want that by the end of therapy; whereas other clients might want to talk about their past at the start of therapy, but by the end realise it was more helpful to talk about their present.

What facilitated preference work?

We really wanted to know what clients felt would help, or hinder, the assessment and accommodation of preferences, but we did not find so much here. The main facilitating factor was being actively asked by the therapist what their preferences were, the main inhibiting factor was their own reluctance of shyness to disclose what they really wanted.

Conclusions

As with all good studies, by the time we got to the end of it, we probably had more questions than answers. I wanted to know more, for instance, of where clients’ preferences came from; and the intricate and nuanced patterns of changes, or stability, of preferences over time. And how, more exactly, did preferences help to build the therapeutic alliance and what was the effect of that? These are all questions that I really hope future researchers will follow up through qualitative (or perhaps also quantitative) work, and it shouldn’t be too difficult: interview clients who are involved in a therapy where there is preference assessment and accommodation, and talk to them about what they’re experiencing (with the appropriate ethical scrutiny in place, of course). That’s what I love about qualitative research: you can just talk to clients, deeply, about what’s going on for them: what could be a better way of finding out about therapy processes and outcomes!

But our research does also have some important implications for practice. Asking clients about their preferences, generally, seems to be a good thing, as part of forming a strong early working alliance. There’s something here for me about just getting that collaborative ‘energy’ going from the start: forming the kind of relationship where you can talk easily about the process of therapy itself, and what clients might or might not prefer–if anything–along with developing a warm and supportive bond. And you can ask clients about preferences that come from their own characteristics and situation, that might come from previous episodes of therapy, and also as the therapy progresses–what are clients finding helpful or not? Actively asking clients about preferences, rather than assuming clients will just say them, seems to make sense. There’s also something here, consistent with the quantitative research, that generally clients do seem to want a quite active style of therapy. I think this raises questions about more ‘passive’ forms of practice (as some types of person-centred and psychodynamic work can be experienced): at the very least, be alert to the fact that some clients here will want a more active therapist presence.

Maybe my biggest learning from this project, as above, is just the sheer value of talking to clients about what works for them in therapy. It’s such a rich, nuanced, complex wellspring of data: there’s so much we can learn about what’s best, particularly if we can put our own biases and agendas to one side. And, of course, there’s no easy, black-and-white answers: and what clients say in general is never as important as what the individual client in front of us. But qualitative research with clients can give us some brilliant insights about where we start from, what to consider, and where or where not to possibly go. It’s where research meets practice (and theory and self-development too): a way of developing therapeutic practice that is fundamentally pluralistic in its evolution as well as in its application.

Acknowledgements

Photo by Nathan Dumlao on Unsplash

Publication

Cooper, M., Di Malta, G., Knox, S., Oddli, H. W., & Swift, J. K. (2023). Patient perspectives on working with preferences in psychotherapy: A consensual qualitative research study. Psychotherapy Research, 1-15. https://doi.org/10.1080/10503307.2022.2161967 (available open access)

Sixth International Conference on Pluralistic Counselling and Psychotherapy. Save the Date!

We are delighted to announce the date and theme of this years conference! It will be on 2nd and 3rd June 2023, and will be titled Applied Pluralistic Therapy: What are We Doing in Practice? Although we are keen to get in person events back up and running, we have chosen to keep this year online, with an aim for an in-person celebration of pluralistic practice at the end of the summer.

Sign up to our mailing list for further details about keynotes, tickets and submission forms if you are keen to present.

Interview with Artificial Intelligence Bot ‘ChatGPT’ about Pluralistic Therapy… and It Writes Us a Poem, Too

Nicola Blunden, Metanoia Institute.

Some of you may have seen the incredible new Artificial Intelligence chatbot, ChatGPT, released recently for free use. I asked it to describe itself for this blog, and it replied:

I am a large language model trained by OpenAI. I am designed to generate human-like text based on the input that I receive. I have been trained on a wide range of text, and I use that training to generate responses that are coherent, plausible, and relevant to the topic at hand. I do not have access to external information, and I do not have the ability to browse the internet or access other external resources. My responses are based solely on my training and my ability to generate text based on that training.

ChatGPT can write emails, plays, essays, legal contracts, coding, and much more. It is about to revolutionise the way that we create. I thought I would ask it some general questions about pluralistic therapy. Take a look at its responses, and comment below. Do you think its answers are accurate? What questions would you ask it? I promise, these are entirely unedited ChatGPT responses to my prompts, amazing as that may seem!

‘Summarise the salient features of a pluralistic approach to therapy’

A pluralistic approach to therapy is a flexible and adaptable form of therapy that uses a wide range of techniques and theories to help clients achieve their goals. Some key features of a pluralistic approach to therapy include:

A focus on the individual needs and goals of each client. Pluralistic therapy is personalized and tailored to the unique experiences and perspectives of each client.A recognition that no one approach is right for everyone. Pluralistic therapy is based on the belief that different clients may benefit from different approaches, and that it is important to be flexible and adaptable in order to provide the best possible care.An emphasis on the therapist-client relationship. Pluralistic therapy places a strong emphasis on the relationship between the therapist and the client, and it seeks to create a warm, empathic, and accepting environment in which the client feels safe and supported.An active role for the client in their own therapy. Pluralistic therapy encourages clients to take an active role in their own therapy, working closely with their therapist to set goals and develop a treatment plan that is right for them.

Overall, pluralistic therapy is a compassionate and empowering approach that can help clients to feel more in control of their lives and to make positive changes. It is a flexible and adaptable approach that can be effective for a wide range of clients and concerns.

‘What is the difference between an integrative and pluralistic approach to therapy?’

An integrative approach to therapy is a type of therapy that combines elements from different theoretical frameworks and approaches. It is based on the belief that different approaches can be complementary and that by combining them, therapists can provide a more comprehensive and effective form of therapy. For example, an integrative therapist might combine cognitive-behavioral therapy with mindfulness techniques, or they might combine person-centred therapy with family therapy.

Pluralistic therapy is similar to an integrative approach in that it also uses a range of techniques and theories. However, the key difference is that pluralistic therapy is less focused on combining specific techniques and theories, and more focused on being flexible and adaptable to the individual needs of each client. Instead of combining specific techniques, pluralistic therapists use a range of techniques and theories to help clients find the approach that works best for them.

Overall, the key difference between an integrative and a pluralistic approach is their focus. An integrative approach is focused on combining specific techniques and theories, while a pluralistic approach is focused on being flexible and adaptable to each client’s individual needs. Both approaches can be effective, and the choice between them may depend on the therapist’s training and experience, as well as the individual needs and preferences of the client.

‘Can you be a therapist trained in a single therapeutic framework, and still pluralistic in your practice?’

Yes, it is possible for a therapist who is trained in a single therapeutic framework to be pluralistic in their practice. Pluralistic therapy is not about following a specific set of techniques or theories, but rather about being flexible and adaptable to the individual needs of each client.

A therapist who is trained in a single therapeutic framework can still be pluralistic in their practice by being open to using a variety of techniques and theories to help their clients. For example, a cognitive-behavioral therapist might use mindfulness techniques to help a client reduce their anxiety, or a person-centred therapist might use family therapy techniques to help a client improve their relationships.

By being open to using a range of techniques and theories, a therapist can provide a personalized and tailored approach to therapy that is responsive to the individual needs of each client. This can be an effective way to help clients achieve their goals and make positive changes in their lives, even if the therapist is trained in a single therapeutic framework.

‘What advice would you give to a therapist who wants to become more pluralistic in their practice? Express this as a friendly bullet list of five points’Learn about the different theories and techniques used in pluralistic therapy. This will help you to understand the range of approaches that are available, and to identify which ones may be most effective for your clients.Consider taking some additional training in pluralistic therapy. This can provide you with hands-on experience and guidance on how to incorporate these approaches into your practice.Be open to trying new things. Pluralistic therapy is all about being flexible and adaptable, so don’t be afraid to experiment with different techniques and theories to see what works best for your clients.Talk to your clients about their goals and preferences. Pluralistic therapy is client-centered, so it’s important to involve your clients in the decision-making process and to use their feedback to guide your approach.Don’t be afraid to seek support from other therapists who are more experienced in pluralistic therapy. You can learn a lot from your colleagues, and they may be able to provide valuable insights and guidance.‘Express pluralistic therapy as a poem’

Pluralistic therapy is a form of care
That’s flexible and adaptable, it’s fair
It uses many a tool
To help people feel cool
And find the path that’s right for them, without any snare.

With empathy and understanding at its core
Pluralistic therapy opens many a door
For those who seek change
And a chance to arrange
Their lives in a way that feels fulfilling and more.

So if you’re feeling stuck or unsure
Consider trying a pluralistic cure
With a skilled therapist by your side
You’ll be able to glide
Towards a brighter future, and feel more secure.

How My Therapist Dumped Me on My Birthday for Voicing Preferences

Simon Yeates, IICP, Dublin, MSc Pluralism, Year 1

In January 2022 I turned 31. During this time, I was struggling. Becoming a new father seven months previously coupled with sleep deprivation and coronavirus restrictions had taken a toll and I had made the decision for both me and my family to enter personal therapy. From training to be a counsellor and learning about client preferences I felt well equipped to speak with my therapist about what I wanted and, even more importantly, what I did not want from therapy. Even with the evidence behind me and being ready to go in and have my voice be heard, I still felt nervous speaking about what I wanted. I had two big preferences for therapy:

I wanted an approach that focused on my feelings as well as my early relationships in life through a trauma focused lens.I did not want to engage in CBT.

Let me reiterate that last bullet point. I did not want to engage in CBT.

I nervously voiced these preferences and hoped I would be heard. The therapist nodded and I was proud and happy with myself for speaking up. The reality was very different as evidenced by the following interaction:

Me: So, for me I find CBT an approach that doesn’t really work for me. I understand that it has a large research base and works for some people but as an approach I’d like to focus more on maybe my emotions and my past experiences. I saw on your profile that person centred is a way that you work and I think that could be really useful for me.

Counsellor: Okay I’m hearing that that there is a lot of fear there around CBT.

Me: Em maybe? I’d just prefer to work in a way that focuses on my emotions as I find I can get quite stuck in my head and don’t really find CBT helpful as it can perpetuate that.

Counsellor: Hmmm. So, it could be good to look at the cognitive triangle a bit here and look at how your thoughts can impact your feelings and behaviours.

Me: …OK? I just don’t really want to do CBT. I find it best to focus on my emotions more so and go from there.

Counsellor: There’s a lot of resistance here that I’m sensing. A real push back towards using CBT as an approach.

Me: I just don’t find it helpful.

Counsellor: It’s important that we don’t neglect the cognitive part of the therapy though as it’s such an important aspect.

Me: Alright I just don’t really feel like I’m being heard right now on what I want from therapy…

[Counsellor looks away for a moment]

Counsellor: Well, let’s spend some time talking about what brings you here.

This above snippet is paraphrasing this encounter but gives a glimpse into the session itself. We somehow made it through, but I came out feeling voiceless and unheard. I imagine if someone came in seeking CBT in particular, the way this therapist worked, understood, and intervened would have been great; but I left feeling worse than when I came in. I decided to try one more time—to relay my preferences the following week—to see if we could work together. However, the next week was pretty much a repeat of the last session:

Counsellor: So how does it feel coming in today.

Me: Honestly, I felt the last session was a little rocky but it’s an important boundary for me to keep, regarding not doing CBT. I get it works for a lot of people but it’s just not my thing. I’d like to focus more on my emotions and feelings. I would like to find a way of working together though that respects that.

Counsellor: Again, there’s a lot of resistance there towards CBT and a real reluctance to go there.

Me: Maybe but I’d just like to work in a way that I find beneficial.

Counsellor: It’s important we don’t neglect that cognitive piece as therapy won’t be complete without it.

This back and forth continued in a similar vein to the first session. She ended it halfway through, said I didn’t have to pay her for the session, and referred refer me on to another colleague of hers. This all happened on my birthday. In hindsight it’s a somewhat funny memory for me that a therapist ‘dumped’ me that day but at the time I felt awful. I didn’t feel like me voicing preferences for therapy was a big deal given what I read on pluralism. I called the next therapist and asked her about her way of working. She was a CBT specialist, and I didn’t return to that therapy practice.

Even though the encounter wasn’t a positive one, there was a huge amount of learning there for me as a pluralistic practitioner. I promised myself as a trainee therapist to listen to clients about their wants and needs for therapy. As Cooper and Norcross speak about in their shared decision-making process, I won’t be taking a laissez faire, ‘do whatever the client wants’ approach, but I also won’t be taking a paternalistic stance where I believe I know what’s best for the client (Cooper and Norcross, 2021).

I teach on a BSc in Education Studies and one of my favourite modules to teach in the United Nations Convention on the Rights of the Child (1989). One aspect that we focus on in the module is Article 12, which relates to the voice of the child:

Parties shall assure to the child who is capable of forming his or her views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child.’

The idea behind this is solid. We give children the right to express their views and have a voice. What happens if we don’t listen to this voice though? Lundy (2007) criticises this article by saying that it’s great to allow children to have an opinion and express views but if we don’t take seriously and act on what their opinions are, then the article doesn’t mean much.

When client ask us for what they want in therapy, and it’s within our capabilities to deliver it, then why shouldn’t we listen to and act on that?

I endured to find another therapist and again persisted to have my preferences for therapy be heard. I stated outright that I didn’t want to do CBT. The reply itself was almost healing: ‘We’re not going to do CBT’, he said. I stayed with that therapist for the guts of a year and got some great work done and, am happy to say, am in a much better place coming into the winter and January. Some of that might be due to sleeping through the night again as a not-so-new parent, but I imagine a lot of that was giving me a voice and allowing my preferences to be heard.

How My Therapist Dumped me on my Birthday for Voicing Preferences

Simon Yeates, IICP, Dublin, MSc Pluralism, Year 1

In January 2022 I turned 31. During this time, I was struggling. Becoming a new father seven months previously coupled with sleep deprivation and coronavirus restrictions had taken a toll and I had made the decision for both me and my family to enter personal therapy. From training to be a counsellor and learning about client preferences I felt well equipped to speak with my therapist about what I wanted and, even more importantly, what I did not want from therapy. Even with the evidence behind me and being ready to go in and have my voice be heard, I still felt nervous speaking about what I wanted. I had two big preferences for therapy:

I wanted an approach that focused on my feelings as well as my early relationships in life through a trauma focused lens.I did not want to engage in CBT.

Let me reiterate that last bullet point. I did not want to engage in CBT.

I nervously voiced these preferences and hoped I would be heard. The therapist nodded and I was proud and happy with myself for speaking up. The reality was very different as evidenced by the following interaction:

Me: So, for me I find CBT an approach that doesn’t really work for me. I understand that it has a large research base and works for some people but as an approach I’d like to focus more on maybe my emotions and my past experiences. I saw on your profile that person centred is a way that you work and I think that could be really useful for me.

Counsellor: Okay I’m hearing that that there is a lot of fear there around CBT.

Me: Em maybe? I’d just prefer to work in a way that focuses on my emotions as I find I can get quite stuck in my head and don’t really find CBT helpful as it can perpetuate that.

Counsellor: Hmmm. So, it could be good to look at the cognitive triangle a bit here and look at how your thoughts can impact your feelings and behaviours.

Me: …OK? I just don’t really want to do CBT. I find it best to focus on my emotions more so and go from there.

Counsellor: There’s a lot of resistance here that I’m sensing. A real push back towards using CBT as an approach.

Me: I just don’t find it helpful.

Counsellor: It’s important that we don’t neglect the cognitive part of the therapy though as it’s such an important aspect.

Me: Alright I just don’t really feel like I’m being heard right now on what I want from therapy…

[Counsellor looks away for a moment]

Counsellor: Well, let’s spend some time talking about what brings you here.

This above snippet is paraphrasing this encounter but gives a glimpse into the session itself. We somehow made it through, but I came out feeling voiceless and unheard. I imagine if someone came in seeking CBT in particular, the way this therapist worked, understood, and intervened would have been great; but I left feeling worse than when I came in. I decided to try one more time—to relay my preferences the following week—to see if we could work together. However, the next week was pretty much a repeat of the last session:

Counsellor: So how does it feel coming in today.

Me: Honestly, I felt the last session was a little rocky but it’s an important boundary for me to keep, regarding not doing CBT. I get it works for a lot of people but it’s just not my thing. I’d like to focus more on my emotions and feelings. I would like to find a way of working together though that respects that.

Counsellor: Again, there’s a lot of resistance there towards CBT and a real reluctance to go there.

Me: Maybe but I’d just like to work in a way that I find beneficial.

Counsellor: It’s important we don’t neglect that cognitive piece as therapy won’t be complete without it.

This back and forth continued in a similar vein to the first session. She ended it halfway through, said I didn’t have to pay her for the session, and referred refer me on to another colleague of hers. This all happened on my birthday. In hindsight it’s a somewhat funny memory for me that a therapist ‘dumped’ me that day but at the time I felt awful. I didn’t feel like me voicing preferences for therapy was a big deal given what I read on pluralism. I called the next therapist and asked her about her way of working. She was a CBT specialist, and I didn’t return to that therapy practice.

Even though the encounter wasn’t a positive one, there was a huge amount of learning there for me as a pluralistic practitioner. I promised myself as a trainee therapist to listen to clients about their wants and needs for therapy. As Cooper and Norcross speak about in their shared decision-making process, I won’t be taking a laissez faire, ‘do whatever the client wants’ approach, but I also won’t be taking a paternalistic stance where I believe I know what’s best for the client (Cooper and Norcross, 2021).

I teach on a BSc in Education Studies and one of my favourite modules to teach in the United Nations Convention on the Rights of the Child (1989). One aspect that we focus on in the module is Article 12, which relates to the voice of the child:

Parties shall assure to the child who is capable of forming his or her views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child.’

The idea behind this is solid. We give children the right to express their views and have a voice. What happens if we don’t listen to this voice though? Lundy (2007) criticises this article by saying that it’s great to allow children to have an opinion and express views but if we don’t take seriously and act on what their opinions are, then the article doesn’t mean much.

When client ask us for what they want in therapy, and it’s within our capabilities to deliver it, then why shouldn’t we listen to and act on that?

I endured to find another therapist and again persisted to have my preferences for therapy be heard. I stated outright that I didn’t want to do CBT. The reply itself was almost healing: ‘We’re not going to do CBT’, he said. I stayed with that therapist for the guts of a year and got some great work done and, am happy to say, am in a much better place coming into the winter and January. Some of that might be due to sleeping through the night again as a not-so-new parent, but I imagine a lot of that was giving me a voice and allowing my preferences to be heard.

A response to Ong, Murphy, and Joseph regarding Cooper and McLeod’s exposition of pluralistic practice

Ross Crisp, ross.crispsy@gmail.com

In their 2020 article, published in Person-Centered and Experiential Psychotherapies, Ong, Murphy, and Joseph claimed that Cooper and McLeod’s exposition of pluralistic practice embraces specific ontological ‘positions’ for different schools of psychotherapy. They argued, incorrectly, that it equates to an ‘ontological eclecticism’ that is incompatible with Carl Rogers’ trust in the client’s actualization tendency and capacity for self-healing.

In the same journal, I have recently counter-argued that the ontology underlying all schools of psychotherapy is universal and invariant; and occurs with the ontic (contingent and changeable) mode of psychotherapy. It is this distinction between the ontological and the ontic that is overlooked by Ong et al.

The ontological Dimension of Psychotherapy

Contra to Ong et al., I am in accord with Kirk Schneider who regards the diverse range of therapies as liberation strategies within an overarching ontological or experiential context. For both members of a therapeutic dyad, human experience is ontologically relational.

The term ‘ontologically relational’ is compatible with ‘the ontological principle’ of Alfred North Whitehead who, in his major work Process and Reality, argued that interrelationships are defined in terms of process – the becoming of actual entities which are potentially connected to every other experience of aliveness in the universe and which holds us in existence. Whitehead put process at the centre of his thinking as did Carl Rogers, Eugene Gendlin, Mick Cooper, John McLeod, Bernie Neville, Art Bohart, and others. The direct influence of Whitehead on Gendlin’s process model is evident. Gendlin argued that we are inherently ontological: we implicitly understand our own manner of being as being-in-the-world, always already in the midst of situations.

Therapists may only be implicitly or partially aware of the ontological dimension of their work. Awareness of the ontology of being is, as Heidegger argued, often elusive due to our immersion in everyday life. This is evident with respect to the ontical dimension of psychotherapy.

The Ontical Dimension of Psychotherapy

Therapists are mostly focused upon addressing ontic questions such as: What are the limits of my theory and practice? Has the client perceived/received my attitudes of congruence, unconditional positive regard, and empathic understanding? Can I help the client by being open to different theoretical perspectives beyond the vantage point of, for example, person-centered therapy (PCT)? Which non-PCT techniques can I apply to help a particular client to achieve their desired therapeutic outcome? Am I sufficiently open to learning from my client?

These ontic questions refer to a therapist’s ‘everyday’ concerns with the changeable nature of the therapeutic process; and to their tacit, perhaps unexamined assumptions and beliefs about the usefulness of their role as a therapist.  In a clinical (ontic) context, a pluralistic therapist may, for example, stay actively attuned to a client’s experiencing and regularly check with the client whether what they are doing is helpful. In turn, a client may perceive, but request more than, a congruent therapist’s unconditional positive regard and empathic understanding. A client may suggest the therapist be more challenging or confronting when the client struggles to address difficult issues or contradicts self. Alternatively, a client may seek advice regarding other therapies (e.g., conventional or traditional healing practices valued by the client’s particular racial/ethnic culture) outside the therapist’s knowledge base. Meta-analyses reported by Norcross and Wampold suggest that better therapeutic outcomes are related to how well therapists adapted and responded to their client’s racial/ethnic culture and religious/spiritual identity.

The Ontologically Relational Dimension of Person-Centered and Pluralistic Practice

The humanistic-existential thinking of Cooper, and the theory-building case study research of McLeod, suggest that they favor a ‘subjective ontology’ based on the reality of intersubjectivity whereby psychological attributes are inferred through the prism of social praxis (as opposed to objects measure in physics, i.e., ‘objective ontology’). It is here that the ontological domain of psychotherapy transcends objectivist and reductionist models where diagnostic labels tend to be inappropriately reified and explained as ‘essences’ when in fact they are (in part, at least) socially constructed.

The influence of Levinas’ ethical commitment to prize the uniqueness of the Other is evident with his emphasis on the ‘absolute difference’ of the Other who always transcends a person’s idea of them. Each human being is so unique that they can never be fully understood by an other. Cooper and McLeod trust in each person’s innate capacity to reconnect with their own internal experiencing. Cooper and McLeod do not seek to unveil the ‘unknowable’ private world of the individual. Instead, they take a stance of ‘not-knowing’ that entails a ‘radical openness’ to receiving whatever issues the client chooses to discuss. There are no preconceived knowledge, opinions or theories privileged ahead of what is experienced in the immediate encounter.

The relational ontology in Cooper’s thinking is based in part on the socially-constructed tool of language whereby the sociocultural world that we inhabit is also inhabiting us. Dialogue, as dialogical person-centered therapist Peter Schmid argued, is an ontological given in which we are not only in dialogue, we are dialogue. In psychotherapy, the ontology of dialogue is juxtaposed with the ontic ‘metacommunicative activity’ of the therapist and the client talking about what they would like to get out of therapy, and how they feel it might be achieved. Both therapist and client draw upon their particular bodies of knowledge and expertise. It is contiguous with both client and therapist experiencing being the Other and focusing on their experiencing of emergent phenomena in an ongoing, always incomplete process of becoming. It involves, as Martin Buber told Carl Rogers, being prepared ‘to change if possible something in the other, but also to let me be changed by him’ (Mendes-Flor). Therapist and client confirm and accept each other in their uniqueness and otherness, which has parallels with Rogers’ concept of unconditional positive regard, with an emphasis on the acceptance of the other in his or her wholeness. By attempting to genuinely accept and empathically understand the client’s immediate concerns, the therapist enhances the client’s capacity to internalize a more accepting attitude towards self. The therapist may also reflexively engage with his or her own assumptions and biases (about, for example, the client’s gender, race, ethnicity, class and so on) that discriminate against the client. In doing so, the therapist is not (in the way suggested by Ong et al.) embracing an ontological ‘position’ that is aligned to a particular school of psychotherapy.

Both therapist and client are already ‘worlded and worlding beings who are actually constituting and being constituted by one another’s existence’ (Erik Craig). Further, from the person-centered perspective of Moreira, adapted from Merleau-Ponty, psychotherapy functions in the present moment. Merleau-Ponty viewed a person’s distress in terms of experiencing the past as the ‘true present’ whereby the person’s present time is arrested; future-oriented engagements with the world and being open to future possibilities are disrupted.

For clients who report being ‘stuck’ or at a ‘standstill’, the pluralistic therapist may invite the client to specify what they would like to achieve from therapy. This process of ontic meta-communication entails the therapist being guided by the client, and supporting the client to articulate what they want from therapy. When the client is uncertain, the therapist may offer suggestions that the client can accept or reject. In this way, the client is encouraged to realize their capacity for choice, to be open to possibilities, and to trust in self to be their own expert. Underlying such activity is the therapist’s presence from which the client senses that the therapist is genuinely, vibrantly and empathically engaged with the client in a mutual encounter of co-transparency, co-acceptance and co-understanding. In so doing, the pluralistic therapist is, contrary to the claim of Ong et al., working in a way that is compatible with PCT.

The client’s co-existence with the therapist attests to the ontology of being relational. I am not referring here to an ontological ‘position’ indicative of a therapist’s particular interpretation of the client’s problems. Therapeutic success resides not in the method of psychotherapy but in the experiential process within the therapeutic relationship. 

Conclusion

The mistaken claim made by Ong et al. that specific ontological ‘positions’ are tied to different schools of psychotherapy provided the impetus for writing this article. Contra to Ong et al., I argued that the ontology underlying all psychotherapies is universal and invariant, and encompasses process and relationship. Both therapist and client engage in a process of organismic re-organization, of self-development, and of a co-created process of relationship development. They participate in each other’s ongoing process of becoming. There is no boundary between self and other and in their being-in-the-world. Their relationship is characterized by intersubjectivity and their interconnection within a broader social context.

The ontological is intertwined with the ontic (the contingent and changeable) mode of the therapeutic relationship. The quality of this relationship may depend on a range of therapist and client factors; for example, the extent to which the therapist empathically understands, and co-experiences, the client’s personal experience their racial or ethnic cultural milieu. Such practice entails a necessarily more ambiguous and holistic understanding of lived experience than the diagnostically-oriented and manualized components of several contemporary psychotherapies.

References

My full paper can be read at:

Crisp, R. (2022). Ontology, culture, person-centered and pluralistic practice: Reply to Ong, Murphy and Joseph. Person-Centered & Experiential Psychotherapies. https://doi.org/10.1080/14779757.2022.2100814

International Conference on Pluralistic Counselling and Psychotherapy Prize Winners

We are delighted to announce our conference prize winners from the last two years. You can find more information on each of the projects and links to watch the presentations below. You can watch all of the recordings from the conference here. Congratulations to all of our prize winners!

Senior Prize – 2022 – Arts for the Blues projectTop row (From left to right): Kathleen Kwakye-Donkor, Joanna Leather, Vicky Karkou, Joanna Omylinska-Thurston
Bottom row (From left to row): Emma Perris, Scott Thurston ,Rachel Calleja

You can watch the presentation here.

Arts for the Blues is an evidence-based, pluralistic creative group psychotherapy originally designed for use with adults for depression, but now diversifying across other groups and conditions. It is the result of an interdisciplinary collaboration between Prof Vicky Karkou, an arts therapist, Dr Joanna Omylinska-Thurston, a counselling psychologist, and Prof Scott Thurston, a poet and performer (and now trainee counsellor), across the institutions of Edge Hill University, the University of Salford and Greater Manchester Mental Health NHS Foundation Trust, and draws on a range of traditions and influences in modern psychotherapy.

The project is currently undergoing expansion through two funding streams: the AHRC’s Scaling up health inequality and intervention strategies and the Arts Council England’s project grants. The underlying pluralistic framework of the model has attracted a number of collaborators, researchers and trainees alike, and we were pleased to present to the Pluralistic Conference alongside our RA Emma Perris and researchers Jo Leather, Kathleen Kwakye-Donkor and Rachel Calleja, whose own unique perspectives have hugely enriched the project.

For more information about Arts for the Blues, please see our website at www.artsfortheblues.com, which features video representations of the key ingredients of the model, a short film about our first full-length pilot with MIND in Ashton-under-Lyne and further information about our research publications.

Photos from some of the Arts for the Blues sessionsJunior Prize – 2022 – Mark Clamp

You can watch the presentation here.

What outcome goals do young people aged 16 to 20 years who self-harm have for therapy and what in therapy helped or hindered them in achieving these goals?

The study, originally not designed from a pluralistic perspective, consisted of a systematic review concerned with young people’s barriers to help seeking, what outcomes they wanted for therapy, and whether they experienced therapy as helpful or unhelpful. It also contains an empirical study which explored the experience of therapy for ten young people who had a history of self-harm with an IAPT service in the East of England.

The narrative synthesis (Popay et al., 2006) fell into two overarching themes: young people, self-harm and help seeking, and young people’s experiences of therapy. The findings show that previous experiences of disclosing self-harm to others and poor experiences, including not feeling in control of the helping process, are a barrier to young people seeking professional help later in their lives.

The empirical study focused on analysis of ten qualitative semi-structured interviews. Interviews were audio recorded, transcribed, coded, and analysed using reflective thematic analysis (Braun and Clarke, 2006; 2019). The analysis identified four themes: Hope of feeling more in control, Therapy changed the way I see things, Therapist enabled a positive therapeutic space, and There are consequences to admitting to self-harming. The data provided detail on how a greater sense of feeling in control over their lives is a common goal for therapy for young people who self-harm. Gaining understanding or reclaiming a sense of being in control resulted in the young person experiencing the therapy in a positive light and assessing it as successful. The results also show that an increased sense of being in control is sometimes overlooked and a missing aspect of therapy with young people who self-harm. The study also demonstrates how the pluralistic approach to therapy can facilitate and foster this sense of control in the therapeutic environment.  However, control over some aspects of young people’s lives cannot be changed because of circumstances and socioeconomic demands of the world they inhabit. In these cases, therapy can only offer a greater understanding and acceptance of where control can or cannot be exerted.

The findings also suggest that connected to a sense of control is the realisation in the young person that their behaviours impact others. What is clear is that in some cases the motivation to seek professional help and hope for the outcome of therapy as being to ‘get better’ is driven by concern for how self-harm impacts significant others over and above the young person’s need to decrease their own emotional difficulties.

References:

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology 3(2), 77-101.

Braun, V., & Clarke, V. (2019). Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise & Health, 11(4), 589-597.

Junior Prize – 2021 – Hilary McNally

The research looked at the experience of using deliberate practice, a training methodology designed to improve performance, in a group of diploma level counselling students.

It was inspired by a workshop on the topic by John and Julia McLeod which filled me with hope. I was at the stage of my own training where I oscillated from passionate enthusiasm for all that I was learning and the possibilities it offered to overwhelming panic and despair that I might never get a handle on it and maybe I just didn’t have what it takes. Being reminded that improvement comes from focused and consistent practice rather than some innate ability and that this was just as true for counselling was exactly what I needed to hear.

I wondered what other counsellors and trainees thought and discovered anecdotally that some shared my enthusiasm while others were sceptical or dismissive of something seen as another demand in an already busy schedule.

I was curious to find out what influenced attitudes to deliberate practice and mentioned this in an email to Julia who suggested it might make a good MSc project. I interviewed a number of counselling students at Abertay University where a deliberate practice framework had been introduced.

With supervision support from Julia and the generosity of students at Abertay, who agreed to give me their time and share their experiences with me, I was able to carry out the research and present the findings at the 2021 Pluralistic Conference.

Pluralistic Practice: A Medical Anthropology Perspective

Dr Natalie Tobert, Medical Anthropologist, natalietobert@gmail.com , https://www.aethos.org.uk/  

Multiple Narratives, Plural Perspectives

One essential requirement of the discipline of medical anthropology is to honour multiple narratives around health and wellbeing. Research within medical anthropology always ensures plural perspectives are explored, so people are witnessed according to their own understandings, and as well as from western Eurocentric perspectives. Plural perspectives are key to undertaking counselling and offering therapy with culturally diverse populations.

The work of a medical anthropologist always involves recording multiple narratives around health, so societies are not only witnessed from western biomedical perspectives, but also according to their own interpretations, acknowledging personal histories. I registered for a degree in medical anthropology ten years after I’d completed a doctorate, as it would offer me a language to engage with medical doctors and psychiatrists. Later I developed courses on Cultural Diversity and Mental Wellbeing and taught them for decades, in order to reduce social inequalities in health, enhance individual and community social inclusion, and support staff in engaging with ‘hard to reach’ people. Medical Anthropology discussion seminars on health and wellbeing, which I offered to first generation migrants at the Abdul Mageed Educational Trust (for African and Arabic Speaking Groups) were not considered therapy by participants, rather they were seen as communal support by known others in the group. These participants seemed to feel safer with shared communal healing.

Although I don’t have a clinical background, for the last 16 years I’ve offered training courses for 1st, 2nd , and 3rd year medical students at Brighton and Sussex Medical School. There students were taught medical anthropology topics, including those below, as part of a strategy to help them as future doctors understand the cultural background of their patients in a deeper way. The same is relevant for therapists and counsellors. Medical anthropology topics that were addressed were: On Being a Migrant; Meanings of Spirituality to Health; Women and Conception; Cultural Assumptions around the Body; Mental Health; Religious Experience and Expanded Consciousness; Death, Dying and Beliefs About Survival Beyond Death; and finally Cultural U-Turns made by Governments and Law Makers.

One Size Fits All?

My friend and colleague, psychotherapist Joe Bartholomew, founder of Radical Culture and The Indigenous and Transpersonal Therapies Alliance (ITTA) introduced me to pluralistic therapy. The pluralistic ethical framework proposes different things help people at different times in their lives. This means a ‘one size fits all’ approach is not appropriate: medical anthropology covers narratives from different communities, in different countries, of different faiths. It also can be used to show how throughout history there are changes in attitude, as governments and their populations shift their understanding and laws over what they believe is morally correct.

The inappropriateness of ‘one size fits all’ is clearly seen if we consider the topic of ‘Normal Body’, and explore what the word ‘normal’ means in this context.  Does it mean we all have similar limbs, eyes and a mouth, or we have the same skin colour, or mobility? Participants explore different cultures’ understanding of ‘normal’, the effects of trauma and history background on body and emotions, and those who are differently sensitive, or have heightened clairvoyant faculties. Under this topic, it also considers plastic surgeries, desired for different parts of the body, in different geographical locations, with its positive and negative effects.

Cultural U-Turns

For myself, understanding a pluralistic ethical framework is essential when observing our current political scenarios and aggressions of war. If we consider the topic of Cultural U-Turns, we can see that nothing remains the same over time. Governments and law makers systematically change their minds, although it sometimes takes them a generation or two to revoke old laws and decriminalise people (for example: sex outside of marriage, babies born out of wedlock assumed to be mental deficient, forced adoption, homosexuality, forced schooling, preferred skin colour, preferred religion, criminalised abortion, certain refugees preferred over others, preferred languages, preferred class, supremacism, domination, and colonisation). The discipline of medical anthropology offers profound support to practitioners who undertake pluralistic therapy training.

Benefits of Medical Anthropology

What can medical anthropology offer to pluralistic therapy and pluralism as diversity in practice?

The discipline honours equality and diversity.It raises awareness of social inclusion.It presents a range of cultural, religious, and spiritual beliefs, without judgment or hierarchyIt illustrates multiple narratives, and shows there is not one single universal worldview, or truth, or belief system, but rather there are many socially and culturally contextualised worldviews and belief systems around the world.It sets out how culturally informed philosophical, metaphysical, and cosmological beliefs provide meaning, purpose, and a sense of identity in many people’s lives, and not simply identity in opposition, or by Othering other people.  It discusses how western medical and therapeutic approaches can be developed and adapted to be more inclusive of the needs of: cultural minorities within society; colonised populations; or people who have moved or been moved from their country of origin.  It acknowledges personal historical narratives.Workshops offer a series of training courses to promote social inclusion, both for new migrants, refugees, and asylum seekers who have been labelled ‘hard to reach’ by mainstream health organisations, and for all front-line staff.   Changing Times

The key issue of the discipline of medical anthropology is the essential requirement to honour multiple narratives and cultural explanations for health and wellbeing, particularly when working with people whose lands have been colonised, or who have been Othered at home, and with new migrant and refugees. However, when facilitating group workshops, it makes a huge difference during sessions if participants feel comfortable enough to offer examples from their own family background. I found that recent cohorts of medical students in Brighton were much more aware of cultural diversity and plural narratives than in earlier years, aware of differences of opinions from more old- fashioned lecturers. This suggests to me times are changing within the medical profession.  

The advantages of providing equality and diversity training from a medical anthropology perspective is that the participatory discussions may reduce practitioner burnout, have a positive impact on trainee medical staff, front-line psychiatrists, psychologists, nurses, social workers, therapists, and counsellors. 

Social inclusion training supports participants to become better informed by raising awareness of ethical practice: it promotes the importance of diversity across global cultural perspectives. It is essential for practitioners to have profound awareness during assessments and case study practices across mental health care services, and when offering therapeutic care for people with mental health challenges, acknowledging their histories and mundane daily life problems.

About the Author

Dr Natalie Tobert is a British Medical Anthropologist, who qualified ten years after gaining a doctorate in Anthropology and Archaeology. She conducted research in Darfur Sudan (1988), undertook two projects in India (2000, 2014), and later in London UK, with new migrants, refugees, and asylum seekers. She also conducted research in UK on spiritual and religious experiences (2007). Dr Tobert conducted research in London UK supported by the Kings Fund and NHS Harrow, with new migrants and refugees (2008), and then a project with the Somali community (2010a).  A three-year health promotion project, showed new migrants how to access medical and health care services (2010b). During that time, community leaders thanked her for presenting access to services, but asked if she might also offer training to staff, to enhance their understanding of different cultural groups. This became the basis of her teaching cultural diversity and equality courses in medical schools, hospitals and with front-line staff. The book Cultural Perspectives on Mental Wellbeing (2016) supports this teaching. For the last 16 years she has offered training courses for 1st, 2nd and 3rd year medical students at Brighton and Sussex Medical School, and for three years for Peer-Supported Open Dialogue (POD) in the UK. She has facilitated in person workshops in UK, Ireland, Poland, Spain, Sweden, Switzerland and USA, as well as offering a 15-week training course online to global participants during the first UK lockdown, under the title ‘Clash of Beliefs’.

Further Reading from Natalie

Tobert, N.  (1988). The Ethnoarchaeology of the Zaghawa of Darfur (Sudan): Settlement and Transience, BAR IS 445, Cambridge Monographs in African Archaeology 30. 

Tobert, N. (2000). Anegondi: Architectural Ethnography of a Royal Village in India, Vijayanagara Research Monograph, no.7, Manohar Press, New Delhi 

Tobert, N. (2007).  In-Sanity: Explanatory Models for Religious Experience, Occasional Paper no.3, Series 3, Religious Experience Research Centre, University of Wales, Lampeter

Tobert, N. (2008). Mental Health Needs Assessment with BME Communities, NHS Harrow

 Tobert, N. (2010a). Somali Advocacy Research Report, Mind in Harrow/Kings Fund

Tobert, N. (2010b).  Bridging Cultures, Dissolving Barriers, Mental Health Promotion With BME Communities, End of Year Evaluation Report 2009 / 2010, NHS Harrow

Tobert, N. (2013). Cultural Equalities: Training Resource Pack for Medical, Health and Social Care Front-line Service Providers (Unpublished).

Tobert, N. (2014). Spiritual Psychiatries: mental health practices in India and UK, Virginia.

Tobert, N. (2016). Cultural Perceptions on Mental Wellbeing: Spiritual Interpretations of Symptoms in Medical Practice. London: Jessica Kingsley Publishers

Introducing ‘pluralistic sand-tray therapy’: Humanistic principles for working creatively with adult clients

Doreen Fleet PhD, Visiting lecturer and PhD Research Supervisor, University of Chester; Author of Pluralistic sand-tray therapy (2022, Routledge)

As a counsellor and trainer, I have always seen the benefit of using sand-tray with adult clients who want to work creatively. The client will select objects to symbolise their inner experience, their personal relationships, and their relationship to the wider world—often related to their distress. The objects act as physical metaphors, helping the client to work in-depth; yet the physical picture in the sand helps them to stay with their process without becoming overwhelmed. It is as if they have taken one step out of their pain without losing connection to it: taking the experiencer-observer position.

It is essential for the therapist to stay close to the client’s meaning of the objects without imposing their own interpretations, to avoid ‘trampling’ on the client’s process. For example, an object of a dragon can represent protection for one client or threat to another. Alternatively, a tree can symbolise reaching out in discovery for one person or an overwhelming challenge to another. 

Sometimes a client may have a sense of something causing them distress yet may be unable to voice that experience. With the therapist’s help, an object symbolising that implicit experience can be explored. I have often witnessed clients finding their ‘right’ words in pluralistic sand-tray therapy (PSTT), helping them make the implicit explicit, often bringing a sense of relief and a phenomenological shift concerning an issue.

‘Jungian sandplay’ predominates contemporary sand-tray literature, yet if a therapist is not Jungian trained, there is little out there that informs the underpinning theoretical process of the client as they engage in sand-tray therapy. Although there is some literature from various stances, it mainly focuses on how to use sand-tray rather than the theoretical process of the client. My book offers additional theoretical understanding from a pluralistic standpoint and provides guidance on delivering PSTT.

The elements of the pluralistic approach such as collaboration, shared decision-making, metacommunication with purposeful questions, goals, therapy tasks, and assessment and feedback are essential to PSTT and are incorporated throughout the text. An advantage of PSST is that the therapist can draw upon aspects of other approaches to meet the client’s goals and expectations for therapy. For example, a therapist can facilitate edge of awareness and unconscious processing and, in my book, I provide examples of these processes taken from the case study.

My pluralistic theoretical framework was established from a multiple case study, and my book describes a range of concepts. These include the sand-tray as a ‘metaphorical experiential theatre’, ‘phenomenological shift’, ‘phenomenological flux’, and two sand-tray-specific mechanisms of ‘phenomenological anchor’ and ‘phenomenological hook’. Excerpts and coloured photographs of sand displays are embedded into the text to provide vivid explanations of each theoretical concept. In addition, further chapters focus on:

Additional benefits of PSTT, which explore how issues such as touch, spatial arrangement, moving objects, adding and removing objects, burying objects ,and protective objects can aid the therapeutic process.Structured sand-tray sessions, offering ideas for working with clients who are not yet at ease with engaging in an unstructured way.Particular challenges a therapist may face when contemplating PSTT, such as cutting through intellectualisation as a defence, the adult persona as a block, male gender socialisation as a block, and adequate resourcing.Protocol for PSTT—offering specific guidance from the initial assessment to the end session.PSTT for specific issues including depression, loss, guilt and shame, relationship problems, suicidal clients, and intentional self-harm.PSTT with different client groups which focuses on age, gender, ethnicity, and race.Clinical PSTT supervision, outlining the difference between other methods of supervision and some key considerations for a supervisee attending PSTT supervision.Drawing on other theoretical orientations in PSTT, providing examples of how this can be done.

New edition of Pluralistic Counselling and Psychotherapy: Call for Feedback and Suggestions

John McLeod & Mick Cooper, PCP2e@pluralisticpractice.com

When Pluralistic counselling and psychotherapy was published by Sage in 2011, it offered an introduction to a collaborative way of working with clients, based on a relatively limited body of practice and research evidence. Over the last decade, pluralistic theory, training, and practice has hugely expanded in terms of the number of practitioners who use it, the range of therapeutic strategies and activities that are available, and the amount of research evidence that has been published. There have also been significant challenges to therapy theory and practice that have emerged over that period: such as an increasing requirement to address social justice issues, and the much wider use of on-line therapy. We believe that this would be a good time to produce a new edition of Pluralistic counselling and psychotherapy. Although there is now The handbook of pluralistic counselling and psychotherapy, many introductory chapters on pluralistic practice are available, and the excellent Pluralistic therapy primer has been written by Kate Smith and Ani de la Prida, it is important to be able to access a book that offers a comprehensive, in depth account of what is involved in working pluralistically – the kind of book that could be referenced as a treatment manual in research studies, and that we can use to explain the approach to colleagues from other therapy traditions.

In the spirit of pluralism, we want the new edition to reflect the diversity and creativity of pluralistic theory and practice, including the tensions and growing edges that exist within it. We ourselves have lots of ideas about what we would like to include. But we have not had the experience of being students or practitioners who have struggled to find the information, explanations, or examples that they need in the existing edition; or being tutors who have found that the present edition does not sufficiently support the topics they need to teach. So, we would like to hear from you – your feedback about bits of the book that are helpful and make sense (and those that do not), your suggestions for areas that should be added, and your thoughts about how the book is written and laid out. We are open to anything you are able to offer. You can send us a few lines outlining one thing you would like to see changed, or an extensive list of points that you believe should be addressed.

Publishers always commission reviews of proposals for new books, or new editions of existing books, from people they regard as leading figures in the profession. SAGE will do that anyway. What we are looking for, from you, are the thoughts and feelings of those for whom the book really matters.

Please email suggestions and any other comments to PCP2e@pluralisticpractice.com