How Counsellors and Psychotherapists Make Sense of Pluralistic Approaches to Therapy Jerome Alexander Beichman A thesis submitted in partial fulfilment of the requirements of the University of Brighton for the degree of Doctor of Philosophy December 2018 1 Abstract This thesis explores how therapists themselves make sense of pluralistic approaches to therapy. Interview data was used to develop a contextual understanding of pluralism within the therapy professions. Semi-structured interviews were conducted with therapists who identified with different approaches via opportunity sampling. 12 therapists were interviewed: 4 participants were male and 8 were female. Their ages ranged from 29 to 74 and post-qualification experience varied from 1 to 28 years. The overarching question was: ‘How do you make sense of pluralistic approaches to counselling and psychotherapy?’ with sub-questions exploring the therapists’ experiences and practices in relation to the main question. Seven themes were identified. Three themes (‘Identity and Approach’, ‘The Flexibility-Rigidity Continuum’, and ‘It’s the Relationship’) were interpreted as belonging to ‘contentious issues’ that fed into a central theme ‘Debates about Pluralistic Approaches to Therapy’. These debates, in turn, lead to three additional themes interpreted as ‘diplomatic attempts at resolution’ (‘The Practice of Metacommunication’, ‘The Uncertainty-Understanding Continuum’, and ‘Common Factors’). The interviews allowed for the identification and interpretation of themes which could form the basis for further research for the benefit of practitioners, providers and clients. How this sample of therapists makes sense of pluralism in relation to their own practice demonstrates how pluralism might be better understood as a continuum or dimension of therapeutic practice rather than a differentiated way of practising. Pluralism is an important concept to understand for framing how training, practice and policies might be developed in the future. However, this research suggests that therapists are less convinced by the practice of ‘pluralistic therapy’ than they are by pluralistic therapy as a perspective. This research contributes an understanding of how pluralism as a perspective might be used politically to increase patient choice within organisations such as the NHS. 2 3 Table of Contents Abstract ......................................................................................................... 2 List of tables .................................................................................................. 8 List of figures ................................................................................................. 8 List of abbreviations ...................................................................................... 8 Preface ........................................................................................................ 12 Acknowledgements ..................................................................................... 16 Declaration .................................................................................................. 18 1: Introduction ............................................................................................. 20 1.1 Counselling, Psychotherapy, Therapy, Clients and Patients ............. 20 1.2 Introduction and Outline of the Chapter ............................................. 21 1.3 Introductory Personal Statement ....................................................... 22 1.4 The Research Context ....................................................................... 27 1.5 The Rationale, Aims and Objectives of the Thesis ............................ 30 1.6 Structure and Outline of the Thesis ................................................... 34 1.6.1 Sociohistorical context ................................................................ 34 1.6.2 Literature review .......................................................................... 35 1.6.3 Research design: methodology and methods ............................. 36 1.6.4 Findings and discussion .............................................................. 37 1.6.5 Conclusions ................................................................................. 39 2: Sociohistorical Context ............................................................................ 40 2.1 Introduction ........................................................................................ 40 4 2.2 Psychoanalysis, Psychotherapy, and Counselling ............................. 41 2.3 Research, Therapy and the Randomised Controlled Trial (RCT)....... 56 2.4 The Knowledge Bases of Therapy ..................................................... 62 2.5 Professionalisation, Regulation, Audit Culture, Managed Care and Evidence-Based Medicine ....................................................................... 66 2.5.1 Therapy and the sociology of the professions ............................. 66 2.5.2 The professionalisation and regulation of therapy ....................... 69 2.5.3 Audit culture, abjection and the social defence model: anxiety in organisations ........................................................................................ 77 2.5.4 Managed care ............................................................................. 78 2.5.5 Evidence-based medicine, evidence-based practice, NICE, IAPT and CBT ............................................................................................... 80 2.6 Integrative Therapy to Pluralistic Therapy .......................................... 86 2.7 Conclusions ....................................................................................... 93 3: Literature Review..................................................................................... 96 3.1 Introduction ........................................................................................ 96 3.2 Pluralism and Pluralistic Therapy ..................................................... 100 3.2.1 William James and A Pluralistic Universe ................................. 100 3.2.2 The meanings of pluralism ........................................................ 102 3.2.3 Theoretical contributions by House and others ......................... 105 3.2.4 Theoretical and research contributions by Cooper and others .. 107 3.3 Conclusions ..................................................................................... 135 4: Research Design: Methodology and Methods ....................................... 136 4.1 Introduction ...................................................................................... 136 4.2 Research Design (Methodology and Methods) ................................ 137 4.2.1 Self-reflexive statement about the research .............................. 137 4.2.2 Research paradigm ................................................................... 142 4.2.3 Other paradigms and methodologies ........................................ 150 5 4.2.4 Interpretive interactionism (II) .................................................... 154 4.2.5 Thematic analysis ..................................................................... 157 4.2.6 Rigour and quality of the research ............................................ 158 4.3 Participants ...................................................................................... 163 4.3.1 Paul ........................................................................................... 167 4.3.2 Joanne ...................................................................................... 167 4.3.3 Nicola ........................................................................................ 168 4.3.4 Amanda ..................................................................................... 168 4.3.5 Lisa ........................................................................................... 168 4.3.6 Debora ...................................................................................... 168 4.3.7 Susan ........................................................................................ 169 4.3.8 Robert ....................................................................................... 169 4.3.9 Peter ......................................................................................... 169 4.3.10 Heidi ........................................................................................ 170 4.3.11 Christine .................................................................................. 170 4.3.12 John ........................................................................................ 170 4.4 Ethics ............................................................................................... 172 4.5 Data Collection ................................................................................ 174 4.6 Data Analysis ................................................................................... 176 4.7 Summary ......................................................................................... 178 5: Findings and Discussion ....................................................................... 182 5.1 Introduction ...................................................................................... 182 5.2 Contentious Issues .......................................................................... 188 5.2.1 Identity and approach ................................................................ 188 5.2.2 The flexibility–rigidity continuum ...............................................