essay on pluralistic approach

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A Pluralistic Perspective on Research in Psychotherapy: Harnessing Passion, Difference and Dialogue to Promote Justice and Relevance

1 School of Applied Sciences, Abertay University, Dundee, United Kingdom

John McLeod

Nicola blunden.

2 Metanoia Institute, London, United Kingdom

Mick Cooper

3 Department of Psychology, Roehampton University, London, United Kingdom

Lynne Gabriel

4 School of Education, Language and Psychology, York St John University, York, United Kingdom

Christine Kupfer

Julia mcleod, marie-clare murphie, hanne weie oddli.

5 Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway

Mhairi Thurston

Laura anne winter.

6 Manchester Institute of Education, Schools of Environment, Education, and Development, University of Manchester, Manchester, United Kingdom

Associated Data

The original contributions presented in the study are included in the article/supplementary material, and further inquiries can be directed to the corresponding author.

The adoption of a pluralistic perspective on research design, processes of data collection and analysis and dissemination of findings, has the potential to enable psychotherapy research to make a more effective contribution to building a just society. A review of the key features of the concept of pluralism is followed by a historical analysis of the ways in which research in counselling, psychotherapy and related disciplines has moved in the direction of a pluralistic position around knowledge creation. Core principles of a pluralistic approach to research are identified and explored in the context of a critical case study of contemporary research into psychotherapy for depression, examples of pluralistically oriented research practices, and analysis of a pluralistic conceptualisation of the nature of evidence. Implications of a pluralistic perspective for research training and practice are discussed. Pluralistic inquiry that emphasises dialogue, collaboration, epistemic justice and the co-existence of multiple truths, creates opportunities for individuals, families and communities from a wide range of backgrounds to co-produce knowledge in ways that support their capacities for active citizenship and involvement in open democratic decision-making. To fulfil these possibilities, it is necessary for psychotherapy research to be oriented towards social goals that are sufficiently relevant to both researchers and co-participants to harness their passion and work together for a common good.

Introduction

Psychotherapy research is conducted on a global scale, by investigators drawn from different occupations and disciplines, using a range of methodologies, and publishing in a large number of independent journals. As a result, notwithstanding a degree of influence exerted by governmental and other funding agencies, the psychotherapy research community can be viewed as comprising a largely self-organising open system that resists centralised direction. At the same time, it can also occasionally be valuable to evaluate the direction of travel of therapy research in terms of its contribution to broader societal objectives. In this paper, we suggest that although the field of therapy research has always reflected an implicit acknowledgement that the complexity of therapy outcomes and processes requires the adoption of a flexible, pluralistic approach to evidence, the full implications of a pluralistic perspective have yet to been fully articulated. More specifically, the predominant interpretation of pluralism that has been used by therapy researchers has not sufficiently taken account of crucial social and political aspects of this construct. By contrast, a more comprehensive application of a pluralistic stance in relation to therapy research has the potential to significantly enhance the contribution of psychotherapy, and related practices, to addressing contemporary social issues.

Pluralism is a philosophical and ethical tradition based on the idea that there is no single perspective or truth that is universally valid ( Rescher, 1993 ). Pluralism represents an acknowledgement of the ultimate impossibility of reducing the interconnectedness, complexity and uniqueness of life to a set of laws or theories. From a pluralistic stance, human experience and forms of life, across all cultural traditions, can be seen to have been characterised by dissensus rather than consensus. Awareness of the existence of a diversity of perspectives, along with a never-ending effort to reconcile such differences, has been a fundamental aspect of both individual and societal development in modern societies ( Taylor, 1992 ). Important aspects of a pluralistic stance include a commitment to dialogue as a means of bridging different perspectives and to a cognitive style that emphasises ‘both/and’ or ‘and/and’ rather than ‘either/or’ dichotomous thinking.

The authors of this paper are aligned with a collaborative framework for therapy practice, known as pluralistic therapy that represents a systematic attempt to develop a form of practice informed by a pluralist philosophy ( Cooper and McLeod, 2011 ; Cooper and Dryden, 2016 ; McLeod, 2018 ; Smith and de la Prida, 2021 ). A key principle of pluralistic therapy is that different people are likely to be helped by different things at different times. Problems in living for which individuals and families seek therapeutic help are viewed as arising from complex interactions between multiple life events and sources of adversity. Pluralistic practice addresses these problems by making use of strategies and methods from multiple sources, including supportive and healing practices available within the community. The process of client-therapist collaboration is organised around clarifying what the client wants to use therapy to achieve (their goals), identifying specific tasks that might contribute to step-by-step progress in the direction of goals and agreeing methods for accomplishing these tasks. The therapist functions as a facilitator or orchestrator of dialogue and shared decision-making around finding and assembling ideas, activities and ways of communicating and relating, suggested by either the client(s) or therapist(s), or emerging in the work itself. Procedures for supporting client-therapist collaboration and shared understanding include therapist transparency around what they can offer, techniques for elicitation of client preferences ( Norcross and Cooper, 2021 ), and active elicitation and application of the client’s knowledge through experience and cultural resources. Strategies for ensuring that therapy remains in alignment with client goals include routine use of metacommunication, process and outcome feedback tools and design tools, such as collaborative case formulation mapping. Pluralistic therapy does not comprise a fixed or static theory or set of procedures. Rather, it comprises an open system and community of practice that encourages dialogue, innovation and sharing of experience.

Over the past decade, the priority of the pluralistic therapy community has been to establish structures for training, practice and supervision to support members in working collaboratively with clients. An important strand of that effort has been the development of a research base that would identify evidence to facilitate the development of pluralistic practice; conducting studies on the process and outcomes of pluralistic therapy itself (e.g. Cooper et al., 2015 ; Di Malta et al., 2020 ). The intention has been to build an approach to therapy that is research-informed rather than research-directed ( Hanley and Winter, 2016 ), based on the principle that effective practice draws on multiple ways of knowing: ethical, personal, theoretical, cultural and scientific ( McLeod, 2016 ).

In the course of developing an evidence base for pluralistic therapy, we gradually came to realise that we were beginning to see the psychotherapy research literature as a whole from a distinct pluralistic perspective. In particular, we came to believe that the more pluralistic a research study or programme was, the more useful it was for practice, and the more likely it was to make a contribution to social justice.

The present paper builds on earlier work by Hanley and Winter (2016 ), in seeking to explore and further refine the nature of a pluralistic perspective on psychotherapy research. A historical overview is provided around how the concept of pluralism has been used in psychotherapy research. This is followed by a summary of key principles of a pluralistic perspective on research, and then, a case example that examines how a more explicitly pluralistic approach might enhance the relevance of research in relation to an area of inquiry that has comprised a central focus of psychotherapy research in recent years. The paper concludes by looking at possible ways in which a pluralistic perspective might be realised. Our aim, in all of these areas, has been to consider the implications of a pluralistic perspective in relation to the field of psychotherapy research in general, rather than solely in respect of pluralistic psychotherapy as a specific therapy orientation.

A Historical Perspective on the Influence of Pluralism in Research in Counselling and Psychotherapy and Related Disciplines

From the start, psychotherapy research has been primarily based in the ideas and methods of psychology and psychiatry – disciplines that have historically prioritised quantitative and experimental approaches to research. Nevertheless, despite these disciplinary pressures, the first generation of therapy researchers, notably Carl Rogers and Hans Strupp, sought to create a flexible and responsive methodology for the study of psychotherapy that was consistent with its existence as a complex, co-constructed, agential and interpersonal form of practice. For example, the research group led by Rogers made use of case study methods, qualitative methods and projective techniques ( Rogers and Dymond, 1954 ). Strupp and Hadley (1977 ), arguing that it was essential to understand therapy outcomes from multiple perspectives (client, therapist and society). However, from the 1970s, the increasing societal profile of psychotherapy, and in particular its growing presence with state-funded healthcare systems, meant that major sectors of practice came to be controlled by assumptions, policies and procedures associated with neoliberal political and economic ideology, and the implementation of these ideas through the adoption in public sector organisations of management philosophies that emphasise competition rather than collaboration ( McLeod, 2016 ; Sundet, 2021 ). For the psychotherapy research community, this shift was reflected in the reification of schools of therapy as products in a crowded mental health marketplace, and the adoption of randomised clinical trial (RCT) methodology as a means of determining ‘winners’ and ‘losers’ within a competitive environment. Within this new approach, studies of psychotherapy effectiveness increasingly adopted a single primary outcome measure, typically in the form of a client self-report symptom scale.

From the 1980s, the concept of pluralism began being used in the psychotherapy literature to signal resistance to the hegemony of RCTs and empirically validated and manualised therapies ( Omer and Strenger, 1992 ; Samuels, 1995 ; Downing, 2004 ). In the context of research, the idea of methodological pluralism was introduced in an influential paper by Howard (1983 ), as a means of legitimising the use of a wide range of methodologies alongside clinical trials. While Howard was commenting specifically on the value of case study methods, later contributions extended the argument to include qualitative methods ( Mearns and McLeod, 1984 ; Goss and Mearns, 1997 ; Slife and Gantt, 1999 ; Barker and Pistrang, 2005 ). While acknowledging that different methodological approaches (quantitative, qualitative and case study) were grounded in contrasting epistemological positions and values and associated with different quality criteria, these writers argued that different research questions were most effectively addressed by different methods and that the study of psychotherapy required the use of multiple research approaches. Important themes within the argument for methodological pluralism were that convergence of findings across methodologies had the potential to reinforce the credibility of research and that evidence hierarchies that gave higher weighting to meta-analyses of findings from RCTs were misguided. Over the years, the principle of methodological pluralism, understood as tacit acceptance of the value of different methodologies, has become widely accepted within the psychotherapy research community.

The vision of methodological pluralism advocated by Howard (1983 ) and others was primarily formulated as a set of broad principles, with limited practical guidance on how to handle different types of data in the process of conducting an actual study. These technical issues troubled researchers, particularly those whose initial training had focused on quantitative designs and techniques. As a consequence, there began to emerge a literature around the use of mixed-methods research (MMR) designs ( Haverkamp et al., 2005 ). An underlying driver within the MMR literature has been a wish to combine the strengths of both qualitative and quantitative methods. As a consequence, authors have highlight concerns and challenges associated with combining multiple methods in one study and emphasised the necessity for having a clear understanding of the distinctive contribution of each approach around such domains as: quality standards for different styles of data collection and analysis; underlying values and epistemological assumptions; and reporting formats. There are many different methodologies that can be combined in different ways for different purposes which have stimulated a proliferation of MMR texts and models ( Tashakkori and Teddlie, 2010 ; Creswell and Plano Clark, 2011 ). Recent years have seen a steady growth in interest in MMR research on psychotherapy topics, including formulation and dissemination of APA guidelines ( Levitt et al., 2018 ).

As MMR research became more established, it became increasingly apparent that many MMR studies operate not primarily on the basis of a pre-determined research design that is then followed through, but on a collaborative process between a team of researchers each of whom represents a distinctive methodological competency, conceptual/theoretical perspective or area of lived experience (a useful discussion of this theme can be found in Wachsmann et al., 2019 ). A key element of this aspect of the real-life implementation of MMR research is that taking methodological pluralism seriously requires making use of people who are immersed in each approach or represent different perspectives, rather than depending on the less intense understanding of contrasting approaches and perspectives that might be available to a single research generalist. An additional area of methodological learning within the recent critical and reflective literature on MMR has been that successful studies pay particular emphasis on areas of difference (across methodologies, participants and theories), as well as areas of convergence, within the process of data collection and analysis ( Johnson, 2017 ).

The next step in the historical evolution of a pluralistic approach in research in psychotherapy and related disciplines has therefore comprised the development of attention to dialogical processes, described by Johnson (2017 ) and colleagues as a form of dialectical pluralism that as:

…asks all of us to appropriately listen to what needs to be listened to for each research question, purpose, stakeholder interest, and practical activity. This broad dialecticalism will enable people to continually interact with different ontologies, epistemologies, ethical principles/systems, disciplines, methodologies, and methods in order to produce useful wholes. The process should continually build on what we know and feel and value now and produce new, dialectically derived, “knowledge(s),” programs, theories, and deliberative democratic human coalitions. ( Johnson, 2017 , p. 158)

Johnson and Schoonenboom (2016 ) present an account of what dialectical pluralism looks like in practice, through exemplary studies on various aspects of healthcare practice. A common pattern of these studies is that researcher beliefs and knowledge (e.g. what they have found in an initial study, such as an RCT) are rigorously exposed to critique by relevant stakeholders (e.g. patients and healthcare providers), leading to a new shared understanding that can then form the basis for further cycles of inquiry. While dialectical pluralism is similar in some respects to a broader acknowledgement of stakeholder perspectives in healthcare research and realist evaluation ( O’Cathain et al., 2019 ), it goes further in calling for a systematic and disciplined capacity for listening, reflexivity and openness to difference on the part of researchers. Detailed accounts have been developed of techniques and strategies used by dialectical realist research teams to support the adoption of a dialectical or dialogical practices ( Johnson and Schoonenboom, 2016 ; Johnson, 2017 ).

A complementary research tradition that similarly incorporates a pluralistic and dialogical ethos can be found in studies that have adopted participative action research and collaborative inquiry approaches ( Ponterotto, 2005 ; McLeod, 2001 ). Such studies reflect a position that the primary aim of research should be to facilitate change in terms of promoting equality and social justice, empowering individuals and communities and solving real-world problems. For these researchers, the capacity to achieve such outcomes is the real test of the value or validity of a research study. This approach to research can be understood as a form of ‘engaged’ inquiry ( Chevalier and Buckles, 2019 ), influenced by the ideas and values promoted by key 20th century thinkers, such as Paulo Freire, Jurgen Habermas and Kurt Lewin ( Reason and Bradbury, 2013 ). It is also consistent with ideas of ‘collaboration as a matter of principle’ outlined as part of the psychotherapy social justice agenda ( Winter, 2019 , p.180). Typically, service users or community members may be involved in the design of a study, collection and analysis of data, writing and dissemination, for example in the programme of collaborative research that has involved service users and therapists working together to establish a basis for more effective therapy and recovery interventions in bipolar disorder ( Veseth et al., 2012 ; Billsborough et al., 2014 ). A similar approach to a collaborative, emancipatory approach to inquiry can be found within the methodological tradition associated with critical psychology ( Teo, 2015 ; Fine et al., 2021 ; Levitt et al., 2021a , b ).

Co-production is a further example of a pluralistically oriented form of research that promotes engagement and shared decision-making between researchers and participants. Drawing from the analysis by Ostrom (1990 ) of the operation of systems of common ownership ( Ostrom, 1990 ), co-production is a justice-based approach ( Cahn, 2000 ) that has been widely applied within national health and social care services in the United Kingdom to empower citizens to become participatory agents in their own care ( Coote, 2002 ; Needham and Carr, 2009 ; Worsley et al., 2021 ). Commitment to co-production is now a central funding criterion of the UK National Institute of Health Research, on the grounds that all research should be carried out ‘with and by patients, rather than to or for them’ ( NIHR, 2021a , b ).

As with the development of co-produced interventions in healthcare, co-produced research ideally involves the equal and reciprocal co-creative involvement from design, through action and into dissemination, with research partners drawn from a range of backgrounds and roles. The inclusion of multiple vested stakeholders in the design and implementation of research, allows for greater complexity of understanding of both the phenomenon at hand, and the nested systems within which it operates ( Gibert et al., 2010 ; Conte and Davidson, 2020 ). Additionally, the involvement of service users to develop relevant and timely research questions may help to reduce the widespread research-practice gap noticed especially in mental health research.

Co-productive research is driven by a commitment to a pluralistic stance that emphasises inclusion of multiple stakeholders and perspectives and mutual trust between research partners. The process of engaging in co-produced research has been termed as ‘turbulent’ and ‘challenging’ ( Worsley et al., 2021 ) due to the complex interpersonal dynamics that can arise when professionals and patients are asked to work together in partnership. Co-production research partners must commit seriously to hermeneutic justice ( Fricker, 2007 ), in which ways of understanding conveyed by different actors are considered to have equal value, especially where the voices of some actors have been previously silenced ( Blunden and Calder, 2020 ). Examples of co-produced psychotherapy research studies include Blunden (2020 ) and Curran et al. (2021 ).

These issues have inevitably led pluralistically oriented therapy researchers to look towards theory, research and practice around decolonisation as a source of understanding around how to handle such issues. A decolonial perspective involves facing up to deeply entrenched areas of injustice in contemporary society that are rooted in large-scale, violent historic exploitation of indigenous peoples and the lands on which they lived. Supported by the work of researchers, scholars, activists and artists in a wide range of disciplines in all parts of the world, this broad approach involves interrogating the roots of injustice and oppression, challenging existing power relations, achieving restorative justice and building postcolonial discourses and communities ( Goodman and Gorski, 2015 ; Barnes, 2018 ; Smith, 2021 ). One of the consequences of colonialism has been not only the unequal distribution of material goods and power, but also the fact that the majority of those in power does not recognise themselves as such but is still playing their part in larger discourses and abstract systems, such as patriarchy, privilege or in what is termed as ‘normal’ (e.g. neurotypicality and heteronormativity). Current movements and frameworks, such as Black Lives Matter, #MeToo, or critical psychology and intersectionality, are about finding one’s voice and amplifying the voices of marginalised others. Pluralistic inquiry can engage with this by asking questions inspired by postcolonial theory that address alienation, power differences and silenced voices. In recent years, even though some researchers and practitioners have begun to develop a postcolonial approach to psychotherapy research, it is clear that more needs to be done. For example, although trauma therapy has received considerable attention from a postcolonial perspective ( Bennett and Kennedy, 2003 ; Andermahr, 2016 ), traumatic experiences of minorities are still marginalised while Western definitions of trauma are taken as universally valid ( Craps, 2013 ).

This historical analysis has sought to provide an outline of how methodologies that reflect an explicit or implicit pluralistic standpoint have emerged over several decades as increasingly salient aspects of research in psychotherapy, counselling and related disciplines. The earliest references to methodological pluralism represented a response to the methodological hegemony of measurement and experimentation in research. Pluralism was put forward as a solution to the perceived limitations of relying solely on quantitative research approaches. These sources used the concept of plurality as a synonym for multiplicity and diversity, often within the conclusion section of an article or chapter, as something to be accepted and move towards (see, for example Rieken and Gelo, 2015 ). Over time, a pluralistic perspective began to move on from arguments about the legitimacy of qualitative and case study approaches to technical solutions to the challenge of combining different kinds of data. The most recent phase has been marked by the establishment of a distinctively dialogical, collaborative and co-production approach to the creation of practical knowledge in psychotherapy and allied disciplines, and then most recently to common purpose with political and scholarly initiatives around decolonisation. The underlying dynamic in this process has been a shift from interpreting pluralism as a form of respectful relativism that acknowledges the co-existence of different points of view to a more active stance that attends closely to difference as a source of learning and insight. This transition has required researchers to engage with uncomfortable and often emotionally troubling differences associated with power, colonialism, unearned privilege and other inequality fault-lines in contemporary society.

Principles of a Pluralistic Perspective on Psychotherapy Research

Although the development of a pluralistic perspective on research in psychotherapy has been based in the work of individuals and groups influenced by different conceptual frameworks and operating in different contexts, it is possible to identify some shared underlying methodological assumptions and practice implications.

Methodological and Epistemological Flexibility and Inclusiveness

A key principle of a pluralistic perspective on research is an appreciation that all ways of knowing and sources of knowledge have something to offer. Pluralistic inquiry does not define itself in opposition to other research traditions or consider any such traditions to be ill-founded. Instead, all forms of inquiry are regarded as possessing their own distinctive strengths and limitations. Pluralistically oriented psychotherapy research does not promote qualitative research over RCTs or neuropsychological studies, favour wholism and emergence over reductionism or vice-versa. An important study in relation to this topic was conducted by Levitt et al. (2020 ) who interviewed leading psychology researchers from a wide range of methodological traditions, around their stance in relation to the adopting a detached, objective research attitude or espousing the use of disciplined subjectivity. A striking finding from these interviews was that all of the research participants regarded both objectivity and subjectivity as serving valuable scientific purposes and had made use of their personal capacities for subjectivity and objectivity as necessary over the course of their careers.

A pluralistic perspective on research seeks to operate from the kind of both/and stance represented by informants in the Levitt et al. (2020 ) study. This principle represents a central implication of the ethical implications of espousing a pluralist view of reality: if different individuals and groups hold contrasting beliefs about what is true, the ethical choice is between discounting, ignoring or suppressing the beliefs of others or engaging in dialogue that seeks to make bridges between alternative ways of thinking. All of the pluralistically inclined research traditions discussed earlier in this paper reflect the latter ethical choice and can be regarded as invitations to move beyond established positions in ways that have the potential to broaden and fuse horizons.

Influential figures in the psychotherapy research community have argued that contemporary psychotherapy research and practice are dominated by a stultifying theoretical and methodological ‘monoculture’ ( Leichsenring et al., 2018 , 2019 ) and that a pluralistic perspective should be regarded as existing as a focus of opposition to such hegemonic tendencies. This is not the inclusive and invitational position adopted in the present paper, which views the psychotherapy research community as comprising many vibrant ‘micro-cultures’ that would benefit from talking to each other a bit more, in ways that would allow us all to learn with and from each other. The fact that large psychotherapy providers, such as government health departments and managed care organisations, might seek to impose uniformity around therapy services that are offered to the public is an indication that psychotherapy research might benefit from adopting a more pluralistic approach that takes political, social and historical and social factors into account.

Expect – and Welcome – Multiple Credible Answers to the Same Question

From a pluralistic perspective, research analyses and conclusions that yield multiple answers (divergence/dissensus) are of equal value to those that generate convergence/consensus. Pluralistically oriented research reports and reviews highlight different interpretations of data (e.g. by an auditor or co-researcher in a qualitative study, through application of alternative statistical techniques and attention to outlier cases) as having potentially significant implications for understanding, research, practice and theory development. Diverging perspectives or findings arising from different data sources or participants are viewed as steps in a dialectical process that has the potential to lead to a new (or more differentiated) theory or synthesis ( Levitt et al., 2020 ). The existence of multiple ‘truths’ is not only a core philosophical assumption of pluralism but also is a routine aspect of the practice of psychotherapy: much of the process of therapy is based on the creation of meaning bridges, empathy and ways of talking and connecting that have the effect of allowing people to function within a multi-voiced intra- and interpersonal reality. By corresponding more closely with everyday experience, multiple answers to a research question have the potential to make findings not less, but more relevant for policy and practice.

Active Promotion of Epistemic Justice

Within both the natural and social sciences, there are multiple ontological and epistemological positions that are utilised in the service of legitimate inquiry. There also exist highly significant knowledge structures within society as a whole, for example in respect of spiritual and faith beliefs, and indigenous systems of knowledge, that operate independently of scientific empirical knowing. In everyday life situations, participants make use of multiple ways of knowing alongside scientific evidence, for example personal experience, knowledge arising from membership of a culture or occupational group, ethical values, theoretical understanding and narrative knowing. Psychotherapists and clients routinely operate within and across these alternative ways of knowing. In relation to psychotherapy research, these factors mean that it makes little sense to regard any single source of knowledge (e.g. RCTs or meta-analysis of RCTs) as offering a reliable guide to practice or decision-making. Instead, practical decisions should be based on a balanced and informed appraisal of all available sources of evidence.

Occasions when someone in authority (e.g. a therapist or policy-maker) unilaterally prioritises one source of evidence over another should be viewed as episodes of epistemic injustice and misuse of epistemic privilege. Fricker (2007 ) identified two forms of epistemic injustice: testimonial injustice , where evidence provided by a person is not taken seriously because of who they are (e.g. a client’s evaluation of therapy being disregarded because of their alleged diminished capacity for rationality) and hermeneutical injustice when a source of evidence is not well enough understood at an institutional or organisational level for it to be taken into account (e.g. when journal reviewers reject qualitative research manuscripts because of lack of knowledge of qualitative methodology). Epistemic injustice has been identified as highly prevalent in mental health settings, for instance in terms of lack of credence given to the cultural and experiential knowledge of service users, and black and minority ethnic staff and clients ( Carel and Kidd, 2014 ; Crichton et al., 2017 ; Kidd and Carel, 2017 ; Newbigging and Ridley, 2018 ). Epistemic injustice may also occur with research groups, for example when qualitative data are analysed by members of a research team that includes novice researchers alongside senior academics, or individuals from different cultural or social class backgrounds ( Levitt et al., 2021a ).

A pluralistic perspective on research pays particular attention to strategies for prevention of epistemic injustice through relevant design, data collection and analysis, and dissemination, and intentional choice of research topics and questions intended to address previous epistemic injustice (e.g. carrying out research in collaboration with members of marginalised groups).

Dialogue as a Criterion for the Validity, Credibility, Trustworthiness and Practical Utility of Research Conclusions

Scientific research is an essentially collective process, that depends not only on the capacity for imagination and rational thinking of individual researchers, but on the capacity of a set of findings to enter and survive the process of dialogue with other, independent members of a scientific community, in the form of critical responses or readers and reviewers, replication studies and data re-analyses ( Brown, 2012 ; Stuckey et al., 2015 ). Because therapy research is fragmented into sub-communities (e.g. groups who study psychodynamic therapies, or CBT, or humanistic therapies), most research reports are only read by those who are already broadly predisposed to agree with what is being reported ( McLeod, 2017 ). In addition, major groups of possible stakeholders who might have a view on the findings of a study, such as practitioners and clients, rarely or never read research papers. In some qualitative research papers, even though data and findings may be made available for comment by independent research auditors, or research participants, the ensuing dialogue with researchers is seldom reported. Taken as a whole, these scenarios mean that therapy research studies are scrutinised to a very limited extent. By contrast, the practice of both pluralistic therapy and pluralistic research relies on a process of putting difference to work through treating contrasting perspectives as opportunities for learning ( Johnson, 2017 ). Both pre- and post-publication open dialogue around research reports have the potential to produce findings that are more nuanced and relevant to practice ( Nosek and Bar-Anan, 2012 ). While the broader scientific community has found it hard to sustain such initiatives ( Wakeling et al., 2019 ), there are sufficient motivated and interested practitioner and service user readers to make such an approach feasible.

Doing Research That Is Oriented Towards the Accomplishment of Social Justice Goals

Pluralism is associated with a pragmatic philosophical stance in its emphasis on evaluating the success of any actions in terms of criteria that are decided at a local level, rather than on the basis of abstract or universal criteria ( Fishman, 1999 ; Hanley and Winter, 2016 ). In pluralistic therapy, for example the process of therapy and the final decision on whether it has been helpful are anchored in goals identified by the client. Similarly, one of the implications of a pluralistic perspective on research is that an important criterion for evaluating studies should be in terms of the difference that they make in relation to social needs and goals that are meaningful to individuals and communities. An example of the difference between research that is personally and theoretically meaningful, as against aiming to address social injustice, can be found in a programme of research into the role of counselling and other forms of emotional support for people experiencing sight loss. This programme originated in a stand-alone grounded theory qualitative study of the emotional impact of sight loss ( Thurston, 2010 ). The experience of conducting this study, and in particular the response of others to its publication, opened a specific societal goal (development of emotional support services for sight loss) that served to guide the direction of further work. Further studies drew on other methodologies, such as case study analysis ( Thurston et al., 2013 ) and surveys ( Thurston and Thurston, 2013 ; Pybis et al., 2016 ). Because the social significance of this research was apparent to individuals with sight loss, health professionals, third sector vision impairment organisations, researchers from other disciplines and politicians, it became able to draw on an expanding network of collaborative consultation and dialogue, and to co-produce training courses for counsellors and other helpers. Many other similar examples of research programmes oriented towards social justice goals could be identified.

Authentically pluralistic and inclusive research that involves collaboration, co-production and dialogue is more likely to occur in situations in which a programme of research is organised around a social goal that is sufficiently broad and practically significant, and whose relevance is sufficiently widely acknowledged to energise the passion, active involvement and passion of individuals and groups beyond the academic community. Such situations enable research partners to bring their own sources of power into a project. In such research contexts, the concept of passion refers to the capacity of participants to be motivated by a goal that transcends their own individual interests, draws on all aspects of who they are as a person and calls for sacrifice in the service of a greater good ( Duffy et al., 2013 ).

The methodological principles outlined above, derived from philosophical and social usage of the concept of pluralism, as well as the range of pluralistically oriented research traditions already discussed, provide a preliminary guide or checklist for thinking about how to incorporate a pluralistic perspective into research in psychotherapy.

Pluralistically Oriented Therapy Research: Illustrative Case Examples

Within the field of psychotherapy research, although there are few studies that have explicitly espoused a pluralistic perspective, it is possible to use pluralistic principles to develop an understanding of what might be missing in the ways that studies and reviews are conducted. In the following sections, the area of research on psychotherapy for depression is used to explore some of the ways in which a pluralistic perspective makes it possible to begin to see how dialogical and collaborative approaches might enhance the practical utility of personal and institutional investment in psychotherapy research into this major mental health issue. The focus then turns, more briefly, to consideration of the relevance of a pluralistic perspective to methodological challenges around collaboration in research, investigating culturally-responsive therapy and conducting pluralistic systematic reviews.

Pluralizing Depression

Apart from its inherent significance as a major area of therapy theory, research and practice, the topic of psychotherapy for depression is of interest from a pluralistic perspective because it has been the recent focus of critical scrutiny in the United Kingdom that makes it possible to identify different ways of thinking about evidence, and significant failures in dialogue. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) 1 is an independent, government-funded organisation that publishes clinical guidelines to support clinical decision-making in physicians and other practitioners in relation to a wide range of health conditions and aspects of social care. Guidelines are informed by an evidence hierarchy in which systematic reviews of RCTs are given the highest weighting and are updated on a regular basis. NICE guidelines are regarded by clinicians in many countries as demonstrating exemplary standards of rigour. In 2009, NICE published a set of guidelines on the treatment of depression, which recommended a range of psychological therapies that might be used for different degrees of symptom severity. In 2017, following an extensive period of consultation and a systematic meta-analysis of new evidence, it produced a draft of an updated depression guideline, which was circulated to stakeholder groups for comment. Despite the fact that the review process and guideline recommendations were formulated by leading figures within the research community, the 2017 draft revised guidelines (which strongly favoured CBT) were widely rejected by key stakeholder groups, including psychologists, psychiatrists, general practitioners, counsellors, psychotherapists and service user organisations (see, for example Barkham et al., 2017 ; McPherson et al., 2018 ; Thornton, 2018 ). The central issue, for critics, was that the procedure had not been sufficiently pluralistic. In particular, application of an evidence hierarchy that placed the highest value on RCTs and systematic reviews of RCT findings was regarded as having had the effect of omitting or downgrading crucial sources of evidence, such as qualitative client experience studies and naturalistic studies of routine therapy practice in everyday therapy settings.

The critical response to the draft NICE depression guidelines is consistent with findings from a study of a different NICE guideline project, that, in itself, RCT evidence is not necessarily regarded as reliable and trustworthy, even within groups of senior researchers who have spent their careers conducting such studies ( Brown et al., 2016 ). The issue of trustworthiness was further explored in relation to RCT evidence relating to psychotherapy for depression in a unique investigation conducted by McPherson et al. (2020 ). In this study, groups of people with an interest in mental issues (mainly service users, carers and GPs) received a detailed presentation on a psychotherapy for depression RCT study and then invited to share their reactions to what they had heard. None of the participants were convinced that the study that had been described to them helped them to understand therapy for depression or provided information that might help them to decide whether or not such therapy might be relevant to them or to other people they knew. They regarded the RCT design as over-simplifying a complex set of issues and generating ‘headline messages’ that were misleading. Participants in the McPherson et al. (2020 ) study also had many suggestions about the type of study that might be more relevant. From a pluralistic perspective, the significance of this study lies in its demonstration that lay people with personal experience of mental health issues are capable of contributing to dialogue around the pros and cons of different types of research, if provided with an appropriate setting within which such conversations can take place.

Another area in which a pluralistic perspective highlights problematic aspects of research on therapy for depression is concerned with how depression is defined, measured and understood. Depression outcome studies typically evaluate the effectiveness of treatment using self-report symptom measures completed by clients, such as the Beck Depression Inventory (BDI) or Patient Health Questionnaire (PHQ-9), at the beginning and end of therapy. Historical analysis by McPherson and Armstrong (2021 ) has demonstrated that the concept of depression embodied in these measures has become narrower over time. Other studies have analysed qualitative evidence around how clients, their family members and therapists decide whether therapy has had an effect on depression and has found that these stakeholders make use of a much wider set of outcome criteria than those deployed in research studies ( Catchpole, 2020 ; Chevance et al., 2020 ; De Smet et al., 2020 ; Krause et al., 2020a , b ). Research into the experience of depression in everyday life has found that lay people possess complex and highly differentiated discourses and frameworks for making sense of recovery from depression ( Hänninen and Valkonen, 2019 ; Llewellyn-Beardsley et al., 2019 ; Bear et al., 2021 ), including a range of possible pathways to change ( Valkonen et al., 2011 ). Finally, studies in non-Western cultures observe important differences between the ways that depression is understood in these settings, and the measures used by therapy researchers ( Haroz et al., 2017 ; Vink et al., 2020 ). Looking at the ways in which depression is measured and understood in therapy research as a whole, it seems apparent that researchers are missing potentially important aspects of the phenomenon they are investigating, and not taking sufficient account of differences between professional and everyday ways of understanding depression. By contrast, a pluralistic orientation to research would suggest that these are crucial areas of investigation for producing a practically relevant evidence base around how to help people to move on from depression. Stänicke and McLeod (2021 ) provide an example of how attention to these forms of difference and paradox may be used to stimulate new directions in therapy research.

Research into therapy for depression predominantly reflects a narrow focus on the process and outcomes associated with specific depression-related aspects of what happens in the therapy room. However, therapy for depression rarely occurs in isolation. Most clients who are depressed report other co-existing problems and issues ( Morrison et al., 2003 ). Clients make use of other forms of help alongside seeing a therapist ( Wilson and Giddings, 2010 ). Family members are involved in a myriad of ways, whether or not the therapist every meets them face to face ( McPherson and Oute, 2021 ). A large proportion of clients has made use of antidepressant medication in the past or is on medication while receiving therapy. These activities are likely to have exposed them to a ‘chemical imbalance’ explanation of depression that may be difficult to reconcile with therapy ( France et al., 2007 ; Kemp et al., 2014 ). The sequencing of therapy and medication may follow different pathways. Some clients turn to therapy when medication has not helped, and they have reached rock bottom ( Wells et al., 2020 ). Others regard medication as energising them sufficiently to engage with psychotherapy ( Cartwright et al., 2018 ). A pluralistic perspective highlights the significance of these (and many other) aspects of therapy for depression that transcend a specific therapy focus or depression focus.

The kind of critical social analysis that is entailed by a pluralistic perspective invites analysis of how differences in power and status have shaped contemporary approaches to research into psychotherapy for depression. The emergence of depression as a major mental health issue, in the 1950s, arose from the efforts of drug companies to develop markets for new products ( Healy, 1999 , 2006 ; Greenberg, 2010 ). These initiatives involved incentives to family physicians to diagnose patients as depressed, direct marketing to members of the public and funding for psychiatrists to revise the diagnostic manual of the American Psychiatric Association to highlight a medicalised concept of depression ( Davies, 2021 ). A Western medicalised understanding of depression was exported to other countries worldwide. For example, Kirmayer (2002 ) described the intensive drive to promote antidepressants in Japan, in the face of considerable local opposition. As psychiatric diagnoses became established as the primary organising principles for mental health provision and conditions for reimbursement and employment, counsellors, psychotherapists and psychologists gradually integrated medical terms, such as depression, into their research and practice. Because diagnosis operates on a universalistic basis in which everyone’s problems are categorised in the same way, it became harder to talk about differences arising from culture, social class and gender. Although psychotherapy for depression does not share the brutal history of colonial exploitation of non-European peoples, the pluralisation of this area of practice has much to learn from decolonising approaches to research ( Kiddle et al., 2020 ; Smith, 2021 ).

This case study of research into psychotherapy for depression illustrated the limitations of existing approaches to depression research in terms of their adoption of a hierarchy of evidence that largely stifled the application of multiple sources of knowledge, use of assessments that were uni-dimensional, the medicalization and decontextualization of complex social problems and persistent euro-centrism. In such a context, the application of a pluralistic perspective has the potential to generate socially relevant research evidence through the adoption of a ‘pluralizing’ mindset that focuses on widening one’s gaze using a ‘both/and’ heuristic, questioning the rationale for any narrowness of view, and deep curiosity around difference.

Openings for Pluralistic Inquiry

While research on psychotherapy and related practices is increasingly shaped by a pluralistic sensibility, the transition to an explicit pluralistic research paradigm is at an early stage. As a result, there are no studies that have fully embraced pluralistic principles. Nevertheless, it is appropriate, in relation the aims of the present paper, to identify some examples of practical strategies that researchers have used to take established psychotherapy research approaches in a more pluralistic direction.

The psychotherapy literature includes many systematic reviews or metasyntheses that bring together the findings from all published studies on a topic. The majority of these reviews focuses on either qualitative or quantitative studies, with the consequence that it is not possible to compare evidence generated by different methodological approaches. Reviews by Pomerville et al. (2016 ), Greenhalgh et al. (2018 ) and Wu and Levitt (2020 ) demonstrate how it is possible to incorporate findings of qualitative and quantitative studies in a single review. The Pomerville et al. (2016 ) review takes a further pluralistic step in reporting review findings in terms of contrasting interpretative themes rather than a unified model. The potential for enhancing the social relevance of reviews through involvement of stakeholders is discussed by Abrams et al. (2021 ). An example of how this can be accomplished can be found in De Weger et al. (2018 ).

A significant development in qualitative research in recent years has been the widespread adoption of the use of multiple data analysts (e.g. an independent external auditor, research team members or research participants) as a validity criterion to support the trustworthiness of findings. The methodological assumption underpinning this procedure has been that the use of multiple analysts operates as a means of reducing misunderstandings of the data that might arise when there is only a single researcher. Within the qualitative research community, this practice has been accompanied by an interest in how power differences in understanding and data interpretation between co-analysts (e.g. members of a research team or between researchers and participants) might be handled (see, for example Levitt et al., 2021a ) to ensure that final consensus judgements reflect open discussion rather than domination by more powerful voices, while still recognising legitimate differences between researchers. While such respect of epistemic justice is consistent with a pluralistic perspective, what is even more valuable is also to attend to the potential meaning and significance of differences in how co-analysts make sense of qualitative data. Nuala Frost and colleagues have shown that attention to the contrasting interpretations offered by different analysts enhances the meaningfulness of findings ( Frost et al., 2010 ; Frost, 2016 ). Studies building on the work of Halling and Leifer (1991 ) have shown that dialogue between researchers (i.e. beyond mere consensus agreement) generates new understanding. A wide range of practical strategies for enabling research participants to engage effectively in such collaborative processes has been described by Moltu et al. (2013 ), Hallett et al. (2017 ), Matheson and Weightman (2020 , 2021 ), Fine et al. (2021 ) and Soggiu et al. (2021 ).

A final area of emergent pluralistically informed practice concerns ways of conducting research that is not only sensitive to cultural difference but actively functions to promote the interests of members of oppressed and silenced communities. How can we create a psychotherapy research discourse that allows those who are currently silenced to be heard? Postcolonial writers, such as Spivak (2003 ), argue that for the ‘subaltern (i.e. the person subjected to colonial rule) to speak, and be heard, they are required to use the language and concepts of the dominant group. In counselling and psychotherapy, this means using the language and theories that have been established in the West. The use of terms, such as ‘ethnopsychotherapy’, ‘indigenous therapy’ and ‘culturally adapted therapy’, reinscribe this hegemony, by implying that Euro-American psychotherapy is the ‘unmarked category’, while others are ‘ethnic’, ‘indigenous’ or ‘adapted’ ( Zerubavel, 2018 ). Pluralistic inquiry calls for awareness of how to ensure that research participants are not subjected to this kind of discursive erasure. Examples of how this can be accomplished include a remarkable study by Gone (2021 ) in which he uses his own insider knowledge as a member of an indigenous community, and his professional knowledge as a psychotherapy researcher, to allow the voice of an indigenous healer to be heard in a manner that would make sense to other therapy practitioners and researchers. A study by Mehl-Madrona (2009 ) used a humility-based strategy in simply asking elders in an indigenous community to tell him that they thought that Western practitioners need to know in order to be helpful to them. In a study by Waddell et al. (2021 ), a research partnership was built up through joint participation in indigenous spiritual rituals over an extended period, prior to data collection and analysis.

The examples of openings for pluralistic inquiry outlined in this section are not intended as a comprehensive account of how to conduct pluralistic research or reviews on psychotherapy topics. Rather, the intention has been to show how a pluralistic perspective builds on existing methodologies in ways that allow difference to become a focus of interest.

A Pluralistic Perspective on Evidence

Within the domain of psychotherapy policy, research and practice, one of the most significant implications of adopting a pluralistic perspective is that it invites further consideration of what counts as evidence. There is broad agreement within professional communities, and society as a whole, around the value of evidence-based practice (EBP). The most widely cited definition of EBP within the field of medicine describes EBP in terms that are consistent with a pluralistic standpoint that acknowledges multiple perspectives and stakeholders:

…the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research [and]… thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences ( Sackett et al., 1996 , p. 71).

A similarly pluralistic stance in relation to evidence is apparent in an APA policy position that resulted from years of debate within the field of psychotherapy research:

Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences ( American Psychological Association, 2006 , p. 273)

When practising in evidence-based way, the APA recommends that the practitioner should draw on a wide range of knowledge sources that may be relevant for each particular case, including:

…clinical observation, qualitative research, systematic case studies, single-case experimental designs, public health and ethnographic research, process-outcome studies, studies of interventions as these are delivered in naturalistic settings (effectiveness research), RCTs and their logical equivalents (efficacy research), and meta-analysis ( Levant, 2005 , pp. 7–8).

The underlying principles of EBPP are radically different from defining evidence in terms of specific methods (e.g. experimental designs, such as RCTs). Instead, the statements cited above advise that clinical decisions should be made in a collaborative manner that takes account of the local context and cultural beliefs and preferences of each client and that information about research findings associated with different methodologies being made equally available to clinicians.

A pluralistic perspective goes further than these EBPP principles, by opening up an appreciation not only of collaborative decision-making around the application of research evidence but also collaborative co-production and critique of the evidence itself. In large part, the medical research being considered by Sackett et al. (1996 ) largely consisted of findings from laboratory science and drugs trials that could only be fully understood by a relatively small number of specialist researchers. By contrast, most research studies of psychotherapy are intelligible, and of interest, to a wide potential readership of therapists, clients and other stakeholders. In a study by McPherson et al. (2020 ) mentioned earlier, when the design, procedures and results of a psychotherapy RCT were explained to service users and other stakeholders, they were highly sceptical of the value of evidence that it provided. The issue of the credibility of evidence from psychotherapy research can be understood as arising from the fact that any research study generates a set of truth claims that are grounded and warranted in terms of methodological procedures that have been followed ( Toulmin, 1958 ). For example, clients have been helped by therapy because they exhibited reduction in depression scores as measured by the BDI which had been administered and analysed in a competent manner by trained researchers. However, therapists or clients who read such a study may have other grounds and warrants available to them, such as an understanding of depression that is different from BDI item content, or other explanations for why scores changed over time ( McLeod, 2021 ). When non-researchers closely scrutinise psychotherapy research studies (as in McPherson et al., 2020 ) it becomes apparent that the truth claims that they encounter in such research reports are to a large extent only warrantable within the narrow parameters of specific research and practice sub-cultures and readily fall apart when exposed to truth claims arising from lived experience.

A pluralistic perspective on psychotherapy research suggests that the quality and credibility of evidence that is available to inform policy and practice would be enhanced by wider dialogue around the design and conduct of studies, data analysis and the meaning and implications of research findings. This dialogue can take place between groups of researchers and across academic disciplines and also between the research community and any other people and groups (clients, practitioners, members of the public and interest groups) who have a stake in making sure that the therapy that is being offered is relevant to the needs of individuals and communities. The relative absence of such dialogue, at the present time, can be understood as representing a form of epistemic injustice that has been described as a manifestation of ‘strategic ignorance’: the process through which members of privileged groups in society retains epistemic control by ‘knowing what not to know’ ( McGoey, 2010 , 2019 ).

In the wider field of healthcare, the limitations of defining evidence in terms of specific methods, such as RCTs and systematic meta-analysis reviews, have been recognised as contributing to difficulties in providing individualised patient-centred care. An important strand of this evolving critique has been the analysis of the implications of basing research in a narrow conceptualisation of causality, alongside a growing awareness of the possibilities associated with a pluralistic understanding of causes that draws on concepts, such as affordances, dispositions and vectors ( Anjum et al., 2020 ). A flexible, conceptually rich framework for making sense of everyday causality already exists within behavioural psychology ( Haynes et al., 2012 ). From a pluralistic perspective, as well as embracing methodological diversity and stakeholder dialogue, the task of enhancing the relevance and sensitivity of research evidence needs to consider the implications of different ideas about causality for the conduct and analysis for all research designs.

Demonstrating the practical societal relevance of co-produced forms of evidence represents a major challenge for those who support the adoption of a more pluralistic approach to psychotherapy research. Currently, we are in a situation in psychotherapy research in which the training received by most researchers limits their understanding of the wide diversity of research approaches that exist. In addition, grant agency boards are filled with researchers who have established their reputations on the basis of expert implementation of a similarly restricted set of established methodologies, and the procedures of grant agencies and governmental guideline commissioning groups generally use an evidence hierarchy framework to inform their decision-making. The views of such sector leaders are unlikely to be swayed by academic debate around research methodology and values. To make an impact on business as usual within psychotherapy research policy and practice, it is necessary to produce actual research findings that demonstrably make a difference.

As discussed earlier, one of the guiding principles of pluralistically informed inquiry is the intention to carry out research that is oriented towards the accomplishment of social justice goals. What this means is that, from a pluralistic perspective, research evidence is evaluated in terms of the extent to which it contributes to creating a better society, alongside whatever technical validity criteria and theory-building aims that may be applicable. Methods for evaluating the extent to which programmes of research accomplish social goals are not well-developed. Nevertheless, at the present time, it is hard to argue that more than 70years of psychotherapy research have led to an improvement in the effectiveness of psychotherapy or the reduction of mental health problems in society. Analysis of historical trends in psychotherapy outcomes has not shown that therapy has become more effective, even in areas of practice that have been supported by considerable investment in research, such as CBT for depression ( Johnsen and Friborg, 2015 ), psychotherapy for problems reported by young people ( Weisz et al., 2019 ) and suicide prevention ( Fox et al., 2020 ). Leading figures in psychotherapy research have argued that the difficulties in applying RCTs in psychotherapy contexts mean that evidence generated by this methodology is best by a wide range of potential biases that are hard to control ( Cuijpers et al., 2019a , b , 2020 ). It has also been suggested that RCT evidence lacks relevance for the development of the kind of service provision that is likely to appropriate to future social needs ( van Os et al., 2019 ). In addition, among those RCTs that have been most influential in setting the agenda for therapy policy and provision, few have ever been replicated, and most stand out as outliers in terms of reporting more positive findings than other similar studies ( Frost et al., 2020 ).

A pluralistic perspective makes it possible to re-vision the types of evidence that can be used to inform psychotherapy practice. For example the logic of a collaborative style of research is consistent with initiatives that use research tools and strategies to enable specific psychotherapy provider organisations, or networks of clinics in a particular city or region, to collect and analyse data from clients and other stakeholders in the context of on-going action research that aims to generate enhanced mental health outcomes at a community level. At the present time, the assumption that service improvement requires the top-down application of generalised knowledge from RCTs has meant that such ground-up projects have rarely been attempted on a sustained basis. Within a 3–5year period, a pluralistically informed action MMR study along these lines, that involved co-productive research alliances with clients, practitioners and community groups, might be able to demonstrate tangible effects on social wellbeing and cultural capital that would be hard to for funders and policy-makers to ignore.

In terms of the type of evidence that is produced by collaborative and co-produced studies, a significant consequence of greater involvement of clients, practitioners and other stakeholders will be that research findings will become more contextualised. On the whole, the type of knowledge that academic researchers bring to the inquiry process is more focused on theoretical perspectives, whereas the knowledge and interest of community-based stakeholders are more focused on the specific local context with which they are familiar. Greenhalgh and Manzano (2021 ) discuss the ways in which attention to context can enhance the practical relevance of research.

The aim of this paper has been to highlight some of the ways in which a pluralistic philosophical stance might enhance the practical value and social relevance of research in psychotherapy and related disciplines. We continue to be surprised by what is uncovered by a pluralizing way of thinking. We are continually challenged by the interpersonal skills and social courage that entailed in a pluralistic perspective, and encourage readers to view our ideas as a starting point and invitation to collaboration and further dialogue. Our experience has been that a pluralistic perspective has heighted our appreciation of the value of existing methodologies. Just as pluralistic therapy provides a framework for channelling existing therapeutic ideas and methods in the service of helping a client to attain their life goals, a pluralistic perspective on research similarly regards existing methodologies as invaluable resources to be cherished and used as appropriate. The therapy research community has created a massive array of research tools (see, for example Liamputtong, 2019 ). A pluralistic perspective does not seek to re-invent these techniques but merely to offer some ideas about how they can be most effectively combined and deployed.

Pluralism offers a philosophical and conceptual meta-model that can be used as a guide (along with other meta-perspectives) to thinking about long-term research objectives and purposes. Pluralism also opens up a wide range of concrete activities, projects and practices that can be pursued immediately. Examples of achievable, low-cost pluralistically oriented research initiatives include as: experimenting with open review/comment journal publishing; conducting pluralistically informed research reviews that incorporate evidence not only from different methodologies but also make use of review teams with different cultural backgrounds and life experience; activating co-production at a local level through collaborative projects that use research to enhance practice in specific agencies/clinics; and learning with and from other disciplines, occupational groups and community organisations through joint seminars and workshops that share experience in co-production, decolonising, and strategies for working constructively with difference.

To move away from euro-centrism, and profession-centrism, the psychotherapy research community needs to do more to recognise forms of practice beyond existing professional labels. There are many places in the world where psychotherapy is not professionalised but where people nevertheless help others through various psycho-social interventions, practices and rituals ( Zacharias, 2006 ). A pluralistic perspective aims to include these practices, perspectives, concepts and principles and recognises their value and potential enrichment of both theory and practice. At the same time, pluralism also takes a critical stance by reflecting on whether these practices and ideas should be subsumed within its own discourse. It can also highlight potentially problematic appropriations. For example some therapeutic schools have borrowed concepts and methods from other cultures (e.g. mindfulness and Morita therapy), but often stripped them of the cultural context, omitting the voices of the people who offered them and developed the ideas around them. Pluralistic inquiry can offer an antithesis to research that whitewashes concepts and methods borrowed from other cultures by revealing their cultural embeddedness. Western concepts and practices of psychotherapy are often implanted without adapting them to cultural contexts, effectively marginalising local knowledge of healing ( Sidhu, 2017 ). Through a pluralistic perspective, researchers can develop dialogues and use tools that support practitioners to develop counselling practices on the basis of indigenous cultural strengths and resources.

Finally, we suggest that it is essential to highlight the potential broader outcomes of pluralistically oriented research, beyond the specific domain of therapy theory and practice. All peoples and cultures are bound together in a collective need to change our way of life and relationship with nature in order to create ways of surviving the inevitable climate crisis that we have brought about. Core elements of that dysfunctional way of life include racism, colonialism, slavery/trafficking and militarism. Erosion of democratic processes represents a key element in the on-going failure to address these crises. Adoption of a pluralistic approach to therapy research has the potential to help us, as psychotherapists, mental health practitioners and researchers, to develop ways of understanding and conducting collective inquiry that provide all participants with awareness and skills around shared decision-making, listening to others, working together, live with complexity and uncertainty and be willing to stand up for collective values and justice. Along with re-visioned therapy practices, these research outcomes represent some of the ways in which we might hope to be able to support individuals, families and communities to engage in active citizenship.

Data Availability Statement

Author contributions.

All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Funding. The authors received publication fees for this article from Abertay University. No other funding was received for the development of this publication.

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A brief introduction to pluralistic counselling and psychotherapy

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Objective: Over the past 25 years, humanistic psychotherapy (HP) researchers have actively contributed to the development and implementation of innovative practice-informed research measures and coding systems. Method: Qualitative and quantitative research findings, including meta-analyses, support the identification of HP approaches as evidence-based treatments for a variety of psychological conditions. Results: Implications for future psychotherapy research, training, and practice are discussed in terms of addressing the persistent disjunction between significant HP research productivity and relatively low support for HP approaches in university-based clinical training programs, funding agencies, and government-supported clinical guidelines. Conclusion: Finally, specific recommendations are provided to further enhance and expand the impact of HP research for clinical training programs and the development of treatment guidelines.

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This essay will explore the integrative and collaborative model for eating disorders (ED) such as: bulimia nervosa, anorexia nervosa, binge eating disorder, as well as eating disorders not otherwise specified. The essay presents the idea of EDs as multifactorial and involving the totality of the person’s life experience, as opposed to merely involving eating and food. Thus, although normalising the person’s eating is of seminal importance, it is not enough in re-establishing the person’s well-being to merely focus on food. Moreover, the author’s 1-year experience at Bodywhys helpline for EDs has served as a practical basis for discussing both person-centred (PCT) and multicultural (MCT) interventions in this essay, both used at Bodywhys. EDs are especially challenging area in that, in the author’s experience, clients often seek technical help rooted in the medical model, while overlooking their life story as well as their feelings as a contributing factor in their behaviour choices, as well as their self-image. Thus, in author’s view, the challenge is to help the client regain a sense of control of their lives, similarly to substance misuse (Parsons 2005; Sharf 2010), but also a sense of goodness with regard to their body image. The key to unlocking the solutions to this personal lack is often outside what the medical and cognitive-behavioural models, no matter how important and vital, can provide. The essay attempts to make a case for multidisciplinary approach to EDs, which would enable a more holistic body-mind-soul view of the person, rather than a strict physiology or cognitive neuroscience take on EDs. Moreover, it is hard to separate sociological and cultural outlook from the actual interventions, when it comes to EDs as an extremely scattered (in terms of explanation) and multifactorial issue. Despite the scarcity of studies directly linking good outcomes for EDs to the chosen modalities (PCT, CT/RT and MCT), this paper will attempt to make a case for a link between EDs and the lack of existential-behavioural autonomy and personal worth that these therapies can provide, which may prove useful in recovery (for instance, Treasure & Schmidt 2001).

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This Roundtable Discussion seeks to engage with the challenge of working existentially in a genuinely phenomenological fashion. The discussion will focus on possible tensions between attempts to conceptualise and formulate clients' issues on the basis of existential theory and a commitment to a phenomenological method of exploration. Phenomenological ways of thinking and working are relational and process-focused and attempt to do without recourse to abstract concepts and notions. By contrast, descriptions of existential approaches to psychotherapy/ counselling often involve the identification of relevant categories drawn from existential philosophy that are then used to make sense of experience. It could be argued that whilst this generates interesting and often helpful insights, it also serves to dilute the phenomenological dimension and renders the 'existential approach' indistinguishable in form (though not, of course, in content) from other theories of human experience and behaviour. The aim of the Roundtable discussion is to reflect on these issues and to identify ways in which 'theory' can be used to guide us without turning into a 'set of tools' or an interpretative frame.

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Mick Cooper Training and Consultancy

Person-centered therapy: A pluralistic perspective

Updated author final version of:

Cooper, M., & McLeod, J. (2011). Person-centered therapy: A pluralistic perspective. Person-Centered and Experiential Psychotherapies , 10(3), 210-223.

INTRODUCTION

Since the 1970s, the field of person-centered therapy has witnessed increasing differentiation (Lietaer, 1990), with the emergence of several distinctive “tribes” (Sanders, 2004; Warner, 2000). Some have questioned the legitimacy of certain members of this family (e.g., Brodley, 1990), but with an increasing emphasis on “inclusivity and the embracing of difference” within the PCE world (Sanders, 2007, p. 108), many now see this diversity as a positive quality to be prized (e.g., Cooper, O’Hara, Schmid, & Wyatt, 2007). From this standpoint, each of the members of the PCE family can be seen as drawing on, and developing, different elements of Rogers’ work. While those who identify with a “classical client-centered” standpoint, for instance, can be seen as orientating primarily around Rogers’ (1942) concept of nondirectivity (e.g., Bozarth, 1998; Brodley, 1990); emotion-focused/process-experiential therapists (e.g., Greenberg, Rice, & Elliott, 1993) can be understood as placing more stress on the affective experiences and processes that Rogers placed at the heart of the therapeutic enterprise (e.g., Rogers, 1959).

The aim of this paper is to introduce, and critically discuss, an alternative reading of what it means to be person-centered. This is one that is primarily rooted in the idiographic assumptions underlying the person-centered worldview: that each individual is distinct, and that the role of the therapist should be to facilitate the actualization of the client’s unique potential in the way that best suits the individual client.

PERSON-CENTERED VALUES: PRIZING THE UNIQUENESS OF HUMAN BEING AND BECOMING

Person-centered therapy, as with other humanistic and existential approaches, can be understood as a form of counseling and psychotherapy which puts particular emphasis on “conceptualizing, and engaging with people in a deeply valuing and respectful way” (Cooper, 2007, p. 11). As a consequence of this, a key element of person-centered thought is a rejection of psychological and psychotherapeutic systems which strive to reduce individual human experiences down to nomothetic, universal laws and mechanisms. Rather, there is an emphasis on viewing each human being “as a unique entity, unlike any other person who has existed or will exist” (Cain, 2002, p. 5). In other words, while person-centered theorists have argued that certain psychological features, such as the need for positive regard or conditions of worth (Rogers, 1959), are universal, there is a particular emphasis on the fact that each human being is distinctive, irreplaceable and inexchangeable. Levitt and Brodley (2005, p. 109), for instance, stated that client-centered therapy “is not centered on what a general client would or should be. It is not centered on a theory external to the client…. The focus of the therapist is entirely on understanding the client as an individual, in all his uniqueness, from moment to moment.”

In Rogers’s work, this idiographic emphasis is particularly evident in his assertion of the “fundamental predominance of the subjective” (Rogers, 1959, p. 191). Each individual, for Rogers (1951, p. 483), “exists in a continually changing world of experience of which he is the center”; and, given that this ever-changing phenomenological experiencing will be unique to the individual, the very essence of each human reality is distinct. Rogers’s (1942) idiographic emphasis is also evident in his critical stance toward diagnosis, preferring to view human beings as unique, individual organisms rather than as manifestations of trans-individual dysfunctional states.

This emphasis on the psychological irreducibility of each client, however, is not merely a theoretical assumption, but is rooted in a deep ethical commitment within the person-centered field to engaging with an Other in a profoundly honoring way. Here, the work of the French philosopher Emmanuel Levinas (1969, 2003) has been particularly influential (e.g., Cooper, 2009; Schmid, 2007; Worsley, 2006), with his emphasis on the “absolute difference” of the Other (Schmid, 2007, p. 39): that they are “infinitely transcendent,” “infinitely foreign,” “infinitely distant,” “irreducibly strange.” For Levinas, the Other always overflows and transcends a person’s idea of him or her, is impossible to reconcile to the Same, is always more than – and outstrips – the finite form that they may be afforded. From this standpoint, then, it is not just that each human being is unique, but that each human being is so unique that they can never be fully understood by an other: Their difference, at least to some extent, is transcendent. This is similar to Rogers’ (1951, p. 483) statement that the private world of the individual “can only be known, in any genuine or complete sense, to the individual himself.”

This idiographic emphasis within the person-centered approach is associated with a theory of psychotherapeutic change in which there is a particular emphasis on helping clients to actualize their distinctive potential and become their “own unique individual self” (Rogers, 1964, p. 130). Person-centered therapy (Rogers, 1957, 1959) aims to provide clients with a set of therapeutic conditions in which they can reconnect with their actual, individual experiences and valuing processes, moving away from a reliance on more external, “leveled down” (Heidegger, 1962) judgments and introjects.

An emphasis on the distinctiveness of each human being and their change processes also means that each individual’s needs and wants can be considered, at least to some extent, unique and unknowable. Bozarth (1998) wrote that the process of actualization – the motivational tendency underpinning all growth and development – “is always unique to the individual” (Bozarth, 1998, p. 29); and he described it as an “idiosyncratic” (Bozarth, 1998, p. 24) process that cannot be predicted (or determined) by another.

A commitment to supporting the actualization of the Other in their own, unique way also reflects a fundamental person-centered ethic of respect for the client’s autonomy (Keys & Proctor, 2007). Grant (2004) has argued that the basis for person-centered therapy lies in the ethic of “ respecting the right of self determination of others ” (Grant, 2004, pp. 158). Similarly, Cain (2002, p. 5) stated that “A fundamental value of humanistic therapists is their belief that people have the right, desire, and ability to determine what is best for them and how they will achieve it.” In Levinas’s (1969, p. 47) terms, this could be described as a fundamental ethical commitment to letting the Other be in all their Otherness: a “non-allergic reaction with alterity.”

TOWARD A PLURALISTIC PERSPECTIVE

At the heart of a person-centered approach, then, is an understanding that human beings may want and need different things, and that an individual’s distinctive wants and needs should be given precedence over any generalized theories that another holds about them. Extrapolated to the therapeutic process, this suggests that a basic person-centered assumption should be that clients are likely to want and need many different things from therapy – both things traditionally associated with PCE practice (such as empathic understanding responses) and things not (such as Socratic questioning) – and that any generic theories of change that we, as therapists, may hold, should be subordinate to the client’s specific needs and wants.

The hypothesis that different clients want different things from therapy is supported by empirical research (see Cooper & McLeod, 2011 for a review of the research). In a major trial (King, et al., 2000), for instance, primary care patients for whom a brief therapeutic intervention was indicated were given the option of choosing between nondirective counseling or cognitive-behavior therapy (CBT). Of those patients who specifically opted to choose one of these two therapies, around 40% chose the nondirective option, while 60% chose the CBT.

Of course, what clients believe they want is not, necessarily, what they need, nor what will necessarily be of greatest benefit to them. However, an emerging body of evidence indicates that different clients do, indeed, benefit from different types of therapeutic practices. While there is clear evidence, for instance, that most clients do best when levels of empathy are high (Bohart, Elliott, Greenberg, & Watson, 2002), there are some clients – individuals “who are highly sensitive, suspicious, poorly motivated” – who seem to do less well with highly empathic relationships (Bohart, et al., 2002, p. 100). There is also evidence that clients with high levels of resistance and with an internalizing coping style tend to do better in nondirective therapies, while those who are judged to be nondefensive and who have a predominantly externalizing coping style tend to benefit from more technique-orientated approaches (Beutler, Blatt, Alimohamed, Levy, & Angtuaco, 2006; Beutler, Engle, et al., 1991; Beutler, Machado, Engle, & Mohr, 1993; Beutler, Mohr, Grawe, Engle, & MacDonald, 1991).

Within the PCE field, this assumption – that different clients may benefit from different therapeutic practices (at different points in time) – has been articulated particularly well by Bohart and Tallman (1999). Process-experiential/emotion-focused therapists (e.g., Greenberg, et al., 1993) have also argued, and demonstrated, that particular therapeutic methods may be more or less helpful at particular moments in the therapy. In addition, from texts such as Keys’s (2003) Idiosyncratic Person-Centred Therapy and Worsley’s (2004) “Integrating with integrity,” it is evident that many person-centered therapists already incorporate a wide range of therapeutic methods into their work. Cain (2002, p. 44) wrote that one of the primary ways in which humanistic therapies have evolved is in their diversity and individualization in practice, and he went on to state that, ideally, humanistic therapists:

Constantly monitor whether what they are doing “fits,” especially whether their approach is compatible with their clients’ manner of framing their problems and their belief about how constructive change will occur. Although the focus of humanistic therapies is primarily on the relationship and processing of experience, they may use a variety of responses and methods to assist the client as long as they fit with the client’s needs and personal preferences.

In recent years, Cooper, McLeod, and colleagues have come to describe this standpoint, which prioritizes the therapist’s responsiveness to the client’s individual wants and needs, as a “pluralistic” one (Cooper & Dryden, 2016; Cooper & McLeod, 2007, 2011; McLeod, 2018). This is a stance which holds that “there is no, one best set of therapeutic methods,” and has been defined as the assumption that “ different clients are likely to benefit from different therapeutic methods at different points in time, and that therapists should work collaboratively with clients to help them identify what they want from therapy and how they might achieve it ” (2011, pp. 7–8). Cooper and McLeod’s pluralistic approach emerges from the person-centered values and practices discussed above, but it has been presented as a way of thinking about, and practicing, therapy which extends these values to the whole psychological therapies domain.

In terms of translating this general pluralistic stance into concrete therapeutic practice, Cooper and McLeod (2007, 2011) have emphasized two particular strategies. The first is to specifically orientate the therapeutic work around the client’s goals (or ‘directions’, Cooper, 2019), and the second is to develop the degree of negotiation, metacommunication, and collaboration in the therapeutic relationship.

CLIENTS’ GOALS AS AN ORIENTATING POINT FOR THERAPY

Cooper and McLeod (2007, 2011) have suggested that the goals that clients have for therapy can – and should – serve as an orientating point for thinking about, practicing, and evaluating therapeutic work. A client, for example, may want “to feel a sense of self-worth,” “to not experience anger and distrust toward my husband,” or “to be able to think about work without feeling stressed or panicky.” From a more classical person-centered standpoint, there is a risk that such a goal focus can lead to an overly mechanistic and ends-oriented approach to therapy, but there are several reasons why it is also highly consistent with a person-centered approach. First, it fits strongly with the concept of the client as active, meaning-orientated agent (Bohart & Tallman, 1999), who is engaged in constructing his or her life and relationships. Second, it privileges the client’s perspective – regarding what he or she want both in life and from therapy – over the therapist’s. Third, it moves away from a diagnostic, or even problem-centered, understanding of the client and the therapeutic process toward a potentiality-centered one – based around where the client wants to “go” in their lives. Finally, an orientation around the client’s goals may be the most explicit way of meeting, and responding to, the client as a self-determined, agentic subjectivity, who has the right to choose for him- or herself how he or she would like to pursue their own process of actualization. However, given that the term ‘goals’ can imply a more ends-oriented, cognitive emphasis, Cooper (2019) has suggested that the term ‘directions’ may be a more appropriate one: embracing embodied and unconscious, as well as cognitive and conscious, hopes, aspirations, and desires.

In order to help clients reach their goals, Cooper and McLeod (2007, 2011) have suggested that it may also be useful to think about the particular pathways by which these can be attained. Cooper and McLeod (2011, p. 12) refer to such possibilities as “tasks”: “The macro-level strategies by which clients can achieve their goals.” Examples of common tasks within therapy might include: “making sense of a specific problematic experience,” “changing behavior,” “negotiating a life transition or developmental crisis,” “dealing with difficult feelings and emotions,” and “undoing self-criticism and enhancing self-care.” Note, while process-experiential/emotion-focused therapists also refer to therapeutic “tasks” (e.g., Elliott, Watson, Goldman, & Greenberg, 2004), Cooper and McLeod use the term in a somewhat higher order sense: to refer to more general pathways or strategies. By contrast, the specific, micro-level concrete activities that clients and therapists undertake to complete these tasks are referred to as “methods,” such as “listening,” “participating in two-chair dialogue,” and “undertaking a guided visualization.” Cooper and McLeod also distinguish between the “therapist activities” that form one part of a therapeutic method and the “client activities.” Such a distinction may be useful when thinking about the kinds of therapeutic “methods” that clients may undertake outside of the immediate therapeutic relationship: for instance, reading self-help literature, exercising, or talking to friends and partners.

COLLABORATIVE ACTIVITY

This goal–task–method framework provides a means for therapists to think about what kind of therapeutic practices may be most helpful to a particular client. Of much more importance, however, is that it highlights three key domains in which collaborative activity can take place within the therapeutic relationship. For Cooper and McLeod (2007, 2011), such collaborative activity needs to be a key element of a pluralistically informed approach to therapy: maximizing the extent to which clients’ perspectives, wants and agencies can inform the therapeutic work. This activity has been described as metatherapeutic communication (Papayianni & Cooper, 2018), and it may be particularly appropriate in a first or early session of therapy: talking to clients about what they would like to get out of the therapeutic work, and how they feel that they might be able to get there. For example, a therapist might ask:

“Do you have a sense of what you want from our work together?”

“What do you hope to get out of therapy?”

“If you were to say just one word about what you wanted from this therapy, what would it be?”

“Do you have a sense of how I can help you get what you want?”

“What have you found helpful in previous episodes of therapy?”

“How would you like me to be in this therapeutic relationship: more challenging, more reflective?”

Although metatherapeutic communication is primarily orientated toward clarifying the client’s perspective, it by no means requires the therapist to ignore his or her own views and experience. Rather, the emphasis is on a dialogue between both members of the therapeutic dyad (Cooper & Spinelli, in press), in which therapist and client draw on their particular bodies of knowledge and expertise. Hence, the goals, tasks and methods of therapy emerge through a collaborative, negotiated dialogue; and may continue to be changed as the therapy unfolds.

An example of dialogue and metatherapeutic communication around a client’s goals for therapy comes from Mick’s work with a young man, Alex (details of clients have been changed to preserve anonymity). Alex was from a working class background, and had recently chosen to leave college feeling that he could no longer cope with his feelings of anxiety and depression. Alex began the session talking about his current difficulties, and the physical abuse he had experienced from his mother as a child.

Alex:    Obviously the fact that it was my mum that I got the abuse from makes it a lot harder. Because I kind of feel that people look at me a little bit – There’s always this sense of attack. Mick:   There’s an underlying sense of attack from people. Alex:    It’s kind of paranoid in a way. It kind of annoys me that I’m still doing it, but it doesn’t make any difference. It doesn’t stop. It’s not even getting gradually better now that I’ve realized – everything’s just exactly the same, but … more frustrating because I know that it’s going to take time, but I feel that I’m kind of at a standstill, and don’t know really where to go ….

At this point, Mick invited Alex to try and specify more clearly where he would like therapy to take him to with this difficulty.  

Mick:   So, if we were to, kind of, think about specific things that you’d want from the counseling, it sounds like one of the things would be around – what would it be? Would it be about not wanting to experience people as so critical or … How would you phrase some of the things that you’d want? So – where – like in 15 or 20 sessions, where would you like to be at the end of it, in contrast to now? Alex:    I suppose I’d like to improve my personal relationships, in the sense that I have more self-worth. Because … mm … in arguments and upsets … I value myself a lot less than I should. I just let people get their own way, just because it makes things easier …. I take a lot of hits from other people. Mick:   So there is something about wanting to feel more of a sense of self-worth? Alex:    Yeah, in that I can make these objections and that my feelings are equal to the other persons. Mick:   So something about being able to feel that my opinions and what I want is valid, and not put other people’s first. Alex:    Yeah.

These goals, as identified by Alex, then served as an orientating point to the ongoing therapeutic work.

A second example of this dialogical process, with respect to collaboration around therapeutic methods, comes from McLeod’s work with a young male client, Haruki.

During one of the early sessions that focused on the task of dealing with his panic feelings, John and Haruki talked together about the various ways that Haruki thought that it might be possible for them to address this issue. John wrote down the ideas that emerged, on a flipchart. Haruki began by saying that the only thing that came to mind for him was that he believed that he needed to learn to relax. John then asked him if there were any other situations that were similar to performing in seminars, but which he was able to handle more easily. He could not immediately identify any scenario of this type, but later in the session he returned to this question, and told John that he remembered that he always took the penalties for his school soccer team, and dealt with his anxieties by running through in his mind some advice that he had received from his grandfather, about following a fixed routine. John then asked him if he would like to hear some of John’s suggestions about dealing with panic. John emphasized that these were only suggestions, and that it was fine for him to reject them if they did not seem useful. John mentioned three possibilities. One was to look at a model of panic, as a way of understanding the process of losing emotional control. The second was to use a two-chair method to explore what was going on in his mind, in terms of what he was internally saying to himself at panic moments. The third was to read a self-help booklet on overcoming panic. (Cooper & McLeod, 2011, p. 93)

From a person-centered standpoint, one counterargument to this call for greater metahtherapeutic communication (as mentioned above) might be that what clients want in therapy – or what they believe themselves to want – is not necessarily what they need . Clients may have introjected, for instance, certain beliefs about what will be most helpful to them (such as external advice or suppression of emotions), and this may run counter to their actual organismic valuing (Rogers, 1959). As indicated above, however, metatherapeutic communication does not simply involve doing whatever the client wants; if the therapist has a different view of what might be helpful, this is something that can be brought into the dialogue. Having said that, any therapeutic approach which claims to be client -centered needs to be very careful not to dismiss, minimize, or override a client’s own views of what it is they want. Moreover, research suggests that clients who get the therapeutic interventions that they want do tend to experience more benefit, and are much less likely to drop out, than those who do not (Swift, Callahan, Cooper, & Parkin, 2018).

A second counterargument to this call for greater metacommunication may be that it overemphasizes verbal and conscious communication processes in the therapeutic relationship, and overlooks the value of more subtle, nonconscious, and intuitive understandings: such as the therapist’s felt-sense of what the client needs, or their embodied empathic understanding (Cooper, 2001). However, research tends to suggest that therapists, in fact, are generally not that good at accurately intuiting what their clients really want or are experiencing (see Cooper, 2008, p. 2). Moreover, a substantial body of research on “client deference” indicates that clients are often very wary of communicating to their therapists what it is that they really want or need (Rennie, 1994) – including to person-centered therapists – and will often hide things from their counselors or psychotherapists (Hill, Thompson, Cogar, & Denman, 1993). Hence, although overt, explicit communication may not be the only channel through which therapists can develop a greater understanding of their clients’ actual wants and needs, empirical research suggests that this is one mode of communication that many therapists could utilize more fully.

Indeed, given the difficulties that clients may have directly expressing their goals, wants, and preferences to their therapists, pluralistic therapists have suggested a range of tools and measures that therapists may want to incorporate into the therapeutic process. For instance, the Cooper-Norcross Inventory of Preferences (Cooper & Norcross, 2016) invites clients to indicate on a range of dimension how they might like their therapist to be: such as, “Be more challenging – Be more gentle,” and “Focus more on my feelings – Focus more on my thoughts and cognitions,” ( download from here ). Another tool that has been developed is the Goals Form ( download from here ) where clients’ goals for therapy can be jotted down in an early session (and revised if necessary), and then rated every week on a 1 ( Not at all achieved ) to 7 ( Completely achieved ) scale. For Alex (discussed above), for instance, three of his identified goals were to “Feel a sense of self-worth,” “Feel that my opinions and wants are valid in relationships,” and “Not interpreting what others say and do in critical way.” At assessment, the average rating across these three items was 1.33 (i.e., very close to “Not at all achieved”) and, by session five, had increased to 3.

IMPLICATIONS FOR ESTABLISHED PERSON-CENTERED AND EXPERIENTIAL THERAPIES

A pluralistic reading of person-centered therapy does not, in any way, challenge the value or legitimacy of other perspectives and practices within the PCE field. Nor does it call on all PCE therapists to be more integrative in their work. Cooper and McLeod (2011) make a clear distinction between pluralism as a perspective on psychotherapy and counseling, and pluralism as a particular form of therapeutic practice . Hence, a therapist who offers classically orientated client-centered therapy could still subscribe to a pluralistic viewpoint: believing that there are many different ways of helping clients, even though they choose to specialize in just one. More specifically, it may be useful to think about a pluralistic approach as residing on a spectrum: from a simple acknowledgment of the value of different therapeutic methods; to an enhanced use of goal orientation, metacommunication and negotiation in the therapeutic work; to a therapeutic practice that draws on methods from a wide range of orientations.

Even at a most minimal level, however, what a pluralistic perspective does offer is a challenge to the assumption that any one person-centered perspective, method or set of hypotheses holds some kind of “metanarrative” status (Lyotard, 1984): that it is true, or superior, for all people at all times. More than that, it challenges “dogmatic person-centeredness” (Worsley, 2001, p. 25): the belief that person-centered and experiential theories or methods are in some, generic way superior to other therapeutic practices and understandings. Rather, it invites members of the person-centered community to hold our person-centered theories and practices “lightly,” and to be open to challenges and different viewpoints from both within, and outside of, the person-centered field. At this level, it invites us to be “person-centered” about person-centered therapy: nondefensive, open to a range of experiences, and willing to be “in process” rather than holding a fixed and rigid concept of self (Rogers, 1961).

A pluralistic perspective also invites PCE therapists to be more explicit about the particular ways in which our therapies may be able to help people; and the kinds of clients and contexts for which they may be most likely to be helpful. Person-centered and experiential therapists, for instance, might find it useful to undertake a “personal audit,” looking at the kinds of goals they feel most able to help clients to achieve, and the particular methods they would have for getting them there. This is something that might then be made clearer to clients prior to starting therapy, such that clients are more enabled to decide whether or not a PCE therapy is right for them. Further empirical research would be particularly helpful in this regard. For instance, we already know that clients with high levels of reactivity tend to be more likely to benefit from nondirective methods than clients with low levels of reactivity, but are there other groups of clients, or problems, or goals for which PCE methods or a PCE attitudinal stance may often be of greatest help?

Finally, for those interested in moving toward a more pluralistic practice , the pluralistic strategies outlined by Cooper and McLeod (2011) may help PCE practitioners to enhance their work through greater dialogue around the goals, tasks, and methods of therapy. And for PCE practitioners who are interested in incorporating other methods into their work, it provides a framework in which this can be achieved in a coherent and client-centered way.

Our hope is that the articulation of a pluralistic understanding of what it means to be person-centered will bring something fresh and vibrant to the person-centered field, even if it primarily involves the explication of something that has always been implicit. First, a pluralistic perspective offers PCE therapists a means of resolving the tension between commitment and antidogmatism (Hutterer, 1993). It provides a conceptual framework in which PCE therapists can feel proud of the work that they do and can develop and deepen this specialism, while at the same time avoiding a judgmental attitude toward other therapeutic orientations. More than this, it has the opportunity to give PCE therapists a unique identity in the therapeutic field: as champions of inclusivity and mutual respect across therapies. Second, closely related to this, it facilitates the building of bridges with other progressive, client-orientated approaches, such as the “client-directed” practices of Duncan, Hubble, Sparks and colleagues (2004) and the work of many postmodern-informed family therapists (see Sundet, 2011). Third, a pluralistic perspective on therapy provides a means of conceptualizing, not just processes within the counseling and psychotherapeutic domain, but the whole range of personal development activities. In this way, a pluralistic perspective can help the person-centered and humanistic field move away from an exclusive focus on how professional therapists “bring about” change in clients, and toward a more client-orientated and client-agentic stance (Bohart & Tallman, 1999). Fourth, a pluralistic viewpoint provides a means by which person-centered practices can be more fully opened up to new and emerging research – as well as new theories and ideas – such that it can remain a growing and actualizing field. Closely linked to that, it provides a framework for researching and thinking about the complex question of how therapists can most constructively engage with our clients’ individual wants and needs. Finally, for some person-centered practitioners, the development of a pluralistic practice may allow them to grown more fully as therapists. It provides a highly flexible model of practice in which therapists can incorporate, and advance, whatever potentialities, strengths and resources they have. If, as Rogers’ (1961, p. 158) suggested, the fully functioning person is not rigid in their constructs, but an “integrated process of changingness,” then a pluralistic form of practice may offer some PCE practitioners a means of moving to a more fluid and creative actualization of their full potentialities.

In summary, from a pluralistic perspective, to be person-centered means to be someone who acknowledges the vast diversity and unknowability of human being, and who prizes the unique needs and wants of each individual client. It means to be someone who puts their clients wants for therapy before their own assumptions about what those wants might be, and who strives to be responsive within the limits of their own training, expertise and interest. For some person-centered therapists, it may also mean drawing on a variety of therapeutic methods from both PCE and non-PCE sources. Whether or not a therapist practices pluralistically, however, a pluralistic person-centered standpoint means an acknowledgment and prizing of the many different ways in which non-PCE therapies can be of value to clients; while also a recognition of the power and depth of the established PCE approaches.

FAQs (2019)

Isn’t pluralism just what a lot of people do anyway? Yes, absolutely, and so we’re not suggesting a new model of practice. But putting words and terms to what we do may help us develop, research, and more deeply understand that way of working.

What’s the difference between ‘pluralism’ and ‘integration’? Two main things. First, from a pluralistic standpoint we put a particularly strong emphasis on the collaborative relationship between therapist and client—metatherapeutic communication—which is there in many integrative forms of therapy but is not implicit to integration per se. For instance, you could have an integrative approach that is very strongly therapist-led. Second, pluralism is proposed as a framework and set of values, as well as a particular form of practice, whereas integration does refer to a particular practice. So you could say, for instance, ‘I practice person-centred therapy from within a pluralistic standpoint,’ but it wouldn’t make sense to say ‘I practice person-centred therapy from within an integrative standpoint.’

But Rogers talks about being flexible with, and responsive to, clients. So how is pluralistic therapy any different? If person-centred therapy is practiced in a genuinely flexible way, where we’re responding to what clients want and need with all of our skills and expertise, then the differences may well be very limited. But pluralism means respecting the wide diversity of methods that may be very helpful to clients—above and beyond empathy, acceptance, and congruence—such as psychoeducation, skills training, and interpretations. Some person-centred therapists, no doubt, do incorporate such methods into their work (with appropriate training and experience) and if that’s in response to client need, then that’s absolutely pluralistic.

Surely a therapist can’t know every different method going. Absolutely, and pluralism is not about being able to give everything to everyone. It’s about recognising what we can and cannot do and being flexible within that.

Isn’t there a danger that the pluralistic therapist ends up just being a chameleon and inauthentic: a different person to each client? That’s certainly a risk, and one of the challenges of pluralism is to try and meet, as well as possible, the client’s wants and needs, while staying true to one’s own self, knowledge, and expertise. So the first step in pluralism is for the therapist to be really aware of what they can, and cannot, offer to a client—where their boundaries are—so they know what they’re able, and willing, to offer. Remember that shared decision-making is not simply a ‘patient choice’ model, whereby the therapist hands over all responsibility to the client. Rather, it’s a dialogical approach that sits midway between paternalistic and ‘patient choice’ approaches to healthcare.

How can you just combine therapies with fundamentally different theoretical assumptions about the person: like person-centred therapy and CBT? Research shows that the differences here are often much more ‘real’ to therapists than clients. If you look at the research on what clients find unhelpful, they rarely say things like, ‘The therapist combined too many approaches,’ or, ‘Their epistemological assumptions just didn’t match their ontologies.’ Clients, in general, are much more interested in real, practical solutions to their problems, and often appreciate a therapist who is willing to draw on whatever skills and knowledge they have to help that as much as possible.

So does pluralism actually have any consistent, underlying philosophy? Yes. Pluralism, itself, is an underlying philosophical framework, see for instance the work of Isaiah Berlin or Nicholas Rescher . Importantly, we can distinguish between a ‘foundational pluralism’, which is akin to relativism, and a more moderate ‘normative pluralism’ , which is underpinned by a unified set of values. What are those? More than anything else, pluralism means an ethics of ‘welcoming otherness’: a commitment to being open, appreciative, and respectful of difference. In that sense, as with Levinas , it puts ethics as ‘first philosophy’: that how we treat others is the most fundamental issue, and a starting point for philosophical questioning that precedes ontology, epistemology, or other philosophical concerns.

What about clients who don’t know what they want from therapy, or what they’d prefer? Something that’s increasingly clear from our research is that clients do, indeed, differ very much in how much they know about therapy, and how clear they are about their own goals or preferences. So a pluralistic approach to therapy doesn’t just mean ‘handing the ball’ to the client and expecting them to do all the work. It’s a dialogical approach, where both therapist and client bring together their understanding and respective expertises to work out what is best for the client.

From a person-centred perspective, the person has the answers within them—their inner growth tendency—so why should they need more from the therapist than contact, empathy, UPR, and congruence? Theoretically, that’s where a pluralistic approach would differ from a purely person-centred approach. Pluralistically, the sources of potential healing are plural. So they definitely might come from ‘within’ the person, but also from ‘without’: books, learning, other people, pets… Rogers developed his ideas as a much needed counterbalance to the behaviourism of his time, which focused solely on external learning. But, taken in isolation, person-centred theory may veer too far the other way, and forget that external learning can be a crucial source of growth too.

Can’t pluralistic therapy end up being a ‘school’ of therapy in itself, with its own dogma, certainty, and closed-mindedness? Yes, that’s absolutely a risk, and one that we’ve tried to be mindful of from the start. So we’ve always advocated holding pluralism lightly, and in a self-critical and reflexive way. And if you look at our literature and research, you can, hopefully, see how the approach has grown and evolved as we’ve seen that some things work better than others. For instance, my latest work on directionality emerged in response to criticisms about ‘goals’ and the somewhat mechanistic, ends-oriented nature of that concept.

Where can I find out more information about pluralism in therapy? A good starting point is the Pluralistic Practice Network website. You can also find some resources and papers on the pluralistic therapy training page on this site.

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Introduction to Folk Psychology: Pluralistic Approaches

• Folk Psychology: Pluralistic Approaches
• Published: 20 August 2020
• Volume 199 , pages 1685–1700, ( 2021 )

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• Kristin Andrews 1 ,
• Shannon Spaulding 2 &
• Evan Westra   ORCID: orcid.org/0000-0003-2005-7998 1  

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This introduction to the topical collection, Folk Psychology: Pluralistic Approaches reviews the origins and basic theoretical tenets of the framework of pluralistic folk psychology. It places special emphasis on pluralism about the variety folk psychological strategies that underlie behavioral prediction and explanation beyond belief-desire attribution, and on the diverse range of social goals that folk psychological reasoning supports beyond prediction and explanation. Pluralism is not presented as a single theory or model of social cognition, but rather as a big-tent research program encompassing both revisionary and more traditionally inspired approaches to folk psychology. After reviewing the origins of pluralistic folk psychology, the papers in the current issue are introduced. These papers fall into three thematic clusters: Folk - psychological strategies beyond propositional attitude attribution (Section 2.1); Enculturation and regulative folk psychology (Section 2.2); and Defenses of pluralism (Section 2.3).

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Acknowledgements

We are extremely grateful to all the authors who contributed papers to this special issue, and to all of the reviewers who refereed submissions. We also thank Tad Zawidzki and Heidi Maibom for their comments on this introduction, and the editors of this journal for their guidance and administrative support. KA was supported by SSHRC Insight Grant 435-2016-1051 and by the York University Research Chair Program. EW was supported by SSHRC Postdoctoral Fellowship 756-2018-0012.

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Andrews, K., Spaulding, S. & Westra, E. Introduction to Folk Psychology: Pluralistic Approaches . Synthese 199 , 1685–1700 (2021). https://doi.org/10.1007/s11229-020-02837-3

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• Jul 11, 2019

What is the pluralistic approach & how is it different from integrative &eclectic practices?

Guest blog: Mick Cooper, Professor of Counselling Psychology, University of Roehampton

The pluralistic approach to therapy is something that John McLeod and I first started to articulate back in 2007 , with our first book in 2011 , and a handbook with Windy Dryden in 2017. John and I both came from person-centred backgrounds, but had also been informed by postmodern thinking (which holds that there are no fixed ‘truths’), psychotherapy research, and a commitment to socio-political change. So although we loved the person-centred approach, we also felt that it could get a bit fixed and rigid at times, and not see that there were other effective ways of working with clients. Linked to that, we also felt that there was something of a paradox when clients came in wanting more direction, guidance, and techniques. How was it ‘person-centred’ if, at times, you were actually going against what the person wanted by only engaging in non-directive ways?

So our pluralistic approach to therapy was, in many ways, trying to develop a person-centred approach to the counselling and psychotherapy field as a whole. To try and hold ‘unconditional positive regard’ to the many different ways in which you could help clients. And then, also, to try and really value the client by listening to what it was that they wanted, and to try and respect their preferences and choices—even if it went again what you, as a therapist, thought was ‘best’ for them.

Of course, we also knew that counsellors and psychotherapists couldn’t offer everything. So we distinguished between a pluralistic perspective on therapy and a pluralistic practice . Subsequent research has shown that, indeed, these are separate dimensions. A pluralistic perspective is about a general attitude of acceptance and valuing to the whole array of therapeutic approaches, but it doesn’t mean you have to practice them all, or even more than one. For instance, you could hold a pluralistic perspective while, at the same time, choosing to just practice psychodynamic therapy yourself, or to offer only EMDR. But the difference between a pluralistic psychodynamic therapist and a non-pluralistic one, is that the former can see the value of other therapeutic approaches and is prepared to refer on, whereas the latter is more stuck in the rhetoric of ‘psychodynamic therapy is best for everyone.’ Then you have a pluralistic practice, which is about actually combining methods from different approaches into a coherent whole, based around what clients and therapists think is best for that particular client. So here you have more extensive use of metatherapeutic communication : talking to clients about their particular preferences, wants, and goals.

So how does this all differ from integrative and eclectic therapies? Well, first of all, it’s probably worth noting that John and I came from person-centred, rather than integrative, backgrounds. And that means the relationship between integration and pluralism is rather complex, because we didn’t specifically set out to develop and advance integrative therapies—rather, we developed something in parallel that both crosses over and doesn’t. A first difference, though, is that, as we’ve seen, pluralism can be a general attitude towards the therapeutic field as a whole, whereas integration or eclecticism refer to a specific practice. So, for instance, while you could say that you practice solely EMDR within a pluralistic framework, it wouldn’t make sense to say that you practice solely EMDR as an integrative therapist. Second, as Linda Harris explains in her excellent blog , some forms of integrative therapy, ‘theoretical integration’, consist of particular integrations of particular therapies (e.g., cognitive analytic therapy, CAT), whereas pluralism is about valuing the full diversity of therapeutic approaches. Of course, you could be a CAT practitioner and still hold a pluralistic outlook, but it’s possible that you could advocate and practice a form of theoretical integration that was as ‘schoolist’ and dogmatic as advocates of a pure form therapy. Finally, in pluralistic therapy, there’s a particular emphasis on metatherapeutic communication between clients and therapists and a tailoring of the practice to the individual client. That is there also in a lot of integrative and eclectic approaches, but it isn’t intrinsic to what it means to be integrative. For instance, it could be possible to combine different theories and methods but in a very therapist-directed way, without ever really consulting the client on what they want or varying it for different clients.

Pluralism isn’t trying to promote itself as another brand of therapy or take over from integrative or eclectic approaches. The whole point of pluralism is about maintaining a critical, reflective edge about our work; so of course we need to be vigilante about getting stuck in a pluralism-ism: when we start saying that pluralism is best and everyone else should be one. So, from a pluralistic standpoint, if counsellors or psychotherapists see themselves as ‘integrative’ or ‘eclectic’ that’s great, and there’s no (or, at least, not much) desire to proselytise. But integrative and eclectic therapists can also think about whether they might be ‘pluralistic’ too: which would be about really wanting to work closely with clients to find out which methods and theories are best for them, and tailoring the therapy as much as possible to each individual client. For some therapists, that’s exactly what ‘integration’ is about, and if that word works best then there’s no need to refer to ‘pluralism’ at all (for instance, a colleague of ours, Biljana van Rijn, refers to pluralism as ‘collaborative integration’). But, for some of us, ‘pluralism’ does represent something a bit broader than ‘integration’ and perhaps more philosophical and political: which is about an ethical and pragmatic commitment to valuing diversity, and seeing the good in difference and dialogue. That’s what I love about the term ‘pluralism’: that it links in to a much wider set of values and practices, linked to democracy, social justice, and progressive change. You find it, for instance, in the work of Isaiah Berlin , who developed the concept of ‘value pluralism’; or in religious or cultural practices that strive to prize multiple perspectives.

I’m going a bit off point so I’ll stop here, but finally just to say that, of course, John and I didn’t create a pluralistic approach to therapy. Rather, we just articulated something that a lot of therapists already think and do—particularly, no doubt, in the integrative field. But ‘pluralism’ describes a particular way of being and doing integration that is, I think, a bit distinctive from other integrative and eclectic perspectives. It’s that commitment, first and foremost, to really valuing and prizing difference; to keeping an ‘open mind’; and to always trying to make sure that the things we say and do are for our clients, and not for our own self-promotion.

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Mick Cooper and John McLeod define pluralistic therapy as ‘the assumption that different clients are likely to benefit from different therapeutic methods at different points in time.’ Pluralism allows for a more responsive and fluid approach to a client’s needs. See the materials below to help you assess your own relationship with therapies.

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Client Assessment: Models and Methods

Using the pluralistic approach it is important to form a shared understanding of the client’s problems and possible solution.

Find out about how client assessment and case formulation are handled using the pluralistic counselling approach.

Therapies Quiz

Specific schools of thought within the counselling and psychotherapy field have fostered growth and creativity.

Use this form to figure out what you like and don’t like. It will help you figure out the relationship between therapies, yourself, and the client.  

Foundations for Pluralistic Approach

Pluralistic therapy has deep, strong and contemporary foundations which are important for its development.

Cooper and McLeod explore the relationship between pluralism as a philosophical concept and the pluralistic approach to therapy.

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Taking the practice of pluralism and considering it in a context of ethics, interventions and interactions will be shaped by the client in a purposeful way, but these may (and almost certainly will) change on a session by session basis, for example.

Gabriel offers a checklist of decision-making prompts for ethical practice (Gabriel, 2016, pp. 307–11):

• Stop, think and identify the situation or problem: it is easy in therapy to become reactive to a given situation and problems. Here, the challenge is to allow time for informed and considered thinking, rooted in reflective practice (and, in turn, shaped by supervision). This best positions the therapist to meet more fully the needs of the client
• Construct a description of the situation: while a reflective position is incredibly useful – and arguably critical to good therapy – finding a space and time to externalise our internal discourse can be helpful in creating some space in our thinking. Writing down thoughts and responses, as well as detail about a situation, can help us to achieve that
• Consider ‘whose ethical issue or challenge it is’: in creating a clearer discourse – preferably externalised – about a situation, it will be more possible to be clear about who the key stakeholders are in any given situation, and the roles and responsibilities that might sit in that context. For example, beyond the client and therapist might also sit a position held by an employer, or organisation, or professional body, or family of the client
• Review the situation in terms of your ethical framework or code of ethics: as a member of a professional body you will almost certainly be required to work within the context of the ethical expectations of that body, as outlined in their framework or code of ethics. It is important you take the detail of your situation and apply it in the context of your ethical requirements to help determine the key factors or considerations
• Consider moral principles and values: We need, therefore, to be able to bring our decision-making process in response to ethical challenges alongside our own positions, and understand what aspects of our own world view are consistent with, or contradictory of, aspects of the situation we are considering
• Reflect upon the relational processes that have played out in the situation: consider the place of the therapeutic relationship in the situation and keep in mind that, from a pluralistic position, it is likely the relationship will be framed and informed by a range of different perspectives and theoretical concepts, drawn across a number of modalities
• Identify what support is available: you will have an opportunity to appropriately draw on different sources of support for your decision-making process, including your supervision, peer supervision, colleagues and your manager, for example. It is important to use these sources fully, keeping in mind the contract of confidentiality with your client and how that is shaped by organisational expectations. Likewise, there may be information and guidance available for your client; it is important to ensure they are made aware of such information if it is available
• Identify and critique potential courses of action: if we keep our position as pluralistic practitioners in focus, we will rightly be drawn to a variety of different perspectives and views. It is important to consider a range of actions in response to the situation, being clear for yourself about the advantages and challenges inherent in any particular action
• Could your course of action be recommended to others in the same/similar situations?
• Would you take the same course of action with another client in a similar context?
• Would your decision be influenced by a client who was famous or influential?
• Evaluate the outcome: consider the outcome and how it mapped onto how you anticipated the outcome might be – was this better, or worse, and why? It is also important to reflect on whether, in hindsight, you had considered all the relevant factors and whether there was learning you might take forward to future situations
• Check for personal impact: re-visiting your reflexive position, as outlined in the first point above – how has this situation impacted on you personally, professionally and in your wider role as a therapist? What additional learning might you glean from this situation, and what ongoing support would be of value to you?

Extract taken from The Handbook of Pluralistic Counselling and Psychotherapy , edited by Mick Cooper and Windy Dryden

What Is Pluralism? Definition and Examples

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The political philosophy of pluralism suggests that we really can and should “all just get along.” First recognized as an essential element of democracy by the philosophers of Ancient Greece , pluralism permits and even encourages a diversity of political opinion and participation. In this article, we will break down pluralism and examine how it works in the real world.

Key Takeaways: Pluralism

• Pluralism is a political philosophy holding that people of different beliefs, backgrounds, and lifestyles can coexist in the same society and participate equally in the political process.
• Pluralism assumes that its practice will lead decision-makers to negotiate solutions that contribute to the “common good” of the entire society.
• Pluralism recognizes that in some cases, the acceptance and integration of minority groups should be achieved and protected by legislation, such as civil rights laws.
• The theory and mechanics of pluralism are also applied in the areas of culture and religion.

Pluralism Definition

In government, the political philosophy of pluralism anticipates that people with different interests, beliefs, and lifestyles will coexist peacefully and be allowed to participate in the governing process. Pluralists acknowledge that a number of competing interest groups will be allowed to share power. In this sense, pluralism is considered a key element of democracy. Perhaps the most extreme example of pluralism is found in a pure democracy , where each individual is allowed to vote on all laws and even court decisions. 

In 1787, James Madison , known as the Father of the U.S. Constitution , argued for pluralism. Writing in the Federalist Papers No. 10 , he addressed fears that factionalism and its inherent political in-fighting would fatally fracture the new American republic . Madison argued that only by allowing many competing factions to participate equally in the government could this dire result be avoided. Though he never used the term, James Madison had essentially defined pluralism.

The argument for modern political pluralism can be traced to early 20th century England, where progressive political and economic writers objected to what they saw as the growing tendency of individuals to become isolated from each other by the effects of unrestrained capitalism. Citing the social qualities of diverse yet cohesive medieval constructs such as trade guilds, villages, monasteries, and universities, they argued that pluralism, through its economic and administrative decentralization, could overcome the negative aspects of modern industrialized society.

How Pluralism Works

In the world of politics and government, it is assumed that pluralism will help achieve a compromise by helping decision-makers become aware of and fairly address several competing interests and principles. 

In the United States, for example, labor laws allow workers and their employers to engage in collective bargaining to address their mutual needs. Similarly, when environmentalists saw the need for laws regulating air pollution, they first sought compromises from the private industry. As awareness of the issue spread, the American public voiced its opinion, as did concerned scientists and members of Congress . Enactment of the Clean Air Act in 1955 and the creation of the Environmental Protection Agency in 1970 were the results of various groups speaking up—and being heard—and were clear examples of pluralism in action.

Perhaps the best examples of the pluralism movement can be found in the end of white apartheid in South Africa , and the culmination of the racial Civil Rights Movement in the United States with the enactment of the Civil Rights Act of 1964 and the Voting Rights Act of 1965.

The ultimate promise of pluralism is that its process of conflict, dialog, and negotiation leading to compromise will result in the abstract value known as “the common good.” Since first conceived by the ancient Greek philosopher Aristotle , “the common good” has evolved to refer to anything that is of benefit to and shared by all or most members of a given community. In this context, the common good is closely related to the theory of the “ social contract ,” the idea expressed by political theorists Jean-Jacques Rousseau and John Locke that governments exist only to serve the general will of the people. 

Pluralism in Other Areas of Society

Along with politics and government, pluralism’s acceptance of diversity is also embraced in other areas of society, most noticeably in culture and religion. To some extent, both cultural and religious pluralism are based on ethical or moral pluralism, the theory that while several diverse values may forever be in conflict with each other, they all remain equally correct.

Cultural Pluralism

Cultural pluralism describes a condition in which minority groups participate fully in all areas of the dominant society, while maintaining their unique cultural identities. In a culturally pluralist society, different groups are tolerant of each other and coexist without major conflict, while minority groups are encouraged to retain their ancestral customs.

In the real world, cultural pluralism can succeed only if the traditions and practices of the minority groups are accepted by the majority society. In some cases, this acceptance must be protected by legislation, such as civil rights laws. In addition, the minority cultures may be required to alter or even drop some of their customs which are incompatible with such laws or values of the majority culture. 

Today, the United States is considered a cultural “melting pot” in which indigenous and immigrant cultures live together while keeping their individual traditions alive. Many U.S. cities have areas like Chicago’s Little Italy or San Francisco’s Chinatown. In addition, many Native American tribes maintain separate governments and communities in which they practice and hand down their traditions, religions, and histories to future generations.

Not isolated to the United States, cultural pluralism thrives worldwide. In India, while Hindus and Hindi-speaking people are the majority, millions of people of other ethnicities and religions live there as well. And in the Middle Eastern city of Bethlehem, Christians, Muslims, and Jews struggle to live peacefully together despite the fighting around them.

Religious Pluralism

Sometimes defined as “respect for the otherness of others,” religious pluralism exists when adherents of all religious belief systems or denominations co-exist harmoniously in the same society. 

Religious pluralism should not be confused with “freedom of religion,” which refers to all religions being allowed to exist under the protection of civil laws or doctrine. Instead, religious pluralism assumes that the different religious groups will voluntarily interact with each other to their mutual benefit. 

In this manner, “pluralism” and “diversity” are not synonymous. Pluralism exists only when engagement between religions or cultures molds diversity into a common society. For example, while the existence of a Ukrainian Orthodox church, a Muslim mosque, a Hispanic Church of God, and a Hindu temple on the same street is certainly diversity, it becomes pluralism only if the different congregations engage and interact with each other.  

Religious pluralism can be defined as "respecting the otherness of others". Freedom of religion encompasses all religions acting within the law in a particular region.

• “ Pluralism .” The Social Studies Help Center.
• “ From Diversity to Pluralism .” Harvard University. The Pluralism Project.
• “ On Common Ground: World Religions in America .” Harvard University. The Pluralism Project.
• Chris Beneke (2006). “ Beyond Toleration: The Religious Origins of American Pluralism .” Oxford Scholarship Online. Print ISBN-13: 9780195305555
• Barnette, Jake (2016). “ Respect the otherness of the other .” The Times of Israel. 
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Pluralistic Counselling and Psychotherapy

In this lecture, Mick Cooper (Professor of Counselling Psychology at the University of Roehampton) introduces the pluralistic approach both as a perspective on counselling and psychotherapy and as a way of working with clients.

This will enable you to gain a good understanding both of what pluralistic therapy is about and of how to apply it in your own supervision and practice.

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Drawing on research carried out at the Tayside Centre for Counselling , Mick explains to you the background to pluralistic counselling – from the first academic paper on the pluralistic framework (published in 2006) to the beginning of training courses and even an international conference dedicated to this approach.

Mick examines how pluralistic counselling pays attention to client preferences and attitudes , based on an understanding that these are key to effective clinical outcomes.

Pluralistic counselling can be seen as an attempt to transcend schoolism in all its forms (including a ‘pluralistic schoolism’) and to re-orientate therapy around clients’ wants and benefits, striving to transcend ‘black-and-white’ dichotomies in the field of counselling and psychotherapy, so that we can most fully engage with our clients in all their complexity and individuality.

By participating in this lecture, you will learn about the two basic assumptions that underpin pluralistic counselling – as well as the philosophy behind the approach and how to practice it.

Mick also explains how pluralistic counselling differs from integrative counselling and eclectic counselling, focusing in particular on the shared decision-making that characterises this approach.

You will join Mick in a deep dive into how to accurately identify clients’ needs and wishes, drawing on meta-therapeutic communication to co-construct therapeutic methods.

Pluralistic counselling can be seen as an attempt to transcend schoolism in all its forms ... and to re-orientate therapy around clients’ wants and benefits, striving to transcend ‘black-and-white’ dichotomies ... so that we can most fully engage with our clients in all their complexity and individuality.

Other topics covered include:

• systematic feedback
• goal-setting
• measuring preferences
• outcome measures.

Mick uses examples from practice to illustrate his teaching, and also provides links to his books, articles and website so you can continue to research this current topic after listening to this lecture.

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Pluralistic Counselling

About the Lecture Presenter

Mick Cooper is an internationally recognised author, trainer, and consultant in the field of humanistic, existential, and pluralistic therapies. 

He is a Chartered Psychologist, and Professor of Counselling Psychology at the University of Roehampton where he heads up the  Centre for Research in Social and Psychological Transformation . 

Mick has facilitated workshops and lectures around the world, including New Zealand, Lithuania, and the US.

Mick's books include:

• Existential Therapies  (Sage, 2017)
• Working at Relational Depth in Counselling and Psychotherapy  (Sage, 2018)
• The Handbook of Person-Centred Psychotherapy and Counselling  (Palgrave, 2013)
• His latest work is  Integrating Counselling and Psychotherapy: Directionality, Synergy, and Social Change  (Sage, 2019)

Mick's principal areas of research have been in shared decision-making/personalising therapy, and counselling for young people in schools. 

In 2014, Mick received the Carmi Harari Mid-Career Award from Division 32 of the American Psychological Association.

He is a Fellow of the  British Association for Counselling and Psychotherapy  and the  Academy of Social Sciences .

Mick lives in Brighton with his four children.

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Person-Centred and Pluralistic Approaches: Similarities and Differences

Mick Cooper, University of Roehampton

‘What’s the difference between pluralism and person-centred therapy?’ It’s a question I get asked fairly often; or the not-so-pleasant variant, ‘Isn’t pluralism just a re-hash of Rogers?’

Some preliminary distinctions

In answering this question, the first thing that’s important to recognise is that there’s lots of different kinds of person-centredness: it’s not just one thing. The best book on this is The Tribes of the Person-Centred Nation edited by Pete Sanders. So there’s ‘classical client-centred therapy’, ‘focusing-oriented psychotherapy’, ‘process-experiential’/’emotion-focused psychotherapy’… and they all take forward different elements of Rogerian thought and practice. So, for instance, the classical approach tends to develop the non-directive element of Rogers’s work, while process-experiential therapy develops the Rogerian emphasis on emotions. There’s also what we might call ‘person-centred values’ (as distinct from any particular practice), which is about really valuing the individual and believing that they have the capacity, and right, to actualise their own potential in their own way.

Second, we also need to distinguish between a pluralistic perspective , and a pluralistic practice . They’re related, but actually the research shows that the correlation between them is only modest. A pluralistic perspective is about a general worldview that there’s lots of different ways of helping clients: that’s there no one, best therapy out there. By contrast, a pluralistic practice is when we draw on therapeutic activities from a range of different approaches, collaborating with our clients to develop the therapy most suited to their wants and needs. To practice in a pluralistic way, we need to have a pluralistic perspective. But having a pluralistic perspective doesn’t mean we have to practice in a pluralistic way. For instance, we could practice in a solely psychodynamic or CBT way, but still value other approaches and recognise the limitations of what we offer.

The pluralistic perspective as a person-centred ‘meta-therapeutic’ stance

So when we look at the relationship between pluralism and the person-centred approach, perhaps the first thing we can say is that a pluralistic perspective is synonymous with a person-centred view of the therapeutic field as a whole: what you might call a ‘metatherapeutic’ stance. It means valuing and appreciating different approaches and understanding their roots: exactly what Rogers meant by the ‘core conditions’ of acceptance and empathy. That parallel, perhaps, isn’t surprising, given that both John McLeod and myself came from a person-centred background, and were deeply committed to the values of the person-centred approach.

So why do we need to call it something different? I guess my experience in the person-centred field is that, at the meta-therapeutic level, it often wasn’t that accepting and understanding of other therapies. For instance, when it came to CBT and CBT practitioners, there was often a real devaluing and judgement: that these therapists were less effective than us (‘Just doing the superficial work’), or controlling and manipulative of their clients. Those person-centred values of prizing the other and valuing their strengths—really valuing their strengths—just wasn’t always extended to other therapies. So while a ‘pluralistic perspective’ can be understood as a person-centred stance towards the therapeutic field as a whole, the use of a different term makes it clear that it’s something over and above being a person-centred practitioner, per se. It’s about really challenging ourselves to be person-centred in our attitudes towards other therapies, and to recognise where our biases and assumptions are: just as we would in other areas of our personal lives and histories (i.e., being congruent).

Pluralistic practice and person-centred practices

So what about pluralistic practice? How does that fit with being person-centred? Well, as discussed above, a lot of it depends on what kind of person-centredness you’re talking about. If it’s classical person-centred therapy, for instance as described by Tony Merry (see the Tribes book), then a pluralistic practice would be likely to use a wider range of pre-defined skills, techniques, and methods of assessments. So a pluralistic practitioner might invite a client to keep a thought diary if they were having a lot of negative thoughts, or introduce some psycho-education if they were struggling with anxiety, or perhaps look at transferential issues if their were problems in the therapy relationship. Here, then, there’d be a wider range of methods drawn on—not such a sole reliance on the therapist’s relational stance. Also, what you might see in pluralistic therapy is more ‘meta-therapeutic communication’ about what the client wants and needs. For instance, the therapist might ask, ‘How do you think we could best address this problem: Shall we talk about your current relationship, or perhaps do a timeline of your past?’ By contrast, in a classical person-centred approach, the determination of how the therapy should proceed might be more implicit: trusting the client’s and therapist’s intuitive sense of where best it should go.

When you take another person-centred practice, for instance focusing-oriented therapy, there’s some different differences but also some of the same ones. In particular, a pluralistic approaches tends to draw from a wider range of practices (both person-centred/humanistic and otherwise) and, again, there’s more metatherapeutic communication. By contrast, in focusing-oriented psychotherapy, there’s more specialised use of a particular method (or way of being), and a more homogeneous understanding of the client and how to help them.

What about integrative person-centred therapy?

And then there’s another way of thinking about person-centred therapy, which is a more integrative understanding (again, see the Tribes book). So here people ‘read’ the person-centred approach as saying that, actually, we should be meeting our individual clients at where they are at, and if that means drawing on different methods and practices from different therapies then that’s fine: that’s what it means to be person-centred . Indeed, some people would argue that a classical person-centred stance is inherently integrative, in that being congruent means drawing on whatever we feel is best for a particular client at a particular time. So, then, if a client asks for advice, or wants us to use a particular technique or give them homework, it’s entirely person-centred to do so.

And if that’s how we interpret what it means to be person-centred then, yes, you could say that person-centred practice and pluralistic practice are essentially the same. Indeed, in a recent blog , John McLeod and I described an understanding of person-centred therapy that is, in its essence, pluralistic. So why do we need to call it something different? I guess not everyone would agree with this definition of person-centred practice. For instance, people are often taught that being person-centred means not giving advice, or that it primarily involves working with an ‘empathic understanding response process’ (see Beth Freire’s chapter in The handbook of person-centred psychotherapy and counselling ). Again, we can see that the relationship between pluralism and the person-centred approach is, to a great extent, dependent on how you define ‘person-centredness’, and there’s no right answers here. Different people understand it in different ways.

Does it really matter?

I think, for me, ultimately what is most important is what we do with clients, rather than what we call it. In my own practice, research, and writing, I really try (though no doubt fail) to come from a place which is as valuing, as much as possible, of the people we work with. So, for me, what’s important is that we talk to clients about what might be most helpful to them (rather than assuming we know best), and try and draw on whatever we think would be best to help them move forward in their lives. You could call that ‘pluralism’, or you could call that being ‘person-centred’, and I’m sure people from CBT would call that essential to their approach too–as would people from many other orientations. Of course, I love it when people use our own pluralistic terminology to describe this stance, but that’s more about my own ego and self-valuation than about what is genuinely most important for clients. And what we know is that, in reality, most clients don’t care too much what you call it (and certainly care even less about giving my ego a boost!). What they want is to feel better.

So if the term ‘pluralism’ feels redundant, that’s fine, and if the term feels helpful, that’s fine too. I guess, for me, it definitely articulates something that wasn’t that clear, or well-defined, before. But what’s so much more important is that we work with our clients in the best way that we can, and help them move from places of suffering to places of thriving and fulfilment in their lives.

[Photo credit: Dom Lavage https://www.flickr.com/photos/wickenden/3259826856 Attribution-ShareAlike 2.0 Generic (CC BY-SA 2.0)]

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Client preferences in counselling for alcohol problems, 2 thoughts on “ person-centred and pluralistic approaches: similarities and differences ”.

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A pluralistic approach to student counselling University and College Counselling, March 2019 Volume 7 Issue 1

At the heart of good therapeutic outcomes is a respectful, collaborative client-therapist relationship.  Marcia Stoll and John McLeod outline how this relationship underscores pluralistic therapy, and argue that it is ideally suited  to student needs.

Counselling and psychotherapy services in colleges and universities are facing unprecedented challenges, with high levels of student stress and mental health difficulties – increasing demand combined with limited resources – with research indicating that this is a global concern. 1,2 Headlines such as ‘One in three freshers show symptoms of mental health disorder’ and ‘UK universities act to tackle student mental health crisis’ dominate our news and highlight the current focus on student mental health. 3,4

Previous research focuses on the effectiveness of university counselling services for academic outcomes and wellbeing, or on how to meet the needs of international students. There is, however, a paucity of research into counselling provision for college students, so perhaps this is something we also need to consider and address. Within the UK alone, students represent a highly diverse client group, including individuals from across the whole range of nationality, ethnicity, religion, age and social class. In addition, the kinds of problems reported by students are extremely varied, encompassing long-term mental health issues, study-related issues (perfectionism, procrastination and imposter syndrome) and a spectrum of situational crises around relationships, adjustment to university life, containment of privacy (such as controlling the impact of social media), existential crises, isolation and debt.

In response to these unique demands of study, it is essential for services to be able to offer a flexible, yet robust approach that is responsive to students’ needs. So the question here is: ‘How can we, as practitioners, respond to meeting this varied and increasing need within the services we currently offer?’ A possible approach, which has emerged in recent years as an integrative model informed by current research evidence into the nature of what is helpful for clients, is pluralistic counselling and psychotherapy. This article offers a brief introduction to key ideas in pluralistic therapy, explores its relevance to student counselling and invites you to think critically about its application.

Something to consider is that therapy training and research continue to be dominated by unitary theoretical models which assume that it is possible to identify single change processes (insight, self-acceptance, cognitive restructuring, mindfulness) that work for everyone. This is despite evidence that the majority of counsellors and psychotherapists do not use a single-theory model of therapy, but instead draw on ideas and methods from different approaches. 5,6 There is also an increasing body of research, using qualitative and quantitative methodologies, which strongly suggests that therapy approaches are broadly equivalent in effectiveness (and ineffectiveness/harmfulness) and that what matters is the ability to offer the client a way of working that is consistent with their beliefs and preferences, and delivered through a collaborative, supportive relationship. 7,8

Pluralistic therapy

Pluralistic therapy has been designed as a framework to allow therapists and clients to work together to find the best way of addressing clients’ concerns, using ideas and methods from both the therapy literature and the client’s life experience. The basic principle of pluralistic therapy is that different people are helped by different processes and activities at different times, and that the best way of deciding on how therapy should proceed is to engage the client in a process of shared decision-making. Given that therapists may be committed to certain assumptions about what will help, and that clients may find it hard (at least at the outset) to be clear about what they think would be helpful or unhelpful for them, pluralistic practice is organised around a specific set of procedures for collaborative working.

At the heart of pluralistic therapy is the intention to be as clear as possible about what the client wants from therapy: the client’s goals. 9 This principle is articulated in sensitivity to the ‘directionality’ of the client – a concept that embraces a broader appreciation of goals being embedded within a sense of movement (or stuckness) in relation to a preferred future. 10 Goal-informed therapy can also be facilitated through the use of ‘goals forms’ that allow the client to write down in their own words their understanding of what they want, to review and revise goals on a regular basis, and to track goal attainment on a week-by-week basis. 10 Having established the broad goals of therapy, the next step is to break these objectives down into a set of achievable tasks. For example, a client who wishes to ‘enjoy life and be less depressed all the time’ might work toward such an objective through activities including coming to terms with feelings of loss, adopting a more healthy lifestyle and diet, developing more satisfying and meaningful relationships with friends, and reducing levels of undermining internal self-talk. 11 Typically, clients in pluralistic therapy pursue more than one task at a time. Once therapeutic tasks or areas of focus have been identified, it is helpful to explore the methods or techniques that might be deployed to facilitate their completion. For example, with some clients it might be preferable to come to terms with loss by engaging in a process of empathic, exploratory conversation with their therapist. For others, art techniques, two-chair work, or reading a self-help book might be more helpful. When clients are encouraged to share their own ideas and preferences around what might be helpful, they sometimes come up with suggestions that readily map onto therapy techniques with which their counsellor is familiar. However, they may also identify strategies that are based in their everyday life experience, such as going on pilgrimage, listening to emotionally moving music, or doing some gardening. In pluralistic therapy, these activities are described as ‘cultural resources’ and are treated as precious gifts that embody the capacity of the client for self-healing and constructive engagement with the wider world.

In pluralistic therapy, the process of seeking explicit agreement around goals, tasks and methods is fluid and dynamic. Even if the therapist uses written forms, these are only meaningful in the context of ongoing conversation and dialogue that aims to ensure maximum client-therapist alignment around the purpose of therapy and the development of shared understanding. It is a process that is underpinned by a relational ethical stance that emphasises the need for the therapist to care for the client in ways that respect the client’s uniqueness as a person. 12

In addition to initiating conversations around goals, tasks and methods, there are three further skills and strategies that are distinctive to pluralistic therapy. At an early stage in therapy, the therapist brings together the different threads of shared decision-making by using a form of collaborative case formulation that involves visual mapping, by client and therapist working together, of the client’s difficulties and goals, their strengths and resources, key life events, and possible ways of moving forward. 13 The therapist intentionally uses metacommunication (such as clarifying, challenging, self-monitoring, process monitoring and questioning), as a means of checking out moment-bymoment alignment of client and therapist purposes, and establishing a way of talking that is reflective, authentic and actively takes account of the intentions of both parties. The therapist also makes use of process and outcome feedback and monitoring tools, to provide the client with a scaffolding and predictable routine, through which they can convey their sense of whether therapy is working for them, and how it might need to change direction or focus. As well as widely used outcome measures such as CORE, pluralistic practice also incorporates qualitative feedback instruments and scales that allow the client to comment directly on specific aspects of the therapist’s style. 14,15

So what does the research say? As an approach to therapy that has been developed only in recent years, there is currently limited evidence of its effectiveness. An open trial of pluralistic therapy for depression reported outcomes that were equivalent to those recorded by established evidence-based therapies, with lower levels of client attrition. 16 Further studies are in progress.

Pluralistic student counselling in action

The following case vignettes, which have been altered to ensure anonymity, provide some examples of how a pluralistic approach has been applied by the first author in the context of a busy university counselling service.

Lola was an international student from an Asian country, who had found it hard to adjust to the demands of university life. On the advice of her tutor, she made an appointment to see a counsellor. At the first session, she described distressing dissociative episodes, problems focusing on work, and relationship difficulties. Although her goal was to try and learn how to cope with her sense of being under stress all the time, and the impact of stress on her studies and relationships, she did not know what to do or where to start. As we discussed her issues, we developed a shared understanding of her challenges and identified some initial therapeutic tasks we could work on together and then review. These tasks were based on Lola’s suggestion that she would be able to cope better if she learned how to express/let go of feelings and emotions, and that this in turn might change her behaviour, improving her focus and her relationships. Lola agreed that it would be helpful to talk about her feelings in therapy, but that it would be hard for her to actually express strong feelings in a room with me.

Further discussion revealed that dance, and writing poetry in her own language, would be useful ways of expressing emotions that she could then tell me about in counselling sessions. This process of segmenting the concrete work of therapy into distinct activities made sense to Lola, and allowed her to begin to feel in control of her emotional states. Attending a dance class in the community also allowed her to meet new people, and we talked about how she might be able to find support from these relationships. Within three sessions, Lola was visibly calmer, and was able to verify this for herself through shifts in scores on her CORE outcome measures. We were then able to turn to further tasks that had become apparent, related to the ways in which poor time-management contributed to her stress.

Janey was 19, and very anxious. She was behind on assignments, and worried about upcoming exams. Janey was unable to eat, sleep, or focus. She constantly felt nauseous, and spent most of her days in bed crying. This had been going on for over three months. She had resisted going to the GP and using antidepressants as her parents had always told her people didn’t need those. Our time together was limited (six sessions). During our first session, Janey was clearly anxious and tearful. It took her a few moments before she was able to talk without crying. I invited Janey to share her story with me. We then spent the first session exploring what she felt that she wanted to work on, established her goals for our sessions (she wanted to be able to focus so she could get her assignments done and study for her exams, and she also wanted to ‘stop feeling this way’) and started to build a time-line map of her difficulties and strengths and how each had developed.

Within this case formulation process, we discussed techniques and strategies that we could use to manage the anxiety she felt before starting her work, during and afterwards, exploring what had worked for her previously (she wasn’t sure) and what hadn’t (breathing apps). We also discussed her preferences: she liked to research and understand why things happen, but didn’t want or need added pressure or homework.

In the following sessions, we collaborated on what Janey wanted from each week. During session two, we explored relaxation techniques and also used CBT to identify, challenge and replace negative thoughts with more realistic ones. Janey also decided that she wanted to spend five minutes in each of our sessions doing a muscle relaxation exercise. We explored her cultural resources (activities she did that made her feel good, such as swimming and playing squash with her brother) and discussed how she could incorporate these into her week. Janey was anxious about an assignment she had to do as she was still struggling to focus during our third session. I asked her if she wanted to do the relaxation first and then discuss the assignment, to which she agreed. We then spent our session discussing her assignment, with Janey writing an essay plan and devising ways to calm herself throughout this process. She also drafted an email to one of her tutors.

In session four, we explored the possible origins of the anxiety, an exploration which emerged as Janey was talking about a phone call with her father. She became aware here that she felt immense pressure to be perfect, and that her parents’ love was conditional on getting good grades. This insight was both helpful and upsetting. I suggested that we did some compassion-focused therapy and self-worth tasks, which we discussed and agreed. Janey and I continued to work together on these tasks, negotiating which methods to use to deepen awareness of herself and her preferences in the work we were doing, and also explored how she could continue to use her cultural resources to help her in the future. This vignette demonstrates how, once trust and shared understanding had been established, a client was able to engage actively in our work, learned to self-soothe and ground herself – strategies that she was then able to apply outside the therapy room.

Alec was a 21-year-old student who felt suicidal. He had recently broken up with his partner, who had cheated on him and lied about it. He was struggling: he felt hurt, angry and humiliated, and did not feel that he knew the ‘whole story’. Alec had always been a high achiever, but was getting lower grades than expected, and felt under immense pressure to do better. He spent the first session telling me his story.

When I asked him if he had made a plan to kill himself, he said he had, so I suggested we could make a suicide safety plan, which Alec decided could be helpful. We then explored what he wanted to work on, and established his goals for our therapy: he wanted to try and make sense of his relationship, and to look at why he had ‘always felt low’. Alec said he wasn’t good at talking and had been to see different counsellors at various stages throughout his life. He said one had been helpful (we discussed what had been helpful – ‘they listened and challenged me’) and that one had been unhelpful (he felt they dismissed and trivialised what he had said).

After discussing his preferences and what he felt he wanted and needed from me, I offered possible ways we might achieve his goals using a variety of tasks (exploring meaning and making sense of his experiences) and by which method/ means (empathic dialogue to help him stay with his emotions to try and understand and process them, and also solution-focused tasks to help him focus on his work). Alec chose to look at and identify his feelings and his history of feeling suicidal. He remembered that his mum had been suicidal throughout his teens, and felt that he had never talked or thought about it before. He then made a link to his ex, who had ‘a lot of problems, was depressed and suicidal’ and how Alec had wanted to ‘save his partners from those emotions’. He then felt that he perhaps unconsciously sought out partners he could ‘fix’.

As our relationship developed, Alec became more present and engaged. He also disclosed that he felt ‘out of control’ and struggled with over-eating whenever he was supposed to do revision or an assignment. We explored his feelings, thoughts and beliefs about the pressure he felt he was under and thought about ways that he could try to relax and calm himself before he started work so he might avoid bingeing. We also explored Alec’s cultural resources (meeting with his friends and re-enacting battles) and discussed how he could incorporate these into his schedule.

When our sessions ended, Alec said he felt he had gained insight into his relationship with his former partner, his relationships with his parents and identified the origin of his ‘sadness’ and unhelpful patterns of behaviour. He also felt more resilient and able to focus.

Conclusions

These case examples describe a pragmatic, flexible approach to therapy that will be familiar to many readers. What is distinctive about a pluralistic way of working lies not in the utilisation of new techniques, but in the adoption of a stance that consistently seeks to position the client as an active partner in a process of shared decision-making. We believe that one of the advantages of this model, in the context of university and college counselling, is that it engages the client right from the start, so that they leave the first session with at least the beginnings of an agreed plan for how counselling might help them to move on in life. 17 Our experience has been that a pluralistic approach sits well within a university and college environment in which a wide range of potentially helpful resources are available to students, such as befriending and mentoring schemes, and cultural, political, sporting and faith-based groups and networks.

In addition, students possess literacy and internet skills that allow them to access apps, self-help reading and other modes of delivery of therapeutic knowledge. Finally, participation in a therapy relationship that allows first-hand experience of collaborative working, goal-setting, and giving and receiving feedback, reinforces life skills and competencies that are highly relevant for both degree-level study and graduate employability.

Our final thought, after speaking to fellow colleagues, is that it seems many student counsellors are already working pluralistically, so perhaps we need a call for research in this area to garner evidence of its efficacy or fallibility as a way to further enhance and support our student population. 

Marcia Stoll is a Teaching Fellow within the Division of Mental Health Nursing and Counselling at Abertay University and works as a student counsellor for college and university students. Currently developing a Postgraduate Certificate in Mental Health Interventions for Children and Young People, her research involves studies of staff experience of working with pupils with mental health difficulties in secondary schools, and how young people make use of cultural resources to manage their mental health issues. John McLeod is Emeritus Professor of Counselling at Abertay University and Visiting Professor of Psychology at the University of Oslo. He has published widely on a range of topics in counselling and psychotherapy research and practice.

1. Macaskill A. The mental health of university students in the United Kingdom. British Journal of Guidance and Counselling 2013; 41(4): 426–41. 2. Stallman HM. University counselling services in Australia and New Zealand: activities, changes, and challenges. Australian Psychologist 2012; 47(4): 249–53. 3. Lacchia A. One in three freshers ‘show symptoms of mental health disorder’. The Guardian. 13 September 2018. 4. Chaffin J. UK universities act to tackle student mental health crisis. The Financial Times. 4 March 2018. 5. Cooper M, McLeod J. Pluralistic counselling and psychotherapy. London: Sage; 2010. 6. Murphy D (ed). Counselling psychology: a textbook for study and practice. Hoboken: John Wiley and Sons; 2017. 7. Wampold BE, Imel ZE. The great psychotherapy debate: the evidence for what makes psychotherapy work. London: Routledge; 2015. 8. McLeod J. What do clients want from therapy? A practicefriendly review of research into client preferences. European Journal of Psychotherapy and Counselling 2012; 14(1): 19–32. 9. Cooper M, Law D (eds). Working with goals in psychotherapy and counselling. Oxford: Oxford University Press; 2018. 10. Cooper M. Integrating counselling and psychotherapy: directionality, synergy and social change. London: Sage; 2019. 11. Cooper M, Dryden W (eds.) The handbook of pluralistic counselling and psychotherapy. London: Sage; 2015. 12. McLeod J. Pluralistic therapy: distinctive features. London: Routledge; 2017. 13. McLeod J, McLeod J. Assessment and formulation in pluralistic counselling and psychotherapy. In Cooper M, Dryden W (eds). The handbook of pluralistic counselling and psychotherapy. London: SAGE: 2016 (pp15–27). 14. Rousmaniere T, Goodyear RK, Miller SD, Wampold BE (eds). The cycle of excellence: using deliberate practice to improve supervision and training. Hoboken: John Wiley and Sons; 2017. 15. Cooper M, Norcross JC. A brief, multidimensional measure of clients’ therapy preferences: the Cooper-Norcross Inventory of Preferences (C-NIP). International Journal of Clinical and Health Psychology 2016; 16(1): 87–98. 16. Cooper M, Wild C, van Rijn B, Ward T, McLeod J. Pluralistic therapy for depression: acceptability, outcomes and helpful aspects in a multisite open-label trial. Counselling Psychology Review: 2015; 30(1): 6–20. 17. Chow D. The first kiss: undoing the intake model and igniting first sessions in psychotherapy. New York: Correlate Press; 2018.

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Forum Prize 2024 – ‘The Art(s) of Delight’

Entries are invited for the 2024 Forum Essay Prize, on the subject of: ‘The Art(s) of Delight’

Forum for Modern Language Studies are looking for bold, visionary and persuasive essays that use academic research to pursue innovative questions. The winning essay will be that judged by the panel to have best addressed the topic with flair, ambition and resonance.

The topic may be addressed from the perspective of any of the literatures and cultures normally covered by the journal: Arabic, English, French, German, Italian, Portuguese, Russian and Spanish. Submissions in comparative literature and literary translation studies are also welcomed, as are those dealing with visual art, film and the performing arts. Forum for Modern Language Studies aims to reflect the essential pluralism of research in modern languages and to provide a forum for world- wide scholarly discussion.

We are seeking submissions that focus on literature, film, art, or other cultural outputs that manifest delight in their content or form and/or which provoke us to find joy in how we read, write, research and teach in our discipline(s). Possible approaches to the subject include, but are not limited to:

• reunions, parties and celebrations;
• epiphanies and happy ends;
• welcome discoveries;
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The competition is open to all researchers, whether established or early career. Previous competitions have been won by scholars in both categories.

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Higher Education Needs More Socrates and Plato

By Ezekiel J. Emanuel and Harun Küçük

Dr. Emanuel and Dr. Küçük are on the faculty of the University of Pennsylvania, where Dr. Emanuel is a professor and the vice provost for global initiatives and Dr. Küçük is an associate professor of the history and sociology of science.

The right attacks colleges and universities as leftist and woke. Progressives castigate them as perpetuating patriarchy and white privilege. The burdens of these culture war assaults are compounded by parents worried that the exorbitant costs of higher education aren’t worth it.

No wonder Americans’ faith in universities is at a low. Only 36 percent of Americans have confidence in higher education, according to a survey by Gallup last year, a significant drop from eight years ago. And this was before colleges and universities across the country were swept up in a wave of protests and counter-protests over the war in Gaza.

But the problems facing American higher education are not just the protests and culture war attacks on diversity, course content, speech and speakers. The problem is that higher education is fundamentally misunderstood. In response, colleges and universities must reassert the liberal arts ideals that have made them great but that have been slipping away.

By liberal arts, we mean a broad-based education that aspires to send out into society an educated citizenry prepared to make its way responsibly in an ever-more complex and divided world. We worry that at many schools, students can fulfill all or most of their general education requirements and take any number of electives without having had a single meaningful discussion that is relevant to one’s political life as a citizen.

Over the past century, what made American higher education the best in the world is not its superiority in career training, but educating students for democratic citizenship, cultivating critical thinking and contributing to the personal growth of its students through self-creation. To revive American higher education, we need to reinvigorate these roots.

In Europe and many countries elsewhere, colleges and universities have undergraduates specialize from Day 1, focusing on developing area-specific skills and knowledge. College students are trained to become doctors, lawyers or experts in international relations, English literature or computer science.

In the United States, European-style specialization for medical, legal, business or public policy careers is the purpose of post-collegiate professional schools. Traditionally, the American college has been about imparting a liberal arts education, emphasizing reasoning and problem solving. Those enduring skills are the critical ingredients for flourishing companies and countries.

Historically, students arriving on American college campuses spent a majority of their first two years taking classes outside their projected majors. This exposed them to a common curriculum that had them engage with thoughtful writings of the past to develop the skills and capacity to form sound, independent judgments.

Over the past half century, American colleges and universities have moved away from this ideal , becoming less confident in their ability to educate students for democratic citizenship. This has led to a decline in their commitment to the liberal arts, a trend underscored in the results last year of a survey of chief academic officers at American colleges and universities by Inside Higher Ed. Nearly two-thirds agreed that liberal arts education was in decline, and well over half felt that politicians, college presidents and university boards were increasingly unsympathetic to the liberal arts.

Today, there is almost no emphasis on shared courses among majors that explore and debate big questions about the meaning of equality, justice, patriotism, personal obligations, civic responsibility and the purpose of a human life. Majors that once required only eight or 10 courses now require 14 or more, and students are increasingly double majoring — all of which crowds out a liberal arts education. Ambitious students eager to land a prestigious consulting, finance or tech job will find it too easy to brush aside courses in the arts, humanities and social and natural sciences — the core of a liberal education.

The devaluing of the first two years of a shared liberal arts education has shortchanged our students and our nation. Educating young adults to be citizens is why the first two years of college still matter.

To that end, the so-called Great Books have long been the preferred way to foster citizenship. This approach is not, contrary to critics on the left and right, about sanctifying specific texts for veneration or a mechanism for heritage transmission.

Books by Plato, Aristotle, Hobbes, Locke, Kant, Emerson, Thoreau, Whitman as well as Wollstonecraft, Austen, Woolf, Baldwin, Hurston and Orwell are worthy of introductory collegiate courses for students of all majors. These writers address the fundamental questions of human life. They explore the ideas of self-determination, friendship, virtue, equality, democracy and religious toleration and race that we have all been shaped by.

As students address those big questions, the Great Books authors provide a road map as they challenge and criticize one another and the conventional wisdom of the past. The Socrates of Plato’s dialogues is the exemplar — asking about beliefs and then subjecting them to respectful but critical analysis and skepticism.

These books are best studied in small seminar discussions, which model and inculcate in students democratic behavior. This discourse is an antidote to the grandstanding in today’s media and social media.

The teacher is less an expert in specific writers and more a role model for intellectual curiosity, asking probing questions, offering critical analyses and seeking deeper understanding. In an idealized Socratic fashion, these discussions require listening at length and speaking briefly and, most important, being willing to go where the argument leads.

Parents who are paying for college might question the value of spending $80,000 a year so that their son or daughter can read Plato, Hobbes and Thoreau instead of studying molecular biology or machine learning. But discussing life’s big value questions in seminars gives students personal engagement with professors that can never be reproduced in large lecture halls. Discussions among students on their deepest thoughts cultivates curiosity and empathy, and forges bonds of friendship important for citizenship and fulfilling lives.

Although we like to set ourselves apart from the past by appeals to modernity, the fundamental questions that we find ourselves asking are not always modern, and the latest answer is not always right. But how would you know how to think beyond the readily presented check boxes if you haven’t done the work of laying things out and putting them back together for yourself?

War was no less a concern for Thucydides, Tacitus and Thoreau than it is today. Discussing Great Books allows students to gain distance from the daily noise and allows their reason to roam free among principles and foundations rather than becoming absorbed in contemporary events. Our biggest problems are often best addressed not by leaning in but by stepping away to reflect on enduring perspectives.

Liberal arts education is not value neutral. That is why it is indispensable today. Freedom of thought, critical reasoning, empathy for others and respectful disagreement are paramount for a flourishing democratic society. Without them, we get the unreasoned condemnations so pervasive in today’s malignant public discourse. With them, we have a hope of furthering the shared governance that is vital to America’s pluralistic society.

Ezekiel Emanuel and Harun Küçük are on the faculty of the University of Pennsylvania, where Dr. Emanuel is a professor and the vice provost for global initiatives and Dr. Küçük is an associate professor of the history and sociology of science.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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METHODS article

A pluralistic perspective on research in psychotherapy: harnessing passion, difference and dialogue to promote justice and relevance.

• 1 School of Applied Sciences, Abertay University, Dundee, United Kingdom
• 2 Metanoia Institute, London, United Kingdom
• 3 Department of Psychology, Roehampton University, London, United Kingdom
• 4 School of Education, Language and Psychology, York St John University, York, United Kingdom
• 5 Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway
• 6 Manchester Institute of Education, Schools of Environment, Education, and Development, University of Manchester, Manchester, United Kingdom

The adoption of a pluralistic perspective on research design, processes of data collection and analysis and dissemination of findings, has the potential to enable psychotherapy research to make a more effective contribution to building a just society. A review of the key features of the concept of pluralism is followed by a historical analysis of the ways in which research in counselling, psychotherapy and related disciplines has moved in the direction of a pluralistic position around knowledge creation. Core principles of a pluralistic approach to research are identified and explored in the context of a critical case study of contemporary research into psychotherapy for depression, examples of pluralistically oriented research practices, and analysis of a pluralistic conceptualisation of the nature of evidence. Implications of a pluralistic perspective for research training and practice are discussed. Pluralistic inquiry that emphasises dialogue, collaboration, epistemic justice and the co-existence of multiple truths, creates opportunities for individuals, families and communities from a wide range of backgrounds to co-produce knowledge in ways that support their capacities for active citizenship and involvement in open democratic decision-making. To fulfil these possibilities, it is necessary for psychotherapy research to be oriented towards social goals that are sufficiently relevant to both researchers and co-participants to harness their passion and work together for a common good.

Introduction

Psychotherapy research is conducted on a global scale, by investigators drawn from different occupations and disciplines, using a range of methodologies, and publishing in a large number of independent journals. As a result, notwithstanding a degree of influence exerted by governmental and other funding agencies, the psychotherapy research community can be viewed as comprising a largely self-organising open system that resists centralised direction. At the same time, it can also occasionally be valuable to evaluate the direction of travel of therapy research in terms of its contribution to broader societal objectives. In this paper, we suggest that although the field of therapy research has always reflected an implicit acknowledgement that the complexity of therapy outcomes and processes requires the adoption of a flexible, pluralistic approach to evidence, the full implications of a pluralistic perspective have yet to been fully articulated. More specifically, the predominant interpretation of pluralism that has been used by therapy researchers has not sufficiently taken account of crucial social and political aspects of this construct. By contrast, a more comprehensive application of a pluralistic stance in relation to therapy research has the potential to significantly enhance the contribution of psychotherapy, and related practices, to addressing contemporary social issues.

Pluralism is a philosophical and ethical tradition based on the idea that there is no single perspective or truth that is universally valid ( Rescher, 1993 ). Pluralism represents an acknowledgement of the ultimate impossibility of reducing the interconnectedness, complexity and uniqueness of life to a set of laws or theories. From a pluralistic stance, human experience and forms of life, across all cultural traditions, can be seen to have been characterised by dissensus rather than consensus. Awareness of the existence of a diversity of perspectives, along with a never-ending effort to reconcile such differences, has been a fundamental aspect of both individual and societal development in modern societies ( Taylor, 1992 ). Important aspects of a pluralistic stance include a commitment to dialogue as a means of bridging different perspectives and to a cognitive style that emphasises ‘both/and’ or ‘and/and’ rather than ‘either/or’ dichotomous thinking.

The authors of this paper are aligned with a collaborative framework for therapy practice, known as pluralistic therapy that represents a systematic attempt to develop a form of practice informed by a pluralist philosophy ( Cooper and McLeod, 2011 ; Cooper and Dryden, 2016 ; McLeod, 2018 ; Smith and de la Prida, 2021 ). A key principle of pluralistic therapy is that different people are likely to be helped by different things at different times. Problems in living for which individuals and families seek therapeutic help are viewed as arising from complex interactions between multiple life events and sources of adversity. Pluralistic practice addresses these problems by making use of strategies and methods from multiple sources, including supportive and healing practices available within the community. The process of client-therapist collaboration is organised around clarifying what the client wants to use therapy to achieve (their goals), identifying specific tasks that might contribute to step-by-step progress in the direction of goals and agreeing methods for accomplishing these tasks. The therapist functions as a facilitator or orchestrator of dialogue and shared decision-making around finding and assembling ideas, activities and ways of communicating and relating, suggested by either the client(s) or therapist(s), or emerging in the work itself. Procedures for supporting client-therapist collaboration and shared understanding include therapist transparency around what they can offer, techniques for elicitation of client preferences ( Norcross and Cooper, 2021 ), and active elicitation and application of the client’s knowledge through experience and cultural resources. Strategies for ensuring that therapy remains in alignment with client goals include routine use of metacommunication, process and outcome feedback tools and design tools, such as collaborative case formulation mapping. Pluralistic therapy does not comprise a fixed or static theory or set of procedures. Rather, it comprises an open system and community of practice that encourages dialogue, innovation and sharing of experience.

Over the past decade, the priority of the pluralistic therapy community has been to establish structures for training, practice and supervision to support members in working collaboratively with clients. An important strand of that effort has been the development of a research base that would identify evidence to facilitate the development of pluralistic practice; conducting studies on the process and outcomes of pluralistic therapy itself (e.g. Cooper et al., 2015 ; Di Malta et al., 2020 ). The intention has been to build an approach to therapy that is research-informed rather than research-directed ( Hanley and Winter, 2016 ), based on the principle that effective practice draws on multiple ways of knowing: ethical, personal, theoretical, cultural and scientific ( McLeod, 2016 ).

In the course of developing an evidence base for pluralistic therapy, we gradually came to realise that we were beginning to see the psychotherapy research literature as a whole from a distinct pluralistic perspective. In particular, we came to believe that the more pluralistic a research study or programme was, the more useful it was for practice, and the more likely it was to make a contribution to social justice.

The present paper builds on earlier work by Hanley and Winter (2016 ), in seeking to explore and further refine the nature of a pluralistic perspective on psychotherapy research. A historical overview is provided around how the concept of pluralism has been used in psychotherapy research. This is followed by a summary of key principles of a pluralistic perspective on research, and then, a case example that examines how a more explicitly pluralistic approach might enhance the relevance of research in relation to an area of inquiry that has comprised a central focus of psychotherapy research in recent years. The paper concludes by looking at possible ways in which a pluralistic perspective might be realised. Our aim, in all of these areas, has been to consider the implications of a pluralistic perspective in relation to the field of psychotherapy research in general, rather than solely in respect of pluralistic psychotherapy as a specific therapy orientation.

A Historical Perspective on the Influence of Pluralism in Research in Counselling and Psychotherapy and Related Disciplines

From the start, psychotherapy research has been primarily based in the ideas and methods of psychology and psychiatry – disciplines that have historically prioritised quantitative and experimental approaches to research. Nevertheless, despite these disciplinary pressures, the first generation of therapy researchers, notably Carl Rogers and Hans Strupp, sought to create a flexible and responsive methodology for the study of psychotherapy that was consistent with its existence as a complex, co-constructed, agential and interpersonal form of practice. For example, the research group led by Rogers made use of case study methods, qualitative methods and projective techniques ( Rogers and Dymond, 1954 ). Strupp and Hadley (1977 ), arguing that it was essential to understand therapy outcomes from multiple perspectives (client, therapist and society). However, from the 1970s, the increasing societal profile of psychotherapy, and in particular its growing presence with state-funded healthcare systems, meant that major sectors of practice came to be controlled by assumptions, policies and procedures associated with neoliberal political and economic ideology, and the implementation of these ideas through the adoption in public sector organisations of management philosophies that emphasise competition rather than collaboration ( McLeod, 2016 ; Sundet, 2021 ). For the psychotherapy research community, this shift was reflected in the reification of schools of therapy as products in a crowded mental health marketplace, and the adoption of randomised clinical trial (RCT) methodology as a means of determining ‘winners’ and ‘losers’ within a competitive environment. Within this new approach, studies of psychotherapy effectiveness increasingly adopted a single primary outcome measure, typically in the form of a client self-report symptom scale.

From the 1980s, the concept of pluralism began being used in the psychotherapy literature to signal resistance to the hegemony of RCTs and empirically validated and manualised therapies ( Omer and Strenger, 1992 ; Samuels, 1995 ; Downing, 2004 ). In the context of research, the idea of methodological pluralism was introduced in an influential paper by Howard (1983 ), as a means of legitimising the use of a wide range of methodologies alongside clinical trials. While Howard was commenting specifically on the value of case study methods, later contributions extended the argument to include qualitative methods ( Mearns and McLeod, 1984 ; Goss and Mearns, 1997 ; Slife and Gantt, 1999 ; Barker and Pistrang, 2005 ). While acknowledging that different methodological approaches (quantitative, qualitative and case study) were grounded in contrasting epistemological positions and values and associated with different quality criteria, these writers argued that different research questions were most effectively addressed by different methods and that the study of psychotherapy required the use of multiple research approaches. Important themes within the argument for methodological pluralism were that convergence of findings across methodologies had the potential to reinforce the credibility of research and that evidence hierarchies that gave higher weighting to meta-analyses of findings from RCTs were misguided. Over the years, the principle of methodological pluralism, understood as tacit acceptance of the value of different methodologies, has become widely accepted within the psychotherapy research community.

The vision of methodological pluralism advocated by Howard (1983 ) and others was primarily formulated as a set of broad principles, with limited practical guidance on how to handle different types of data in the process of conducting an actual study. These technical issues troubled researchers, particularly those whose initial training had focused on quantitative designs and techniques. As a consequence, there began to emerge a literature around the use of mixed-methods research (MMR) designs ( Haverkamp et al., 2005 ). An underlying driver within the MMR literature has been a wish to combine the strengths of both qualitative and quantitative methods. As a consequence, authors have highlight concerns and challenges associated with combining multiple methods in one study and emphasised the necessity for having a clear understanding of the distinctive contribution of each approach around such domains as: quality standards for different styles of data collection and analysis; underlying values and epistemological assumptions; and reporting formats. There are many different methodologies that can be combined in different ways for different purposes which have stimulated a proliferation of MMR texts and models ( Tashakkori and Teddlie, 2010 ; Creswell and Plano Clark, 2011 ). Recent years have seen a steady growth in interest in MMR research on psychotherapy topics, including formulation and dissemination of APA guidelines ( Levitt et al., 2018 ).

As MMR research became more established, it became increasingly apparent that many MMR studies operate not primarily on the basis of a pre-determined research design that is then followed through, but on a collaborative process between a team of researchers each of whom represents a distinctive methodological competency, conceptual/theoretical perspective or area of lived experience (a useful discussion of this theme can be found in Wachsmann et al., 2019 ). A key element of this aspect of the real-life implementation of MMR research is that taking methodological pluralism seriously requires making use of people who are immersed in each approach or represent different perspectives, rather than depending on the less intense understanding of contrasting approaches and perspectives that might be available to a single research generalist. An additional area of methodological learning within the recent critical and reflective literature on MMR has been that successful studies pay particular emphasis on areas of difference (across methodologies, participants and theories), as well as areas of convergence, within the process of data collection and analysis ( Johnson, 2017 ).

The next step in the historical evolution of a pluralistic approach in research in psychotherapy and related disciplines has therefore comprised the development of attention to dialogical processes, described by Johnson (2017 ) and colleagues as a form of dialectical pluralism that as:

…asks all of us to appropriately listen to what needs to be listened to for each research question, purpose, stakeholder interest, and practical activity. This broad dialecticalism will enable people to continually interact with different ontologies, epistemologies, ethical principles/systems, disciplines, methodologies, and methods in order to produce useful wholes. The process should continually build on what we know and feel and value now and produce new, dialectically derived, “knowledge(s),” programs, theories, and deliberative democratic human coalitions. ( Johnson, 2017 , p. 158)

Johnson and Schoonenboom (2016 ) present an account of what dialectical pluralism looks like in practice, through exemplary studies on various aspects of healthcare practice. A common pattern of these studies is that researcher beliefs and knowledge (e.g. what they have found in an initial study, such as an RCT) are rigorously exposed to critique by relevant stakeholders (e.g. patients and healthcare providers), leading to a new shared understanding that can then form the basis for further cycles of inquiry. While dialectical pluralism is similar in some respects to a broader acknowledgement of stakeholder perspectives in healthcare research and realist evaluation ( O’Cathain et al., 2019 ), it goes further in calling for a systematic and disciplined capacity for listening, reflexivity and openness to difference on the part of researchers. Detailed accounts have been developed of techniques and strategies used by dialectical realist research teams to support the adoption of a dialectical or dialogical practices ( Johnson and Schoonenboom, 2016 ; Johnson, 2017 ).

A complementary research tradition that similarly incorporates a pluralistic and dialogical ethos can be found in studies that have adopted participative action research and collaborative inquiry approaches ( Ponterotto, 2005 ; McLeod, 2001 ). Such studies reflect a position that the primary aim of research should be to facilitate change in terms of promoting equality and social justice, empowering individuals and communities and solving real-world problems. For these researchers, the capacity to achieve such outcomes is the real test of the value or validity of a research study. This approach to research can be understood as a form of ‘engaged’ inquiry ( Chevalier and Buckles, 2019 ), influenced by the ideas and values promoted by key 20th century thinkers, such as Paulo Freire, Jurgen Habermas and Kurt Lewin ( Reason and Bradbury, 2013 ). It is also consistent with ideas of ‘collaboration as a matter of principle’ outlined as part of the psychotherapy social justice agenda ( Winter, 2019 , p.180). Typically, service users or community members may be involved in the design of a study, collection and analysis of data, writing and dissemination, for example in the programme of collaborative research that has involved service users and therapists working together to establish a basis for more effective therapy and recovery interventions in bipolar disorder ( Veseth et al., 2012 ; Billsborough et al., 2014 ). A similar approach to a collaborative, emancipatory approach to inquiry can be found within the methodological tradition associated with critical psychology ( Teo, 2015 ; Fine et al., 2021 ; Levitt et al., 2021a , b ).

Co-production is a further example of a pluralistically oriented form of research that promotes engagement and shared decision-making between researchers and participants. Drawing from the analysis by Ostrom (1990 ) of the operation of systems of common ownership ( Ostrom, 1990 ), co-production is a justice-based approach ( Cahn, 2000 ) that has been widely applied within national health and social care services in the United Kingdom to empower citizens to become participatory agents in their own care ( Coote, 2002 ; Needham and Carr, 2009 ; Worsley et al., 2021 ). Commitment to co-production is now a central funding criterion of the UK National Institute of Health Research, on the grounds that all research should be carried out ‘with and by patients, rather than to or for them’ ( NIHR, 2021a , b ).

As with the development of co-produced interventions in healthcare, co-produced research ideally involves the equal and reciprocal co-creative involvement from design, through action and into dissemination, with research partners drawn from a range of backgrounds and roles. The inclusion of multiple vested stakeholders in the design and implementation of research, allows for greater complexity of understanding of both the phenomenon at hand, and the nested systems within which it operates ( Gibert et al., 2010 ; Conte and Davidson, 2020 ). Additionally, the involvement of service users to develop relevant and timely research questions may help to reduce the widespread research-practice gap noticed especially in mental health research.

Co-productive research is driven by a commitment to a pluralistic stance that emphasises inclusion of multiple stakeholders and perspectives and mutual trust between research partners. The process of engaging in co-produced research has been termed as ‘turbulent’ and ‘challenging’ ( Worsley et al., 2021 ) due to the complex interpersonal dynamics that can arise when professionals and patients are asked to work together in partnership. Co-production research partners must commit seriously to hermeneutic justice ( Fricker, 2007 ), in which ways of understanding conveyed by different actors are considered to have equal value, especially where the voices of some actors have been previously silenced ( Blunden and Calder, 2020 ). Examples of co-produced psychotherapy research studies include Blunden (2020 ) and Curran et al. (2021 ).

These issues have inevitably led pluralistically oriented therapy researchers to look towards theory, research and practice around decolonisation as a source of understanding around how to handle such issues. A decolonial perspective involves facing up to deeply entrenched areas of injustice in contemporary society that are rooted in large-scale, violent historic exploitation of indigenous peoples and the lands on which they lived. Supported by the work of researchers, scholars, activists and artists in a wide range of disciplines in all parts of the world, this broad approach involves interrogating the roots of injustice and oppression, challenging existing power relations, achieving restorative justice and building postcolonial discourses and communities ( Goodman and Gorski, 2015 ; Barnes, 2018 ; Smith, 2021 ). One of the consequences of colonialism has been not only the unequal distribution of material goods and power, but also the fact that the majority of those in power does not recognise themselves as such but is still playing their part in larger discourses and abstract systems, such as patriarchy, privilege or in what is termed as ‘normal’ (e.g. neurotypicality and heteronormativity). Current movements and frameworks, such as Black Lives Matter, #MeToo, or critical psychology and intersectionality, are about finding one’s voice and amplifying the voices of marginalised others. Pluralistic inquiry can engage with this by asking questions inspired by postcolonial theory that address alienation, power differences and silenced voices. In recent years, even though some researchers and practitioners have begun to develop a postcolonial approach to psychotherapy research, it is clear that more needs to be done. For example, although trauma therapy has received considerable attention from a postcolonial perspective ( Bennett and Kennedy, 2003 ; Andermahr, 2016 ), traumatic experiences of minorities are still marginalised while Western definitions of trauma are taken as universally valid ( Craps, 2013 ).

This historical analysis has sought to provide an outline of how methodologies that reflect an explicit or implicit pluralistic standpoint have emerged over several decades as increasingly salient aspects of research in psychotherapy, counselling and related disciplines. The earliest references to methodological pluralism represented a response to the methodological hegemony of measurement and experimentation in research. Pluralism was put forward as a solution to the perceived limitations of relying solely on quantitative research approaches. These sources used the concept of plurality as a synonym for multiplicity and diversity, often within the conclusion section of an article or chapter, as something to be accepted and move towards (see, for example Rieken and Gelo, 2015 ). Over time, a pluralistic perspective began to move on from arguments about the legitimacy of qualitative and case study approaches to technical solutions to the challenge of combining different kinds of data. The most recent phase has been marked by the establishment of a distinctively dialogical, collaborative and co-production approach to the creation of practical knowledge in psychotherapy and allied disciplines, and then most recently to common purpose with political and scholarly initiatives around decolonisation. The underlying dynamic in this process has been a shift from interpreting pluralism as a form of respectful relativism that acknowledges the co-existence of different points of view to a more active stance that attends closely to difference as a source of learning and insight. This transition has required researchers to engage with uncomfortable and often emotionally troubling differences associated with power, colonialism, unearned privilege and other inequality fault-lines in contemporary society.

Principles of a Pluralistic Perspective on Psychotherapy Research

Although the development of a pluralistic perspective on research in psychotherapy has been based in the work of individuals and groups influenced by different conceptual frameworks and operating in different contexts, it is possible to identify some shared underlying methodological assumptions and practice implications.

Methodological and Epistemological Flexibility and Inclusiveness

A key principle of a pluralistic perspective on research is an appreciation that all ways of knowing and sources of knowledge have something to offer. Pluralistic inquiry does not define itself in opposition to other research traditions or consider any such traditions to be ill-founded. Instead, all forms of inquiry are regarded as possessing their own distinctive strengths and limitations. Pluralistically oriented psychotherapy research does not promote qualitative research over RCTs or neuropsychological studies, favour wholism and emergence over reductionism or vice-versa. An important study in relation to this topic was conducted by Levitt et al. (2020 ) who interviewed leading psychology researchers from a wide range of methodological traditions, around their stance in relation to the adopting a detached, objective research attitude or espousing the use of disciplined subjectivity. A striking finding from these interviews was that all of the research participants regarded both objectivity and subjectivity as serving valuable scientific purposes and had made use of their personal capacities for subjectivity and objectivity as necessary over the course of their careers.

A pluralistic perspective on research seeks to operate from the kind of both/and stance represented by informants in the Levitt et al. (2020 ) study. This principle represents a central implication of the ethical implications of espousing a pluralist view of reality: if different individuals and groups hold contrasting beliefs about what is true, the ethical choice is between discounting, ignoring or suppressing the beliefs of others or engaging in dialogue that seeks to make bridges between alternative ways of thinking. All of the pluralistically inclined research traditions discussed earlier in this paper reflect the latter ethical choice and can be regarded as invitations to move beyond established positions in ways that have the potential to broaden and fuse horizons.

Influential figures in the psychotherapy research community have argued that contemporary psychotherapy research and practice are dominated by a stultifying theoretical and methodological ‘monoculture’ ( Leichsenring et al., 2018 , 2019 ) and that a pluralistic perspective should be regarded as existing as a focus of opposition to such hegemonic tendencies. This is not the inclusive and invitational position adopted in the present paper, which views the psychotherapy research community as comprising many vibrant ‘micro-cultures’ that would benefit from talking to each other a bit more, in ways that would allow us all to learn with and from each other. The fact that large psychotherapy providers, such as government health departments and managed care organisations, might seek to impose uniformity around therapy services that are offered to the public is an indication that psychotherapy research might benefit from adopting a more pluralistic approach that takes political, social and historical and social factors into account.

Expect – and Welcome – Multiple Credible Answers to the Same Question

From a pluralistic perspective, research analyses and conclusions that yield multiple answers (divergence/dissensus) are of equal value to those that generate convergence/consensus. Pluralistically oriented research reports and reviews highlight different interpretations of data (e.g. by an auditor or co-researcher in a qualitative study, through application of alternative statistical techniques and attention to outlier cases) as having potentially significant implications for understanding, research, practice and theory development. Diverging perspectives or findings arising from different data sources or participants are viewed as steps in a dialectical process that has the potential to lead to a new (or more differentiated) theory or synthesis ( Levitt et al., 2020 ). The existence of multiple ‘truths’ is not only a core philosophical assumption of pluralism but also is a routine aspect of the practice of psychotherapy: much of the process of therapy is based on the creation of meaning bridges, empathy and ways of talking and connecting that have the effect of allowing people to function within a multi-voiced intra- and interpersonal reality. By corresponding more closely with everyday experience, multiple answers to a research question have the potential to make findings not less, but more relevant for policy and practice.

Active Promotion of Epistemic Justice

Within both the natural and social sciences, there are multiple ontological and epistemological positions that are utilised in the service of legitimate inquiry. There also exist highly significant knowledge structures within society as a whole, for example in respect of spiritual and faith beliefs, and indigenous systems of knowledge, that operate independently of scientific empirical knowing. In everyday life situations, participants make use of multiple ways of knowing alongside scientific evidence, for example personal experience, knowledge arising from membership of a culture or occupational group, ethical values, theoretical understanding and narrative knowing. Psychotherapists and clients routinely operate within and across these alternative ways of knowing. In relation to psychotherapy research, these factors mean that it makes little sense to regard any single source of knowledge (e.g. RCTs or meta-analysis of RCTs) as offering a reliable guide to practice or decision-making. Instead, practical decisions should be based on a balanced and informed appraisal of all available sources of evidence.

Occasions when someone in authority (e.g. a therapist or policy-maker) unilaterally prioritises one source of evidence over another should be viewed as episodes of epistemic injustice and misuse of epistemic privilege. Fricker (2007 ) identified two forms of epistemic injustice: testimonial injustice , where evidence provided by a person is not taken seriously because of who they are (e.g. a client’s evaluation of therapy being disregarded because of their alleged diminished capacity for rationality) and hermeneutical injustice when a source of evidence is not well enough understood at an institutional or organisational level for it to be taken into account (e.g. when journal reviewers reject qualitative research manuscripts because of lack of knowledge of qualitative methodology). Epistemic injustice has been identified as highly prevalent in mental health settings, for instance in terms of lack of credence given to the cultural and experiential knowledge of service users, and black and minority ethnic staff and clients ( Carel and Kidd, 2014 ; Crichton et al., 2017 ; Kidd and Carel, 2017 ; Newbigging and Ridley, 2018 ). Epistemic injustice may also occur with research groups, for example when qualitative data are analysed by members of a research team that includes novice researchers alongside senior academics, or individuals from different cultural or social class backgrounds ( Levitt et al., 2021a ).

A pluralistic perspective on research pays particular attention to strategies for prevention of epistemic injustice through relevant design, data collection and analysis, and dissemination, and intentional choice of research topics and questions intended to address previous epistemic injustice (e.g. carrying out research in collaboration with members of marginalised groups).

Dialogue as a Criterion for the Validity, Credibility, Trustworthiness and Practical Utility of Research Conclusions

Scientific research is an essentially collective process, that depends not only on the capacity for imagination and rational thinking of individual researchers, but on the capacity of a set of findings to enter and survive the process of dialogue with other, independent members of a scientific community, in the form of critical responses or readers and reviewers, replication studies and data re-analyses ( Brown, 2012 ; Stuckey et al., 2015 ). Because therapy research is fragmented into sub-communities (e.g. groups who study psychodynamic therapies, or CBT, or humanistic therapies), most research reports are only read by those who are already broadly predisposed to agree with what is being reported ( McLeod, 2017 ). In addition, major groups of possible stakeholders who might have a view on the findings of a study, such as practitioners and clients, rarely or never read research papers. In some qualitative research papers, even though data and findings may be made available for comment by independent research auditors, or research participants, the ensuing dialogue with researchers is seldom reported. Taken as a whole, these scenarios mean that therapy research studies are scrutinised to a very limited extent. By contrast, the practice of both pluralistic therapy and pluralistic research relies on a process of putting difference to work through treating contrasting perspectives as opportunities for learning ( Johnson, 2017 ). Both pre- and post-publication open dialogue around research reports have the potential to produce findings that are more nuanced and relevant to practice ( Nosek and Bar-Anan, 2012 ). While the broader scientific community has found it hard to sustain such initiatives ( Wakeling et al., 2019 ), there are sufficient motivated and interested practitioner and service user readers to make such an approach feasible.

Doing Research That Is Oriented Towards the Accomplishment of Social Justice Goals

Pluralism is associated with a pragmatic philosophical stance in its emphasis on evaluating the success of any actions in terms of criteria that are decided at a local level, rather than on the basis of abstract or universal criteria ( Fishman, 1999 ; Hanley and Winter, 2016 ). In pluralistic therapy, for example the process of therapy and the final decision on whether it has been helpful are anchored in goals identified by the client. Similarly, one of the implications of a pluralistic perspective on research is that an important criterion for evaluating studies should be in terms of the difference that they make in relation to social needs and goals that are meaningful to individuals and communities. An example of the difference between research that is personally and theoretically meaningful, as against aiming to address social injustice, can be found in a programme of research into the role of counselling and other forms of emotional support for people experiencing sight loss. This programme originated in a stand-alone grounded theory qualitative study of the emotional impact of sight loss ( Thurston, 2010 ). The experience of conducting this study, and in particular the response of others to its publication, opened a specific societal goal (development of emotional support services for sight loss) that served to guide the direction of further work. Further studies drew on other methodologies, such as case study analysis ( Thurston et al., 2013 ) and surveys ( Thurston and Thurston, 2013 ; Pybis et al., 2016 ). Because the social significance of this research was apparent to individuals with sight loss, health professionals, third sector vision impairment organisations, researchers from other disciplines and politicians, it became able to draw on an expanding network of collaborative consultation and dialogue, and to co-produce training courses for counsellors and other helpers. Many other similar examples of research programmes oriented towards social justice goals could be identified.

Authentically pluralistic and inclusive research that involves collaboration, co-production and dialogue is more likely to occur in situations in which a programme of research is organised around a social goal that is sufficiently broad and practically significant, and whose relevance is sufficiently widely acknowledged to energise the passion, active involvement and passion of individuals and groups beyond the academic community. Such situations enable research partners to bring their own sources of power into a project. In such research contexts, the concept of passion refers to the capacity of participants to be motivated by a goal that transcends their own individual interests, draws on all aspects of who they are as a person and calls for sacrifice in the service of a greater good ( Duffy et al., 2013 ).

The methodological principles outlined above, derived from philosophical and social usage of the concept of pluralism, as well as the range of pluralistically oriented research traditions already discussed, provide a preliminary guide or checklist for thinking about how to incorporate a pluralistic perspective into research in psychotherapy.

Pluralistically Oriented Therapy Research: Illustrative Case Examples

Within the field of psychotherapy research, although there are few studies that have explicitly espoused a pluralistic perspective, it is possible to use pluralistic principles to develop an understanding of what might be missing in the ways that studies and reviews are conducted. In the following sections, the area of research on psychotherapy for depression is used to explore some of the ways in which a pluralistic perspective makes it possible to begin to see how dialogical and collaborative approaches might enhance the practical utility of personal and institutional investment in psychotherapy research into this major mental health issue. The focus then turns, more briefly, to consideration of the relevance of a pluralistic perspective to methodological challenges around collaboration in research, investigating culturally-responsive therapy and conducting pluralistic systematic reviews.

Pluralizing Depression

Apart from its inherent significance as a major area of therapy theory, research and practice, the topic of psychotherapy for depression is of interest from a pluralistic perspective because it has been the recent focus of critical scrutiny in the United Kingdom that makes it possible to identify different ways of thinking about evidence, and significant failures in dialogue. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) 1 is an independent, government-funded organisation that publishes clinical guidelines to support clinical decision-making in physicians and other practitioners in relation to a wide range of health conditions and aspects of social care. Guidelines are informed by an evidence hierarchy in which systematic reviews of RCTs are given the highest weighting and are updated on a regular basis. NICE guidelines are regarded by clinicians in many countries as demonstrating exemplary standards of rigour. In 2009, NICE published a set of guidelines on the treatment of depression, which recommended a range of psychological therapies that might be used for different degrees of symptom severity. In 2017, following an extensive period of consultation and a systematic meta-analysis of new evidence, it produced a draft of an updated depression guideline, which was circulated to stakeholder groups for comment. Despite the fact that the review process and guideline recommendations were formulated by leading figures within the research community, the 2017 draft revised guidelines (which strongly favoured CBT) were widely rejected by key stakeholder groups, including psychologists, psychiatrists, general practitioners, counsellors, psychotherapists and service user organisations (see, for example Barkham et al., 2017 ; McPherson et al., 2018 ; Thornton, 2018 ). The central issue, for critics, was that the procedure had not been sufficiently pluralistic. In particular, application of an evidence hierarchy that placed the highest value on RCTs and systematic reviews of RCT findings was regarded as having had the effect of omitting or downgrading crucial sources of evidence, such as qualitative client experience studies and naturalistic studies of routine therapy practice in everyday therapy settings.

The critical response to the draft NICE depression guidelines is consistent with findings from a study of a different NICE guideline project, that, in itself, RCT evidence is not necessarily regarded as reliable and trustworthy, even within groups of senior researchers who have spent their careers conducting such studies ( Brown et al., 2016 ). The issue of trustworthiness was further explored in relation to RCT evidence relating to psychotherapy for depression in a unique investigation conducted by McPherson et al. (2020 ). In this study, groups of people with an interest in mental issues (mainly service users, carers and GPs) received a detailed presentation on a psychotherapy for depression RCT study and then invited to share their reactions to what they had heard. None of the participants were convinced that the study that had been described to them helped them to understand therapy for depression or provided information that might help them to decide whether or not such therapy might be relevant to them or to other people they knew. They regarded the RCT design as over-simplifying a complex set of issues and generating ‘headline messages’ that were misleading. Participants in the McPherson et al. (2020 ) study also had many suggestions about the type of study that might be more relevant. From a pluralistic perspective, the significance of this study lies in its demonstration that lay people with personal experience of mental health issues are capable of contributing to dialogue around the pros and cons of different types of research, if provided with an appropriate setting within which such conversations can take place.

Another area in which a pluralistic perspective highlights problematic aspects of research on therapy for depression is concerned with how depression is defined, measured and understood. Depression outcome studies typically evaluate the effectiveness of treatment using self-report symptom measures completed by clients, such as the Beck Depression Inventory (BDI) or Patient Health Questionnaire (PHQ-9), at the beginning and end of therapy. Historical analysis by McPherson and Armstrong (2021 ) has demonstrated that the concept of depression embodied in these measures has become narrower over time. Other studies have analysed qualitative evidence around how clients, their family members and therapists decide whether therapy has had an effect on depression and has found that these stakeholders make use of a much wider set of outcome criteria than those deployed in research studies ( Catchpole, 2020 ; Chevance et al., 2020 ; De Smet et al., 2020 ; Krause et al., 2020a , b ). Research into the experience of depression in everyday life has found that lay people possess complex and highly differentiated discourses and frameworks for making sense of recovery from depression ( Hänninen and Valkonen, 2019 ; Llewellyn-Beardsley et al., 2019 ; Bear et al., 2021 ), including a range of possible pathways to change ( Valkonen et al., 2011 ). Finally, studies in non-Western cultures observe important differences between the ways that depression is understood in these settings, and the measures used by therapy researchers ( Haroz et al., 2017 ; Vink et al., 2020 ). Looking at the ways in which depression is measured and understood in therapy research as a whole, it seems apparent that researchers are missing potentially important aspects of the phenomenon they are investigating, and not taking sufficient account of differences between professional and everyday ways of understanding depression. By contrast, a pluralistic orientation to research would suggest that these are crucial areas of investigation for producing a practically relevant evidence base around how to help people to move on from depression. Stänicke and McLeod (2021 ) provide an example of how attention to these forms of difference and paradox may be used to stimulate new directions in therapy research.

Research into therapy for depression predominantly reflects a narrow focus on the process and outcomes associated with specific depression-related aspects of what happens in the therapy room. However, therapy for depression rarely occurs in isolation. Most clients who are depressed report other co-existing problems and issues ( Morrison et al., 2003 ). Clients make use of other forms of help alongside seeing a therapist ( Wilson and Giddings, 2010 ). Family members are involved in a myriad of ways, whether or not the therapist every meets them face to face ( McPherson and Oute, 2021 ). A large proportion of clients has made use of antidepressant medication in the past or is on medication while receiving therapy. These activities are likely to have exposed them to a ‘chemical imbalance’ explanation of depression that may be difficult to reconcile with therapy ( France et al., 2007 ; Kemp et al., 2014 ). The sequencing of therapy and medication may follow different pathways. Some clients turn to therapy when medication has not helped, and they have reached rock bottom ( Wells et al., 2020 ). Others regard medication as energising them sufficiently to engage with psychotherapy ( Cartwright et al., 2018 ). A pluralistic perspective highlights the significance of these (and many other) aspects of therapy for depression that transcend a specific therapy focus or depression focus.

The kind of critical social analysis that is entailed by a pluralistic perspective invites analysis of how differences in power and status have shaped contemporary approaches to research into psychotherapy for depression. The emergence of depression as a major mental health issue, in the 1950s, arose from the efforts of drug companies to develop markets for new products ( Healy, 1999 , 2006 ; Greenberg, 2010 ). These initiatives involved incentives to family physicians to diagnose patients as depressed, direct marketing to members of the public and funding for psychiatrists to revise the diagnostic manual of the American Psychiatric Association to highlight a medicalised concept of depression ( Davies, 2021 ). A Western medicalised understanding of depression was exported to other countries worldwide. For example, Kirmayer (2002 ) described the intensive drive to promote antidepressants in Japan, in the face of considerable local opposition. As psychiatric diagnoses became established as the primary organising principles for mental health provision and conditions for reimbursement and employment, counsellors, psychotherapists and psychologists gradually integrated medical terms, such as depression, into their research and practice. Because diagnosis operates on a universalistic basis in which everyone’s problems are categorised in the same way, it became harder to talk about differences arising from culture, social class and gender. Although psychotherapy for depression does not share the brutal history of colonial exploitation of non-European peoples, the pluralisation of this area of practice has much to learn from decolonising approaches to research ( Kiddle et al., 2020 ; Smith, 2021 ).

This case study of research into psychotherapy for depression illustrated the limitations of existing approaches to depression research in terms of their adoption of a hierarchy of evidence that largely stifled the application of multiple sources of knowledge, use of assessments that were uni-dimensional, the medicalization and decontextualization of complex social problems and persistent euro-centrism. In such a context, the application of a pluralistic perspective has the potential to generate socially relevant research evidence through the adoption of a ‘pluralizing’ mindset that focuses on widening one’s gaze using a ‘both/and’ heuristic, questioning the rationale for any narrowness of view, and deep curiosity around difference.

Openings for Pluralistic Inquiry

While research on psychotherapy and related practices is increasingly shaped by a pluralistic sensibility, the transition to an explicit pluralistic research paradigm is at an early stage. As a result, there are no studies that have fully embraced pluralistic principles. Nevertheless, it is appropriate, in relation the aims of the present paper, to identify some examples of practical strategies that researchers have used to take established psychotherapy research approaches in a more pluralistic direction.

The psychotherapy literature includes many systematic reviews or metasyntheses that bring together the findings from all published studies on a topic. The majority of these reviews focuses on either qualitative or quantitative studies, with the consequence that it is not possible to compare evidence generated by different methodological approaches. Reviews by Pomerville et al. (2016 ), Greenhalgh et al. (2018 ) and Wu and Levitt (2020 ) demonstrate how it is possible to incorporate findings of qualitative and quantitative studies in a single review. The Pomerville et al. (2016 ) review takes a further pluralistic step in reporting review findings in terms of contrasting interpretative themes rather than a unified model. The potential for enhancing the social relevance of reviews through involvement of stakeholders is discussed by Abrams et al. (2021 ). An example of how this can be accomplished can be found in De Weger et al. (2018 ).

A significant development in qualitative research in recent years has been the widespread adoption of the use of multiple data analysts (e.g. an independent external auditor, research team members or research participants) as a validity criterion to support the trustworthiness of findings. The methodological assumption underpinning this procedure has been that the use of multiple analysts operates as a means of reducing misunderstandings of the data that might arise when there is only a single researcher. Within the qualitative research community, this practice has been accompanied by an interest in how power differences in understanding and data interpretation between co-analysts (e.g. members of a research team or between researchers and participants) might be handled (see, for example Levitt et al., 2021a ) to ensure that final consensus judgements reflect open discussion rather than domination by more powerful voices, while still recognising legitimate differences between researchers. While such respect of epistemic justice is consistent with a pluralistic perspective, what is even more valuable is also to attend to the potential meaning and significance of differences in how co-analysts make sense of qualitative data. Nuala Frost and colleagues have shown that attention to the contrasting interpretations offered by different analysts enhances the meaningfulness of findings ( Frost et al., 2010 ; Frost, 2016 ). Studies building on the work of Halling and Leifer (1991 ) have shown that dialogue between researchers (i.e. beyond mere consensus agreement) generates new understanding. A wide range of practical strategies for enabling research participants to engage effectively in such collaborative processes has been described by Moltu et al. (2013 ), Hallett et al. (2017 ), Matheson and Weightman (2020 , 2021 ), Fine et al. (2021 ) and Soggiu et al. (2021 ).

A final area of emergent pluralistically informed practice concerns ways of conducting research that is not only sensitive to cultural difference but actively functions to promote the interests of members of oppressed and silenced communities. How can we create a psychotherapy research discourse that allows those who are currently silenced to be heard? Postcolonial writers, such as Spivak (2003 ), argue that for the ‘subaltern (i.e. the person subjected to colonial rule) to speak, and be heard, they are required to use the language and concepts of the dominant group. In counselling and psychotherapy, this means using the language and theories that have been established in the West. The use of terms, such as ‘ethnopsychotherapy’, ‘indigenous therapy’ and ‘culturally adapted therapy’, reinscribe this hegemony, by implying that Euro-American psychotherapy is the ‘unmarked category’, while others are ‘ethnic’, ‘indigenous’ or ‘adapted’ ( Zerubavel, 2018 ). Pluralistic inquiry calls for awareness of how to ensure that research participants are not subjected to this kind of discursive erasure. Examples of how this can be accomplished include a remarkable study by Gone (2021 ) in which he uses his own insider knowledge as a member of an indigenous community, and his professional knowledge as a psychotherapy researcher, to allow the voice of an indigenous healer to be heard in a manner that would make sense to other therapy practitioners and researchers. A study by Mehl-Madrona (2009 ) used a humility-based strategy in simply asking elders in an indigenous community to tell him that they thought that Western practitioners need to know in order to be helpful to them. In a study by Waddell et al. (2021 ), a research partnership was built up through joint participation in indigenous spiritual rituals over an extended period, prior to data collection and analysis.

The examples of openings for pluralistic inquiry outlined in this section are not intended as a comprehensive account of how to conduct pluralistic research or reviews on psychotherapy topics. Rather, the intention has been to show how a pluralistic perspective builds on existing methodologies in ways that allow difference to become a focus of interest.

A Pluralistic Perspective on Evidence

Within the domain of psychotherapy policy, research and practice, one of the most significant implications of adopting a pluralistic perspective is that it invites further consideration of what counts as evidence. There is broad agreement within professional communities, and society as a whole, around the value of evidence-based practice (EBP). The most widely cited definition of EBP within the field of medicine describes EBP in terms that are consistent with a pluralistic standpoint that acknowledges multiple perspectives and stakeholders:

…the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research [and]… thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences ( Sackett et al., 1996 , p. 71).

A similarly pluralistic stance in relation to evidence is apparent in an APA policy position that resulted from years of debate within the field of psychotherapy research:

Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences ( American Psychological Association, 2006 , p. 273)

When practising in evidence-based way, the APA recommends that the practitioner should draw on a wide range of knowledge sources that may be relevant for each particular case, including:

…clinical observation, qualitative research, systematic case studies, single-case experimental designs, public health and ethnographic research, process-outcome studies, studies of interventions as these are delivered in naturalistic settings (effectiveness research), RCTs and their logical equivalents (efficacy research), and meta-analysis ( Levant, 2005 , pp. 7–8).

The underlying principles of EBPP are radically different from defining evidence in terms of specific methods (e.g. experimental designs, such as RCTs). Instead, the statements cited above advise that clinical decisions should be made in a collaborative manner that takes account of the local context and cultural beliefs and preferences of each client and that information about research findings associated with different methodologies being made equally available to clinicians.

A pluralistic perspective goes further than these EBPP principles, by opening up an appreciation not only of collaborative decision-making around the application of research evidence but also collaborative co-production and critique of the evidence itself. In large part, the medical research being considered by Sackett et al. (1996 ) largely consisted of findings from laboratory science and drugs trials that could only be fully understood by a relatively small number of specialist researchers. By contrast, most research studies of psychotherapy are intelligible, and of interest, to a wide potential readership of therapists, clients and other stakeholders. In a study by McPherson et al. (2020 ) mentioned earlier, when the design, procedures and results of a psychotherapy RCT were explained to service users and other stakeholders, they were highly sceptical of the value of evidence that it provided. The issue of the credibility of evidence from psychotherapy research can be understood as arising from the fact that any research study generates a set of truth claims that are grounded and warranted in terms of methodological procedures that have been followed ( Toulmin, 1958 ). For example, clients have been helped by therapy because they exhibited reduction in depression scores as measured by the BDI which had been administered and analysed in a competent manner by trained researchers. However, therapists or clients who read such a study may have other grounds and warrants available to them, such as an understanding of depression that is different from BDI item content, or other explanations for why scores changed over time ( McLeod, 2021 ). When non-researchers closely scrutinise psychotherapy research studies (as in McPherson et al., 2020 ) it becomes apparent that the truth claims that they encounter in such research reports are to a large extent only warrantable within the narrow parameters of specific research and practice sub-cultures and readily fall apart when exposed to truth claims arising from lived experience.

A pluralistic perspective on psychotherapy research suggests that the quality and credibility of evidence that is available to inform policy and practice would be enhanced by wider dialogue around the design and conduct of studies, data analysis and the meaning and implications of research findings. This dialogue can take place between groups of researchers and across academic disciplines and also between the research community and any other people and groups (clients, practitioners, members of the public and interest groups) who have a stake in making sure that the therapy that is being offered is relevant to the needs of individuals and communities. The relative absence of such dialogue, at the present time, can be understood as representing a form of epistemic injustice that has been described as a manifestation of ‘strategic ignorance’: the process through which members of privileged groups in society retains epistemic control by ‘knowing what not to know’ ( McGoey, 2010 , 2019 ).

In the wider field of healthcare, the limitations of defining evidence in terms of specific methods, such as RCTs and systematic meta-analysis reviews, have been recognised as contributing to difficulties in providing individualised patient-centred care. An important strand of this evolving critique has been the analysis of the implications of basing research in a narrow conceptualisation of causality, alongside a growing awareness of the possibilities associated with a pluralistic understanding of causes that draws on concepts, such as affordances, dispositions and vectors ( Anjum et al., 2020 ). A flexible, conceptually rich framework for making sense of everyday causality already exists within behavioural psychology ( Haynes et al., 2012 ). From a pluralistic perspective, as well as embracing methodological diversity and stakeholder dialogue, the task of enhancing the relevance and sensitivity of research evidence needs to consider the implications of different ideas about causality for the conduct and analysis for all research designs.

Demonstrating the practical societal relevance of co-produced forms of evidence represents a major challenge for those who support the adoption of a more pluralistic approach to psychotherapy research. Currently, we are in a situation in psychotherapy research in which the training received by most researchers limits their understanding of the wide diversity of research approaches that exist. In addition, grant agency boards are filled with researchers who have established their reputations on the basis of expert implementation of a similarly restricted set of established methodologies, and the procedures of grant agencies and governmental guideline commissioning groups generally use an evidence hierarchy framework to inform their decision-making. The views of such sector leaders are unlikely to be swayed by academic debate around research methodology and values. To make an impact on business as usual within psychotherapy research policy and practice, it is necessary to produce actual research findings that demonstrably make a difference.

As discussed earlier, one of the guiding principles of pluralistically informed inquiry is the intention to carry out research that is oriented towards the accomplishment of social justice goals. What this means is that, from a pluralistic perspective, research evidence is evaluated in terms of the extent to which it contributes to creating a better society, alongside whatever technical validity criteria and theory-building aims that may be applicable. Methods for evaluating the extent to which programmes of research accomplish social goals are not well-developed. Nevertheless, at the present time, it is hard to argue that more than 70years of psychotherapy research have led to an improvement in the effectiveness of psychotherapy or the reduction of mental health problems in society. Analysis of historical trends in psychotherapy outcomes has not shown that therapy has become more effective, even in areas of practice that have been supported by considerable investment in research, such as CBT for depression ( Johnsen and Friborg, 2015 ), psychotherapy for problems reported by young people ( Weisz et al., 2019 ) and suicide prevention ( Fox et al., 2020 ). Leading figures in psychotherapy research have argued that the difficulties in applying RCTs in psychotherapy contexts mean that evidence generated by this methodology is best by a wide range of potential biases that are hard to control ( Cuijpers et al., 2019a , b , 2020 ). It has also been suggested that RCT evidence lacks relevance for the development of the kind of service provision that is likely to appropriate to future social needs ( van Os et al., 2019 ). In addition, among those RCTs that have been most influential in setting the agenda for therapy policy and provision, few have ever been replicated, and most stand out as outliers in terms of reporting more positive findings than other similar studies ( Frost et al., 2020 ).

A pluralistic perspective makes it possible to re-vision the types of evidence that can be used to inform psychotherapy practice. For example the logic of a collaborative style of research is consistent with initiatives that use research tools and strategies to enable specific psychotherapy provider organisations, or networks of clinics in a particular city or region, to collect and analyse data from clients and other stakeholders in the context of on-going action research that aims to generate enhanced mental health outcomes at a community level. At the present time, the assumption that service improvement requires the top-down application of generalised knowledge from RCTs has meant that such ground-up projects have rarely been attempted on a sustained basis. Within a 3–5year period, a pluralistically informed action MMR study along these lines, that involved co-productive research alliances with clients, practitioners and community groups, might be able to demonstrate tangible effects on social wellbeing and cultural capital that would be hard to for funders and policy-makers to ignore.

In terms of the type of evidence that is produced by collaborative and co-produced studies, a significant consequence of greater involvement of clients, practitioners and other stakeholders will be that research findings will become more contextualised. On the whole, the type of knowledge that academic researchers bring to the inquiry process is more focused on theoretical perspectives, whereas the knowledge and interest of community-based stakeholders are more focused on the specific local context with which they are familiar. Greenhalgh and Manzano (2021 ) discuss the ways in which attention to context can enhance the practical relevance of research.

The aim of this paper has been to highlight some of the ways in which a pluralistic philosophical stance might enhance the practical value and social relevance of research in psychotherapy and related disciplines. We continue to be surprised by what is uncovered by a pluralizing way of thinking. We are continually challenged by the interpersonal skills and social courage that entailed in a pluralistic perspective, and encourage readers to view our ideas as a starting point and invitation to collaboration and further dialogue. Our experience has been that a pluralistic perspective has heighted our appreciation of the value of existing methodologies. Just as pluralistic therapy provides a framework for channelling existing therapeutic ideas and methods in the service of helping a client to attain their life goals, a pluralistic perspective on research similarly regards existing methodologies as invaluable resources to be cherished and used as appropriate. The therapy research community has created a massive array of research tools (see, for example Liamputtong, 2019 ). A pluralistic perspective does not seek to re-invent these techniques but merely to offer some ideas about how they can be most effectively combined and deployed.

Pluralism offers a philosophical and conceptual meta-model that can be used as a guide (along with other meta-perspectives) to thinking about long-term research objectives and purposes. Pluralism also opens up a wide range of concrete activities, projects and practices that can be pursued immediately. Examples of achievable, low-cost pluralistically oriented research initiatives include as: experimenting with open review/comment journal publishing; conducting pluralistically informed research reviews that incorporate evidence not only from different methodologies but also make use of review teams with different cultural backgrounds and life experience; activating co-production at a local level through collaborative projects that use research to enhance practice in specific agencies/clinics; and learning with and from other disciplines, occupational groups and community organisations through joint seminars and workshops that share experience in co-production, decolonising, and strategies for working constructively with difference.

To move away from euro-centrism, and profession-centrism, the psychotherapy research community needs to do more to recognise forms of practice beyond existing professional labels. There are many places in the world where psychotherapy is not professionalised but where people nevertheless help others through various psycho-social interventions, practices and rituals ( Zacharias, 2006 ). A pluralistic perspective aims to include these practices, perspectives, concepts and principles and recognises their value and potential enrichment of both theory and practice. At the same time, pluralism also takes a critical stance by reflecting on whether these practices and ideas should be subsumed within its own discourse. It can also highlight potentially problematic appropriations. For example some therapeutic schools have borrowed concepts and methods from other cultures (e.g. mindfulness and Morita therapy), but often stripped them of the cultural context, omitting the voices of the people who offered them and developed the ideas around them. Pluralistic inquiry can offer an antithesis to research that whitewashes concepts and methods borrowed from other cultures by revealing their cultural embeddedness. Western concepts and practices of psychotherapy are often implanted without adapting them to cultural contexts, effectively marginalising local knowledge of healing ( Sidhu, 2017 ). Through a pluralistic perspective, researchers can develop dialogues and use tools that support practitioners to develop counselling practices on the basis of indigenous cultural strengths and resources.

Finally, we suggest that it is essential to highlight the potential broader outcomes of pluralistically oriented research, beyond the specific domain of therapy theory and practice. All peoples and cultures are bound together in a collective need to change our way of life and relationship with nature in order to create ways of surviving the inevitable climate crisis that we have brought about. Core elements of that dysfunctional way of life include racism, colonialism, slavery/trafficking and militarism. Erosion of democratic processes represents a key element in the on-going failure to address these crises. Adoption of a pluralistic approach to therapy research has the potential to help us, as psychotherapists, mental health practitioners and researchers, to develop ways of understanding and conducting collective inquiry that provide all participants with awareness and skills around shared decision-making, listening to others, working together, live with complexity and uncertainty and be willing to stand up for collective values and justice. Along with re-visioned therapy practices, these research outcomes represent some of the ways in which we might hope to be able to support individuals, families and communities to engage in active citizenship.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, and further inquiries can be directed to the corresponding author.

Author Contributions

All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

The authors received publication fees for this article from Abertay University. No other funding was received for the development of this publication.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: dialogue, epistemic (in)justice, pluralism, psychotherapy research, social relevance

Citation: Smith K, McLeod J, Blunden N, Cooper M, Gabriel L, Kupfer C, McLeod J, Murphie M-C, Oddli HW, Thurston M and Winter LA (2021) A Pluralistic Perspective on Research in Psychotherapy: Harnessing Passion, Difference and Dialogue to Promote Justice and Relevance. Front. Psychol . 12:742676. doi: 10.3389/fpsyg.2021.742676

Received: 16 July 2021; Accepted: 05 August 2021; Published: 06 September 2021.

Reviewed by:

Copyright © 2021 Smith, McLeod, Blunden, Cooper, Gabriel, Kupfer, McLeod, Murphie, Oddli, Thurston and Winter. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Kate Smith, [email protected]

† These authors share first authorship

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