Atlas›Domain II · Behavioural & cognitive›Guide 089
Guide II-089

Method of levels

William T. Powers, Timothy Carey1950
A 31 · L 29 · M 4016 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Timothy Carey's two-goal Method of Levels as set out in Carey 2006 (2024 edition) and Carey 2008 (Hold That Thought), and later with Warren Mansell and Sara Tai (Mansell, Carey & Tai 2013; Carey, Mansell & Tai 2015). Scheduling follows patient-led appointment scheduling (Carey & Spratt 2009; Carey, Tai & Stiles 2013), and principles follow the IAPCT's current statement of MOL. Sources and status: this guide draws on the full text of Carey 2008, the opening chapters of Carey 2006/2024, Mansell's review of Carey 2006, the IAPCT MOL page, the Next Level trial protocol paper (Griffiths et al. 2018), the abstracts of Carey & Spratt 2009 and Carey, Tai & Stiles 2013, and the contents list of Mansell, Carey & Tai 2013. Claims tagged [source: …] were confirmed in those pages. Claims tagged [uncertain] are not confirmed. These are mainly the practice chapters of Carey 2006, the body of Mansell, Carey & Tai 2013 and Carey, Mansell & Tai 2015, and the IAPCT accreditation rules.

Method of Levels (MOL) is a transdiagnostic, conversation-based psychotherapy built on William T. Powers' Perceptual Control Theory (PCT). PCT holds that people act to keep their perceptions of themselves and their world matching internal reference values (goals). These goals are arranged in a hierarchy, in which higher-level goals set the reference values for lower-level ones. In the early 1950s Powers and Kirk Sattley noticed that a person's background thoughts could be brought into the foreground, again and again. Powers' description of this was cut from his 1973 book at the editor's suggestion, and he never tested it clinically. David Goldstein in New Jersey began using MOL with patients in the 1990s. Timothy Carey in Australia took it into clinical practice and research. Mansell, Tai, de Hullu, Churchman and colleagues now research and teach it. [source: Powers' foreword in Carey 2006/2024; Wikipedia: Method of levels]

How change happens: Carey names three ways control is lost: forces that are overwhelming, the lack of an internal reference, and conflict. Persistent distress is almost always chronic internal conflict: the person holds two goals at once that cannot both be met, so control is lost on both. Carey describes such a conflict as spanning at least three levels: the symptoms (such as anxiety or irritability), the two opposing goals, and a higher level where the conflict is generated. PCT proposes that an innate, trial-and-error change process called reorganisation goes where awareness goes. When awareness moves up to the level that generates the conflict and stays there, reorganisation can alter the system until the conflict dissolves. The therapist supplies no solutions. The therapist's job is to help the person move awareness "up" and keep it there, to "hold that thought". [source: Carey 2008; Griffiths et al. 2018; IAPCT MOL page]

2. Framework

MOL is a single-method therapy without fixed phases. It has no separate assessment, formulation, skills or relapse-prevention stage, and MOL therapists avoid summarising, structuring, interpreting, diagnosing and advising. Every session uses the same two-goal process, and the structure comes from the client's choices. [source: IAPCT MOL page; Mansell's review of Carey 2006; Carey 2008] The working structure is set out below.

Within each session (the two goals) [source: Carey 2008; Griffiths et al. 2018]

  • Goal 1: get the person talking about whatever is in their awareness about the problem at the moment, and keep them talking, in as much present-moment detail as they choose. The client picks the topic.
  • Goal 2: ask about disruptions, or about possible higher-level thoughts when no disruptions appear. Disruptions are brief shifts in awareness that show in speech or manner. Examples include pausing or interrupting their own flow, smiling, head-shaking, glancing away, speeding up or slowing down, getting louder or softer, and judging what they have just said (Carey's example: "That sounds really silly"). Subtler signs include faint reddening, misting or narrowing eyes, or an unusual word or phrase that keeps recurring. Asking about the disruption invites the client to attend to that higher-level perception, and Goal 1 then continues from there.
  • The therapist moves back and forth between the two goals for the whole session. Carey suggests setting these two goals before each session and evaluating against them afterwards. There is no agenda-setting, homework review or skill teaching. [source: Carey 2008; IAPCT MOL page]

Across sessions (course structure)

  • Entry: routine service intake and risk assessment as your setting requires. MOL itself needs no formulation before it starts. Clients can be invited to start talking about whatever is bothering them in the first session. [source: Mansell, Carey & Tai 2012] [synthesis: service-mandated risk assessment remains the clinician's duty]
  • Frequency and number: patient-led appointment scheduling. The client decides whether and when to book another session, and there is no fixed course length. Carey argues that the time reorganisation takes "can't be specified in advance" and that counting sessions looks at the wrong thing [source: Carey 2008]. Carey's clinic in remote Australia took 92 referrals. The 51 patients who attended more than one appointment had a mean of 3.6 sessions (median 3, range 2–11) [source: Carey, Tai & Stiles 2013 abstract, which does not name the therapy used]. The UK Next Level feasibility trial in first-episode psychosis set no minimum or maximum number of sessions within a 10-month treatment window. Participants booked by text message, phone or an online booking site [source: Griffiths et al. 2018].
  • Session length: flexible, and the client can stop at any point. Carey 2008 gives no standard length [source: Carey 2008]. In the Next Level trial, sessions typically ran 15 to 60 minutes [source: Griffiths et al. 2018].
  • Moving on and ending: these are the client's decisions, not the therapist's. The client stops booking when the problem no longer troubles them enough to come back. Carey & Spratt report that waiting times and access improved in a GP practice once patients, not clinicians, decided the frequency and duration of treatment. They also note that this creates dilemmas when clinician and patient preferences differ. [source: Carey & Spratt 2009 abstract] The service should leave an easy route back in. [synthesis]
  • Signs that a session is "working" stand in for phase criteria. One sign is a sudden shift in affect, such as a fleeting smile, as the client turns to a background thought. Another is the client talking about the process of their thinking rather than only its content. A third is the client seeing both sides of a dilemma together and finding a way to honour both. Mansell's example is a man torn between keeping and selling his house who realised he could live there for a while and sell later. [source: Mansell's review of Carey 2006; Carey 2008] Calm after emotion and the problem being reported as less important are inferred signs, not checked in the sources. [synthesis] [uncertain]

3. Guiding principles

Sources for this section, with wording paraphrased throughout:

  • The four principles the IAPCT lists (client control, exploration, noticing, sustaining awareness) come from the IAPCT MOL page.
  • Curiosity, "assume less, inquire more" and not getting in the way come from Carey 2008 and Carey 2006.
  • Control of perception, arbitrary control, and distress rather than symptoms come from the contents list of Mansell, Carey & Tai 2013.
  • Efficiency and patient choice come from Carey & Spratt 2009 and Carey, Tai & Stiles 2013.
  • People are living control systems. Practical meaning: behaviour is the client's way of controlling what they perceive (Mansell, Carey & Tai: "the control of perception, not the control of behaviour"). Ask what the client is trying to keep stable rather than trying to change their behaviour.
  • Distress is conflict, not deficit. Practical meaning: listen for two wants pulling against each other, rather than a missing skill or a faulty belief to correct. [source: Carey 2008]
  • Reorganisation does the changing. Practical meaning: reorganisation is not a willed process, and you do not have to produce the solution, so don't try. [source: Carey 2008; Mansell's review of Carey 2006]
  • Reorganisation follows awareness. Practical meaning: every question aims to direct and sustain the client's attention, especially toward the perceptions behind what is being said. [source: Carey 2008]
  • Go "up a level". Practical meaning: background thoughts about the problem matter more than further detail at the same level, so follow the disruption. [source: Carey 2008]
  • Client control (IAPCT principle). Practical meaning: the client sets the timing, content and direction of the session, and can always stop. [source: IAPCT MOL page; Carey 2008]
  • Exploration (IAPCT principle). Practical meaning: stay curious about every aspect of the concern, without judgement. Carey: pretend you have no idea what the person means, and "assume less, inquire more". [source: IAPCT MOL page; Carey 2008]
  • Noticing (IAPCT principle). Practical meaning: watch verbal and non-verbal signals that other control systems are involved (disruptions). [source: IAPCT MOL page]
  • Sustaining awareness (IAPCT principle). Practical meaning: help the client stay with discomfort long enough for reorganisation, rather than steering away from painful experience. [source: IAPCT MOL page]
  • Don't get in the way (from the subtitle of Carey 2006). Practical meaning: Powers' foreword lists three ways a therapist gets in the way: having insights into the problem, deciding what is wrong, and telling the client what to do. These stall progress and move the spotlight onto the therapist. Be a spectator, not a back-seat driver (Carey's image). [source: Carey 2006/2024 foreword; Carey 2008]
  • Present-moment focus. Practical meaning: ask in the present tense. Even when the client talks about the past or the future, ask how it is for them now. [source: Carey 2008]
  • Arbitrary (inflexible) control maintains distress. Practical meaning: avoid controlling the client's goals, including through persuasion, homework or fixed session counts. Keep no implicit agenda, such as getting them to confront fears, tolerate distress or reduce symptoms. Service structures should also give choice. [source: Mansell, Carey & Tai 2013 contents; Mansell's review of Carey 2006; Carey & Spratt 2009]
  • Work with the client's problem and distress, not symptoms. Practical meaning: the setting condition is a problem the client is willing to talk about. Carey 2006 addresses people who come willingly with problems they themselves experience, not problems defined only by others. The target is the distress attached to a symptom. [source: Carey 2006/2024 ch. 3; Mansell, Carey & Tai 2013 contents]
  • Transdiagnostic. Practical meaning: the same method applies across diagnoses. Diagnosis informs risk and logistics, not technique. [source: Mansell, Carey & Tai 2013 contents; Wikipedia]
  • Efficiency. Practical meaning: help in as few sessions as the client needs, and accept early ending as a possible success. [source: Carey, Tai & Stiles 2013; Carey & Spratt 2009]

4. Intervention inventory

MOL deliberately has a very small toolkit. The IAPCT describes two therapist actions: curious questions that follow the client's current attention, and noticing and asking about signs of background thoughts. Carey 2008 names the two goals as encouraging the person to talk and picking up on disruptions. The entries below break these into teachable parts. Items 1–8 and 12–14 are the core method [source: Carey 2008; IAPCT MOL page]. Items 9–11, 15 and 16 are the surrounding practices the authors describe. Example language marked (illustrative) was written for this guide. Short quotes in quotation marks with a citation are Carey's own examples from Carey 2008.

1. Opening: inviting the problem

  • Purpose / when: start of each session. It hands topic choice to the client straight away.
  • Steps: (1) After greeting, ask an open question about what the client wants to talk about. Do not set an agenda or review previous material unless the client raises it. (2) If the client says they don't know where to start, treat that as the topic. Carey's chapter heading is "Even not having a topic is a topic", and he asks about the not-knowing itself. (3) In a first session, add a sentence or two about how you work (item 9) if the client seems unsure what will happen. Mansell, Carey & Tai 2013 has a section on what to say at the first session. (4) Once a topic appears, move straight into curious questioning (item 2). [source: Carey 2008; Mansell, Carey & Tai 2013 contents] [uncertain: the content of that first-session section]
  • Example language: "What would you like to talk about today?" / "Anything at all, whatever's most on your mind." (illustrative) / "Tell me about not knowing where to start." (Carey 2008)
  • Watch for: clients who wait for you to lead; treat that hesitation as material (item 4). It is working when the client names something that matters to them, not something they think you want to hear.

2. Curious questioning about the problem (Goal 1)

  • Purpose / when: throughout the session. It keeps the client's attention on the problem as they experience it now, which is where the conflict is.
  • Steps: (1) Pick up a word, image or phrase the client has just used. (2) Ask a short, open question about their experience of it. Carey advises being curious, pretending you have no idea what the person means, and asking simple, even seemingly obvious, questions. (3) Ask one question at a time and let the answer finish. (4) Use the client's own words rather than your paraphrase or labels. (5) Keep questions on the client's perceptions, not on other people's motives or facts you need. "Why" questions are fine when they explore the client's own goals and purposes. (6) Do not summarise, interpret or structure; the IAPCT lists these among the things MOL therapists avoid. Carey 2008 does use questions that ask clients to listen to their own words, for example "How does it sound to you when you hear yourself say it like that?" [source: Carey 2008; IAPCT MOL page]
  • Example language (illustrative): "What's that like?" / "When you say 'stuck', what's happening for you?" / "What goes through your mind as you tell me that?" / "How do you know when it's starting?" / "What's the worst part of it?" / "Tell me more about the 'have to'."
  • Watch for: questions that steer toward your hypothesis, or questions about facts you want to know; both pull control away from the client. It is working when answers become more personal and present-tense, the client slows down, and new information appears that the client had not put into words before.

3. Staying with the client's topic (following)

  • Purpose / when: whenever the client changes subject or you feel pulled to redirect.
  • Steps: (1) Follow the client's current topic even if it seems off-track. In PCT terms, the client is controlling what they attend to. (2) If they change topic, ask about the new one, or ask about the shift itself as a disruption (item 5). (3) Do not bring the client back to "the main problem" on your own initiative.
  • Example language (illustrative): "You've moved on to your sister — what's coming up about her?" / "Before we went there you were talking about work; what was going on in your mind as you switched?"
  • Watch for: your own urge to cover a checklist. It is working when the client experiences the session as their space and keeps returning to what is important without prompting.

4. Noticing disruptions (Goal 2, observation)

  • Purpose / when: continuously. Disruptions are signs that a background, higher-level perception (an evaluation, a doubt, a value) has become briefly active.
  • Steps: (1) While the client talks, watch and listen for momentary changes [source: Carey 2008]:
    • pausing or interrupting their own flow
    • glancing away, smiling, laughing or sighing, head-shaking
    • a change in volume or speed
    • evaluative comments on what they have just said
    • subtler signs such as faint reddening, misting or narrowing eyes
    • an unusual word or phrase they keep repeating
    Contradictions, "but…" and sudden topic changes are reasonable additions [synthesis]. (2) Mind the timing. Ask while the disruption is fresh, because the higher-level thought may only be there for a moment. (3) Choose whether to ask now (item 5) or let the client finish the thought. [source: Carey 2008; Griffiths et al. 2018]
  • Example language: none. This is internal observation.
  • Watch for: over-reading every small movement. Choose disruptions that seem to carry an evaluation of what was just said. It is working when asking about a disruption leads to talk about the problem rather than more description of it.

5. Asking about disruptions / background thoughts ("going up a level")

  • Purpose / when: soon after a noticed disruption. This is the central MOL move. It invites awareness up to the perception that sets or evaluates the goals in conflict.
  • Steps: (1) Name what you noticed briefly and neutrally, without interpreting it. (2) Ask in the present tense what is going on for them right now, so you catch the higher-level thought while it is still there. (3) Accept whatever they report, including "nothing". (4) When the answer hints at a higher level, ask two, three or more follow-up questions to help them stay there. Keep the focus on the process of their thinking rather than its content. (5) Return to Goal 1 on whatever has come up, and keep watching for the next disruption. Successive moves can take the client through several levels in one session. [source: Carey 2008]
  • Example language: "What's making you smile?" / "What made you pause?" / "What stopped you just then?" (Carey 2008) / "You said 'this is silly'. What's the thought about it being silly?" / "What are you thinking about what you just said?" (illustrative)
  • Watch for: the client feeling observed or caught out. Keep your tone light and curious and only ask occasionally, and back off if the client is irritated (see section 5). It is working when the client starts commenting on their own patterns, says something like "I've never noticed that before", has an emotional shift, or a new perspective emerges.

6. Exploring both sides of the conflict

  • Purpose / when: when the client describes being torn ("I want to… but…"), or when two incompatible wishes show up in different parts of the talk. Carey places the source of a conflict at a level above the two opposing goals. The aim is for awareness to take in both goals together, and then the process that sets them up, rather than settling on one side. Mansell's review of Carey 2006 describes a client torn between keeping and selling his house who was helped to examine the process of weighing the two options. [source: Carey 2008; Mansell's review of Carey 2006] [uncertain: how Mansell, Carey & Tai 2013 frame this is not verified]
  • Steps: (1) Ask about one side in present-moment detail. (2) Ask about the other side in the same way. Do not argue for either. (3) Ask what it is like to hold both at once, or what the client notices as they move between them. (4) Ask about what makes each side matter, which moves up a level toward the higher-level goal setting both. (5) Do not propose a compromise or decision.
  • Example language (illustrative): "Part of you wants to leave — what's that part about?" / "And the part that wants to stay?" / "What happens in your mind when you hold both of those together?" / "What makes each of them so important to you?"
  • Watch for: you siding with the "healthier" option. That is the therapist joining one side of the conflict, which MOL predicts will strengthen the conflict. It is working when the client stops arguing for one side, describes the dilemma differently, or a third option occurs to them spontaneously.

7. Sustaining awareness: pacing and silence

  • Purpose / when: after significant answers, emotional moments, or when the client goes quiet while thinking. "Sustaining awareness" is one of the four IAPCT principles: it means helping the client stay with discomfort long enough for reorganisation, rather than avoiding painful experience. Carey asks about silences rather than filling them. [source: IAPCT MOL page; Carey 2008]
  • Steps: (1) Allow silence. Do not fill it with reassurance or a new topic. (2) When the client looks up or seems ready, ask a short question about what has been going on for them in the silence. (3) Slow your own speech. (4) Keep questions minimal when the client is clearly thinking hard.
  • Example language: "Take your time." (illustrative) / "Can you tell me about the silence just now?" (Carey 2008)
  • Watch for: silence that is distress or dissociation rather than reflection (see section 5). It is working when the client comes out of the pause with something new.

8. Checking the client's control within the session

  • Purpose / when: at moments of strong emotion, when a topic seems sensitive, or when the client seems to be going along with you. It reaffirms that the client controls depth and direction.
  • Steps: (1) Ask whether it is OK to keep talking about this, or whether they would rather go somewhere else. Carey stresses that people must know they can stop. He suggests offering to suspend or end the session, with an invitation to come back when they feel ready. (2) Respect the answer without probing why. (3) Optionally, ask what made them decide, which is itself an up-a-level question [synthesis]. [source: Carey 2008]
  • Example language: "Is this OK to keep talking about, or would you rather leave it there?" (illustrative) / "Are you unsure if this is what you want to be doing?" (Carey 2008)
  • Watch for: using it so often that it interrupts. It is working when the client deliberately chooses to continue or stop.

9. Brief explanation of how MOL works (optional)

  • Purpose / when: first session, or whenever the client is puzzled that you are "only asking questions". Carey 2008 notes that explaining why looking at difficult areas matters helps some people, though not everyone wants the reasoning. Mansell, Carey & Tai 2013 has a section on what to say at the first session. [source: Carey 2008; Mansell, Carey & Tai 2013 contents] [uncertain: the content of that section]
  • Steps: (1) In two or three sentences, explain that you will ask questions to help them look at the problem from different angles, that you won't give advice, and that they decide what to talk about and when to come back. (2) Invite questions. (3) Return to the problem. Do not teach PCT theory unless asked.
  • Example language (illustrative): "The way I work is mostly by asking questions, to help you look at what's going on from different angles. I won't be giving advice. You choose what we talk about, and you decide whether and when to come back."
  • Watch for: turning the explanation into a lecture. It is working when the client stops waiting for instructions.

10. Ending the session and patient-led appointment scheduling

  • Purpose / when: end of every session. It puts the frequency and number of sessions under the client's control. Carey and colleagues report better access and waiting times, and more improvement per session attended. [source: Carey & Spratt 2009; Carey, Tai & Stiles 2013 abstracts]
  • Steps: (1) When time is nearly up, or the client signals they are done, ask whether they would like another appointment and, if so, when. (2) Accept "no", "not now" or "I'll call" equally. (3) Tell them clearly how to rebook. (4) Optionally, ask briefly how the session was for them. (5) Record the client's choice. Do not chase non-rebooking as dropout unless risk requires contact. [synthesis: risk-related follow-up]
  • Example language (illustrative): "Would you like to book another time? It's completely up to you, and if you'd rather leave it for now, you can call whenever." / "How was today for you?"
  • Watch for: services that turn non-booking into discharge after a fixed interval. Agree a policy that keeps re-entry easy, and offer several ways to book. The Next Level trial used text message, phone and an online booking site, with a set number of weekly slots at each site [source: Griffiths et al. 2018]. It is working when clients use the flexibility: they book sooner when struggling, and space sessions out or stop when better [synthesis].

11. Practising and evaluating MOL (training and self-review)

  • Purpose / when: for clinicians learning the method, and for ongoing self-review.
    • MOL began as a two-person exploration of background thoughts by Powers and Kirk Sattley [source: Carey 2006/2024 foreword].
    • Carey 2008's practice activities include spotting disruptions in television interviews. They also include setting the two goals before a session and evaluating afterwards: rating your own curiosity from 1 to 10, and counting the disruptions you noticed and the questions you asked [source: Carey 2008].
    • In research, adherence is rated from audio recordings with the MOL Session Evaluation Form, and therapists get weekly supervision from experienced MOL practitioners [source: Griffiths et al. 2018].
    • The IAPCT lists training programmes, intervision and supervision groups, and an accreditation route [source: IAPCT MOL page] [uncertain: the accreditation requirements].
  • Steps: (1) Watch recorded interviews. Note each disruption and the question you would ask [source: Carey 2008]. (2) Practise in pairs: one person talks about a current minor concern while the other uses only items 2 and 5, then swap [synthesis: pair format]. (3) Before each client session, remind yourself of the two goals. Afterwards, rate your curiosity and count the disruptions you noticed and the questions you asked [source: Carey 2008]. (4) In supervision, review recordings and count advice, interpretations and summaries [synthesis]. The MOL Session Evaluation Form can structure this review if trainers provide it [uncertain: availability].
  • Example language: as for items 2 and 5.
  • Watch for: practitioners adding advice or interpretations out of habit. Count them in review.

12. Asking about background thoughts when no disruptions appear

  • Purpose / when: when the client talks without visible disruptions, or you have lost the thread. Carey's Goal 2 includes asking about possible higher-level thoughts even when there is no disruption. [source: Carey 2008, chapter "In the Absence of Disruptions"]
  • Steps: (1) Ask directly what is running through the back of their mind as they talk. (2) Look more closely for subtle signs such as narrowing, reddening or misting eyes. (3) If your hunch leads nowhere, say so plainly and go back to where the client was. (4) If you feel stuck, remind yourself that your only job is to help the client's awareness move up. Carey recommends an "anywhere is better than here" attitude. [source: Carey 2008]
  • Example language: "What's going through your mind right now?" / "I'm sorry, I got us a bit off track there. Where were we?" (Carey 2008) / "As you tell me this, is anything else going on in the background?" (illustrative)
  • Watch for: asking about the background so often that it breaks the client's flow. It is working when a comment about the problem appears, rather than more of the story. [synthesis]

13. Working with metaphors, repeated words and blankness

  • Purpose / when: when the client uses an image ("keeping the lid on"), keeps returning to an unusual word, or describes going blank. [source: Carey 2008]
  • Steps: (1) Treat the image as the client's own perception and ask about it literally. (2) Ask about the verb (the action in the image) or the noun (the object). (3) Ask about blankness as if it were a physical thing. (4) Follow up with Goal 1 questions about whatever comes up. [source: Carey 2008]
  • Example language: "Does it take much effort to keep the lid on?" / "What sort of a lid is it?" / "Does it have edges?" (Carey 2008)
  • Watch for: supplying your own meaning for the image. It is working when the client elaborates the image and then steps back to comment on it. [synthesis]

14. Bringing past and future into the present, and asking about avoided topics

  • Purpose / when: use this when the client:
    • talks about past events or imagined futures
    • describes their problems from a distant, third-person stance
    • seems to skirt round something
    [source: Carey 2008, chapter "Right Here, Right Now"; Mansell, Carey & Tai 2013 has a related section, "Using the past, controlling the present, and living for the future" [uncertain]]
  • Steps: (1) Let the client describe the past or future. (2) Ask how it is for them now, as they remember or picture it. (3) If they speak from a distance, ask how their problems look from that position. (4) If you sense avoidance, ask about it openly and accept any answer, including no. [source: Carey 2008]
  • Example language: "How is it for you to picture the future like that just now?" / "Is there something you're wanting to not talk about?" (Carey 2008)
  • Watch for: pressing on an avoided topic. The client controls what is discussed (item 8). It is working when talk becomes present-tense and personal. [synthesis]

15. Working without disclosure ("Green Apples")

  • Purpose / when: Mansell, Carey & Tai 2013 include a section titled "'Green Apples': working through problems without disclosure". It is for clients who do not want to, or cannot, tell the therapist what the problem is. [source: Mansell, Carey & Tai 2013 contents]
  • Steps: [uncertain: the section is not drawn on. These steps are inferred from its title and the two-goal method, and are not the authors' procedure.] (1) Offer the client the option of giving the problem a neutral label without describing what it is. (2) Ask MOL questions about their experience as they hold it in mind now: what happens, what they notice, what goes through their mind. (3) Watch for disruptions and ask about them as usual. [synthesis]
  • Example language (illustrative): "You don't need to tell me what it is. We could just give it a name, and you tell me what happens for you as you think about it."
  • Watch for: any pressure to disclose; don't apply it. It is working when the client can explore their reactions without giving the content. [synthesis]

16. Outcome monitoring

  • Purpose / when: Mansell, Carey & Tai 2013 include sections on outcome monitoring, on evaluating your own practice, and on focusing on distress rather than symptoms [source: Mansell, Carey & Tai 2013 contents]. The Next Level trial measured psychological distress rather than psychotic symptoms [source: Griffiths et al. 2018]. [uncertain: which measures the authors recommend for routine MOL is not verified]
  • Steps: (1) Use a brief measure of distress that your service accepts, at the sessions the client chooses to attend. (2) Present it as routine, and don't let scores set the topic. (3) Review the trend in supervision, not as an agenda for the client. [synthesis]
  • Example language (illustrative): "This short form helps us keep track of how things are for you. It doesn't decide what we talk about."
  • Watch for: scores steering your questions toward symptom reduction, which is an implicit agenda. [synthesis]

Not found / not included: Mansell's review of Carey 2006 confirms that the method includes no formulations, written techniques, advice, psychoeducation or therapist interpretations. It also involves no implicit therapist agenda, such as confronting fears, tolerating distress or reducing symptoms. The IAPCT likewise lists summarising, structuring, interpreting, diagnosing and advising as things MOL therapists avoid. Do not add homework, worksheets, exposure tasks or skills modules and call the result MOL. Mansell, Carey & Tai 2013 also has sections that go beyond the core two-goal session: building MOL into other therapies, using control theory within existing CBT, and "Interventions without talking: testing the controlled variable". Those sections are not drawn on, and any use of them is integration [uncertain] [synthesis]. [source: Mansell's review of Carey 2006; IAPCT MOL page; Mansell, Carey & Tai 2013 contents]

5. Handling problems

Carey 2008 gives direct guidance on "I don't know", silence, getting stuck and difficult topics. The other responses below follow from the general stance of client control and no persuasion, and are marked [synthesis]. [source: Carey 2008; IAPCT MOL page; Griffiths et al. 2018]

Client says "I don't know" or "nothing" to most questions. Treat not knowing as something to explore rather than a dead end. Ask about the not-knowing, the silence or the blankness as present experience (item 13). Carey's examples: "Tell me about not knowing where to start" and "Can you tell me about the silence just now?" Do not supply possible answers [source: Carey 2008]. Asking about smaller, concrete moments of the problem may also help [synthesis].

Client wants advice or answers. Carey holds that people in conflict do not need to be told what to do, and that an onlooker's solutions rarely fit. The helper's role is to help the person look at where a solution might be found, not to supply it. Respond with curiosity about the question itself (Carey's example: "What made you ask that question just now?") [source: Carey 2008]. Then explain how you work (item 9), and ask what they hope advice would do for them [synthesis]. If they still want advice, respect their choice to look elsewhere and leave rebooking open [synthesis].

Stuck: going round the same story, or the therapist feels lost. Stop asking for more detail at the same level. Ask about background thoughts (item 12), ask how it sounds to them as they hear themselves tell it again, and keep an "anywhere is better than here" attitude. If you have pulled the conversation off course, say so and ask where you were. [source: Carey 2008]

"Resistance": irritation at questions, or feeling observed. In PCT terms this is the client protecting a controlled perception from your disturbance. Ask disruptions less often, soften your tone, check control (item 8), and ask whether the questions feel OK. Never push. [source: PCT rationale, Carey 2006] [synthesis: specific responses]

Overwhelm or high emotion. Slow down, allow time, and check whether they want to continue or step back (item 8). Carey suggests that if a topic is too difficult, the session can end gently with an invitation to come back when the client feels ready [source: Carey 2008]. MOL does ask the therapist to help the client stay with discomfort long enough for reorganisation (the IAPCT principle of sustaining awareness), so the decision to continue rests with the client [source: IAPCT MOL page]. If dissociation or a crisis develops, step out of MOL and attend to safety. Then offer to return when they choose [synthesis].

Risk to self or others. MOL's client-led stance does not override standard duties. Carry out current-standard risk assessment and safety planning, including lethal-means counselling (safe storage and removal) when indicated, collaboratively and openly, and then return to MOL. With patient-led booking, agree in advance how you will follow up if risk is present and the client doesn't rebook. [synthesis]

Non-attendance and long gaps. These are expected under patient-led scheduling and are not treated as non-adherence. Make rebooking easy. Contact the client only according to an agreed risk or service policy. [source: Carey 2017] [synthesis: risk-policy detail]

Ruptures: the client feels unhelped or that you are "just asking questions". Ask about the reaction itself (an up-a-level move), acknowledge it, and offer a choice: continue, explain the approach again, or consider a different kind of help. Do not defend the method. [synthesis]

Therapist pulls: urge to advise, reassure, formulate, set homework, or side with the "healthy" option. Use supervision with recordings to count off-model responses, and rehearse returning to items 2 and 5. In MOL terms, siding with one side of a conflict risks strengthening it. [source: Carey 2006, 2008] [synthesis: supervision method]

Services that require fixed courses, outcome measures or discharge rules. Use outcome measures as the service requires, keep them brief, and explain them as service requirements. Negotiate a flexible session ceiling rather than a fixed number. [source: Carey 2017 on service design] [synthesis]

Clients with psychosis. MOL has been tested in first-episode psychosis services in the Next Level feasibility trial. The protocol paper reports no psychosis-specific changes to the method; whether any are needed was one of its research questions. The features chosen for this population were patient-led booking with no minimum or maximum number of sessions over 10 months, and outcomes centred on distress rather than psychotic symptoms. The trial recorded self-harm, overdose, harm to others and hospital admissions as adverse events. [source: Griffiths et al. 2018] Explore unusual experiences like any other perception, without challenging beliefs, and keep usual care coordination and risk management running alongside [synthesis].

Children and young people, and clients with limited verbal ability. The sources describe use with diverse populations. Keep questions shorter and more concrete, and allow non-verbal answers such as drawing or pointing. [uncertain] [synthesis]

Sources

Sources:

Further reading (not drawn on): MOL accreditation – IAPCT.

Books and papers cited:

  • Powers, W. T. (1973). Behavior: The Control of Perception. Aldine.
  • Carey, T. A. (2006; 2024 edition). The Method of Levels: How to Do Psychotherapy Without Getting in the Way. Living Control Systems Publishing. Includes a foreword by W. T. Powers.
  • Carey, T. A. (2008). Hold That Thought: Two Steps to Effective Counseling and Psychotherapy with the Method of Levels. St. Louis, MO: newview.
  • Mansell, W., Carey, T. A., & Tai, S. J. (2013; released November 2012). A Transdiagnostic Approach to CBT using Method of Levels Therapy: Distinctive Features. Routledge. https://doi.org/10.4324/9780203081334
  • Carey, T. A., Mansell, W., & Tai, S. J. (2015). Principles-Based Counselling and Psychotherapy: A Method of Levels Approach. Routledge. https://doi.org/10.4324/9781315695778 [uncertain]
  • Carey, T. A. (2017). Patient-Perspective Care: A New Paradigm for the Health Professions. Routledge. [uncertain; no longer cited in the body]
  • Carey, T. A., Tai, S. J., & Stiles, W. B. (2013). Effective and efficient: Using patient-led appointment scheduling in routine mental health practice in remote Australia. Professional Psychology: Research and Practice, 44, 405–414. https://doi.org/10.1037/a0035038 [the journal name is inferred from the APA DOI; the abstract page did not state it]
  • Carey, T. A., & Spratt, M. B. (2009). When is enough enough? Structuring the organization of treatment to maximize patient choice and control. the Cognitive Behaviour Therapist, 2(3), 211–226. https://doi.org/10.1017/S1754470X09000208
  • Griffiths, R., Mansell, W., Carey, T. A., Edge, D., Emsley, R., & Tai, S. J. (2018). Method of levels therapy for first-episode psychosis: rationale, design and baseline data for the feasibility randomised controlled Next Level study. BJPsych Open, 4(5), 339–345. https://doi.org/10.1192/bjo.2018.44
  • Mansell, W. (n.d., c. 2006–2007). Review of T. A. Carey, The Method of Levels: How to Do Psychotherapy Without Getting in the Way. Written for the British Association for Behavioural and Cognitive Psychotherapies. [the exact year and outlet were not confirmed]
  • International Association for Perceptual Control Theory (IAPCT). Method of Levels [web page].
← Previous · II-088Cognitive narrative psychotherapyNext · II-090 →Cognitive behavioural analysis system of psychotherapy