Rethinking Therapy: Making Our Worlds as We Would Like Them to Be

It’s funny how things turn out. I would never have anticipated becoming interested in the way in which psychological treatment is provided to people. A benign comment by a manager at the beginning of my clinical psychology career, however, piqued my interest and things have never been the same since.

After I completed my PhD in clinical psychology in Australia I headed over to Scotland to spend some time working in the National Health Service. When I arrived at the clinical psychology department where I would work for almost five years, I was told that the protocol was to schedule appointments every two weeks with patients. I thought this was odd because I had been used to scheduling weekly appointments in Australia. Almost immediately I began to wonder which the better schedule was.

My first inclination was to consult the literature to see what the evidence had to say about the ideal frequency for treatment appointments. Prior to my training in clinical psychology I had been a preschool and special education teacher and, because I knew the cognitive behaviour therapies were based, at least in part, on learning theories, I thought there might have been some suggestion that, for people to learn a new skill or new way of thinking then regular, evenly spaced sessions over a three- to four-month period was ideal. As I scoured the literature my interest spread to include not only information about the scheduling of appointments but also the number of sessions for which treatments were designed.

I was surprised and intrigued to discover that there was no evidence indicating that any particular treatment protocol was ideal (Carey, 2005). Decisions about how long a treatment should be and how frequently treatment sessions should be provided are routinely made by researchers and clinicians. While there are lots of studies demonstrating that some therapy or another is better than a different therapy or no therapy at all, there are no studies demonstrating what is necessary or essential. For example, a study demonstrating that 12 sessions of Therapy A is better than 12 sessions of Therapy B and also better than 8 sessions of Therapy A is not a study demonstrating that 12 sessions of Therapy A is necessary for the alleviation of psychological distress.

Given that there is no compelling rationale for any particular protocol of treatment provision it is intriguing to wonder how various treatment regimens arose. One suggestion has been that psychological treatment was packaged in neatly spaced intervals and of pre-determined duration so that these treatments could be compared directly to pharmacological treatments. Another deliciously provocative suggestion was that the convention of hourly appointments was determined historically when therapists decided to charge people for units of time rather than results (Haley, 1990). It is amazing to wonder where our field might be today if people accessing therapy paid for results rather than time!

Another important discovery I made in my search of the literature is that there is a dramatic disconnect between how long researchers and clinicians think treatments should be and how long people accessing treatment think treatment should be (Carey, 2011). Most treatments are designed to be longer than ten sessions but most people access fewer than ten sessions. This is perhaps the most potent example of the need to listen more carefully to the people using therapy and to design treatments that match their preferences.

Because I could find no guidance from the literature, I wondered what would happen if I did nothing at all to constrain or restrict people’s access to therapy. I established systems so that people could make appointments to see me whenever they wanted to within the constraints of service availability. My clinics were located in different places so availability depended, at least in part, on how often my clinic was held in a particular location but, within these limits, people could make appointments as they required them. In one clinic, for example, a colleague of mine and I were there twice a week each. So, we told the people we saw that they could come as often as they liked for as long as they liked. We told them they could come four times a week, or once a week, or whatever they decided was best (Carey & Mullan, 2007). Often, we worked in GP practices so people were able to book appointments to see us the same way they would book appointments to see GPs.

I called this approach “patient-led treatment” because I developed it in the NHS where people were referred for treatment by their GPs. In other settings I call it “client-led treatment” but my favourite term is “person-led treatment.” The only problem with the “person-led” term is that it does not specify who the person is who should be doing the leading. Since a therapist is a person too it could easily be assumed that they should doing the leading. For me, the crucial word in this term is the “led” not the “patient”.

I think mental health services could do much better at following the lead of the people who access the services. Even terms such as “patient-centred” or “patient-focussed” do not specify clearly enough whose decisions should have primacy. Treatment providers who determine when and how treatment will be delivered, for example, could insist that patients are at the centre of their decision making.

I’ve found that the patient-led approach is an amazing way to work. I have conducted evaluations and replications in primary care in Scotland and in secondary care in remote Australia (Carey, Tai, & Stiles, 2013). In all of the evaluations I have found that people come for about the same number of sessions that they attend when treatment providers do the appointment scheduling (about four to six appointments is the average) but the number of missed and cancelled appointments reduces dramatically. It perhaps shouldn’t be surprising that if people make their own appointments they tend to keep them.

The “patient-led” approach to treatment provision fits very neatly with the type of treatment I provide. For over two decades I have been interested in an explanation of behaviour as a process of control (Powers, 2005). From this perspective successful day-to-day functioning arises when people are able to control the things that are important to them and problems arise when control is interrupted. It is not surprising that the mental health literature constantly refers to mental health problems in terms of control. Mental health difficulties, for example, might arise through trouble controlling thoughts or emotions or behaviours or impulses. Successful mental health treatment entails helping people to re-establish control.

The control perspective explains behaviour from an “inside looking out” point of view. With regard to mental health problems this means taking people’s account of their situation as the starting point and helping them to make different sense of the things that are bothering them. When people describe having mental health problems, it is assumed from a control framework that there is a difference between the way things are from each individuals’ perspective and the way they would like them to be. Therapy helps people reduce this difference by becoming clearer about what is important to them and the direction in which they would like to head.

The therapy I use that is based on the concept of control is called the Method of Levels (MOL; Carey, 2006, 2008; Mansell, Carey, & Tai, 2012). Because MOL works with people based on the problems as they are individually defined, it is not restricted to diagnostic categories. In fact, MOL has been described as a “transdiagnostic cognitive therapy.” The “transdiagnostic” term just refers to the fact that MOL focusses on processes and problems that are not limited to any particular diagnostic category. The “cognitive” term is used loosely to highlight that the therapy addresses the goings-on of a person’s mind. MOL does not only address people’s thoughts but works with problems in whatever way they are manifesting. If people have troublesome images or voices then that is what MOL addresses.

In my work I see therapy as a resource that people can access whenever they want to spend time making their worlds be more as they would like them to be. I see it as my purpose to be as “therapeutically useful” as I can to people by addressing their problems as they describe them without assuming I know what is best for them or what the right solution is.

Both patient-led treatment and MOL are optimistic and respectful approaches that assume that people can generate successful solutions to their afflictions if they are given the time and assistance to consider their situation in ways they might not previously have thought of. In this approach there are no “treatment dropouts” or “resistant clients” to deal with and no “comorbidity” to contend with either. The approach is not magic and it doesn’t suit everyone but it does help a wide range of people in a compassionate and sensitive way that honours their personal account and helps them navigate a path to calmer waters in the time-frame that is right for them.

References

Carey, T. A. (2011). As you like it: Adopting a patient-led approach to the issue of treatment length. Journal of Public Mental Health, 10(1), 6-16.

Carey, T. A. (2005). Can patients specify treatment parameters? Clinical Psychology and Psychotherapy: An International Journal of Theory and Practice, 12(4), 326-335.

Carey, T. A. (2008). Hold that thought! Two steps to effective counseling and psychotherapy with the Method of Levels. Chapel Hill, NC: newview Publications.

Carey, T. A. (2006). The Method of Levels: How to do psychotherapy without getting in the way. Hayward, CA: Living Control Systems Publishing.

Carey, T. A., & Mullan, R. J. (2007). Patients taking the lead: A naturalistic investigation of a patient led approach to treatment in primary care. Counselling Psychology Quarterly, 20(1), 27-40.

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.

Haley, J. (1990). Why not long-term therapy? In J.K. Zeig, & S.G. Gilligan (Eds.), Brief therapy: Myths, methods, and metaphors (pp. 3–17). New York: Brunner/Mazel.

Mansell, W., Carey, T. A., & Tai, S. J. (2012). A Transdiagnostic Approach to CBT Using Method of Levels Therapy: Distinctive Features. London: Routledge. ISBN: 978-0-415-50764-6

Powers, W. T. (2005). Behavior: The control of perception (2^nd ed.). New Canaan, CT: Benchmark.