When to change direction,
and when to stay.
It wasn’t the exercises. It was the sheets.
Four different decisions, from adapting access to referring on, and how to keep a course of therapy coherent as it changes.
What this is: a guide to reviewing and changing direction in therapy.
Why it matters: methods that don’t fit can waste time and wear people out.
The sharpest reframe: adapt access before abandoning a method.
One thing to take away: change direction for a reason you can both name.
The short version
In pluralistic therapy, changing course isn’t a failure. Therapist and client agree goals, choose tasks and methods together, and check whether things are helping. When something isn’t working, there are four different decisions they might make: adapt access, adjust how the method is delivered, change the therapeutic task, or change approach or refer on. Telling these apart matters, especially for disabled clients, because a method that hasn’t been made accessible isn’t the same as a method that doesn’t suit. The aim is a method that fits the person, serves the agreed purpose and is delivered with skill, and a course of therapy that stays coherent even as it changes.
You might recognise this
Illustrative statementsDrawn together from common experiences. They are not quotes from individual people.
Fit, purpose and skilled delivery
Established theoryCooper and McLeod’s pluralistic framework starts from the idea that different people are helped by different things at different times, and that the client is a source of knowledge about what helps them. Therapy is built around shared decisions about goals, tasks and methods, and those decisions stay open to review.
Our frameworkIt can be tempting to set “fitting the person” against “sticking to the method”. That isn’t quite right. A method can often be adapted to someone’s communication or energy while still doing the therapeutic work it is meant to do. And a comfortable or preferred activity may not address the difficulty the person came with. So three questions matter together:
Fit
Can this person take part, and does the method suit them?
Purpose
Does it serve the task and goal you agreed?
Skilled delivery
Is it being offered competently, as intended?
Four different decisions
Our framework“Change direction” can mean very different things. Before deciding, it helps to ask which of these is needed:
1. Adapt access
The person takes part differently: audio instead of writing, breaks, communication support, a different format. The method stays.
2. Adjust delivery
The pace, examples, structure or order changes. The task stays.
3. Change the therapeutic task
The work needed towards the goal is different from what you thought.
4. Change approach, or refer
A different method, treatment or practitioner is needed.
The first two keep the work going in a form the person can use. Skipping straight to the fourth because of an access barrier can quietly narrow what disabled clients are offered. Equally, insisting on a method because it “should” work can turn into pressure.
Signs it may be time to review
Our frameworkNothing is shifting
Scores, goals or the person’s own sense of things haven’t moved over several sessions.
The person seems to be going along with it
Agreement without much energy might mean tiredness, politeness or uncertainty. It’s worth asking, without assuming.
The method costs too much
Fatigue, pain or sensory load after sessions outweighs what the person gets from them.
Something has changed in their life
A flare, a new diagnosis, a care change or a crisis may change what they need now.
The goal has changed
What mattered in week one may not matter in week eight.
You’re changing things too often
Lots of switching can be a sign that nobody has stopped to ask what the person needs.
Nollaig is 52 and has multiple sclerosis. She asked for help with low mood and with feeling she had “lost her place” at work. She and her therapist agreed to try behavioural activation, planning small valued activities each week. By week five, her mood ratings hadn’t moved, and she said the planning sheets made her feel like she was failing.
In a review session, they looked at it together. The activities themselves weren’t the problem: the sheets were. Writing tired her hand, and filling them in at night felt like a test. They switched to a short voice note on Mondays: an access adaptation, with the method unchanged. Two weeks later, the ratings still hadn’t moved much, and Nollaig said what she really wanted was to talk about what MS had taken from her. They changed direction again: this time the therapeutic task itself changed, towards more meaning-centred conversation about loss. They kept one small weekly activity she liked.
Nollaig is a fictional teaching example, not a real person.
Why this method? Behavioural activation for Nollaig
Our framework- The reasoning: to explore whether accessible, meaningful activity could lift her mood and reconnect her with things she valued.
- What would challenge this understanding: her mood staying low even when she did the activities, or the activities feeling meaningless rather than restoring.
- What burden it might create: planning and recording take time, energy and, here, writing; reduced activity may also reflect MS fatigue, not only mood.
- What would tell us to adapt or stop: no change after a fair trial in an accessible form, or the person saying the work misses what matters most.
- What the therapist needs to offer it: training in behavioural activation, and enough understanding of MS fatigue to pace activities realistically.
A realistic fear isn’t a thinking error
Sometimes a method stops fitting because it rests on an assumption that isn’t true for this person. A common example: treating fears about a health condition getting worse, about services, or about discrimination as distorted thinking to challenge. Some of these fears are realistic.
When that happens, the method may need to change. It can help to separate what might realistically happen from the spiral of worry on top of it. The realistic part may need planning, support or grief, not challenge.
How to review together
Our frameworkLook at the goals again
Are these still the goals? Has anything changed?
Look at what’s been happening
Use whatever you’ve been tracking: a measure, a goal rating, or the person’s own words. Ask how they experience the sessions, not just their symptoms.
Separate the method from its format
Is the problem the method, or the way it was delivered? Could it work in another format?
Name the options
Keep going, adapt, try something different, pause, or refer on. Be honest about what you can and can’t offer.
Agree, and set the next review
Write down what you’ve agreed, in a format the person can use, and when you’ll look again.
What it might sound like
We said we’d look at how it’s going around now. Can I ask you honestly: is this helping?
I don’t want to say no. You’ve put a lot into it.
It’s my job to change things if they aren’t helping. Saying so doesn’t hurt my feelings. It helps me.
Then no, not really. The sheets feel like homework I keep failing.
Is it the sheets, or the whole idea of planning things?
The sheets. I like having one thing to look forward to.
What changes: they keep the activities and drop the sheets.
Staying with a method long enough
Our frameworkChanging direction too quickly has costs too. Some methods take time to help, and some useful work is uncomfortable. Constant switching can stop anything from going deep enough to make a difference.
A coherent course of therapy can include variation and still hang together: the same goals, a shared understanding of the difficulty, and agreed points to review. What it shouldn’t be is a different technique every week with no thread between them.
Before starting a method, it can help to agree:
- Why this method: what it is meant to help with, in plain words.
- What it will ask of the person: time, energy, writing, talking, movement or emotional intensity.
- How long to try it: a rough number of sessions before reviewing.
- What would tell you it’s working, or not.
- Whether it’s within your training. Pluralistic guidance is clear that no therapist can offer every method. Know what you can offer, say so, and refer on when needed.
Hard is not the same as unhelpful. But a person saying “this is too much” deserves to be heard, not explained away as resistance.
The risk of drifting
CritiqueA common criticism of pluralistic and integrative ways of working is that they can drift into unfocused eclecticism: trying a bit of everything, without a clear rationale or enough skill in each method. Changing direction should be a decision you make together, for a reason you can name, not a habit.
It also matters to be honest about your own training. Being open to many methods doesn’t mean being competent in all of them. Sometimes the right change of direction is a referral.
What needs attention here?
The person seems to be going along with it
Possible focus: asking directly, and making it safe to say no
Watch for: taking agreement at face value
A method keeps failing because of an access barrier
Possible focus: adapting the format before deciding
Watch for: dropping the method without trying
You keep switching methods
Possible focus: stopping to review goals together
Watch for: trying another technique straight away
The person needs something you can’t offer
Possible focus: referral, explained clearly
Watch for: stretching beyond your competence
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?
- Changes of direction were agreed, with a reason you could both name.
- Access was adapted before methods were dropped.
- The person felt able to say something wasn’t working.
Is it helping with what matters?
- The new direction moves things on for the person.
- The course of therapy still hangs together around their goals.
Words you can use
For clientsQuestions worth carrying, as a therapist
Therapist Reflection- Am I keeping a method because it helps, or because I like it?
- Have I checked whether the problem is access, before deciding the method doesn’t suit?
- Have I made it easy for this person to tell me it isn’t working?
- Am I switching too often, or giving up on methods before they’ve had a fair try?
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. (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. (2011), Pluralistic Counselling and Psychotherapy. London: Sage.
On knowing what you can and can’t offer, and referring on: “Frequently asked questions on the pluralistic approach”, pluralisticpractice.com.
The review steps, the warning signs, the questions to agree before starting a method and the distinction between a method that doesn’t suit and one that hasn’t been made accessible are this site’s synthesis.
Nollaig and the dialogue are constructed for learning. She is not a real person.
Our targeted searches did not find studies designed around disability, or reporting results by disability, on when or how pluralistic therapists change direction.
Last reviewed: October 2026.
How to cite this page: Donaghey, C. (2026). When to Change Direction. Disability in Psychotherapy. Available at: https://disabilityinpsychotherapy.online/what-is-psychotherapy/pluralistic-psychotherapy/when-to-change-direction/ (Accessed: [date]).
Shared under CC BY-NC 4.0, with an extra permission to teach from it on fee-paying courses. Credit the site. See Reusing This Material.