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TIM CAREY describes what therapy might be like when it is informed by the principles of Perceptual Control Theory (PCT). PCT offers an understanding of the activity of living that is quite different from many current ways of conceptualising human activity. To highlight the differences a case study is provided of a 19-year-old woman who presented with depressive symptomatology in the extremely severe range. After four therapy sessions the woman’s symptoms were in the none to minimal range and were maintained in this range at a ten-week follow up. The implications of applying PCT to therapeutic practices are discussed.

In this paper I provide data that were obtained when patients made decisions regarding the scheduling of treatment sessions. I outline relevant information from the literature and describe Perceptual Control Theory as the theoretical basis of this work. The implications and limitations of the data are discussed as well as suggestions for future research. The data are interpreted as preliminary evidence that patients can take responsibility for decisions made during psychological treatment programs.

Mental health problems are increasing in society. To effectively deal with these problems it is imperative that appropriate treatments are delivered. Some evidence suggests that the design of many treatments is longer than patients attend treatment for. The aim of this study was to estimate the average length of treatment for patients referred to the adult specialty of a large clinical psychology department. A stratified sampling strategy was chosen to obtain an unbiased and precise estimator of the average treatment length for the population of patients whose files had been closed in one calendar year (n = 3021). A pilot study was undertaken to estimate the sample size needed and the variances for each of the strata selected. The main study was then conducted using the information from the pilot study. From data obtained in the pilot study the figure of 77 was calculated as an appropriate sample size. The stratified sampling mean estimator for the population mean was 3.9 appointments with a 95% confidence interval of (3.2, 4.6). The average treatment length of 3.9 appointments is smaller than many treatments offered to patients. Standard treatments are often planned to be more than ten appointments. These results suggest that many patients are failing to receive the full treatment planned by mental health professionals. Perhaps more treatments need to be delivered over a small number of appointments. Stratified sampling could be used to estimate treatment duration in particular contexts thereby allowing treatments to be designed to meet local needs.

Mental health problems are increasing in society. To effectively deal with these problems it is imperative that appropriate treatments are delivered. Some evidence suggests that the design of many treatments is longer than patients attend treatment for. The aim of this study was to estimate the average length of treatment for patients referred to the adult specialty of a large clinical psychology department. A stratified sampling strategy was chosen to obtain an unbiased and precise estimator of the average treatment length for the population of patients whose files had been closed in one calendar year (n = 3021). A pilot study was undertaken to estimate the sample size needed and the variances for each of the strata selected. The main study was then conducted using the information from the pilot study. From data obtained in the pilot study the figure of 77 was calculated as an appropriate sample size. The stratified sampling mean estimator for the population mean was 3.9 appointments with a 95% confidence interval of (3.2, 4.6). The average treatment length of 3.9 appointments is smaller than many treatments offered to patients. Standard treatments are often planned to be more than ten appointments. These results suggest that many patients are failing to receive the full treatment planned by mental health professionals. Perhaps more treatments need to be delivered over a small number of appointments. Stratified sampling could be used to estimate treatment duration in particular contexts thereby allowing treatments to be designed to meet local needs.

From the Introduction “Just so you know”:

I’d like this book to be a resource for anybody who is interested in improving their effectiveness in psychotherapy by learning MOL. I’ve not written this book to persuade you that you should become an MOL psychotherapist, rather, I’ve written it to help you improve your practices on the assumption that you’ve already decided you want to get better at MOLing. If you still need convincing about the value of MOL, this book might not provide you with what you require.

Regardless of the type of psychotherapy considered, change is the predominant goal. Psychotherapies differ in their explanations of how change occurs and what it is that needs to change, but pursuing change of something in some way is common. Psychotherapeutic methods, therefore, should be enhanced as knowledge of the change process improves. Furthermore, improving our knowledge about general principles of change may be of greater benefit to psychotherapy than increased knowledge about any particular change technique. This study addresses the questions ‘What is psychological change?’ and ‘How does it occur?’ from patients’ viewpoints. Answers to these questions were sought using qualitative methodology. At the end of treatment, 27 people were interviewed about their experience of change. Interviews were taped and transcripts analysed using the Framework approach. Change occurred across three domains: feelings, thoughts and actions. Participants described change as both a gradual process and an identifiable moment. In relation to how change occurred, six themes emerged: motivation and readiness, perceived aspects of self, tools and strategies, learning, interaction with the therapist and the relief of talking. Change was experienced in similar ways irrespective of type of treatment. Current stage models of change may not be suited to the explanations of change provided by the participants of this study; the process of insight through reorganization might be a more accurate explanation. Understanding change as a process involving sudden and gradual elements rather than a process occurring through sequential stages could inform the development of more efficacious psychological treatments.

A system of self-selecting first appointments resulted in reduced DNAs when compared with a system of allocated first appointments replicating Reid and McIvor’s (2005) results.

In an earlier paper (Carey, T. A. (2005). Can patients specify treatment parameters? A preliminary investigation. Clinical Psychology and Psychotherapy, 12, 326-335) an approach to treatment delivery was examined in which the duration and frequency of the appointments was scheduled by patients. Results of this approach were encouraging but the generalizability of the results was constrained because only one clinician trialed the approach and no standardized assessment measures were used. In the present study there are two clinicians involved and the Depression Anxiety Stress Scale (DASS) was used. The approach was introduced at one GP practice and monitored over a six-month period. Results suggest that this approach might be an effective way of promoting patient access to, and involvement in, service delivery as well as reducing waiting times.

We held focus group discussions in psychology departments around Scotland to gauge the feasibility of conducting a large-scale trial of patient lead treatment.

The formulation of psychological problems is an integral part of psychological treatment. Since perceptual control theory provides one explanation of how problem-free living occurs it also suggests the form that problems might take when satisfactory day-to-day living is disrupted. In this article I briefly outlineperceptual control theory and explain how psychological difficulties are conceptualised with this theory. Next I offer some examples from clinical practice which illustrate the problem formulation of perceptual control theory. Finally I explore the implications of this formulation approach for people who assist others in the amelioration of psychological troubles.

Transdiagnostic approaches to psychological treatment offer the opportunity to consider common processes across seemingly disparate disorders. Although psychological distress exhibits dramatic variability across individuals, it is possible to discern common underlying processes. One of these processes is internal perceptual conflict. Perceptual Control Theory (PCT) provides an explanation for the manifestation and also the resolution of this conflict. A therapeutic approach called the Method of Levels (MOL) has been developed from PCT principles. MOL promotes the reorganization of conflict by shifting an individual’s awareness to meta, or more fundamental, goal states. This paper explains PCT and MOL and concludes by describing early empirical evidence for MOL.

An investigation of the method of levels (MOL) was undertaken. Based on the principles of perceptual control theory (PCT), MOL is a way of helping people to reduce psychological distress. MOL assumes that psychological distress results when people are unable to control experiences that are important to them. The approach was implemented over six months in a large urban GP practice. Patients attended for between one and six sessions. Patients who attended for more than one session demonstrated significant reductions in scores of symptomatology on a standardized questionnaire. Effect sizes of these differences were relatively large. There appeared to be no relationship between the number of sessions a patient attended and the amount of reduction in symptomatology that was recorded. Similarly, there was no relationship between the number of sessions a patient attended and their recorded level of symptomatology at their first appointment. Although the study has important limitations we suggest that these findings might offer new directions for future research and might provide a way of unifying the specific and common factors as well as understanding the Dodo Bird effect.

The Method of Levels (MOL) shares many similarities with other therapeutic approaches and is perhaps most distinguishable by what it does not include rather than what it does use in sessions. MOL has two basic steps which are followed in an iterative procedure until the patient/client experiences a change or shift in their understanding and experience of a problem. This article explains the steps and uses examples and suggestions for practice to promote understanding.

Dismantling studies are used in psychotherapy in order to understand the important components of treatment. Typically, this has occurred so that people could understand the unique contributions provided by cognitive versus behavioural techniques. Recently, mindfulness-based approaches have apparently added a third dimension to the dismantling enterprise. Dismantling is seen as an important way of understanding the change process in psychotherapy and, therefore, clarifying how we might most effectively promote change. The way in which an entity is dismantled, however, exposes assumptions about the nature of the entity and its organization. In this paper we argue that dismantling studies in psychotherapy have perhaps generated more confusion than consensus and have provided little practical benefit for clinicians. We suggest that the phenomenon of control might provide a unifying perspective from which to approach the integration of behavioural, cognitive, and mindfulness approaches. In one sense all these seemingly different approaches are doing the same thing and it is this ‘thing’ we highlight in this paper.

The psychological treatment offered to clients is important. However, an equally important consideration may be the way the treatment is delivered. Reducing waiting lists and improving access to services are priorities for many health services. So is increasing patient control over their own health-care outcomes. While waiting times and access to services have typically been addressed by increasing the numbers of clinicians available, our work suggests that a strategy of providing patients with the ability to determine the frequency and duration of their treatment may be an option that is simpler, more effective, and financially more attractive. After describing policy and ethical guidelines as well as empirical and theoretical information, we provide data from our work in one GP practice about the improvements in waiting times and access to services that occurred when we adopted an approach that allowed patients rather than clinicians to decide how the organization of treatment would occur. There seem to be many benefits to this approach; however, it may also raise dilemmas for clinicians when patients’ preferences differ from their own. Ultimately, these conundrums can only be reconciled by the individual clinicians based on their attitudes to mental health problems and service provision.

‘Control’ can be defined as the maintenance of a variable within fixed limits despite external disturbances. There is substantial evidence that the experience of loss of control characterizes psychological disorders. Therefore, we take a historical perspective on how modern psychology as a science has attempted to explain the process of control over the last century, beginning with William James’s (1890) proposal of the ‘pursuance of fixed ends by variable means’ as the essence of mentality. We conclude that, after a long diversion from this perspective during the 20th century, recent approaches within psychology are again considering the importance of understanding control. We propose that Perceptual Control Theory (PCT) presents the most focused and applicable account, as characterized by its relevance for psychological therapy in the form of the Method of Levels (MOL). This is a therapeutic technique directed at guiding the client’s awareness to the higher level (or meta-) control processes that maintain their current problem of conflict between their personal goals. We cover the emerging evidence base for PCT and MOL and propose that an understanding of control through PCT has the capacity to link theory, research, and practice within the field of psychotherapy.

This paper looks at issues regarding case formulation in psychotherapy. Case formulation is well recognized as being helpful in the conceptualizing of psychological problems and as a useful tool in the practice of cognitive therapy. Control, as opposed to behaviour, is increasingly being seen as that human process most relevant to psychopathology. We look at the diagnosis and treatment of a small number of people, treated in a naturalistic setting, who were selected without any specific criteria other than being people whose problems were treated using the Method of Levels, a form of cognitive therapy based on the principles of Perceptual Control Theory, and who completed both pre- and post-treatment questionnaires. We then consider how the problems these people presented with, and their treatment, might be formulated as a result of taking this approach.

How long should psychological treatments last and how frequently should treatment appointments be scheduled? The number of appointments and how often they are scheduled are almost invisible aspects of service provision, but the way in which these decisions are made can have a major impact on access to services. The evidence-based movement is here to stay. Typically, however, the evidence-base focuses on what therapy is provided not how this therapy is delivered. This chapter addresses the issue of how therapy is delivered, and suggests that patient-led treatment is a low intensity (LI) approach, which can dramatically improve the access, efficiency, and effectiveness of mental health services.

Purpose – The purpose of this paper is to look at the design and delivery of psychological treatments offered by the UK National Health Service (NHS) and in particular, ask how much treatment is enough, or who should decide when the patient has had enough treatment. Design/methodology/approach – The data reported in this section were coffected during routine clinical practice in the NHS in Scotland. Findings – It was found that treatments could be redesigned so that important therapeutic information is provided in time frames that match patient preferences, leading to more efficient and effective services. Originality/value – Clinicians, predominantly, determine the design and delivery of treatment programmes, whereas the paper suggests that programmes should be focused on the patient and their needs.

Even though the effectiveness of psychotherapy is generally acknowledged, researchers are yet to agree on a plausible explanation for this effectiveness or on possible mechanisms of change that are activated by psychotherapy. To enhance developments in these areas some researchers have called for a focus on treatment principles rather than treatment techniques. In this respect, the technique of exposure is instructive. Despite its common use with anxiety disorders and the successful outcomes it produces, it has only recently been considered as a treatment for other disorders. By focussing on the underlying principles of exposure it is possible to consider exposure as a transdiagnostic component of successful psychotherapies. Understanding exposure from the perspective of Perceptual Control Theory (PCT) enables the identification of a functional, rather than a conceptual or statistical, mechanism of change. Functionally, exposure can be understood as an essential precursor to the internal reorganization that is necessary for the amelioration of psychological distress. PCT suggests a more considered and widespread use of exposure in psychotherapy as a way of improving both the efficiency and the effectiveness of the treatments offered. Despite the proliferation of psychotherapies in recent years there has not been a commensurate growth in our understanding of the effective ingredients of treatment. It seems unlikely that there are multitudes of different mechanisms and processes through which psychological distress is resolved and that each of these different psychotherapies utilises a distinct item from the collection. In fact, the spawning of hundreds of different psychotherapies is perhaps the most telling sign that there may still be much work to do before the important principles of treatment are described and fundamental mechanisms of change are identified. Could a technique as mundane as exposure hold the key to effective psychotherapy? For psychotherapy, is there just one road leading to Rome but a plethora of ways to travel that road?

Objectives. Given that most people who experience psychological distress resolve this distress without the assistance of psychotherapy, the study sought to increase our understanding of naturally occurring change including the facilitators of this change. Design. The study sought to replicate and extend earlier work in this area. The design involved recruiting participants who had experienced some form of psychological distress and had resolved this distress without accessing psychotherapy services. Methods. Qualitative methods were used for this study because the lived experience of the participants was of interest. Semi-structured interviews were used following a pro forma developed in earlier work. Interpretive Phenomenological Analysis was the analytical method adopted for this study to identify themes and patterns in the transcripts of the interviews of the participants. Results. Data analysis identified the themes of identity, connection, threshold, desire to change, change as a sudden and gradual process, and thinking process. An unexpected finding was the subjectivity associated with deciding whether or not a problem had actually resolved. Conclusions. The results are discussed in terms of their implications for clinical practice including the apparent importance of people reaching an emotional threshold prior to change. A sense of identity also appears to be important in change experiences.

Autism is defined as a developmental disorder that is often characterized by deficits in a broad range of social functioning. The present qualitative study attempts to begin to understand the subjective and functional nature of these apparent deficits in one boy diagnosed with autism. Using Interpretive Phenomenological Analysis and the framework of Perceptual Control Theory the child’s behaviours were considered to be attempts to control his perceptual experience of his environment. Understanding autistic behaviour in this way might allow for a greater understanding of the capabilities of a child with autism rather than focusing on deficits. Stimulation, certainty, and self-interest were identified as possible perceptual themes controlled by the participant. The implications of these findings are discussed in reference to current literature.

Evidence clearly suggests that the therapeutic relationship is important to successful outcomes in psychotherapy. It is less clear as to why this might be the case. Throughout the literature, various factors such as warmth, empathy, compassion, unconditional positive regard, and openness are identified as key. The way in which factors such as warmth and empathy bring about an amelioration of psychological distress, however, is not entirely obvious. We suggest that one possible mechanism through which these factors become important is by helping to create an environment where clients can examine their problems freely. Furthermore, we propose that when the therapeutic relationship is therapeutic, clients feel comfortable to consider whatever comes into their mind; with any filtering or evaluating happening after the ideas have been expressed, and not before. Psychological processes identified as maintaining psychological distress (e.g. thought suppression, avoidance, rumination) block this capacity. Our suggestion is that as internal experiences are being examined, the client has an opportunity to become aware of facets of the problem that were previously unattended to; and to continue this process outside therapy. Through this awareness raising process the client’s problem can be reorganized via intrinsic learning processes to achieve a more contented state of mind.

Patient-led appointment scheduling is a form of responsive regulation in which patients schedule their own psychotherapy appointments within the constraints of available resources. Of 92 patients referred to a clinical psychology clinic in the public mental health service of a remote country town in Australia, 51 attended more than 1 appointment (M = 3.6; median = 3; range = 2–11). The average number of missed and cancelled appointments was between 0 and 1.1. As compared with reported results of other practice-based studies, this approach to treatment scheduling was equivalently effective (in terms of effect size) and substantially more efficient (in terms of effect size achieved per session attended). Patient-led regulation of treatment parameters holds promise in a context of heavy demands and limited resources in mental health services.

Using Perceptual Control Theory (Powers, Clark, and McFarland, 1960a, b; Powers, 1973, 2005, 2008), this chapter focuses on the phenomena that are described under the umbrella of ‘dissociation’ and concentrates on defining when, how, and why, these phenomena would be significant problems.

The scientific and practical justifications for transdiagnostic CBT are well known and yet there is no consensus on the theoretical approach that should inform it. In this article, we explain the scientific and practical benefits of using Perceptual Control Theory (PCT) by introducing the theory, discussing how it explains the maintenance of psychological distress, the different ways that distress is manifested across disorders, and reviewing evidence for the theory and its applications. We explain how PCT can inform existing active ingredients of CBT such as exposure, behavioral activation, decentering, formulation, and the therapeutic alliance. We also introduce Method of Levels therapy as a transdiagnostic CBT informed by
PCT, and describe the implications for service organization and modes of delivery, understanding help-seeking, and recovery. We conclude by considering limitations and directions for future developments.

Although the biopsychosocial model has been a popular topic of discussion for over four decades it has not had the traction in fields of research that might be expected of such an intuitively appealing idea. One reason for this might be the absence of an identified mechanism or a functional architecture that is authentically biopsychosocial. What is needed is a robust mechanism that is equally important to biochemical processes as it is to psychological and social processes. Negative feedback may be the mechanism that is required. Negative feedback has been implicated in the regulation of neurotransmitters as well as important psychological and social processes such as emotional regulation and the relationship between a psychotherapist and a client. Moreover, negative feedback is purported to also govern the activity of all other organisms as well as humans. Perceptual Control Theory (PCT) describes the way in which negative feedback establishes control at increasing levels of perceptual complexity. Thus, PCT may be the first biopsychosocial model to be articulated in functional terms. In this paper we outline the working model of PCT and explain how PCT provides an embodied hierarchical neural architecture that utilizes negative feedback to control physiological, psychological, and social variables. PCT has major implications for both research and practice and, importantly, provides a guide by which fields of research that are currently separated may be integrated to bring about substantial progress in understanding the way in which the brain alters, and is altered by, its behavioral and environmental context.

To understand mental illness more accurately, context is increasingly recognised as essential. Relevant features of genetic and biochemical profiles are no doubt important, but the integration of these characteristics with the psychological and social milieu within which they are embedded is even more crucial.

To achieve the improvements advocated by Emily Holmes and colleagues for psychological treatments (Nature 511, 287–289; 2014), researchers need to conceptually link studies of specific psychiatric disorders with fundamental processes that are shared by different disorders.

The Method of Levels (MOL) is a transdiagnostic cognitive therapy that addresses the dilemmas, tensions, and conflicts underlying symptom patterns rather than focusing on the symptom patterns directly. With its unique theoretical framework, it has similarities with approaches such as motivational interviewing and provides a bridge between cognitive-behavioral therapy and person-centered counseling. MOL optimistically and respectfully provides the time and the focus for people to generate their own solutions to the difficulties they experience. It is very much an experiential therapy, in which a conversation is developed to first generate some of the distress the person experiences outside of therapy and then to facilitate the processing of this distress in such a way that new perspectives and insights are developed and the person is able to find a
more contented and satisfying way to live.

Principles-Based Counselling and Psychotherapy promotes a Method of Levels (MOL) approach  to counselling and psychotherapy. Using clinical examples and vignettes to help practitioners implement a principles-based approach, this book describes three fundamental principles for effective therapeutic practice and their clinical implications. The first chapter of the book provides a rationale for the principles-based approach. The second chapter describes the three principles of control, conflict, and reorganisation and how they relate to each other from within a robust theory of physical and psychological functioning. The remainder of the book covers important aspects of psychological treatment such as the therapeutic relationship, appointment scheduling, and the change process from the application of these three principles.

The field of psychopathology needs a paradigm shift to revitalise its research methodology and translational practice. We describe Darwin’s transformation of biology and its implications for science and culture, and we infer the implications of an analogous approach to psychopathology. Darwin challenged the assumptions of the biological classification system with compelling evidence to support a quantifiable, mechanistic theory of change across all life. Specifically, he showed that species were changeable, that individuals showed substantial variation in their features, and that these features were functional adaptations to the environment. Similarly, there is substantial evidence of continuous change, shared symptoms and functionality across the categories of psychiatric classification. Our novel research methodology, inspired by perceptual control theory, include both qualitative and quantitative methods, and entail the study of universal processes within heterogeneous samples and studying dynamic processes prospectively within individual cases, drawing direct analogies with evolutionary dynamic systems (e.g. trade-offs, speciation).

A review of the literature on psychotherapy suggests that improvements in effectiveness, efficiency and accessibility have been hampered by a lack of understanding of how psychotherapy works. Central to gaining such understanding is an accurate description of the change process that occurs when someone solves a psychological problem. We describe the Perceptual Control Theory (PCT) model of human functioning, which can be used to understand the nature of psychological problems and how they are solved. PCT suggests that problems can be broadly grouped into two categories: those that can be solved using existing skills and those that require the generation of new skills. In general, psychological problems belong in the second category. PCT describes a fundamental form of learning in which existing structures and systems are reorganized to create new skills, perspective and insights. Psychotherapy based on PCT is aimed at directing reorganization to the source of the problem.

Delivering mental health services as patient-centered care has been an international priority for more than 50 years. Despite its longevity there is still not widespread agreement regarding how it should be defined or how it should guide the delivery of services. Generally, though, prioritizing the patient’s values and preferences seem to be at the core of this particular approach. It is not clear, however, that services attend to patient values and preferences as closely as they should. Terms such as “treatment resistant” and “noncompliant” seem to belie an attitude where the therapist’s opinion is privileged rather than the patients. To improve the effectiveness and efficiency of mental health services a move from patient-centered care to patient-perspective care is recommended. An attitude of patient perspective care would require service providers recognizing that help can only ever be defined by the helpee rather than the helper. A patient perspective service that was structure around the preferences and perspectives of patients might finally help to end the long-term suffering of many people who experience mental health problems.

This chapter discusses:

• The purpose of therapy as well as what boundaries are and why we have them

• Different types of boundaries including professional boundaries such as ethical
  and professional codes of practice, contextual boundaries such as the
  duration and frequency of therapy sessions, and interpersonal boundaries
  such as touch, self-disclosure and multiple relationships

• Applying boundaries flexibly and responsively to promote the effectiveness of
  therapy

Timely access to effective and efficient services is an important component of successfully resolving mental health problems. A large amount of evidence has been accumulated through Randomised Controlled Trials (RCTs) regarding the efficacy of various treatments but very little research effort has been directed towards establishing what the ideal treatment protocol should be. Given the disparity between the research context of an RCT and the clinical settings in which treatments are delivered translating the findings from research to practice has not been straightforward.

Inappropriate health care is an escalating and expensive problem. It affects high-, middle-, and low-income countries and wastes billions of dollars annually and harms individuals and communities. Inappropriate care refers to both the overuse and underuse of tests and treatments and, ironically, can occur concurrently within the same health system. Even though patient-centred care is still the prevailing ethos, specifying where patients should be situated geographically has not required health professionals to consider the preferences, values, and priorities of patients when making treatment decisions.

Patient-perspective care demands that the decisions health professionals make are in the service of patient’s goals. Health care, ultimately, is helping individuals to live the lives they would wish for themselves. To meet this imperative, health professionals must work towards understanding what their patients would like to achieve through their engagement with health services. This book details the extent and scope of inappropriate care and how we have arrived at this position. The necessity for patient-perspective care is outlined and provides a theoretical framework that explains why patient-perspective care is so critical. The implications of this theory are then explored, and specific strategies for moving towards a patient-perspective approach are discussed.

Mental health problems present an increasing global disease burden making the development of effective and efficient psychological treatments an urgent public health priority. Despite the continued proliferation of treatments and large numbers of randomized controlled trials (RCTs), evidence suggests that pre-post effect sizes have been decreasing over time not increasing. Promoting RCTs as a gold standard of evidence has not been a useful strategy for advancing progress in the development of increasingly effective and efficient psychological treatments and has, in fact, created a divide between research and practice in professional psychology. To close this divide, other methodologies are needed that can assist in the rigorous development and evaluation of treatments in routine clinical practice. We outline some of the problems with using RCTs as the sole means of generating evidence for treatment effectiveness and efficiency and we use the development and evaluation of a transdiagnostic cognitive therapy to illustrate an alternative way of accumulating evidence through a much closer connection between research and practice. Ultimately, including other methodologies alongside RCTs that combine research and practice more seamlessly, will produce treatments of greater effectiveness and efficiency and help to reduce the global burden of mental health problems.

Consciousness has been under intense scrutiny by researchers and philosophers for countless centuries and yet it remains mysterious. It is still not clear what consciousness is or what it is for. A fundamental problem that may be hampering substantial progress in consciousness studies is the lack of a clear understanding of the nature of the brain. It is unremarkable to suggest that consciousness is related, in some way, to brain activity, so without an authentic appreciation of what that activity is, it is improbable that an accurate and coherent articulation of consciousness will be delivered. In this paper, Perceptual Control Theory (PCT) is offered as a solution to the puzzle of the brain. From the perspective of PCT, the brain is a control system. The organization and functioning of this control system architecture is described and then the implications for the way in which we consider consciousness are discussed. Some current ideas about consciousness are overturned while others are preserved but integrated and synthesized into a coherent framework with negative feedback control as the unifying phenomenon. By recognizing consciousness as both, a phenomenon created by a massively interconnected network of sophisticated control systems that can, among other things, produce language, imagine, plan, and contemplate, and a property of this massive network, PCT provides us with the opportunity to rethink concepts as fundamental as: causation; stimulus and response; and objectivity and subjectivity.

Background: Stepped care has been promoted as one solution to improving access to psychological services. In the United Kingdom (UK) and Australia a new workforce has been established for the implementation of stepped care. Thus, there are two different models of stepped care: Multi clinician stepped care (MCSC) and single clinician stepped care (SCSC). Given that the MCSC improving access to psychological therapies initiative in the UK was initially economically motivated, it was of interest to discover whether or not an MCSC workforce is more effective and efficient than an SCSC workforce. The objective of this review was to answer the research question “Is an MCSC workforce more effective and efficient than an SCSC workforce?”.

Methods: A comprehensive systematic review was conducted to identify studies comparing the effectiveness and efficiency of MCSC with SCSC programs in terms of patient outcomes, patient satisfaction, waiting times, and cost-effectiveness.

Results: The systematic review revealed that there are no studies comparing MCSC with SCSC.

Conclusion: The rationale for an MCSC workforce is not clear. The findings of this systematic review are discussed in terms of the way in which treatments are conceptualised and delivered including adopting a patient-led approach to appointment scheduling and a patient-perspective attitude towards treatment provision and recovery.

Background: Method of levels (MOL) is an innovative transdiagnostic cognitive therapy with potential advantages over existing psychological treatments for psychosis.

Aims: The Next Level study is a feasibility randomised controlled trial (RCT) of MOL for people experiencing first-episode psychosis. It aims to determine the suitability of MOL for further testing in a definitive trial (trial registration ISRCTN13359355).

Method: The study uses a parallel group non-masked feasibilityRCT design with two conditions: (a) treatment as usual (TAU) and (b) TAU plus MOL. Participants (n = 36) were recruited from early intervention in psychosis services. Outcome measures are completed at baseline, 10 and 14 months. The primary outcomes are recruitment and retention.

Results: Participants’ demographic and clinical characteristics are presented along with baseline data.

Conclusions: Next Level has recruited to target, providing evidence that it is feasible to recruit to a RCT of MOL for first-episode psychosis.

Declaration of interest: None.

Progress in the development of more effective and efficient psychological therapies could be accelerated with innovative and nuanced approaches to research methodology. Therapy development has been dominated by a mono-methodology attitude with randomized controlled trials (RCTs) regarded as a “gold standard” despite the concept of a single methodology being ascribed gold standard status having been called into question. Rather than one particular methodology being considered superior to all others, the gold standard approach should be matching appropriate methodologies to important research questions. The way in which that matching should occur, however, is far from clear. Moving from a mono-methodological approach to mixed-method designs has not been straightforward. The ways in which methods should be mixed, to arrive at robust and persuasive answers to genuine research questions, is not entirely clear. In this paper, we argue that attention to the meta-methods underpinning all research designs will improve research precision and provide greater clarity about the contribution of any particular program of research to scientific progress in that field. From a meta-method perspective, the matter of what changed can be delineated from why or how these changes occurred. Different methods and different types of mixing can be justified for each meta question. A meta-method approach should make explicit the assumptions that guide the development of research designs and also promote the articulation of putative mechanisms that might be relevant. By paying greater attention to assumptions such as how causality occurs, and important mechanisms of change, the mixing of methodologies that are still not mainstream in this area such as routine outcome monitoring and evaluation and functional model building, can occur. By adopting methodologies that focus on learning about a program’s strengths and weaknesses rather than presiding over judgments of whether or not the program is deemed to be effective, we will move much closer to a position of being able to understand what programs under which conditions people find most helpful for their purposes.

In this study, we aimed to understand how people with first-episode psychosis experienced a transdiagnostic cognitive therapy called method of levels (MOL). Semistructured interviews were conducted with 12 individuals who were participants of a feasibility randomized controlled trial of MOL for first-episode psychosis. Interviews were analysed using thematic analysis. Four superordinate themes were identified: ‘The therapist’s approach’; ‘I was in control’; ‘Thinking and talking’; and ‘Looking at problems from a different perspective’. Our findings suggest that therapy was experienced as most helpful when participants perceived themselves to have control over the process of therapy, could explore and express a wide range of difficulties, and were able to generate new perspectives on their problems. MOL and its associated system of client-led appointment scheduling were predominantly perceived to be helpful and appear suitable for further testing in a larger clinical trial.

Objective: We aimed to determine the feasibility and acceptability of Method of Levels (MOL) for people experiencing first‐episode psychosis (FEP) to inform decision making about the therapy’s suitability for further testing in a larger clinical trial.

Method: A parallel group randomized controlled trial design was used. Participants (N = 36) were allocated to receive
either treatment as usual (TAU) or TAU plus MOL. Recruitment and retention in the trial and the acceptability of the MOL intervention were the primary outcomes.

Results: The recruitment target was met within the planned time frame. Retention in the trial at final follow‐up was 97%, substantially higher than the 80% threshold prespecified as a successful feasibility outcome. Participant feedback
provided initial evidence of the acceptability of the study design and intervention for this population.

Conclusion: Results support progressing to a larger trial of MOL for FEP. Recommendations for the design of future
trials are provided.

The identification of fundamental mechanisms is an important scientific pursuit in many fields of enquiry. With regard to the development of psychological treatments, understanding the mechanisms through which change occurs such that psychological distress resolves, can enable us to develop more effective and efficient interventions. In the field of psychotherapy, mechanisms are often identified either statistically or conceptually. The most powerful and useful mechanisms, however, are functional rather than statistical or conceptual. More specifically, with regard to mechanisms relevant to psychotherapy, it is difficult to identify what any of these mechanisms actually do in a mechanistic sense. That is, the mechanics of putative mechanisms are generally unspecified. In order to obtain a rigorous and comprehensive account of the current mechanisms in psychotherapy, as well as to evaluate their usefulness, a systematic scoping review was conducted. The systematic scoping review did not yield any mechanisms that were expressed in functional terms. We argue that, in order for psychotherapy to improve its effectiveness and efficiency, the standard for what is accepted as a useful mechanism needs to be substantially raised. Only functional mechanisms that express plausible
actions consistent with known biological processes should be used to inform therapeutic interventions.

This article describes how an empirically supported theory of human behaviour, perceptual control theory, can be used to advance nursing practice and improve health outcomes for people who are accessing nursing care. Nursing often takes a pragmatic approach to the delivery of care, with an emphasis on doing what appears to work. This focus on pragmatism can sometimes take precedence over any consideration of the underlying theoretical assumptions that inform decisions to take one particular approach over another or the mechanisms through which nursing interventions have their effects. For nursing to develop as a profession, there needs to be an increased focus on the core principles that underpin the delivery of care. In addition to understanding what works, nurses must develop their understanding of how and why particular approaches work or do not work. Understanding the fundamental principles that underpin nurses’ actions will lead to more efficient and effective approaches to the delivery of nursing care. It will also enable nurses to maximize those elements of their practice that are most beneficial for people and minimize other activities that either have little effect or actually lead to worse outcomes. In this article, we will propose that the phenomenon of control is fundamental to human health. Perceptual control theory provides a coherent theoretical framework that enables us to understand the phenomenon of control through a functional model of human behaviour. People are healthy when their neurochemical, physiological, biological, psychological and social states are all controlled satisfactorily. We will explain the implications of understanding health as control throughout the paper. From this perspective, we will argue that the aim of nurses and nursing should be to support people to maintain or recover control over those aspects of their lives that are important and meaningful to them.

Our very strong conviction is that for problems to be solved repeatedly, efficiently, and systematically, an accurate and precise understanding of the problem is required. The strength of problem solving in areas such as physics and engineering is, we would argue, largely due to the very robust scientific principles that form the foundations of these fields. Unfortunately, problem solving in the mental health domain is typically not based on a solid foundation.

In this chapter, we argue that progress in the field of mental health has been constrained by a reliance on assumptions which often lack a credible evidence-base. These assumptions are, from our perspective, either untested or, worse, untestable. In addition to lacking empirical support, the assumptions are frequently implicit and left unstated, although this does not appear to diminish the influence on the research and practice that occurs (Carey, Huddy, & Griffiths, 2019). It is our position that many of these assumptions could, in fact, be characterised as myths. After explaining what we mean by the term “myth” in this context, we will describe why we think it is problematic for myths to inform mental health research and practice. We will also provide some examples of concepts and practices that we believe fit into the category of myth.