The MOL formulation of psychological problems

Generally each psychological therapy has an explanation or a rationale for its particular techniques and treatment regime. Part of this explanation is often a description about the problems that the techniques are designed to address. Perhaps what is not so commonly addressed is what makes a problem a problem. Consider the following examples of negative automatic thoughts and dysfunctional assumptions:

It is easy to accept that people who are psychologically troubled might express these kinds of ideas but what is less obvious is what is troubling about these sentiments. What is it about having any of these particular thoughts in one's head that leads to misery?

What often seems to get overlooked in accounts of unhappiness is the relativity of thoughts. Apparently the Greek Stoic philosopher, Epictetus said ‘We are disturbed not by events, but by the views which we take of them’. Similarly, Shakespeare wrote ‘Nothing is either good or bad, but thinking makes it so’. My position is that while these statements are mostly accurate, they can be misleading because they fail to emphasize the relativity of thinking.

By ‘relativity’ I mean that the value we attribute to a particular thought is always determined by the way in which it measures up to other thoughts, ideas, goals, and beliefs that we have. Consider the above example ‘I'm going to make a fool of myself and people will laugh at me’. It can easily be appreciated that someone might feel unhappy if they believed this. If, on the other hand, that person was a clown in a circus, this would be an extremely reassuring thought to have. The same line of reasoning can be used with each of those thoughts or beliefs. My contention is that with any apparently dysfunctional or negative cognition it would always be possible to imagine a situation or a person for whom having that cognition was not negative or dysfunctional.

Even people who believe they are 100% bad might not necessarily be disturbed by that thought. Some people might have the attitude that you have to be bad to get ahead. If they want to get ahead, then being bad would be good for those people. However, other people might consider that bad people are disliked, ridiculed, and avoided. If these people desire social relationships then believing they are bad will create distress.

Therefore, it is the relativity of a particular thought or condition that creates the problem. Undoubtedly, many factors will contribute to this relativity. The degree to which people perceive their environments as predictable and controllable might affect how various beliefs measure up to each other. However, from the perspective of MOL, the way in which the relativity is brought about is not as important as the fact that it exists, because it is how thoughts relate to other thoughts that bring about distress or contentment. When thoughts are generally consistent or compatible with one another the person experiencing those thoughts will enjoy a sense of contentment or satisfaction. When thoughts are inconsistent or incompatible or in opposition to each other, the person will encounter psychological distress. It is important to keep in mind that it is the internal experiencing of the thoughts that is important. Even if the compatibility of certain thoughts is unfathomable to someone else, if they are genuinely compatible to the individual then they will not generate distress. Thus, if someone thinks that they are going to get fired from their job and they want their employment to end, then their cognitions around this issue will be generally compatible and they will be satisfied. If, on the other hand, the person develops the idea that they are going to get fired but they do not want their employment to end, they will become agitated, anxious, and distressed.

The situation where two thoughts, beliefs, or cognitions are in opposition with each other is known as conflict (Powers, Reference Powers1998). Conflict seems to be evident in most forms of conventionally described psychological disorders. When people describe the manifestation of their psychological distress it is typical to hear them discussing ‘fighting’ or arguing with themselves, or telling themselves to do one thing but then doing the opposite. Themes such as wanting to be assertive and independent but also wanting to fit in, or wanting to be laid back and easy-going but also wanting specific outcomes to occur are common.

Conflict is recognized in current psychological therapies. Strosahl et al. (Reference Strosahl, Hayes, Wilson, Gifford, Hayes and Strosahl2004), for example, describe one of the Acceptance and Commitment Therapy exercises as ‘Polarities: You are perfect, you are scum’ (p. 41) and Wells (Reference Wells2005) suggests that being in ‘two minds about worrying’ (p. 110) is a feature of generalized anxiety disorder. Others have described conflict as a general model of psychopathology (e.g. Mansell, Reference Mansell2005).

At a conceptual level there are potentially limitless ways of describing the way in which conflict might occur within the attitude and belief structures of a person. However, physical models provide a more exacting and specific depiction of a phenomenon than do conceptual models. Conceptual models can often be the beginning of the formulation of a physical model; however, if left at the conceptual level there is very little way of deciding between models other than personal preference. A sketch of a dream home might be analogous to a conceptual model of psychological distress. When sketching a dream home you can depict ideas and structures as you would like them to be even if they might not actually be possible. However, an architect's house plan is more like a physical model. Indeed, from architects' plans, physical models of buildings are often constructed. While a sketch of a dream home might help guide an architect in constructing a suitable plan, the two figures are not analogous. Architects must pay attention to the way in which material is able to be assembled in a physical sense rather than an imaginary one. Architects, therefore, are much more constrained in the models they produce and have more exacting standards for judging the appropriateness of their models.

With physical models of behaviour one can determine quantitatively how accurately the model simulates the phenomenon being modelled. For this reason, the model of conflict I prefer is based on Perceptual Control Theory (PCT; Powers, Reference Powers1998, Reference Powers2005). I have described the PCT formulation of conflict elsewhere (e.g. Carey, Reference Carey2006, Reference Carey2008a, Reference Careyc); however, providing the basic elements in this paper will be useful to assist in understanding the rationale behind the two steps of MOL.

PCT offers a control system operating as a negative feedback, closed causal loop as the basic building block for living things (Powers, Reference Powers2005). To explain the complexity of living that people engage in, these control systems are arranged in parallel and hierarchically. It is their hierarchical arrangement that is of particular interest to this discussion. Control systems at one level of the hierarchy control their perceptual signals by adjusting the reference signals of control systems at the level below. For example, to keep a constant amount of congeniality in social relationships I may vary the amount of honesty I control for at different times. So when I am asked what I think of a work colleague's new hairstyle or latest shopping acquisition I might make a comment that is less than completely honest so that a friendly and cordial relationship is maintained.

Conflicts, from a PCT perspective, involve at least three of these hierarchical levels of control systems. The middle level is where the oppositional goals are situated – be here and be there, do this but do that, and so on. The level below the conflicted goals is where the symptoms of irritability, indecision, apathy, etc. are manifest. The level above the conflicted control systems is the level actually creating the conflict by sending incompatible signals to the lower-level systems.

Although conflict is extremely common for control systems, persistent conflict is not. Normally, control systems are adept at figuring out how to correct the struggle that has been created. However, conflicts sometimes endure. When this occurs symptoms seem to intensify. At this point, people might take action to reduce the intensity of the symptoms without dealing with the conflict. Substance misuse, for example, could serve to dull the pain of chronic psychological distress. In this instance people might say that they want to change their habits; although, focusing on changing the action of drug taking without attending to the levels above is unlikely to have a lasting effect on the manifestation of psychological distress. Many people seem to spend a lot of time focusing on goals that cannot be achieved or symptoms that feel as though they are gradually taking over. Unfortunately, while the highest level in this conflicted arrangement continues to send incompatible signals to the middle level no amount of attention at the two lower levels will bring about a resolution. For the conflict to be removed attention needs to be directed and sustained at the highest level. This is the role of MOL.

A general description of the method

When used to assist a client who is psychologically distressed, the sole purpose of MOL is to help shift the client's awareness to higher levels in their perceptual hierarchy so that the level at which the conflict is being created can be altered. Within the PCT model is a fundamental form of learning called reorganization (Powers, Reference Powers2005). Reorganization randomly alters the parameters and characteristics of control systems until control returns or improves. Reorganization is linked with awareness so that the control system in awareness is the control system where reorganization will be occurring (Carey, Reference Carey2006). This explains why attending to the lower levels will not necessarily affect the conflict. It is the highest level in the conflict that needs to be reorganized. MOL, therefore, involves helping to redirect a client's awareness to this level.

As it turns out, shifting awareness is not difficult. The mobility of awareness is stunning. In the space of a minute or two I can become aware of the pressure of my legs on the chair, and the words that are appearing on the screen as I type, and the number of appointments I have to organize today, and the speech I will make at the function tonight, and the great holiday I had last year, and the tightness in my right calf from the exercising I have been doing, and the state of my life at the moment. Awareness seems to wander across our hierarchies in a seemingly arbitrary fashion. A useful metaphor for awareness is shining a torch around a large gothic cathedral in the middle of the night. The entire cathedral is there all of the time but at any point in time only a fraction of the structure can be seen.

MOL harnesses this mobility and directs it in a systematic fashion. As a person discusses a topic or describes a particular event it can be observed that, from time to time, the flow of words they are producing is disrupted or altered in some way. They might pause, or look away, or speed up what they are saying (or slow down), or get quieter (or louder), or shake their head, or smile to themselves, etc. These disruptions occur for everyone. Disruptions will be outlined more fully below but it is worth pre-empting that discussion here. It seems that it is difficult to try and make them not occur. Whenever you get the opportunity to observe people discussing a topic you will most probably be able to observe disruptions. If you are able to watch a politician being interviewed on television or an athlete talking about a recent sporting performance you might see their stream of words occasionally falter or change.

In MOL these changes in word flow are understood to indicate shifts in awareness. So when someone momentarily pauses, or shakes their head, it is assumed that they suddenly became aware of something other than what they were just describing a moment before. Experientially, this often feels like a thought ‘popping’ into one's head.

Frequently, this awareness shift will be brief, and the person will return to the topic they were talking about a moment ago. Moreover, the direction of these shifts is unpredictable. Sometimes, as people are talking, they might suddenly remember that they left the iron on at home. The awareness shifts can be quite unrelated to the topic. However, at other times the thoughts that pop into awareness will be about the topic being discussed. The person might suddenly think something like ‘Is he understanding of all this?’ or ‘This sounds really trivial she must think I just can't cope’ or any other thought which seems to be an evaluation of what they have been describing.

From a MOL perspective, the evaluative thoughts are of particular interest. It is assumed that in order to evaluate something you have to be somewhat removed from it. When dining out at a favourite restaurant you might be thoroughly enjoying the tastes and smells of the chef's handiwork. You might also think things like ‘I wish I could afford to eat here every night’ or ‘I'd love to be able to cook like this’. In PCT terms, awareness of these ideas would be at a higher level than where it was previously, when it was alerting you to the sumptuous tastes and textures in your mouth. It is these higher-level places that awareness picks up that are of prime importance to MOL. They are important because of the PCT formulation of conflict. Conflicts are experienced at one level but they are generated from a level above.

The basic method of MOL then, is to engage someone in conversation about a topic they want to consider more closely. Through the MOL clinician's questioning clients are invited to consider the topic from different perspectives or angles and to a degree of detail they may not have noticed before. As they discuss the topic it can be expected that their awareness will, periodically and unpredictably, move to other places in their neural network. Some of these places will be higher levels than the level of the topic under scrutiny. When one of these places is caught by awareness the client is encouraged to consider this new level in the same way that they were exploring the previous level just a few moments ago. As they discuss this new level their awareness will shift again and, when this shift illuminates a still higher level, they are encouraged to explore this level more fully.

MOL then, is a process of ‘awareness hopping’ in which the only purpose in discussing a particular topic is to give awareness time to pick up a higher level. When a higher level appears the MOL clinician encourages the client to shift their focus to this level. This process continues until the client reaches some resolution to their problem, or develops a new insight, or perhaps even runs out of things to say for the time being. The only steps in MOL then, are encouraging someone to talk in detail about a particular topic and noticing disruptions when they occur. Once a disruption is noticed, the first step – encouraging them to explore the topic – begins again. More details about these two steps will be explained below.

Getting specific: keep them talking

The first step in MOL is to encourage clients to talk about the difficulty they would like to resolve. First and foremost the MOL environment needs to be a place where clients feel safe to talk about the things that are bothering them. This includes those particularly worrying ideas and beliefs in the furthest reaches and darkest corners of their mind. In day-to-day conversations with friends, partners, and colleagues it is common to conduct a kind of censoring or filtering about the way ideas are expressed. Some topics are avoided because they might be ‘sensitive issues’ and ideas and attitudes might be phrased in particular ways as a kind of ‘image management’ strategy. These activities are appropriate in general social situations but they are not likely to be helpful when solving internal conflict.

For reorganization to satisfactorily alter the necessary control system, this system needs to be brought into awareness. However, there is no way of knowing, where that control system might be (Carey, Reference Carey2008b). If the client was aware of which control system was generating their conflict they would probably have already resolved the problem. Finding the necessary control system is likely to be easiest when awareness is able to freely move around an individual's neural network. Awareness will be inhibited, and the necessary reorganization will be delayed, if people are being careful about what they say or how they say it.

So the first task is to let the client know that the time they spend with you is a time when they can discuss things freely. All of the lessons from the literature about building trust, conveying empathy, establishing rapport, and communicating respect will be important here. However, the purpose of focusing on these qualities is so the client will feel comfortable enough to talk freely. Sometimes it might even help to tell them that directly ‘The most important thing about our time together is that you feel comfortable to discuss whatever is bothering you in detail. If I'm doing things that make you feel on edge or guarded please let me know so we can figure out how I can help you be more comfortable’.

One of the ways that you can help to establish a safe and supportive environment is to maximize the time that you are asking questions and minimize the time you are giving advice or providing suggestions. Asking questions allows you to focus on the clients' world as they experience and understand it. The questions, therefore, should be asked from a curious and interested perspective. Essentially you want clients to teach you what it means to be them with the problems they have.

Some clients might be reluctant to freely explore their concerns due to past experiences that leave them feeling weak and pathetic. Because MOL focuses on process and not content, it can be especially useful in these situations. You can explain to clients that your job is to help them look at their thoughts and to do that you do not have to know what those thoughts are. I let clients know that they can call the topic of concern ‘flying elephants’ or ‘men in suits’ or whatever they wish and I can still ask them questions about the experience of focusing on these concerns. In this situation you could also focus on ‘reluctance’ as a process. Being reluctant to discuss something seems to suggest both wanting and not wanting the discussion at the same time. Therefore, exploring the experience of reluctance might be helpful regardless of what the reluctance is about. Using MOL in this way can help promote the therapeutic alliance through a sense of trust, safety, and respect.

Making assumptions tends to stifle conversations so, at all times, adopting a mindset that you have no idea what is going on for the other person may be useful in helping you generate questions to ask. For example, if someone tells you that they have panic attacks you can help them to start investigating these experiences by asking detailed questions. Many of these questions will already be familiar: How often do they occur? In what sort of situations? How do they come on? When did they start? However, other questions may be more unusual: Does it bother you to have panic attacks? What bothers you about that? What makes you call them ‘panic attacks’? What's the sense of panic you become aware of? Are you aware of that feeling now, as we talk about it? What is the ‘attack’ component of what you're experiencing?

Keep in mind that the purpose of the questions is to start clients talking about their problem and listening to themselves talking about it. The purpose is not so that you can get the information you need to solve their problem for them. Asking simple, sometimes obvious, even apparently ‘dumb’ questions will help clients begin to consider their problem in different ways and from angles and perspectives they may not have considered before (Carey, Reference Carey2008b).

A caveat to this questioning is that, occasionally, because you are spending time asking questions about clients' problems, to a level of detail they might not be familiar with, they might get the idea that they are not giving you the right answer. Some people think when you ask a number of questions about the same topic that they have not told you what you want to hear yet. This can be extremely helpful to recognize. If you are questioning clients to steer them in a particular direction, or to have them look at things in a particular way, this may well inhibit the movement of their awareness. Even if they think that is what you are doing they are likely to be attending to the answers they assume you want rather than other thoughts, images, and feelings that pop into their awareness. Talking about this process when you suspect it might be happening can be useful: Do you want to give me the answers that you think I expect? What answers do you think I might be looking for? How do you feel about answering all these questions?

Asking about the process of clients' thinking can be a useful general guideline. If they seem to talk a lot about the way things are now and the way things used to be you might get the idea that they are comparing their present with their remembered past. You could ask things like: Are you comparing things now with how they used to be? How do they measure up? What do you notice when you look at them together like that? What standards are you comparing them on?

Always keep in mind that the purpose at every point in asking questions is to help clients listen to the experiences they are describing. As they are describing their experiences and then listening to what they are saying their awareness might shift to other places and you may get a sense of this in the form of a disruption. Once you do, it is important to leave the current topic of conversation and begin asking about the disruption.

Staying specific: ask about disruptions

At the start of this section it is important to emphasize that PCT did not invent or otherwise create disruptions. Disruptions are there for anyone to observe. The PCT contribution to our understanding of disruptions is an explanation of what might be occurring internally to explain the external disruption that can be observed.

To sharpen your MOL skills you could spend time noticing disruptions in normal, everyday conversation. Although I introduced the idea of disruptions previously, their importance to MOL justifies a more detailed consideration now. When you are chatting with friends and colleagues, if you pay attention to how they are telling their story rather than what the story is about you might notice that, from time to time, the stream of words they are producing is somehow disrupted. It just seems to naturally occur that periodically there are breaks in a person's word flow. As mentioned previously, observing people like politicians or athletes being interviewed is also a good resource for practising picking up on disruptions.

By disruption I just mean some difference in the way the person is talking. Some examples already suggested are that they might pause, or shake their head, or increase (or decrease) their volume (or pace), or they might smile or look away. The way in which the break happens will differ but the important point to pick up on is that there has been some change in speech or mannerisms or demeanour. Sometimes they might continue talking in exactly the same way but you will notice their eyes mist over or a slight reddening of their cheeks or some other subtle change (Carey, Reference Carey2008b).

The PCT explanation for these disruptions is that, at the time they occur, the client's awareness has momentarily shifted somewhere else. For the most part they are aware of the details of the story they are telling you but, every now and then, they will become aware of something else. Sometimes, these ‘something else's’ will be irrelevant – they might have just remembered that it is their turn to pick up the children from school. However, at other times, the ‘something else’ will be a thought about what they are discussing at the moment. Sometimes they might even articulate something like ‘That sounds really dumb’ which indicates how they are evaluating what they have just been listening to. At other times the indication might be non-verbal such as a shake of their head or perhaps a shrug of their shoulders.

It is seldom clear at the time what the client's awareness has highlighted during the disruption so the best thing to do is to ask. This involves nothing more technical than simply enquiring about what you have just observed: What went through your mind when you shrugged just then?; What were you shaking your head at?; What made you smile to yourself just now?; What thoughts are going through your mind while you're pausing at the moment?

It is important to ask about the disruption at the time it is occurring. If you wait until they get back on track and finish the point they were making the disruption will be a faded memory and they will probably have to guess at what had occurred to them a few moments ago. At times this can almost seem to be rude because you might feel as though you are interrupting and talking over the top of the client so it is important to be clear about the purpose of what you are doing. In MOL the content of what clients are talking about is only useful as a way of providing clues as to where to look for a shift to a higher level. The content is the means to the end but the higher-level perspective is the ultimate goal.

From a PCT perspective we can assume that the higher level is there in existence all the time (Carey, Reference Carey2006). We do not need to create it or teach clients about it. We just need to help them keep their attention on it once their awareness highlights it for us. So, as a MOL therapist, the job is to ask about disruptions when they occur in order to determine if that disruption was a shift to a higher level.

If an enquiry about a disruption indicates that a higher level was not brought into awareness then just return to the topic of conversation with something like: I'm sorry, that got a bit off track. Where were we? There are bound to be some ‘blind alleys’ with your questioning; however, if you persist with asking about disruptions there will also be times when an important higher level is discovered. When that occurs, you help the client to keep their attention at this new place by asking them more questions about whatever they have just expressed. So, at this time, go back to the first step in the MOL process and encourage them to explore in detail this new focus of attention.

Over and over again

The MOL process, therefore, is an iterative procedure involving just two steps. The first step is to ask questions about whatever topic the client volunteers. The second step is to ask about disruptions when they occur. Once a disruption indicates a possible higher perceptual level you return to the first step and begin asking questions about this new topic. For example, a client might be telling you about a difficult decision they have been trying to make and then pause, look down, and shake their head. If you ask what is going through their mind at that point they might say something like ‘I just hate being uncertain’. That sounds like it could be a more general idea than the specifics of making a decision so you could hypothesize that this was an important higher level of perception and test this hypothesis out by helping them explore this idea a little bit: Tell me about being uncertain; Is it all uncertainty you hate or just particular types? Are there other areas of your life where you feel uncertain? What is it about uncertainty you don't like?

With these two steps in mind you can set goals for your conduct of MOL sessions. To begin with you might start out with the two standard goals of: Encourage people to talk about whatever is on their mind; and Ask about disruptions when they occur. You could use these goals for a week and, at the end of each session, evaluate how completely you achieved these goals. Perhaps use a scale from 1 (not at all) to 10 (completely) and rate how well you thought you did. Further, after each session you could nominate two things you were particularly pleased about and two things you would do differently next time.

From this evaluation you can begin to set more specific goals. Perhaps you noticed that you consistently gave yourself high ratings at asking about the topic but you were not so good at noticing disruptions. You might set a goal for next week to ask about at least five disruptions every 15 minutes. It might take some practice to keep track of this as well as attending to the general conduct of MOL but, with time, you should be able to monitor these kinds of goals as well. Reviewing tapes of sessions might help you identify disruptions where you did not think there were any when you were conducting the session. The same evaluation procedure could occur after each session and, once again, information from these evaluations could be used to inform subsequent goal setting.

Instead of asking about disruptions, you may have noticed that you were having more difficulty sustaining conversations about a particular topic. A goal such as: Ask four questions about the same topic before discussing another topic, might help you to encourage deeper exploration of particular issues. Or it might be that you notice yourself having difficulty with particular responses. When you ask about a disruption and the client says ‘I've just gone blank’ perhaps you find yourself at a loss about what to say next. You might set a specific goal about asking questions regarding the state of ‘blank’. A goal of: Ask five different questions about being blank, might help to improve your questioning in this area. It could even require that you develop a little bank of questions ahead of time. Questions such as: How do you feel about being blank? Do you go blank very often? Is there a border around the blank or does it cover everywhere? Is there anything behind the blank or perhaps above it? What colour is the blank? Are there any feelings or sounds associated with the blank? Did it occur all of a sudden or did it come on slowly like a fog rolling in? and Tell me about blank (even though this is not strictly a question), might occur to you easily and efficiently if you have practised them beforehand.

Sometimes it might help to set goals about doing less of something. In your evaluations you might have noticed that, when you cannot think of the next question to ask, you tend to provide a suggestion or some advice and you might want to decrease this so as to encourage more conversation. However, doing less of something, often involves doing more of something else so focusing on what you would like to do more of rather than what you need to do less of might have the same effect. For example, you might want to become better at tolerating silences rather than filling them with you questions or suggestions. You might set a goal to count to ten (or fifteen or some other number that requires a wait) whenever the patient pauses before you break the silence.

MOL can be quite a difficult therapeutic style to feel comfortable with (Carey, Reference Carey2008). There might always be areas you identify for improvement or extra practice. Moreover, part of using MOL well, might be knowing when not to use it. While I think MOL is the method of choice for resolving internal conflict, not all human upsets arise from conflict (although my hypothesis is that the chronic ones do). If someone experiences the death of a partner, for example, they could be expected to be extremely sad and upset but they might not be conflicted. Also, if someone just learns that they have developed diabetes, they might be at a loss as to know what this means but might not be conflicted. As our understanding of human problems from this perspective grows we might become more sophisticated at discerning which type of problem a person is experiencing. In the meantime, I use MOL as my standard approach and let people tell me when it is not suitable.

Concluding remarks

For me, the way I learned and improved at the practice of MOL was to set some goals for myself and start doing it. I also found some interested colleagues and started a regular peer supervision group. During our meetings we would discuss our progress and how we could continue to improve. In these meetings, whenever an area required greater clarification we found it useful to return to PCT for guidance.

MOL in practice does not unfold as neatly as it may seem by the description I have provided. Although the ultimate intention is to help clients push their awareness to higher levels, it may seem as though there are lots of sideways trips and excursions to dead ends. When you are dealing with someone else's internal experiential landscape a circuitous route is perhaps to be expected. However, many roads lead to Rome, and, if you persist with the pursuit of higher levels, they will arrive in their own time-frame. Perhaps more than anything, a MOL attitude requires having a clear idea of the direction that is needed and a willingness to allow the client to lead while you follow them on their own path to greater awareness and new perspectives of their difficulties. It is as little, and as much, as that.