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
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
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
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.
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