Book Review

by T.A. Carey, W. Mansell & S. Tai, 2015, East Sussex & New York: Routledge

Reviewed by Bruce E Nevin

©  Bruce E. Nevin 2016

The schools of psychotherapy number in the hundreds but fall into five broad groups. The age-old practice of empathetic listening and counsel underlay the elaborate psychodynamic constructs of Freud and his followers and successors. The anti-mentalist strictures of behaviorism dictate the manipulations of cognitive-behavior therapy. Rejecting the determinism inherent in both of these streams, beginning in the 1950s, humanistic therapies celebrated the capacity to awaken emotional awareness, create meaning, and actualize human potential. Family systems therapy emerged from these in the late 1960s, informed in part by earlier communication studies by Gregory Bateson and others. (This was the focus of my own training in the late 1970s.) In the midst of this, an unholy alliance has got established between psychiatry, the pharmaceutical industry, and the insurance industry (Angell 2014), and with it the management of symptoms as a surrogate for health.

Faced with this spectrum of dogma and practice, the majority of therapists regard their approach as eclectic or "integrative", picking up tricks and techniques here and there to add to one's therapeutic "toolbox".

"Unfortunately, despite the regular appearance of new and seemingly innovative approaches on the psychotherapy scene, there has not been a steady advance in the effectiveness or efficiency of our treatments. Many innovations are often only innovative at a superficial level and actually turn out to be recycled versions of well-established, more fundamental methods. Exposure is a good example of this. Exposure, in its broadest sense, occurs when people maintain an awareness of distressing images, thoughts, feelings, and objects for a prolonged period of time, and arrive at a different, less upsetting, understanding of these experiences than they had previously. Much of the stock available in the marketplace of psychotherapy techniques is, at its core, a way of promoting exposure, even though it might be packaged very differently".

Further, it is obvious that no theory or technique is successful all the time, nor is any therapist successful all the time, and not every therapist avoids the temptation to blame the client with talk of resistance, non-compliance, and so forth.

The book under review presents three principles which are claimed to be in effective use whenever the psychological distress of a client is resolved, no matter who the therapist was, what technique they employed, or what theoretical explanation they gave. A Joint Presidential Task Force of the Society of Clinical Psychology (Division 12 of the APA) and of the North American Society for Psychotherapy Research came up with more than 60 "empirically grounded" principles described by more than 40 chapter authors (Castonguay & Beutler 2006). The bold claim is that the reader will find that this eclectic mix of principles (such as "Client's expectations are likely to play a role in treatment outcome" and "The therapist is likely to be more effective if he or she is patient") boils down in practice to the three principles identified in this book.

These principles are empirically established, and not anecdotal or eclectic, because they are fundamental aspects of a third grand theory of psychology, also originating in the 1950s and 1960s, that is now coming to broad recognition alongside the more familiar behaviorist and cognitive theories (Mansell & Marken 2015), namely Perceptual Control Theory (PCT).

The three principles are control, conflict, and reorganization. Controlling is what living things do, that is, acting so as to experience matters as one wishes them to be. Control is ubiquitous, from homeostatic systems in the body to acting on an opportunity to advance one's career, from buttoning a shirt to integrating a new concept into familiar prior understandings. Control is generally unnoticed unless it becomes challenging, and in most instances, control is completely autonomous - indeed, controlling is what makes one autonomous. Push an open door and it closes; push a person or an animal and what they do depends on what they want. When one attempts to control another person (Marken & Carey 2015), the result can be conflict. We routinely resolve minor conflicts with scarcely a thought -pedestrians on a busy sidewalk nimbly tweaking their paths to avoid collisions.

Obviously, there are also conflicts within a person, and again routine conflicts get resolved all the time with little fuss. Every choice we make is the resolution of a conflict: "Which shirt to wear? This one is just right with the pinstripe suit, this one goes that beautiful tie Mary just gave me. Oh, but that important interview is today. I'll wear the more businesslike combination." Others are more difficult. "I want people to like me and enjoy my company, but I also want people to take me seriously and agree with my opinions." "I hate my parents for how they treated me, but it's a sin to hate your parents." "I want to let go and move on, but what we had was so special I don't want to let go of it." "I want to make a living with my art, but I don't want to sell out." Psychological distress results when conflict persists over important personal values. The relationships of values, and their resolution, are unique to each person.

PCT provides an exquisite, testable model of cognitive function and behavior that explains how conflict arises and how it is resolved. Conflict occurs when two control systems are at cross-purposes. Achieve one, and the other is unhappy; achieve the other, and the first is unhappy. One purpose is to take pleasure in showing off the beautiful gift necktie, the other purpose is to impress an interviewer. So long as attention is focused on the bone of contention - the striped shirt or the checked shirt, which should I wear? - the conflict is irresolvable. By shifting attention up a level to the purpose for wearing one vs. the purpose for wearing the other, one sees the obvious resolution. More deep-seated and emotionally fraught conflicts take longer, but the process is the same.

The basis of the process is in the third principle, reorganization. When all else fails, the system falls back on its most primitive, unlearned process for learning and change. Reorganization is an unconscious process that changes an organism in the same way that evolution changes a population of organisms. Evolution depends upon random differences between individuals. The characteristics of those that are not successful in bringing offspring to reproductive maturity become less common and over time disappear from the population entirely, leaving only those which are well adapted to a changing environment. In a like manner, reorganization makes random changes in the internal specifications for controlling one's experience. If the experience does not improve, the reorganization process makes another random tweak, and doesn't stop doing so (with pauses) until things are getting better.

For reasons that are not yet well understood, reorganization appears to localize where a person's conscious attention is focused. In the Method of Levels (MOL), the therapist helps the client shift attention from the bone of contention ("Which shirt, the checked one or the striped one?") up to the disparate purposes that generate the conflict. The emphasis in the therapeutic dialog shifts from the symptoms (with their various bandaid "solutions") to the experience of distress about the symptoms, and to commentary and attitudes about the distress, opening pathways to bring the higher-level sources of the conflict into awareness. No advice is given, only relentless curiosity about what the client is experiencing and about what might be behind the client's current words and feelings.

[T]here is something very different between having a thought inside your head and saying it out loud. It is more different still if, when you say it out loud, you say it to someone else. We do not shy away from letting clients know that we do not understand the reasons for this difference very well yet, but the difference is there nevertheless. Even when thoughts seem jumbled or racing or hard to pin down, by engaging in a conversation and answering the questions of another, some kind of change seems to occur.

The resolution of distress is not controlled, either by the therapist or by the client; it is discovered. Like a cat before a mouse-hole, the therapist is alert to "disruptions" in the flow of talk - a pause, a shift of gaze, a muttered side comment - to demand what was that about, what was passing through your mind just then? Each disruption is a potential opening from the current bubble of awareness to a meta-perspective about it. The goals for the therapist are simple: (1) Encourage the client to talk, maintaining focus on some mismatch between their experience of what is and what should be, developing an uncensored flow, with no filtering or editing, deferring any review of thoughts until after they are spoken. (2) As the client overhears what they themselves are saying, inquire into their disruptions of that flow, so as to help them shift focus to a deeper or higher perspective on the issue. The specific content is unimportant to the therapist. There is absolutely no need to bring childhood traumas or the like to awareness, nor any prohibition either. The Method of Levels enables the client to open their own way to letting go of all that (whatever it may be) and moving on with their life in freedom. In all of this, the client is the locus of change but not the agent, and the process is to facilitate the innate power of reorganization unconsciously to achieve a healthful balance of the client's own desires and needs. Because the trial-and-error changes of internal reorganization can make things seem worse before they get better, this requires an informed faith that the client has all the resources they need to create just the right solution for themselves.  

Many consequences follow for the conduct of therapy and for the design of mental health programs. You treat the distress, not the symptoms. This runs against the imperatives of insurance formalities. Goals are set for the therapist (goals 1 and 2 above), not for the client. Problems such as non-compliance, resistance, and non-attendance are reframed by asking what the client is controlling by these means. Progress is directed by the client. Although reorganization is initiated by shifting attention to a higher level, there is no need for the client to maintain that awareness after a session. Because the process of reorganization is unconscious and of unpredictable duration, the scheduling of appointments is put in the client's hands, to come in when they feel ready to do some more work. Reminiscent of the innovations of Milton H. Erickson in hypnotherapy, this runs counter to managerial expectations in programs and institutions. Experience is cited showing that, even when MOL practice has amply demonstrated both effectiveness and efficiency, eliminating a backlog caseload that had been intractable for years, administrators resist and may even prohibit MOL practice, preferring what fits into their familiar categories. Therapists themselves can be profoundly unsettled by seeming to be adrift with the client in an ocean of possibilities in which there is no a priori right answer, no preconceived plan, and no recipe for success other than encouraging pertinent talk, listening with tireless curiosity, ignoring the interpretations and pat solutions that their training and experience may bring to mind (the gaining of which may have been what drew them to psychology), poised to pounce on subtle clues of background thoughts and feelings as a new focus of talk. But what a recipe for success that is! Try it. You'll like it. 

Angell, Marcia. 2014. The Illusions of Psychiatry. New York Review of Books, JULY 14, 2011. http://www.nybooks.com/articles/2011/07/14/illusions-of-psychiatry/

Castonguay, L. G., & L. E. Beutler (eds). 2006. Principles of therapeutic change that work. Oxford: Oxford University Press.

Mansell, W. & R. S. Marken. 2015. The origins and future of control theory in psychology. Review of general psychology 19.4:201-430.

Marken, R. S. & T. A. Carey (2015) Controlling people: The paradoxical nature of being human. Samford Valley, Australia: Australian Academic Press Group.

Norcross, J.C. (2005). A primer on psychotherapy integration. In J.C. Norcross & M.R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 3-23). New York: Basic Books.

Principles-based counselling and psychotherapy: a Method of Levels approach, by T.A. Carey, W. Mansell, & S. Tai, 2015, East Sussex & New York: Routledge.

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This page last updated on August 2, 2019