protocol for systematic case study research in pluralistic counselling and psychotherapy

A protocol for systematic case study research in pluralistic counselling and psychotherapy

McLeod, John and Cooper, Mick ( 2011 ) A protocol for systematic case study research in pluralistic counselling and psychotherapy. Counselling Psychology Review - British Psychological Society , 26 (4). pp. 47-58. ISSN 0269-6975

Pluralistically-oriented therapy is tailored to the needs and preferences of each client, with the consequence that the course of therapy does not follow a standard pattern. Examining the outcomes and processes of pluralistic therapy therefore requires the adoption of research methodologies that are capable of representing complexity. Systematic case studies comprise a form of inquiry that is well suited to this task. A flexible case study protocol is described, that is capable of being integrated into routine practice by both students and experienced clinicians. Examples are provided of types of research knowledge that may be generated through the use of this approach. Issues associated with the future development of this protocol are highlighted.

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T1 - A protocol for systematic case study research in pluralistic counselling and psychotherapy

AU - McLeod, John

AU - Cooper, Mick

PY - 2011/12/1

Y1 - 2011/12/1

N2 - Pluralistically-oriented therapy is tailored to the needs and preferences of each client, with the consequence that the course of therapy does not follow a standard pattern. Examining the outcomes and processes of pluralistic therapy therefore requires the adoption of research methodologies that are capable of representing complexity. Systematic case studies comprise a form of inquiry that is well suited to this task. A flexible case study protocol is described, that is capable of being integrated into routine practice by both students and experienced clinicians. Examples are provided of types of research knowledge that may be generated through the use of this approach. Issues associated with the future development of this protocol are highlighted.

AB - Pluralistically-oriented therapy is tailored to the needs and preferences of each client, with the consequence that the course of therapy does not follow a standard pattern. Examining the outcomes and processes of pluralistic therapy therefore requires the adoption of research methodologies that are capable of representing complexity. Systematic case studies comprise a form of inquiry that is well suited to this task. A flexible case study protocol is described, that is capable of being integrated into routine practice by both students and experienced clinicians. Examples are provided of types of research knowledge that may be generated through the use of this approach. Issues associated with the future development of this protocol are highlighted.

KW - case study research

KW - narrative

KW - outcome

KW - pluralistic counselling

KW - research

KW - counselling

UR - https://shop.bps.org.uk/publications/publications-by-subject/counselling/counselling-psychology-review-vol-26-no-4-december-2011.html

M3 - Article

SN - 0269-6975

JO - Counselling Psychology Review - British Psychological Society

JF - Counselling Psychology Review - British Psychological Society

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A protocol for systematic case study research in pluralistic counselling and psychotherapy

• John McLeod
• Mick Cooper

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*John McLeod

School of Social and Health Sciences University of Abertay Dundee

[email protected]

Mick Cooper Counselling Unit Strathclyde University

[email protected]

*Author for correspondence

Purpose. Pluralistically-oriented therapy is tailored to the needs and preferences of each client, with the consequence that the course of therapy does not follow a standard pattern. Examining the outcomes and processes of pluralistic therapy therefore requires the adoption of research methodologies that are capable of representing complexity. Systematic case studies comprise a form of inquiry that is well suited to this task. Methods. A flexible case study protocol is described, that is capable of being integrated into routine practice by both students and experienced clinicians. Examples are provided of types of research knowledge that may be generated through the use of this approach. Discussion. Issues associated with the future development of this protocol are highlighted.

3 The historical development of counselling and psychotherapy has been accompanied by a proliferation of competing theories and models. There is currently a growing appreciation within the discipline that it is unlikely that these ideas and practices can or will ever be integrated into a single unified approach to therapy. Instead, there is a movement in the direction of a pluralistic stance, which acknowledges the value of a wide range of therapy concepts and methods. The existence of multiple plausible therapeutic strategies inevitably raises the question of whether, and in what ways, these ideas can be combined in work with specific clients (McLeod, 2009).

In response to these issues, a pluralistic framework for the practice of counselling, counselling psychology and psychotherapy has been outlined by Cooper & McLeod (2007, 2011). A key feature of this approach is the notion that both the client and the therapist possess skills and knowledge that can be brought to bear on the work of helping the client to accomplish his or her therapeutic goals. Pluralistic practice therefore centres on a capacity on the part of the therapist to engage in collaborative conversations with the client around the client’s preferences, and his or her experience of what has been helpful or unhelpful for them in their efforts to resolve their problems and move forward in their life. The therapist is called on to identify therapeutic tasks and methods that reflect client preferences: the aim is to construct a personalised approach that builds on the client’s strengths. At the same time, the knowledge and skill base of each therapist is inevitably limited – the adoption of a pluralistic orientation to therapy requires an ability to engage in dialogue around ways of making connection between what the client wants and what the therapist can offer.

The task of carrying out research into the process and outcomes of pluralistic therapy faces a number of challenges that are not present in investigations of ‘pure’ therapy

approaches such as psychodynamic psychotherapy, person-centred therapy or cognitive-behaviour therapy (CBT). Each of these established therapy approaches is grounded in a set of assumptions about specific change activities that should occur (e.g., interpretation of transference, empathic reflection, behavioural experiments). It is therefore possible to anchor research by measuring, describing or enhancing these processes. By contrast, within any particular case, a pluralistic approach to therapy may encompass all, or none, of these change processes. In order to carry out meaningful investigation of what happens in pluralistic therapy, and how useful it is for clients, it is therefore necessary to adopt a research strategy that allows the potential complexity of the therapeutic pathway to be taken into account. Systematic case study research represents a methodology that is particularly well suited to this kind of investigative task (McLeod, 2010). In seeking to develop a knowledge base for pluralistic therapy, there is certainly a role for all forms of research (e.g., qualitative

interviews with groups of clients around their experience of pluralistic therapy, randomised controlled trials that compare the outcomes of pluralistic and other forms of therapy, etc.). However, it can be argued that, for pluralistic counselling and psychotherapy, it is desirable that studies conducted using larger samples are used to determine the generalisability of preliminary findings from case-based studies, rather than as a primary research strategy. This is because large-n studies will always limit the extent to which a plurality of therapeutic processes can be depicted.

4 psychotherapy. The following section describes general data collection procedures and

instruments used in therapy case study research. There is then a discussion of specific data collection tools that are particularly appropriate for research into pluralistic therapy.

Strategies for analysing case data are described, and then some examples of relevant research designs and research questions are explored. The paper concludes with a brief discussion of possible future developments in systematic case study research in counselling and

psychotherapy. For reasons of length, this paper cannot offer a comprehensive manual of how to conduct case study research into pluralistic therapy. Readers wishing to put these ideas into practice are advised to consult Elliott (2001, 2002), McLeod (2010), Stinckens, Elliott & Leijssen (2009), and other sources referenced in these texts, for further detailed information on particular aspects of the process of case study research.

Systematic case study research in counselling and psychotherapy: a standard protocol

Over the last 20 years, considerable progress has been achieved in relation to the validity and rigour of case study research in counselling and psychotherapy. Further information on these debates can be found in McLeod (2010), and in collections of methodological papers in the on-line journal Pragmatic Case Studies in Psychotherapy. It is possible to specify a standard research protocol that has emerged in recent years, and which is widely used by research groups in several centres. This protocol consists of four main elements:

1. Careful management of ethical issues around informed consent and confidentiality.

2. The construction of a ‘rich case record’ (Elliott 2001, 2002) consisting of information about the process and outcomes of therapy, using a mix of qualitative and quantitative data sources.

3. Team-based analysis of data, in which a group of researches systematically consider divergent interpretations of the case data.

4. Presentation of findings in a format that allows the reader to follow and monitor the process of data collection and analysis, and independently evaluate the credibility of the conclusions of the study.

Further elaboration on each of these areas can be found in McLeod (2010). A set of sample informed consent information sheets and forms is available from the authors.

From the point of view of being able to generate interesting and practically valuable findings, the construction of a sufficiently rich case record represents the heart of any attempt to carry out systematic case study research. The case record needs to be able to be

comprehensive enough to include information about all aspects of the therapy that might have a bearing on the interpretation of the case. It also needs to include multiple sources of

information about therapeutic events and processes, sufficient to allow ‘triangulation’ through which the validity of interpretations can be supported by reference to different segments of the data. The minimum requirement for a rich data set includes:

 pre-therapy or assessment information about the client;

5  at least one standard measure of the quality of the therapeutic relationship (e.g., the

Working Alliance Inventory Short From: Hatcher and Gillaspy, 2006) completed by the client on a regular basis (e.g., every second or third session);

 information on client and therapist experience of the process of therapy, for instance administering the Helpful Aspects of Therapy (HAT; Llewelyn, 1989) form at the end of each session;

 therapist notes;

 copies of any documents generated during the therapy, such as drawings, diagrams, client diary entries, etc.;

 recordings of therapy sessions;

 therapist end-of-therapy summary account of the process and outcome of the case;  follow-up interview.

No-cost copies of suitable instruments are available on various websites (see McLeod 2010). Recent studies that exemplify different styles of team-based analysis of rich case records include Elliott et al. (2009), Hill et al. (2008), Kasper, Hill & Kivlighan (2008) and Rabu, Halvorsen & Haavind (2011).

Collecting data on pluralistic aspects of therapy

Assembling a rich case record by using the instruments described in the previous section provides a basis for understanding many aspects of a pluralistic approach. However, it can be valuable to augment a standard protocol with additional data collection techniques that specifically focus on dimensions of therapy that are central to a pluralistic stance. The methods described below comprise some research tools that are currently available. Detailed information on these techniques, and copies of scales, can be found at

www.strath.ac.uk/humanities/counsellingunit/pluralistic/ or by contacting the authors. It is probable that the further development of research and practice in pluralistic counselling and psychotherapy will result in an increasing range of data-collection techniques, and further versions of the instruments listed here.

1. Pre-therapy strengths and resources interview (PTSRI). A pluralistic perspective

emphasises the client’s contribution to therapy, in terms of the strengths and resources that he or she can draw on in working to reach their goals. It also suggests that the outcomes of therapy are best understood in terms of the client’s own criteria for change. It is valuable to collect information around both of these areas before the start of therapy, to provide a baseline against which data gathered later in therapy can be compared. The client’s pre-therapy account of his or her approach to life is also of interest in that it is relatively free of any client-therapist co-construction. The PTSRI consists of a pluralistically-oriented pre-therapy assessment interview that can be administered in around 30-40 minutes, and can be adapted for use in different settings.

6 which they can report on their preferences. At present, two client preference scales are

available. The Therapy Personalisation Scale (TPS: developed by Bowens, Johnston and Cooper, see Cooper & McLeod, 2011, Appendix B) is a 20-item measure that can be completed both prior to, and during, therapy in which participants use an 11-point bipolar rating scale to indicate how they would like their therapist to respond to them (sample item: focus more on my past vs. focus more on my future). The Psychotherapy Preferences and Experiences Questionnaire (PEX), developed by David Clinton and Rolf Sandell, is a 25-item measure in which respondents use a 6-point scale (agree not at all to agree completely) to indicate their preferences for specific therapeutic activities (sample items: sharing bottled-up emotions; getting good advice). The PEX scale has been used in large-n studies to

examine the extent to which outcome is predicted by the degree of fulfilment of client preferences (Berg, Sandahl & Clinton 2008; Sandell et al. in press). Therapist versions of both TPS and PEX have been developed, to measure the therapist’s perception of the preferences of their client (and thus enable degree of therapist-client agreement to be assessed).

3. Structured therapist session note form (STN). The therapist is an essential source of information on the process of therapy. Therapists tend to develop idiosyncratic styles of note-keeping, so for purposes of collecting data for a systematic case study, it can be useful to ensure that therapist observations and perceptions around key elements of pluralistic practice are routinely recorded. The STN is a modification of the therapist form developed by Robert Elliott for use in research into emotion focused therapy (see Elliott et al 2009; www.experiential-researchers.org/instruments.html), and consists of open-ended items (examples: describe important extra-therapy events; describe client use of social/cultural resources), accounts of pluralistically-focused episodes in the session (e.g., collaborative conversation) and ratings of self-perceived competence in use of pluralistic skills. The STN can be adapted for application in different settings.

4. Client goals assessment form. The pluralistic framework for practice developed by Cooper & McLeod (2007; 2011) suggests that clarification and agreement around the client’s goals

represents the starting point for collaborative exploration of multiple ways in which these goals might be attained. Information about client-defined goals therefore forms part of any case study of pluralistic practice. There are several goals instruments that can be used. A very simple tool is the Goal Assessment Form (GAF: See www.pluralistictherapy.com), which invites clients to develop goals for their therapy -- in dialogue with their therapists -- and then to rate their

proximity to these goals, at the start of every session, on a seven point scale (Not at all achieved to Completely achieved). There are several alternative instruments that can be used to record and monitor this dimension of therapy (see Cooper & McLeod 2011; McLeod 2010), most of which tend to invite clients to formulate their response in terms of problems rather than goals.

5. Measures of client use of extra-therapy resources and activities. One of the basic

7 there is no scale or interview schedule that has been developed to collect this kind of data from therapy clients. However, there are scales that address aspects of this issue. Elkins et al. (2005) and Kessler et al (2001) have devised a measure of client use of complementary and alternative therapies (e.g., yoga, massage). Jorm et al. (2000) have constructed a measure of strategies used by members of the public (examples: taking more exercise, drinking less coffee) to overcome depression. These scales can be modified and adapted for use in therapy case study research, or could form the basis for a new purpose-built scale.

6. Therapist intervention scales. A crucial dimension of pluralism in therapy relates to the ideas and methods that the therapist uses within their work with a client. In pluralistically-oriented therapy, it is likely that a therapist will make use of a wide range of methods and theories, at various stages within a case. In order to makes sense of what is happening, it is therefore necessary to collect information around therapist interventions. Although it is important to ask the therapist in a case study about the therapy theories that influence them, this information is not likely to be adequate in itself, because it is probable that the therapist will make use of component of major orientations rather than apply all aspects of an

approach. It is also likely that a pluralistic therapist will engage in many ’non-specific’ interventions that cannot be categorised as being derived from one specific therapy

orientation. Therapist use of interventions can be recorded in the therapist notes. There are also several scales that can be used to provide the therapist with a structure that they can use in describing their work with a client (either in a session or across the case as a whole). Appropriate scales include the Therapeutic Procedures Inventory (McNeilly & Howard, 1991), Comprehensive Therapeutic Interventions Rating Scale (Trijsburg, 2004) and the Therapist Techniques Survey Questionnaire (Thoma & Cecero, 2009). The Psychotherapy Process Q-sort (Ablon & Jones, 1998; Jones & Pulos, 1993) is a therapist intervention coding system that can be applied to therapy transcripts.

8 It is perhaps important to note that measurement scales are used in a different way in case study research, compared to conventional studies where data from large samples of participants are aggregated. In large-n studies, it is essential to use scales for which the psychometric properties (validity, reliability) have been established. In case studies, the psychometric status of a scale is less important. In analysing case data, there are some circumstances in which it is valuable to have access to psychometric norms for a scale, for the purposes of positioning a client (or segment of discourse) in relation to a wider

population. However, scales that have not been validated can also be employed, because the process of systematic case analysis (see below) calls for constant comparison of all pieces of data against each other. This means, for example, that the meaning of responses to individual items from a scale may be of considerable analytic significance.

A wide range of potential data collection activities have been introduced in this section, as well as in the preceding ‘basic protocol’ section. It is important not to assume that it is necessary to collect information under each of these categories. Collecting data that is too ‘thin’ leads to difficulties at the analysis stage, if there is not sufficient information to allow patterns to be reliably identified, or to support robust conclusions. But it can also cause problems if too much information is collected – there is a risk that the research team can be overwhelmed by detail, or that participants spend time completing scales that are then not used. When planning a case study, it is useful to take some time to anticipate the possible findings of the study, then to work back and identify the type of data that would be required in order to substantiate such findings, and then work out the actual data collection

instruments and data administration points that would be required. This kind of planning does not imply that the findings of a study merely reflect the prior assumptions of the researcher. What it means, instead, is that the broad focus of the study needs to be clarified from the outset. For example, if the focus of a study is to document the outcome of therapy, and demonstrate links between certain therapeutic procedures and outcome, then specific types of process and outcome data need to be collected (see Elliott et al. 2009 for an example of this kind of study). If, on the other hand, the focus of a case study is on the role of the client-therapist relationship, then it will be appropriate to collect other types of data (see Rabu et al., 2011 for an example of such a study). One of the key choice-points for case study

researchers, with respect to data collection, is to decide whether or not to make recordings of therapy sessions. Therapy transcripts provide rich material, but are very time-consuming to produce and then to analyse. Mindful of these issues, many case study researchers make use of supplementary instruments, such as the Helpful Aspects of Therapy form (HAT: Llewelyn 1989) that can be used to direct the research time toward particular segments of transcript (i.e., a turning point in a session) that are worth transcribing.

Strategies for analysing case study data

Historically, it has been widely acknowledged that one of the major methodological

9 resemble self-promoting or self-justificatory exercises that promulgated the therapist’s beliefs or approach, but made a minimal contribution to the knowledge base for counselling and psychotherapy as a whole. In recent years, it has become good practice to overcome this problem by using a team of researchers, who independently analyse the case (or segments of the case) and then compare findings. There are various ways in which such a research team can be organised (see McLeod 2010 for examples). The basic principle is that the ultimate findings or conclusions of the case analysis can be shown to have been generated by a process of open dialogue in which competing interpretations are systematically evaluated in terms of their ‘fit’ with the data: i.e., a pluralistic analysis. The usual way in which such a team operates is that the principal investigator takes responsibility for collating all of the case data into a ‘case book’, copies of which are which is then distributed to all members of the team. The team then meets and agrees on a set of analytic procedures (e.g., identifying episodes in the case where the therapist is responsive to client preferences, or segmenting the process of the therapy into discrete stages). Each member then completes the procedure independently. The team then meets to share their analysis, discuss discrepancies, and arrive at an acceptable consensus. The team then works through the next steps in the analysis, until it has exhausted all possible ‘readings’ of the material and has the confidence to proceed to the writing stage.

The task of analysing complex and voluminous case data is challenging for most researchers. What tends to be helpful is to work out a step-by-step approach, that begins by getting a sense of the case as a whole, and then moves to more fine-grained analysis of particular areas of data. For example, it can be helpful for each member of the research team to begin by reading through the case book and making a brief summary of the key themes within each session, and their overall sense of how helpful the therapy was, and the factors within the therapy that made a positive or negative contribution to outcomes. It also useful, then, to identify stages in the therapy, give names to these stages, and to develop some ideas about what happened to facilitate a shift from one stage to the next. Once this kind of overall, non-theoretical understanding of the case has been accomplished, it is then possible to move to more detailed, theoretically-informed analysis of specific processes. For example, in a poor outcome or ambiguous outcome case, it might be hypothesised from a pluralistic perspective that there was a mismatch between client preferences and what the therapist could offer, or a failure to engage in collaborative conversations. These hypotheses could be tested by

examining particular facets of the case record. For example, failure to engage in collaborative conversation might have been mentioned by the client in their follow-interview, or be

expressed in low working alliance ratings, or be observable in an absence of

metacommunicative sequences in therapy transcript data. An example of how this kind of analytic process is structured can be found in McLeod and Balamoutsou (2001). A valuable analystic strategy that has been used by several groups of case study researchers has been to organise data analysis around competing sub-teams who each produce alternative

interpretations of the case material, and then invite a group of judges to decide on which version is the most convincing. Different ways of conducting this kind of ‘adjudicated’ case study method are described in Fishman (2011) and McLeod (2010).

10 practically useful understanding and representation of what happened within a case. This kind of research is carried out with the awareness that alternative interpretations are always

possible. Hermeneutic inquiry does not claim to result in a single, once-and-for-all ‘objective’ truth, but to construct a perspective on, or reading of, a case that is demonstrably grounded in the facts of the matter, and which opens up new possibilities for insight and action. The philosophical rationale for this approach to inquiry is explained in detail by Fishman (1999), who argues that systematic case studies provide the kind of knowledge that is most relevant to the advancement of professional practice. The incorporation of both qualitative and quantitative data sources represents a significant source of strength of this kind of pragmatic research, because it enables the sensitivity to complexity and context of qualitative tools to be combined with access to standardised norms available for quantitative process and outcome measures. The use of both types of data reflects a growing appreciation within the research

community of the value of mixed methods research strategies (Hanson, Creswell et al., 2005).

Research designs: different questions that can be addressed through case study inquiry

Within the field of research in counselling, counselling psychology and psychotherapy, case studies have been used to examine four discrete types of research goals or questions:

• Outcome questions: How effective has therapy been in this case? To what extent can changes that have been observed in the client be attributed to therapy?

• Theory-building questions: How can the process of therapy in this case be understood in theoretical terms? How can the data in this case be used to test and refine an

existing theoretical model?

• Pragmatic questions: What strategies and methods did the therapist use in this case, that contributed to the eventual outcome? How were therapeutic methods adapted and modified to address the needs of this specific client? What are the principles of good practice that can be derived from this case?

• Experiential or narrative questions. What was it like to be the client or therapist in this case? What is the story of what happened, from the client or therapist point of view?

Further elaboration of the ways in which particular case study investigations can be oriented toward one or more of these aims can be found in McLeod (2010).

These four types of research question open up a wide research agenda around the outcomes and processes of pluralistically-oriented counselling and psychotherapy. One of the current priorities, for the further development and professional acceptance of pluralistic therapy, is to publish systematic case studies of the effectiveness of this approach with clients reporting different kinds of presenting problems, and different degrees of therapy

11 particular pluralistic strategies are associated with outcome. The relevance of this type of research can be supported by reference to developments within the field of emotion-focused therapy (Greenberg, 2002). There is good evidence that EFT is effective for clients suffering from depression (Watson, Gordon, Stermac, et al., 2003). In the last few years, case study evidence has been presented to demonstrate that EFT can also be effective for clients suffering from phobias (Elliott et al., 2009) and social anxiety. These cases have established not only that EFT is in principle effective with these conditions, but also how it is effective.

The domain of theory-building case studies (Stiles, 2007) offers many opportunities for projects that seek to elucidate aspects of the process of pluralistic therapy. For example, not enough is known about how productive collaborative conversations take place, about the process of identifying and agreeing goals, or about the therapeutic tasks that are associated with specific problems such as depression. The work of the research group led by Clara Hill, on the development of a theory of immediacy in therapy, provides an example of what can be achieved. This group have published two case studies (Hill et al., 2008, Kasper, Hill & Kivlighan, 2008) in which the operation of therapist immediacy has been analysed in relation to the overall process and outcome of each case. One case was chosen for analysis because it was known that the therapist favoured the use of immediacy, and a comparison case was chosen in which the therapist employed this skill to only a moderate extent. These two case studies, taken together, have produced a significant advance in the practical understanding of how this intervention functions within therapy.

Pragmatic case studies (Fishman 1999; McLeod 2010) are studies that seek to document the professional activity of the therapist – the way in which the therapist’s

underlying conceptual framework plays out in the context of his or her work with a particular client. A crucial aspect of this type of case study is the level of detail with which all aspects of the case are reported. The aim is to provide the reader with a comprehensive representation of what happens when a particular approach is used with a specific client. An on-line journal, Pragmatic Case Studies in Psychotherapy, has been established to function as a repository of such cases, with the long-term aim of operating as a professional resource – a place where therapists can consult if they are looking for ideas about possible ways of responding to the needs of clients with certain patterns of problems. The aim of the pragmatic case study initiative is to accumulate a bank of practical knowledge about what can work. This kind of knowledge is crucially important for the advancement of pluralistically-informed therapy, because pluralistic therapists need to be continually curious and open to learning, around the concrete details of how other colleagues have worked with clients to break down complex problems into step-by-step tasks, and then agreed on methods to accomplish such tasks.

12 preferences. Similarly, there are no narrative accounts of therapist experiences of living with the uncertainty that accompanies a pluralistic stance. Basically, the voices of clients and therapists (and supervisors, and family members...) are not being recorded and are therefore not being heard. Philosophically and ethically, a pluralistic stance implies a high degree of open-ness to such diversity, as opposed to the construction of a knowledge base that is dominated by the writings of authority figures. The development of a narrative case tradition within pluralistic therapy is therefore of great significance.

For anyone planning to undertake a systematic case study investigation, it is probably wise to concentrate on one of these aims or questions, or at most, one primary aim (e.g., documenting outcome) with a second subsidiary aim (e.g., generating a model of the factors that contribute to outcome). There are no case studies within the currently available literature that successfully achieve all four of the aims that have been outlined in this section. Before embarking on a case study, it is valuable to take time to be immersed in the case study

literature, to get a feel for how other researchers and research teams have dealt with the issues involved in condensing lengthy case records into a journal-length report.

Conclusions

The purpose of this paper has been to provide an overview of the potential role of systematic case study research in the development of pluralistically-informed ways of doing therapy, and to offer an outline of the practical and methodological issues and procedures associated with this form of investigation. It has been argued that case study methods are well suited to the exploration of pluralistic processes and outcomes, because case-based research is uniquely placed to capture the complexity of pluralistic work. Readers who wish to pursue this type of research are encouraged to consult McLeod (2010) and other sources, in order to develop sufficient background knowledge to enable them to make good decisions around research design, and the process of data collection and analysis. In recent years, there have been significant developments in case study methodology in fields such as education, political science and organisational studies, and there are several excellent texts that provide accessible accounts of the case study approaches that have evolved within these fields. Particularly recommended are Simons (2009) and Yin (2009).

13 other therapy practitioners represent the best source of potential case study material, because they are likely to work with a wide range of clients, and will thus have many interesting case-based stories to tell. It is clearly easier for clinicians to carry out case study research if they have already learned about methods of systematic case study inquiry in their initial

professional training. Experienced practitioners may regard the time demands of case study research as a barrier to their involvement in this type of activity. However, case study research can be incorporated into group supervision, and can form a powerful means of continuing professional development (see McLeod, 2010). Finding the time for case study research may therefore be accomplished by re-organising existing supervision and CPD arrangements.

Finally, it is important to emphasise that, in the end, the contribution of case study research to the development of flexible, personalised, pluralistically-oriented therapy services depends on the on-going production of many case studies. Just as a single survey or RCT has limited impact until it has been replicated, a single case study only really has meaning and practical significance when it can be set alongside other cases. To get maximum value from the potential methodological richness of case study research, it is necessary to think in terms of case series, the selection of new cases that stand in contrast to (or replicate) previous cases, and case study meta-analysis. It is also necessary to look for ways to integrate case studies into large-scale practice-based outcome studies and randomised clinical trials (Dattilio, Edwards. and Fishman 2010; Edwards, Dattilio and Bromley 2004).

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A protocol for systematic case study research in pluralistic counselling and psychotherapy

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Anthony Ward

Objectives: The aim of this study was to assess the outcomes, acceptability and helpful aspects of a pluralistic therapeutic intervention for depression. Design: The study adopted a multisite, non-randomised, pre-/post-intervention design. Methods: Participants experiencing moderate or more severe levels of depression (as assessed by a score of 10 or greater on the Patient Health Questionnaire depression scale, PHQ-9) were offered up to 24 weeks of pluralistic therapy for depression. This is a collaborative integrative practice oriented around shared decision making on the goals and methods of therapy. Of the 42 participants assessed, 39 (92.9 per cent) completed two or more sessions. Participants were predominantly female (N=28, 71.8 per cent) and white (N=30, 76.9 per cent), with a mean age of 30.9. The principal outcome indicator was improvement and recovery on the PHQ-9 and Generalised Anxiety Disorder 7-item (GAD-7) scale. Results: Of the completer sample, 71.8 per cent of clie...

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Adapted from: Cooper, M., & Dryden, W. (2016). Introduction to pluralistic counselling and psychotherapy. In M. Cooper & W. Dryden (Eds.), Handbook of pluralistic counselling and psychotherapy . London: Sage.

Development of the Pluralistic Approach

The origins of the pluralistic approach to therapy were developed by Mick Cooper and John McLeod in 2006, and stemmed from the idea that all therapeutic approaches offered useful insights into how to help people therapeutically.  Cooper and McLeod views, in particular, were a reaction to what they saw as dogmatism within the counselling and psychotherapy field, and the lines that were being drawn between different therapeutic orientations.  Their goal was to create and develop an approach to therapy that was flexible and suited to the needs of each individual client.

An original paper on the pluralistic approach was published in 2007, entitled ‘A pluralistic framework for counselling and psychotherapy: Implications for research’ (Cooper & McLeod, 2007).  This article laid out the basic principles of a pluralistic approach within a research-informed context.  At the same time, McLeod and Cooper developed two courses oriented around pluralistic principles: The Postgraduate Diploma in Counselling at the University of Abertay and the Doctorate in Counselling Psychology at Glasgow Caledonian University and the University of Strathclyde.  Pluralistic research clinics were also established at both Abertay and Strathclyde universities.  McLeod and Cooper, together and separately, began to deliver workshops on pluralistic therapy around the UK and at training events and conferences.

In early 2011, Cooper and McLeod published Pluralistic counselling and psychotherapy , which provided a coherent and comprehensive introduction to the core principles and practices of a pluralistic approach.  Since its publication, the book has had over 300 citations on Google Scholar, and has become the standard text for pluralistic therapy.  Later in 2011, the Universities Psychotherapy and Counselling Association, in association with the Research Centre for Therapeutic Education at Roehampton University, held an international conference on ‘A pluralistic approach to practice? — Implications for the psychological therapies.’  The papers for this conference were later published in a special issue of the European Journal of Psychotherapy and Counselling (vol. 14: 1) (Bowens & Cooper, 2012; Cooper & McLeod, 2012; Dryden, 2012; Mcleod, 2012; Miller & Willig, 2012; Ross, 2012; Thompson & Cooper, 2012; Watson, Cooper, McArthur, & McLeod, 2012).  Windy Dryden, who attended the conference and authored a commentary on the main papers for this special issue, began to develop an interest in the interface between the pluralistic approach and cognitive-behavioural therapy (CBT).  He started to work more closely with Cooper and McLeod on developing a pluralistic approach in Britain.  The handbook of pluralistic counselling and psychotherapy was published in 2015, co-edited by Cooper and Dryden.

Since the publication of Pluralistic counselling and psychotherapy in 2011, a number of pluralistic trainings in counselling, psychotherapy and counselling psychology have developed in the UK.  In addition, several introductions to the approach have been published in counselling and psychotherapy textbooks (McLeod & Cooper, 2012, 2015; McLeod, McLeod, Cooper, & Dryden, 2014). 

In the UK, the field of counselling psychology has been particularly receptive to pluralistic ideas and practices.  Applications of the approach have been discussed in the British Psychological Society’s (BPS) Division of Counselling Psychology (DCoP) journal, Counselling Psychology Review (Scott, 2014; Scott & Hanley, 2012; Wilk, 2014); and pluralistic concepts and practices have featured extensively in two recent texts: one on counselling psychology work with adolescents (Hanley, Humphrey, & Lennie, 2012), and the other on counselling psychology’s contribution to therapeutic and social issues (Milton, 2010).  In addition, in 2013, the BPS DCoP provided funding support for a pilot study of pluralistic therapy for depression (Cooper et al., 2015).  The study, based at three research clinics in the UK — the University of the West of England, the Metanoia Institute, and the University of Strathclyde — assessed the outcomes, acceptability and helpful aspects of a pluralistic therapeutic intervention for depression (see below).  The pluralistic therapy for this study was delivered by trainee and qualified counselling psychologists, trained and supervised by John McLeod at the University of Abertay.

Internationally, training and talks on pluralistic practice have been delivered by McLeod and Cooper around the world, and a Master’s-level training in pluralistic practice has now been established in Ireland.  Although dissemination in the US is more sparse, the feedback-informed approach of Duncan, Miller, Sparks and colleagues bears many similarities to the pluralistic model. 

Pillars and Principles

Pluralism can be defined as the philosophical belief that ‘any substantial question admits of a variety of plausible but mutually conflicting responses’ (Rescher, 1993, p. 79).  More than that, it is an ethical commitment to valuing diversity; and a wariness towards monolithic, all-consuming ‘truths’, because of the way that they can suppress individuality and difference.  In respect to counselling and psychotherapy, this pluralistic standpoint implies that there are a variety of views that can be taken on a wide range of therapeutic issues, and that there is no inherent right or wrong way.  This forms the grounds for three pillars that underpin a pluralistic approach to counselling and psychotherapy. 

The first pillar is pluralism across orientations .  This means that a pluralistic practitioner is open to considering a variety of different ways in which clients get distressed and, correspondingly, a variety of different ways of helping them.  Taking this stance poses a direct challenge to the schoolism that has been endemic in the field of counselling and psychotherapy. 

The second pillar is pluralism across clients .  This is marked by the emphasis that is placed on recognising and celebrating diversity across clients.  What follows from this is that pluralistic practitioners are keen to offer each client a bespoke approach to counselling and psychotherapy rather than one that is ‘off the peg’. 

This relates to closely to the third pillar of a pluralistic approach: pluralism across perspectives.  A pluralistic therapeutic approach advocates that both participants in the therapeutic relationship — clients as well as practitioners — have much to offer when it comes to making decisions concerning therapeutic goals and the selection of therapy tasks and methods.  This means that a pluralistic approach emphasises shared decision-makingand feedback across clients and therapists.

These three pillars of the pluralistic approach can be summarised in the following principles:

• There is no one right way of conceptualising clients’ problems — different understandings are useful for different clients at different points in time
• There is no one right way of practising therapy — different clients need different things at different points in time
• Many disputes and disagreements in the therapeutic field can be resolved by taking a ‘both/and’ perspective, rather than an ‘either/or’ one
• It is important that counsellors and psychotherapists respect each others’ work and recognise the value that it can have
• Counsellors and psychotherapists should acknowledge and celebrate clients’ diversity and uniqueness
• Clients should be involved fully at every stage of the therapeutic process
• Clients should be understood in terms of their strengths and resources, as well as areas of difficulty
• Counsellors and psychotherapists should have an openness to multiple sources of knowledge on how to practice therapy: including research, personal experience, and theory
• It is important that counsellors and psychotherapists take a critical perspective on their own theory and practice: being willing to look at their own investment in a particular position and having the ability to stand back from it.

Research Evidence

As a relatively new development in the field of counselling and psychotherapy, the evidence base for pluralistic counselling and psychotherapy is still at a nascent stage.  Nevertheless, there are several lines of evidence in the psychotherapy research field that provide initial support for a pluralistic approach to counselling and psychotherapy. 

First, clients do seem to do better in therapy when it matches their preferences (Swift, Callahan, & Vollmer, 2011).  More specifically, clients who receive a preferred intervention are ‘between a half and a third less likely to drop out of therapy prematurely compared with clients who did not receive their preferred therapy conditions’ (Swift et al., 2011, p. 307); and also show a small but significant increase in outcomes ( d = 0.31).  This is consistent with the research in the field of shared decision-making, which shows that patients are more satisfied with their medical treatment and less likely to drop out if they are involved in making decision about their health care (Joosten et al., 2008; The Health Foundation, 2014). 

Second, there is strong relationship between client-therapist agreement on the tasks and goals of therapy, and therapeutic outcomes (Horvath, Del Re, Fluckinger, & Symonds, 2012; Tryon & Winograd, 2012).  That is, clients do best in therapy when they feel that their therapists are striving for the same therapeutic goals as they are, and are in agreement about the best therapeutic methods to be used.

Third, there is research to suggest that flexible practice, tailored the needs of individual clients, is experienced by clients as a helpful and important aspect of therapy (Cooper et al., 2015; Perren, Godfrey, & Rowland, 2009).  This is supported by quantitative research suggesting that flexibly tailored practice can, in certain instances, lead to improved outcomes and greater engagement with therapy (e.g., Jacobson et al., 1989). 

Fourth, randomised controlled studies indicate that the use of systematic client feedback — which is integral to the pluralistic approach — can lead to significantly enhanced therapeutic outcomes, particularly for clients who might otherwise deteriorate in therapy (Lambert & Shimokawa, 2011).  Indeed, feedback-informed treatments are now recognised as evidence-based programs by the US government’s Substance Abuse and Mental Health Services Administration (SAMHSA). 

            In addition, UK-based studies of a specifically pluralistic practice — both for clients with depression (Cooper et al., 2015, see above) and for a more heterogeneous sample (Cooper, 2014) — have shown that it has relatively positive outcomes, as well as good rates of engagement and retention.  As indicated above, these studies have also found that most clients value the flexibility and collaborative approach that is at the core of pluralistic practice. 

Bowens, M., & Cooper, M. (2012). Development of a client feedback tool: a qualitative study of therapists’ experiences of using the Therapy Personalisation Forms. European Journal of Psychotherapy and Counselling, 14 , 47-62.

Cooper, M. (2014). Strathclyde pluralistic protocol. Glasgow: University of Strathclyde.

Cooper, M., & McLeod, J. (2007). A pluralistic framework for counselling and psychotherapy: Implications for research. Counselling and Psychotherapy Research, 7 (3), 135-143. doi: 10.1080/14733140701566282

Cooper, M., & McLeod, J. (2012). From either/or to both/and: Developing a pluralistic approach to counselling and psychotherapy. European Journal of Psychotherapy and Counselling, 14 (1), 5-18.

Cooper, M., Wild, C., van Rijn, B., Ward, T., McLeod, J., Cassar, S., . . . Sreenath, S. (2015). Pluralistic therapy for depression: Acceptability, outcomes and helpful aspects in a multisite study. Counselling Psychology Review, 30 (1), 6-20.

Dryden, W. (2012). Pluralism in counselling and psychotherapy: Personal reflections on an important development. European Journal of Psychotherapy & Counselling, 14 (1), 103-111.

Hanley, T., Humphrey, N., & Lennie, C. (Eds.). (2012). Adolescent Counselling Psychology: Theory, Research and Practice . London: Routledge.

Horvath, A. O., Del Re, A. C., Fluckinger, C., & Symonds, D. (2012). Alliance in individual psychotherapy. In J. C. Norcross (Ed.), Psychotherapy Relationships that Work: Evidence-based responsiveness (pp. 25-69). New York: Oxford University Press.

Jacobson, N. S., Schmaling, K. B., Holtzworth-Munroe, A., Katt, J. L., Wood, L. F., & Follette, V. M. (1989). Research-structured vs clinically flexible versions of social learning-based marital therapy. Behaviour Research and Therapy, 27 (2), 173-180.

Joosten, E. A., DeFuentes-Merillas, L., De Weert, G., Sensky, T., Van Der Staak, C., & de Jong, C. A. (2008). Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychotherapy and psychosomatics, 77 (4), 219-226.

Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed., pp. 203-223). New York: Oxford University.

Mcleod, J. (2012). What do clients want from therapy? A practice-friendly review of research into client preferences. European Journal of Psychotherapy and Counselling, 14 (1), 19-32.

McLeod, J., & Cooper, M. (2012). Pluralistic counselling and psychotherapy. In C. Feltham & I. Horton (Eds.), The Sage handbook of counselling and psychotherapy (pp. 368-371). London: Sage.

McLeod, J., & Cooper, M. (2015). Pluralistic counselling and psychotherapy. In S. Palmer (Ed.), The beginner’s guide to counselling and psychotherapy (2nd ed., pp. 322-332). London: Sage.

McLeod, J., McLeod, J., Cooper, M., & Dryden, W. (2014). Pluralistic therapy. In W. Dryden & A. Reeves (Eds.), Handbook of individual therapy (6th ed., pp. 547-573). London: Sage.

Miller, E., & Willig, C. (2012). Pluralistic counselling and HIV-positive clients: the importance of shared understanding. European Journal of Psychotherapy and Counselling, 14 (1), 33-46.

Milton, M. (2010). Therapy and Beyond: Counselling Psychology Contributions to Therapeutic and Social Issues . London: Wiley-Blackwell.

Perren, S., Godfrey, M., & Rowland, N. (2009). The long-term effects of counselling: The process and mechanisms that contribute to ongoing change from a user perspective. Counselling and Psychotherapy Research, 9 (4), 241 – 249.

Rescher, N. (1993). Pluralism: Against the Demand for Consensus . Oxford: Oxford University.

Ross, A. (2012). The new pluralism–a paradigm of pluralisms. European Journal of Psychotherapy & Counselling, 14 (1), 113-119.

Scott, A. J. (2014). How to skin a cat: A case for and against the use of mindfulness-based cognitive therapy in pluralistic therapy. Counselling Psychology Review, 28 (1), 81-90.

Scott, A. J., & Hanley, T. (2012). On becoming a pluralistic therapist: A case study of a student’s reflexive journal. Counselling Psychology Review, 27 (4), 29.

Swift, J. K., Callahan, J. L., & Vollmer, B. M. (2011). Preferences. In J. C. Norcross (Ed.), Psychotherapy relationships that work (2nd ed., pp. 301-315). NY: Oxford University.

The Health Foundation. (2014). Person-centred care: From ideas to action. London: The Health Foundation.

Thompson, A., & Cooper, M. (2012). Therapists’ experiences of pluralistic practice. European Journal of Psychotherapy and Counselling, 14 (1), 63-76. doi: 10.1080/13642537.2012.652393

Tryon, G. S., & Winograd, G. (2012). Goal consensus and collaboration. In J. C. Norcross (Ed.), Psychotherapy Relationships that Work: Evidence-based responsiveness (2nd ed., pp. 153-167). New York: Oxford University Press.

Watson, V., Cooper, M., McArthur, K., & McLeod, J. (2012). Helpful therapeutic processes: A pluralistic analysis of client activities, therapist activities and helpful effects. European Journal of Psychotherapy and Counselling, 14 (1), 77-90.

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A protocol for systematic case study research in pluralistic counselling and psychotherapy ·  ·...

A protocol for systematic case study research in pluralistic counselling and psychotherapy

A protocol for systematic case study research in pluralistic counselling and

psychotherapy

John McLeod

School of Social and Health Sciences

University of Abertay Dundee

jmcleodabertayacuk

Mick Cooper

Counselling Unit

Strathclyde University

mickcooperstrathacuk

Author for correspondence

Submitted to Counselling Psychology Review August 2011 This paper has not been

published elsewhere and is not under consideration elsewhere

Purpose Pluralistically-oriented therapy is tailored to the needs and preferences of each

client with the consequence that the course of therapy does not follow a standard pattern

Examining the outcomes and processes of pluralistic therapy therefore requires the adoption

of research methodologies that are capable of representing complexity Systematic case

studies comprise a form of inquiry that is well suited to this task Methods A flexible case

study protocol is described that is capable of being integrated into routine practice by both

students and experienced clinicians Examples are provided of types of research knowledge

that may be generated through the use of this approach Discussion Issues associated with the

future development of this protocol are highlighted

Keywords case study method narrative outcome pluralism research

The historical development of counselling and psychotherapy has been accompanied by a

proliferation of competing theories and models There is currently a growing appreciation

within the discipline that it is unlikely that these ideas and practices can or will ever be

integrated into a single unified approach to therapy Instead there is a movement in the

direction of a pluralistic stance which acknowledges the value of a wide range of therapy

concepts and methods The existence of multiple plausible therapeutic strategies inevitably

raises the question of whether and in what ways these ideas can be combined in work with

specific clients (McLeod 2009)

In response to these issues a pluralistic framework for the practice of counselling

counselling psychology and psychotherapy has been outlined by Cooper amp McLeod (2007

2011) A key feature of this approach is the notion that both the client and the therapist

possess skills and knowledge that can be brought to bear on the work of helping the client to

accomplish his or her therapeutic goals Pluralistic practice therefore centres on a capacity on

the part of the therapist to engage in collaborative conversations with the client around the

clientrsquos preferences and his or her experience of what has been helpful or unhelpful for them

in their efforts to resolve their problems and move forward in their life The therapist is called

on to identify therapeutic tasks and methods that reflect client preferences the aim is to

construct a personalised approach that builds on the clientrsquos strengths At the same time the

knowledge and skill base of each therapist is inevitably limited ndash the adoption of a pluralistic

orientation to therapy requires an ability to engage in dialogue around ways of making

connection between what the client wants and what the therapist can offer

The task of carrying out research into the process and outcomes of pluralistic therapy

faces a number of challenges that are not present in investigations of lsquopurersquo therapy

approaches such as psychodynamic psychotherapy person-centred therapy or cognitive-

behaviour therapy (CBT) Each of these established therapy approaches is grounded in a set

of assumptions about specific change activities that should occur (eg interpretation of

transference empathic reflection behavioural experiments) It is therefore possible to anchor

research by measuring describing or enhancing these processes By contrast within any

particular case a pluralistic approach to therapy may encompass all or none of these change

processes In order to carry out meaningful investigation of what happens in pluralistic

therapy and how useful it is for clients it is therefore necessary to adopt a research strategy

that allows the potential complexity of the therapeutic pathway to be taken into account

Systematic case study research represents a methodology that is particularly well suited to

this kind of investigative task (McLeod 2010) In seeking to develop a knowledge base for

pluralistic therapy there is certainly a role for all forms of research (eg qualitative

interviews with groups of clients around their experience of pluralistic therapy randomised

controlled trials that compare the outcomes of pluralistic and other forms of therapy etc)

However it can be argued that for pluralistic counselling and psychotherapy it is desirable

that studies conducted using larger samples are used to determine the generalisability of

preliminary findings from case-based studies rather than as a primary research strategy This

is because large-n studies will always limit the extent to which a plurality of therapeutic

processes can be depicted

The aim of the present paper is to provide an outline of a protocol for practice-based

systematic case study research in pluralistic counselling counselling psychology and

psychotherapy The following section describes general data collection procedures and

instruments used in therapy case study research There is then a discussion of specific data

collection tools that are particularly appropriate for research into pluralistic therapy

Strategies for analysing case data are described and then some examples of relevant research

designs and research questions are explored The paper concludes with a brief discussion of

possible future developments in systematic case study research in counselling and

psychotherapy For reasons of length this paper cannot offer a comprehensive manual of how

to conduct case study research into pluralistic therapy Readers wishing to put these ideas into

practice are advised to consult Elliott (2001 2002) McLeod (2010) Stinckens Elliott amp

Leijssen (2009) and other sources referenced in these texts for further detailed information

on particular aspects of the process of case study research

Systematic case study research in counselling and psychotherapy a standard protocol

Over the last 20 years considerable progress has been achieved in relation to the validity and

rigour of case study research in counselling and psychotherapy Further information on these

debates can be found in McLeod (2010) and in collections of methodological papers in the

on-line journal Pragmatic Case Studies in Psychotherapy It is possible to specify a standard

research protocol that has emerged in recent years and which is widely used by research

groups in several centres This protocol consists of four main elements

1 Careful management of ethical issues around informed consent and confidentiality

2 The construction of a lsquorich case recordrsquo (Elliott 2001 2002) consisting of information

about the process and outcomes of therapy using a mix of qualitative and quantitative

data sources

3 Team-based analysis of data in which a group of researches systematically consider

divergent interpretations of the case data

4 Presentation of findings in a format that allows the reader to follow and monitor the

process of data collection and analysis and independently evaluate the credibility of

the conclusions of the study

Further elaboration on each of these areas can be found in McLeod (2010) A set of sample

informed consent information sheets and forms is available from the authors

From the point of view of being able to generate interesting and practically valuable

findings the construction of a sufficiently rich case record represents the heart of any attempt

to carry out systematic case study research The case record needs to be able to be

comprehensive enough to include information about all aspects of the therapy that might have

a bearing on the interpretation of the case It also needs to include multiple sources of

information about therapeutic events and processes sufficient to allow lsquotriangulationrsquo

through which the validity of interpretations can be supported by reference to different

segments of the data The minimum requirement for a rich data set includes

pre-therapy or assessment information about the client

at least one standard outcome measure (such as CORE-OM Barkham et al 2006)

administered on a regular basis (preferably at each session and at follow-up)

at least one standard measure of the quality of the therapeutic relationship (eg the

Working Alliance Inventory Short From Hatcher and Gillaspy 2006) completed by

the client on a regular basis (eg every second or third session)

information on client and therapist experience of the process of therapy for instance

administering the Helpful Aspects of Therapy (HAT Llewelyn 1989) form at the end

of each session

therapist notes

copies of any documents generated during the therapy such as drawings diagrams

client diary entries etc

recordings of therapy sessions

therapist end-of-therapy summary account of the process and outcome of the case

follow-up interview

No-cost copies of suitable instruments are available on various websites (see McLeod 2010)

Recent studies that exemplify different styles of team-based analysis of rich case records

include Elliott et al (2009) Hill et al (2008) Kasper Hill amp Kivlighan (2008) and Rabu

Halvorsen amp Haavind (2011)

Collecting data on pluralistic aspects of therapy

Assembling a rich case record by using the instruments described in the previous section

provides a basis for understanding many aspects of a pluralistic approach However it can be

valuable to augment a standard protocol with additional data collection techniques that

specifically focus on dimensions of therapy that are central to a pluralistic stance The

methods described below comprise some research tools that are currently available Detailed

information on these techniques and copies of scales can be found at

wwwstrathacukhumanitiescounsellingunitpluralistic or by contacting the authors It is

probable that the further development of research and practice in pluralistic counselling and

psychotherapy will result in an increasing range of data-collection techniques and further

versions of the instruments listed here

1 Pre-therapy strengths and resources interview (PTSRI) A pluralistic perspective

emphasises the clientrsquos contribution to therapy in terms of the strengths and resources that he

or she can draw on in working to reach their goals It also suggests that the outcomes of

therapy are best understood in terms of the clientrsquos own criteria for change It is valuable to

collect information around both of these areas before the start of therapy to provide a

baseline against which data gathered later in therapy can be compared The clientrsquos pre-

therapy account of his or her approach to life is also of interest in that it is relatively free of

any client-therapist co-construction The PTSRI consists of a pluralistically-oriented pre-

therapy assessment interview that can be administered in around 30-40 minutes and can be

adapted for use in different settings

2 Client preferences scales A pluralistic stance reflects a position that the life experience of

each client has led him or her to have a sense of what will be helpful for them in therapy

Information about client preferences can be collected through therapist notes and analysis of

session transcripts However it can also be useful to provide clients with a structure through

which they can report on their preferences At present two client preference scales are

available The Therapy Personalisation Scale (TPS developed by Bowens Johnston and

Cooper see Cooper amp McLeod 2011 Appendix B) is a 20-item measure that can be

completed both prior to and during therapy in which participants use an 11-point bipolar

rating scale to indicate how they would like their therapist to respond to them (sample item

focus more on my past vs focus more on my future) The Psychotherapy Preferences and

Experiences Questionnaire (PEX) developed by David Clinton and Rolf Sandell is a 25-

item measure in which respondents use a 6-point scale (agree not at all to agree completely)

to indicate their preferences for specific therapeutic activities (sample items sharing bottled-

up emotions getting good advice) The PEX scale has been used in large-n studies to

examine the extent to which outcome is predicted by the degree of fulfilment of client

preferences (Berg Sandahl amp Clinton 2008 Sandell et al in press) Therapist versions of

both TPS and PEX have been developed to measure the therapistrsquos perception of the

preferences of their client (and thus enable degree of therapist-client agreement to be

3 Structured therapist session note form (STN) The therapist is an essential source of

information on the process of therapy Therapists tend to develop idiosyncratic styles of note-

keeping so for purposes of collecting data for a systematic case study it can be useful to ensure

that therapist observations and perceptions around key elements of pluralistic practice are

routinely recorded The STN is a modification of the therapist form developed by Robert Elliott

for use in research into emotion focused therapy (see Elliott et al 2009 wwwexperiential-

researchersorginstrumentshtml) and consists of open-ended items (examples describe

important extra-therapy events describe client use of socialcultural resources) accounts of

pluralistically-focused episodes in the session (eg collaborative conversation) and ratings of

self-perceived competence in use of pluralistic skills The STN can be adapted for application in

different settings

4 Client goals assessment form The pluralistic framework for practice developed by Cooper amp

McLeod (2007 2011) suggests that clarification and agreement around the clientrsquos goals

represents the starting point for collaborative exploration of multiple ways in which these goals

might be attained Information about client-defined goals therefore forms part of any case study

of pluralistic practice There are several goals instruments that can be used A very simple tool is

the Goal Assessment Form (GAF See wwwpluralistictherapycom) which invites clients to

develop goals for their therapy -- in dialogue with their therapists -- and then to rate their

proximity to these goals at the start of every session on a seven point scale (Not at all achieved

to Completely achieved) There are several alternative instruments that can be used to record and

monitor this dimension of therapy (see Cooper amp McLeod 2011 McLeod 2010) most of which

tend to invite clients to formulate their response in terms of problems rather than goals

5 Measures of client use of extra-therapy resources and activities One of the basic

assumptions of a pluralistic approach to therapy is the concept of the lsquoactive clientrsquo (Bohart amp

Talmann 1999) ndash the idea that clients are actively involved in using whatever resources are

available to them (eg exercise complementary therapies diet reading) alongside and in

combination with any psychotherapy that they receive A comprehensive case analysis of the

process of therapy therefore needs to encompass information about extra-therapy activities

and events that may have an influence on the achievement of therapeutic goals At present

there is no scale or interview schedule that has been developed to collect this kind of data

from therapy clients However there are scales that address aspects of this issue Elkins et al

(2005) and Kessler et al (2001) have devised a measure of client use of complementary and

alternative therapies (eg yoga massage) Jorm et al (2000) have constructed a measure of

strategies used by members of the public (examples taking more exercise drinking less

coffee) to overcome depression These scales can be modified and adapted for use in therapy

case study research or could form the basis for a new purpose-built scale

6 Therapist intervention scales A crucial dimension of pluralism in therapy relates to the

ideas and methods that the therapist uses within their work with a client In pluralistically-

oriented therapy it is likely that a therapist will make use of a wide range of methods and

theories at various stages within a case In order to makes sense of what is happening it is

therefore necessary to collect information around therapist interventions Although it is

important to ask the therapist in a case study about the therapy theories that influence them

this information is not likely to be adequate in itself because it is probable that the therapist

will make use of component of major orientations rather than apply all aspects of an

approach It is also likely that a pluralistic therapist will engage in many rsquonon-specificrsquo

interventions that cannot be categorised as being derived from one specific therapy

orientation Therapist use of interventions can be recorded in the therapist notes There are

also several scales that can be used to provide the therapist with a structure that they can use

in describing their work with a client (either in a session or across the case as a whole)

Appropriate scales include the Therapeutic Procedures Inventory (McNeilly amp Howard

1991) Comprehensive Therapeutic Interventions Rating Scale (Trijsburg 2004) and the

Therapist Techniques Survey Questionnaire (Thoma amp Cecero 2009) The Psychotherapy

Process Q-sort (Ablon amp Jones 1998 Jones amp Pulos 1993) is a therapist intervention coding

system that can be applied to therapy transcripts

7 Pluralistically-oriented outcome interview A pluralistic perspective invites a critical and

questioning stance in relation to the reporting of the outcomes of therapy Characterising the

outcome of a case in terms of a single dimension of lsquogood vs poor outcomersquo or attainment of

lsquoclinically significant changersquo on a symptom measure reflect a monist assumption that there

is one kind of change or therapeutic gain that applies to all clients A pluralistic position by

contrast is open to the possibility that there are a multiplicity of change pathways or

trajectories and that practical knowledge about how to help people will be enhanced if a

more differentiated model of change can be developed within the profession As a result in

systematic case study research into pluralistic therapy it is necessary to include standard

outcome measures (such as BDI and CORE-OM) which allow outcomes of the target case to

be readily compared with benchmark findings from other studies individualised goal

measures and also more open-ended strategies for collecting information about the breadth

and range of impact of outcomes for the client The Change Interview (Elliott 1999) a

structured follow-up interview that takes 45-60 minutes provides a valuable tool for this

aspect of case study data collection In some circumstances it may be useful to augment the

Change Interview with items from other post-therapy interview schedules developed by

Nilsson et al (2007) and Lilliengren amp Werbart (2005) The Life Space Map (LSM Rodgers

2006) is an interview schedule that makes use of creative arts techniques to facilitate client

description of outcomes

It is perhaps important to note that measurement scales are used in a different way in

case study research compared to conventional studies where data from large samples of

participants are aggregated In large-n studies it is essential to use scales for which the

psychometric properties (validity reliability) have been established In case studies the

psychometric status of a scale is less important In analysing case data there are some

circumstances in which it is valuable to have access to psychometric norms for a scale for

the purposes of positioning a client (or segment of discourse) in relation to a wider

population However scales that have not been validated can also be employed because the

process of systematic case analysis (see below) calls for constant comparison of all pieces of

data against each other This means for example that the meaning of responses to individual

items from a scale may be of considerable analytic significance

A wide range of potential data collection activities have been introduced in this section

as well as in the preceding lsquobasic protocolrsquo section It is important not to assume that it is

necessary to collect information under each of these categories Collecting data that is too

lsquothinrsquo leads to difficulties at the analysis stage if there is not sufficient information to allow

patterns to be reliably identified or to support robust conclusions But it can also cause

problems if too much information is collected ndash there is a risk that the research team can be

overwhelmed by detail or that participants spend time completing scales that are then not

used When planning a case study it is useful to take some time to anticipate the possible

findings of the study then to work back and identify the type of data that would be required

in order to substantiate such findings and then work out the actual data collection

instruments and data administration points that would be required This kind of planning does

not imply that the findings of a study merely reflect the prior assumptions of the researcher

What it means instead is that the broad focus of the study needs to be clarified from the

outset For example if the focus of a study is to document the outcome of therapy and

demonstrate links between certain therapeutic procedures and outcome then specific types of

process and outcome data need to be collected (see Elliott et al 2009 for an example of this

kind of study) If on the other hand the focus of a case study is on the role of the client-

therapist relationship then it will be appropriate to collect other types of data (see Rabu et al

2011 for an example of such a study) One of the key choice-points for case study

researchers with respect to data collection is to decide whether or not to make recordings of

therapy sessions Therapy transcripts provide rich material but are very time-consuming to

produce and then to analyse Mindful of these issues many case study researchers make use

of supplementary instruments such as the Helpful Aspects of Therapy form (HAT Llewelyn

1989) that can be used to direct the research time toward particular segments of transcript

(ie a turning point in a session) that are worth transcribing

Strategies for analysing case study data

Historically it has been widely acknowledged that one of the major methodological

limitations and weaknesses of case study research was that data were collected and analysed

solely by the therapist As a result there was no possibility of independent or external

critique of the therapistrsquos account of the case and many published case studies came to

resemble self-promoting or self-justificatory exercises that promulgated the therapistrsquos beliefs

or approach but made a minimal contribution to the knowledge base for counselling and

psychotherapy as a whole In recent years it has become good practice to overcome this

problem by using a team of researchers who independently analyse the case (or segments of

the case) and then compare findings There are various ways in which such a research team

can be organised (see McLeod 2010 for examples) The basic principle is that the ultimate

findings or conclusions of the case analysis can be shown to have been generated by a

process of open dialogue in which competing interpretations are systematically evaluated in

terms of their lsquofitrsquo with the data ie a pluralistic analysis The usual way in which such a

team operates is that the principal investigator takes responsibility for collating all of the case

data into a lsquocase bookrsquo copies of which are which is then distributed to all members of the

team The team then meets and agrees on a set of analytic procedures (eg identifying

episodes in the case where the therapist is responsive to client preferences or segmenting the

process of the therapy into discrete stages) Each member then completes the procedure

independently The team then meets to share their analysis discuss discrepancies and arrive

at an acceptable consensus The team then works through the next steps in the analysis until

it has exhausted all possible lsquoreadingsrsquo of the material and has the confidence to proceed to

the writing stage

The task of analysing complex and voluminous case data is challenging for most

researchers What tends to be helpful is to work out a step-by-step approach that begins by

getting a sense of the case as a whole and then moves to more fine-grained analysis of

particular areas of data For example it can be helpful for each member of the research team

to begin by reading through the case book and making a brief summary of the key themes

within each session and their overall sense of how helpful the therapy was and the factors

within the therapy that made a positive or negative contribution to outcomes It also useful

then to identify stages in the therapy give names to these stages and to develop some ideas

about what happened to facilitate a shift from one stage to the next Once this kind of overall

non-theoretical understanding of the case has been accomplished it is then possible to move

to more detailed theoretically-informed analysis of specific processes For example in a poor

outcome or ambiguous outcome case it might be hypothesised from a pluralistic perspective

that there was a mismatch between client preferences and what the therapist could offer or a

failure to engage in collaborative conversations These hypotheses could be tested by

examining particular facets of the case record For example failure to engage in collaborative

conversation might have been mentioned by the client in their follow-interview or be

expressed in low working alliance ratings or be observable in an absence of

metacommunicative sequences in therapy transcript data An example of how this kind of

analytic process is structured can be found in McLeod and Balamoutsou (2001) A valuable

analystic strategy that has been used by several groups of case study researchers has been to

organise data analysis around competing sub-teams who each produce alternative

interpretations of the case material and then invite a group of judges to decide on which

version is the most convincing Different ways of conducting this kind of lsquoadjudicatedrsquo case

study method are described in Fishman (2011) and McLeod (2010)

The form of analysis that is being described here is fundamentally hermeneutic or

interpretive in intent (Elliott 2001 2002 McLeod 2011) The aim is to develop a credible and

practically useful understanding and representation of what happened within a case This kind

of research is carried out with the awareness that alternative interpretations are always

possible Hermeneutic inquiry does not claim to result in a single once-and-for-all lsquoobjectiversquo

truth but to construct a perspective on or reading of a case that is demonstrably grounded in

the facts of the matter and which opens up new possibilities for insight and action The

philosophical rationale for this approach to inquiry is explained in detail by Fishman (1999)

who argues that systematic case studies provide the kind of knowledge that is most relevant

to the advancement of professional practice The incorporation of both qualitative and

quantitative data sources represents a significant source of strength of this kind of pragmatic

research because it enables the sensitivity to complexity and context of qualitative tools to be

combined with access to standardised norms available for quantitative process and outcome

measures The use of both types of data reflects a growing appreciation within the research

community of the value of mixed methods research strategies (Hanson Creswell et al 2005)

Research designs different questions that can be addressed through case study inquiry

Within the field of research in counselling counselling psychology and psychotherapy case

studies have been used to examine four discrete types of research goals or questions

bull Outcome questions How effective has therapy been in this case To what extent can

changes that have been observed in the client be attributed to therapy

bull Theory-building questions How can the process of therapy in this case be understood

in theoretical terms How can the data in this case be used to test and refine an

existing theoretical model

bull Pragmatic questions What strategies and methods did the therapist use in this case

that contributed to the eventual outcome How were therapeutic methods adapted and

modified to address the needs of this specific client What are the principles of good

practice that can be derived from this case

bull Experiential or narrative questions What was it like to be the client or therapist in

this case What is the story of what happened from the client or therapist point of

Further elaboration of the ways in which particular case study investigations can be oriented

toward one or more of these aims can be found in McLeod (2010)

These four types of research question open up a wide research agenda around the

outcomes and processes of pluralistically-oriented counselling and psychotherapy One of the

current priorities for the further development and professional acceptance of pluralistic

therapy is to publish systematic case studies of the effectiveness of this approach with clients

reporting different kinds of presenting problems and different degrees of therapy

sophistication being seen in different kinds of therapy settings (eg voluntary agencies

NHS private practice) Such a body of systematic case-based literature would allow

colleagues clients and trainees to learn about how a pluralistic stance can be effective in

some situations and less effective in other situations and to understand the ways in which

particular pluralistic strategies are associated with outcome The relevance of this type of

research can be supported by reference to developments within the field of emotion-focused

therapy (Greenberg 2002) There is good evidence that EFT is effective for clients suffering

from depression (Watson Gordon Stermac et al 2003) In the last few years case study

evidence has been presented to demonstrate that EFT can also be effective for clients

suffering from phobias (Elliott et al 2009) and social anxiety These cases have established

not only that EFT is in principle effective with these conditions but also how it is effective

The domain of theory-building case studies (Stiles 2007) offers many opportunities

for projects that seek to elucidate aspects of the process of pluralistic therapy For example

not enough is known about how productive collaborative conversations take place about the

process of identifying and agreeing goals or about the therapeutic tasks that are associated

with specific problems such as depression The work of the research group led by Clara Hill

on the development of a theory of immediacy in therapy provides an example of what can be

achieved This group have published two case studies (Hill et al 2008 Kasper Hill amp

Kivlighan 2008) in which the operation of therapist immediacy has been analysed in relation

to the overall process and outcome of each case One case was chosen for analysis because it

was known that the therapist favoured the use of immediacy and a comparison case was

chosen in which the therapist employed this skill to only a moderate extent These two case

studies taken together have produced a significant advance in the practical understanding of

how this intervention functions within therapy

Pragmatic case studies (Fishman 1999 McLeod 2010) are studies that seek to

document the professional activity of the therapist ndash the way in which the therapistrsquos

underlying conceptual framework plays out in the context of his or her work with a particular

client A crucial aspect of this type of case study is the level of detail with which all aspects

of the case are reported The aim is to provide the reader with a comprehensive representation

of what happens when a particular approach is used with a specific client An on-line journal

Pragmatic Case Studies in Psychotherapy has been established to function as a repository of

such cases with the long-term aim of operating as a professional resource ndash a place where

therapists can consult if they are looking for ideas about possible ways of responding to the

needs of clients with certain patterns of problems The aim of the pragmatic case study

initiative is to accumulate a bank of practical knowledge about what can work This kind of

knowledge is crucially important for the advancement of pluralistically-informed therapy

because pluralistic therapists need to be continually curious and open to learning around the

concrete details of how other colleagues have worked with clients to break down complex

problems into step-by-step tasks and then agreed on methods to accomplish such tasks

Finally narrative or experiential case studies have substantial heuristic value in

documenting the experiences of clients and therapists around the therapy in which they have

participated Knowing more about client and therapist experience will play an essential role

in the establishment of pluralistic approaches to therapy For example a criticism that is

sometimes made of pluralistic therapy is that clients may feel confused and unsupported by

being asked about their preferences around therapy methods But to what extent is this true

At the present time there are no published case narratives in which clients of pluralistic

therapy report that they were unhappy (or otherwise) about being invited to explore

preferences Similarly there are no narrative accounts of therapist experiences of living with

the uncertainty that accompanies a pluralistic stance Basically the voices of clients and

therapists (and supervisors and family members) are not being recorded and are therefore

not being heard Philosophically and ethically a pluralistic stance implies a high degree of

open-ness to such diversity as opposed to the construction of a knowledge base that is

dominated by the writings of authority figures The development of a narrative case tradition

within pluralistic therapy is therefore of great significance

For anyone planning to undertake a systematic case study investigation it is probably

wise to concentrate on one of these aims or questions or at most one primary aim (eg

documenting outcome) with a second subsidiary aim (eg generating a model of the factors

that contribute to outcome) There are no case studies within the currently available literature

that successfully achieve all four of the aims that have been outlined in this section Before

embarking on a case study it is valuable to take time to be immersed in the case study

literature to get a feel for how other researchers and research teams have dealt with the issues

involved in condensing lengthy case records into a journal-length report

Conclusions

The purpose of this paper has been to provide an overview of the potential role of systematic

case study research in the development of pluralistically-informed ways of doing therapy and

to offer an outline of the practical and methodological issues and procedures associated with

this form of investigation It has been argued that case study methods are well suited to the

exploration of pluralistic processes and outcomes because case-based research is uniquely

placed to capture the complexity of pluralistic work Readers who wish to pursue this type of

research are encouraged to consult McLeod (2010) and other sources in order to develop

sufficient background knowledge to enable them to make good decisions around research

design and the process of data collection and analysis In recent years there have been

significant developments in case study methodology in fields such as education political

science and organisational studies and there are several excellent texts that provide

accessible accounts of the case study approaches that have evolved within these fields

Particularly recommended are Simons (2009) and Yin (2009)

There is a significant emerging challenge for the field of systematic case study

research in counselling and psychotherapy in the area of training In contrast to other types

of research students and practitioners tend to report that case study research is intrinsically

interesting and rewarding (see McLeod 2010) However in order to conduct good quality

case studies students and practitioners need to have opportunities to learn about and try out

a range of possible ways of collecting and analysing case data Probably one of the best

means of offering such training is on an apprenticeship basis where novice case study

researchers are members of research teams that are led by more experienced colleagues A

good example of this approach can be found in Jackson Chui amp Hill (2012) Another strategy

is to integrate systematic case inquiry into basic therapist training in the manner pioneered

by Stinckens et al (2009) A further contribution might involve giving greater acceptance to

case study projects in the context of Masters and Doctoral work Counselling psychology and

other therapy practitioners represent the best source of potential case study material because

they are likely to work with a wide range of clients and will thus have many interesting case-

based stories to tell It is clearly easier for clinicians to carry out case study research if they

have already learned about methods of systematic case study inquiry in their initial

professional training Experienced practitioners may regard the time demands of case study

research as a barrier to their involvement in this type of activity However case study

research can be incorporated into group supervision and can form a powerful means of

continuing professional development (see McLeod 2010) Finding the time for case study

research may therefore be accomplished by re-organising existing supervision and CPD

arrangements

Finally it is important to emphasise that in the end the contribution of case study

research to the development of flexible personalised pluralistically-oriented therapy services

depends on the on-going production of many case studies Just as a single survey or RCT has

limited impact until it has been replicated a single case study only really has meaning and

practical significance when it can be set alongside other cases To get maximum value from

the potential methodological richness of case study research it is necessary to think in terms

of case series the selection of new cases that stand in contrast to (or replicate) previous cases

and case study meta-analysis It is also necessary to look for ways to integrate case studies

into large-scale practice-based outcome studies and randomised clinical trials (Dattilio

Edwards and Fishman 2010 Edwards Dattilio and Bromley 2004)

Ablon JS amp Jones EE (1998) How expert cliniciansrsquo prototypes of an ideal treatment

correlate with outcome in psychodynamic and cognitive-behavioral therapy

Psychotherapy Research 8 71-83

Barkham M Mellor-Clark J Connell J amp Cahill J (2006) A core approach to practice-

based evidence A brief history of the origins and applications of the CORE-OM and

CORE System Counselling and Psychotherapy Research 6 3-15

Berg A L Sandahl C amp Clinton D (2008) The relationship of treatment preferences and

experiences to outcome in generalized anxiety disorder (GAD) Psychology and

Psychotherapy Theory Research and Practice 81 247ndash259

Bohart A C amp Tallman K (1999) How clients make therapy work the process of active

self-healing Washington DC American Psychological Association

Cooper M amp McLeod J (2007) A pluralistic framework for counselling and

psychotherapy Implications for research Counselling and Psychotherapy Research

Cooper M amp McLeod J (2011) Pluralistic counselling and psychotherapy London Sage

Dattilio F Edwards D amp Fishman D (2010) Case studies within a mixed methods

paradigm Toward a resolution of the alienation between researcher and practitioner

in psychotherapy research Psychotherapy Theory Research Practice Training

Edwards D J A Dattilio F amp Bromley D B (2004) Developing evidence-based

practice The role of case-based research Professional Psychology Research and

Practice 35 589-597

Elliott R (1999) Client Change Interview protocol Network for Research on Experiential

Psychotherapies from httpexperiential-

researchersorginstrumentselliottchangeihtml

Elliott R (2001) Hermeneutic single-case efficacy design an overview In KJ Schneider J

Bugental amp JF Pierson (Eds) The handbook of humanistic psychology leading

edges in theory research and practice (pp315-324) Thousand Oaks CA Sage

Elliott R (2002) Hermeneutic Single Case Efficacy Design Psychotherapy Research 12

Elliott R Partyka R Wagner J AlperinR Dobrenski R Messer SB Watson JC amp

Castonguay LG (2009) An adjudicated Hermeneutic Single Case Efficacy Design

study of experiential therapy for panicphobia Psychotherapy Research 19 543-

Elkins G Marcus J Rajab H amp Durgan S (2005) Complementary and alternative

therapy use by psychotherapy clients Psychotherapy Theory Research Practice amp

Training 42 232-235

Fishman DB (1999) The case for a pragmatic psychology New York NYU Press

Fishman DB (2011) A promising strategy for critically evaluating case studies Introduction

to an issue on the Adjudicated Case Study Method Pragmatic Case Studies in

Psychotherapy httppcsplibrariesrutgersedu Volume 7 Module 1 Article 1 pp

1-5 02-28-11

Greenberg L (2002) Emotion-focused therapy coaching clients to work through feelings

Washington DC American Psychological Association

Hanson WE Creswell JW Plano-Clark VL Petska KS amp Creswell JD (2005)

Mixed methods research designs in counseling psychology Journal of Counseling

Psychology 52 4-35

Hatcher RL amp Gillaspy JA (2006) Development and validation of a revised short form

of the Working Alliance Inventory Psychotherapy Research 16 12-25

Hill CE Sim WE Spangler P Stahl J Sullivan T amp Teyber E (2008) Therapist

immediacy in brief psychotherapy Case Study 2 Psychotherapy Theory Research

Practice and Training 45 298ndash315

Jackson JL Chui HT amp Hill CE (2012) The modification of Consensual Qualitative

Research for case study research an introduction to CQR-C In CE Hill (Ed)

Consensual Qualitative Research a practical resource for investigating social

science phenomena (pp 285-304) Washington DC American Psychological

Association

Jorm AF Medway J Christensen H Korten AE Jacomb PA amp Rodgers B (2000)

Public beliefs about the helpfulness of interventions for depression effects on

actions taken when experiencing anxiety and depression symptoms Australian amp

New Zealand Journal of Psychiatry 34 619ndash626

Kasper LB Hill CE amp Kivlighan DE (2008) Therapist immediacy in brief

psychotherapy Case Study 1 Psychotherapy Theory Research Practice and

Training 45 281ndash297

Kessler R C Soukup J Davis R B Foster D F Wilkey S A Van Rompay M I amp

Eisenberg D M (2001) The use of complementary and alternative therapies to treat

anxiety and depression in the United States American Journal of Psychiatry 158

289ndash294

Lilliengren P amp Werbart A (2005) A model of therapeutic action grounded in the patientsrsquo

view of curative and hindering factors in psychoanalytic psychotherapy

Psychotherapy Theory Research Practice Training 3 324-399

Jones EE amp Pulos SM (1993) Comparing the process in psychodynamic and cognitive-

behavioral therapies Journal of Consulting and Clinical Psychology 61 306-316

Llewelyn S (1988) Psychological therapy as viewed by clients and therapists British

Journal of Clinical Psychology 27 223-238

McLeod J (2009) An introduction to counselling 4th edn Maidenhead Open University

McLeod J (2010) Case study research in counselling and psychotherapy London Sage

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Is IPT Time-Limited Psychodynamic Psychotherapy?vuir.vu.edu.au/19368/22/vol7no3.pdfpsychodynamic psychotherapy. The authors discuss similarities and differences between IPT and short-term

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