Pluralism
in the room.
So it doesn’t work.
A worked case across several sessions, following the therapist’s decisions, uncertainties, disagreements and changes of direction.
What this is: one fictional course of pluralistic therapy about anxiety around personal assistance.
Why it matters: it shows the decisions behind the approach, not just the principles.
The sharpest reframe: a missed task can be information about fit, not avoidance.
One thing to take away: each decision should follow from what happened before.
The short version
This page follows one fictional client, Peig, through a course of pluralistic therapy about anxiety around receiving personal assistance. It shows why each decision follows from what happened before: how the concern was defined, how tasks and methods were chosen, what happened when a method didn’t fit, how a mixed result was reviewed, and how the direction changed. It includes uncertainty and disagreement. It is a teaching example, not a template.
Peig is 38 and has cerebral palsy. She uses a wheelchair and has personal assistants who help her get up, wash and dress each morning. She works part time from home. She contacted a therapist because she wakes with dread on days when certain assistants are due, and because she feels she has “no privacy left”.
Peig is a fictional teaching example, not a real person. The therapist and their thinking are also constructed for learning.
Clarifying the concern
Peig said she wanted less dread before assistance, and more privacy. The therapist had read a referral note that mentioned “difficulty accepting dependence”. They didn’t adopt it. They asked Peig what she wanted, and wrote her two goals down in her words.
Access was agreed at the same time: video sessions at midday, after her assistance and before work, with a written summary afterwards because she found typing during sessions tiring.
The therapist’s thinking
The referral describes a problem with Peig. She describes a problem with her mornings. I’ll start from hers, and stay curious about whether acceptance matters to her at all.
Exploring the context
They mapped her current care arrangements: which assistants, which mornings, which tasks. Two things stood out. One long-standing assistant was respectful and easy. A newer agency worker talked on the phone during personal care and commented on her body. Peig also mentioned, briefly, an earlier carer who had been rough with her. She said she didn’t want to go into that now. The therapist agreed, and asked what she wanted kept private in their notes.
What wasn’t clear
The therapist didn’t know how much of the dread came from the current worker, how much from earlier experiences, and how much from the general loss of privacy. They said so, and suggested they keep all three possibilities open.
Safety before assertiveness
Peig said she wanted practical help first. The obvious idea was to practise asking the agency worker to stop using his phone. But the therapist already knew this worker commented on her body during personal care. Before suggesting anything, they asked: would making a request feel safe? What did she think might happen?
Peig said she was afraid he would be rougher, or complain to the agency that she was “difficult”. They talked about alternatives that didn’t depend on her confronting him alone: raising it with the agency, asking for her long-standing assistant to cover those mornings, or keeping a note of what happened. Peig decided to try a request with both workers, because she wanted to be able to ask for things in her own home, and to contact the agency if it went badly.
The therapist’s thinking
Assertiveness can’t be the first answer to someone else’s misconduct. Her choice to try a request is hers to make, but she needs other routes, and I need to keep safety in view.
Why this method? Rehearsing a request
Our framework- The reasoning: to practise a communication Peig wants to make, and to explore what she expects will happen, so her predictions can be checked against what actually happens.
- What would challenge this understanding: if her fears turn out to be accurate, the problem is the worker’s behaviour, not her expectations.
- What burden it might create: rehearsal can stir up anxiety, and making the request carries real risk with someone who isn’t treating her well.
- What would tell us to adapt or stop: any sign that making the request has made her less safe, or that the work is shifting responsibility onto her.
- What the therapist needs to offer it: skills in assertiveness work, and knowledge of safeguarding routes and care arrangements for disabled adults.
A method that didn’t fit, and whose mistake it was
The therapist had suggested writing down her predictions between sessions. Peig hadn’t done it. She said writing after work was exhausting.
The therapist said: “You told me at the start that writing tires you, and I still suggested it. That was my mistake, not yours.” They dropped the homework and did the prediction work briefly in the session instead, out loud, with the therapist adding it to the written summary.
The therapist’s thinking
It would be easy to call this avoidance. It wasn’t. I didn’t use what she told me. The task stays; the method changes; and I say so.
A mixed result, and two different measures
Peig made the request to both workers. The long-standing assistant apologised and changed straight away. The agency worker laughed it off and carried on. Peig came to the next session saying, “So it doesn’t work.”
What wasn’t clear
They disagreed. The therapist thought the request had worked: she had made it, and one person had changed. Peig thought it had failed, because the person who mattered most hadn’t. Talking it through, the therapist realised they had been measuring a successful exercise, while Peig had been measuring a safer morning. Those are different outcomes, and hers was the one that mattered.
They revised their understanding. Much of the dread wasn’t about Peig’s communication. It was about a worker who wasn’t listening, and an arrangement she had little control over. Peig decided to contact the agency, and the therapist helped her plan what to say.
When the agency acts, and if it hadn’t
The agency replaced the worker within two weeks, and the mornings became easier.
What if the agency had delayed or refused?
Therapy can’t produce adequate care. If the agency had been slow or said no, the therapist could have helped Peig think through other routes, such as a formal complaint, an advocate, or the body that funds her support, and supported her through the mornings in the meantime. They would also have needed to consider whether her safety meant acting on safeguarding concerns, which they would have explained at the start as part of what therapy can and can’t keep confidential. The work would have been to support her, not to pretend therapy could fix the situation.
With the mornings easier, Peig said she now wanted to look at something else: the shame she felt every time she needed help, even from people she trusted. The therapist explained a few ways they could work with it: exploring where the shame came from, noticing her self-critical thoughts as they happened, or working on self-compassion. Peig chose to start by exploring where it came from, and asked if they could include the earlier carer, slowly.
The therapist’s thinking
This is a bigger change of direction, and she has chosen it. I need to go at her pace, keep checking in, and be honest if this moves beyond what I can offer.
Reviewing what changed
They reviewed more than attendance or a questionnaire score. They asked about privacy, dread, self-criticism and the care arrangement itself. Peig said her mornings were “mostly okay now”, she felt less ashamed asking her long-standing assistant for things, and the shame work was “just starting”.
They agreed to continue for another eight sessions and review again. Eight was the therapist’s suggestion for a review point: long enough to give the shame work a fair try, short enough to check it was helping. Peig could afford that block, and she said she’d rather have a date to look at than an open ending. Either of them could ask to review sooner.
What this case shows
Our frameworkThe concern was hers
The therapist didn’t substitute the referral’s “accepting dependence” for what Peig asked for.
Safety came before assertiveness
A direct request wasn’t treated as the answer to someone else’s misconduct.
The therapist owned a mistake
The missed homework came from the therapist ignoring what Peig had said. The method changed; the task stayed.
Disagreement was spoken
The therapist was measuring a successful exercise; Peig was measuring a safer morning.
The understanding was revised
Part of the problem was in the care arrangement, not in Peig.
Therapy had limits
Contacting the agency mattered as much as anything in the room, and therapy couldn’t have produced adequate care on its own.
The direction changed by her choice
From practical work to shame, once she was ready.
What needs attention here?
A referral defines the problem differently from the client
Possible focus: starting from the client’s account
Watch for: adopting the referral’s framing
Between-session work isn’t done
Possible focus: asking what got in the way
Watch for: calling it avoidance
A result is mixed
Possible focus: reviewing it together, including disagreement
Watch for: declaring success or failure alone
The problem is partly in the world
Possible focus: practical action alongside therapy
Watch for: treating it as only an inner problem
Possible starting points, agreed with the person, not rules.
How you’d know it helped
Two different questions: whether the work is going well, and whether it is actually helping.
Is the work collaborative and accessible?
- The goals stayed Peig’s throughout.
- Each change of method or direction had a reason both could name.
- Safety and her own choices shaped what was tried.
Is it helping with what matters?
- Less dread before assistance, and more privacy.
- Less self-criticism when asking for help.
- A safer care arrangement, which therapy supported but couldn’t guarantee.
Questions worth carrying, as a therapist
Therapist Reflection- Whose description of the problem did I start from?
- When a task wasn’t done, what did I assume?
- When I disagreed with a client about whether something worked, did I say so?
- What help did the person need outside therapy?
Evidence & sources
Sources checked in October 2026, using targeted searches rather than a systematic review. “We have not located” means our searches did not find it.
Cooper, M. & McLeod, J. (2011), Pluralistic Counselling and Psychotherapy. London: Sage.
The stages, the therapist’s thinking and the learning points are this site’s synthesis.
Peig, the therapist, the assistants and the therapist’s thinking are constructed for learning. They are not real people.
Our targeted searches did not find published case studies of pluralistic therapy focused on disabled clients.
Last reviewed: October 2026.
How to cite this page: Donaghey, C. (2026). Pluralism in the Room. Disability in Psychotherapy. Available at: https://disabilityinpsychotherapy.online/what-is-psychotherapy/pluralistic-psychotherapy/pluralism-in-the-room/ (Accessed: [date]).