Perceptual Control Theory

While there are many theories about concepts such as goals, expectations, and self-regulation, very few theories are expressed in functional terms in the sense of how an expectation actually works to influence behaviour. PCT (Powers, Reference Powers1973, Reference Powers2005) is one such theory. Interestingly, it is based on a ‘control systems’ approach that is also utilized in both attachment theory (Bowlby, Reference Bowlby1969) and contemporary CBT (Mansell, Reference Mansell2005; Watkins, Reference Watkins2011). PCT provides the foundation for our proposal as it offers an explanation of how the therapeutic relationship might facilitate therapeutic outcomes. PCT describes the way in which behaviour is constantly adjusted through negative feedback to keep perceived deviations from an internal benchmark (reference, belief, goal, expectation, etc.) at a minimum.

Based on PCT principles, an interaction between two people can be conceptualized as the linking of two control systems through a shared environment (see Fig. 2). Both people in the interaction have their own goals about the interaction (and about many other things as well) and make constant alterations to their behaviour so that what they perceive (see, hear, feel) remains close to what they want to experience (internal reference or goal). When treatment proceeds satisfactorily both the therapist and the client are able to keep any deviation they sense to a minimum.

Fig. 2.

Generic model of the interaction of two people conceptualized as control systems. * Sensors can be thought of things such as eyes, ears, and skin in which environmental input is converted into neuronal signals. † Muscles and glands are those parts of the system that allow individuals to affect their environments.

To illustrate this process, suppose that a therapist has a goal of understanding the situations in which a client's panic attacks occur. The therapist will ask questions about when, where, how often, for how long, and so on, until they have the amount of information they think is necessary. Perhaps the client has a goal of helping the therapist understand what they are going through so they answer questions and provide details about their panic experiences. This interaction is summarized diagrammatically in Figure 3.

Fig. 3.

Model of a therapist seeking to understand a client's panic attacks, and a client wanting to help the therapist understand the attacks.

From time to time, as the client describes their experiences, they might be reminded of various incidents and may even begin to explain these to the therapist. For example, the client might remember how happy they were when they graduated from university. If they start to tell the therapist about this, however, the therapist (who is sticking to their goal of finding out about the panic attacks) will begin to sense that the topic is getting ‘off track’ (a deviation) and will ask more questions about the current panic attacks.

Similarly, there may be times when the therapist spends too much time on one area (from the client's perspective). Perhaps the therapist takes some time at the beginning to ask the client about how their week has been but the client might just want to get straight into the problem [this could be considered to be a divergence of perspectives from Reis & Brown's (Reference Reis and Brown1999) point of view]. The client might give short, brief answers and start talking about their panic attacks in order to reduce the difference between what they are talking about and what they want to talk about. Throughout this conversation there may well be subtle adjustments by both the therapist and the client to keep the conversation happening the way each of them prefers.

McCabe & Priebe (Reference McCabe and Priebe2008), use an example with a potentially different outcome. They describe a situation where ‘One patient asked “Why don't people believe me when I say I'm God?” to which the doctor, after initial avoidance, replied “What should I say now?” ’ (p. 404). In this instance the patient could be considered to be attempting to reduce a discrepancy – perhaps they have attended the session to understand more about their situation. They currently do not understand what is happening and they would like a better understanding (see Fig. 4). When they ask this question, however, it appears to create a deviation for the doctor. Perhaps the doctor has a goal of discussing the patient's medication and also the social engagement activities the patient has enjoyed this week. When the patient asks a question related to their symptoms this creates a mismatch for the doctor between what is expected and what is happening. Initial avoidance occurs and then a request for assistance from the patient.

Fig. 4.

Model based on an example by McCabe & Priebe (Reference McCabe and Priebe2008) of a doctor seeking to review a patient's medication as well as their level of social engagement for the past week while the patient is seeking to understand some aspect of their interactions with other people.

This example highlights the simplicity of Figure 2. Actually, both the doctor and the patient will have many goals that are important to them when they are interacting. According to PCT, these goals are arranged in parallel and hierarchically in a network of negative feedback control systems. Elsewhere we have discussed the role of multiple goals in the manifestation of psychological distress (e.g. Carey, Reference Carey2008a, b; Mansell, Reference Mansell2005). For this example, however, it can be appreciated that the doctor, as well as the patient, may be experiencing conflicting goals. The doctor might have a goal about discussing particular topics but may also have a goal about keeping the patient engaged. Now, in response to the patient's question, if the doctor does things to keep that patient engaged (by answering their question) that will increase the deviation for the doctor's other goal about what should be discussed in the session (from the doctor's perspective). If the doctor decreases the deviation about what should be discussed by staying on the topics of medication and social engagement, this will increase the deviation away from the doctor's goals about keeping the patient engaged in the session. The doctor's conflict in this situation can be understood as having an important overarching goal and two incompatible goals related to achieving the overarching goal (see Fig. 5). These goals might not always be incompatible but in this context they are.

Fig. 5.

Possible internal conflict between incompatible goals of the doctor in the example by McCabe & Priebe (Reference McCabe and Priebe2008) resulting in indecision and uncertainty.

The literature provides some clues for therapists about important goals to adopt when providing treatment. Although it seems to be rarely stated explicitly, it does not seem contentious to suggest that a prerequisite for therapy to commence is that the client must consider, talk about, or otherwise express their problem, or at least a problem that is relevant to therapy. So the therapist needs to establish an environment that is conducive to this.

Prior to coming for treatment, however, it is likely that the client has thought about their problem and talked about it with people other than the therapist. Therefore, it is not talking about their problem per se that is important (because they may already have been doing this), but talking in a focused and specific way about the problem. A range of evidence suggests that the manner in which the client thinks about their problem normally can be problematic. For example, ruminative thinking (Watkins, Reference Watkins2011) and avoidance of experiencing emotion (Hayes et al. Reference Hayes, Wilson, Strosahl, Gifford and Folette1996) are associated with the maintenance of distress because they result in avoidance of talking about the problem, but helping clients focus on emotional experience (Johnson, Reference Johnson2002), deeper meanings such as ‘core beliefs’ (Dudley et al. Reference Dudley, Kuyken and Padesky2010), and directly addressing their problems (Nezu & Perri, Reference Nezu and Perri1989) is associated with the long-term relief of distress. We suggest that, mostly in therapy, the way in which this relief is facilitated is through talking to the client in various ways (questioning, reflecting, etc.).

While this kind of directive, focused conversation is an element of many different therapies, it has been distilled as the main element in a transdiagnostic cognitive therapy called the Method of Levels (MOL; Carey, Reference Carey2006) for which there is accumulating evidence collected in naturalistic studies conducted across different time periods, contexts, and therapists (e.g. Carey et al. Reference Carey, Carey, Mullan, Spratt and Spratt2009). It is beyond the scope of this paper to describe MOL in detail; however, it is a focused problem-solving cognitive therapy in which the only activity is to facilitate the client's in-depth exploration of their incongruent attitudes and beliefs in order to find higher-order, more important values and ideals through which this incongruence can be reconciled.

MOL is based on the principles of PCT and maintains that by using questioning to encourage the client to review their problem in detail the client will become aware of aspects of their problem they had previously not attended to. In particular, the therapist is involved in a type of guided discovery to help the client focus on their present moment thoughts and feelings and how they may be related to longer term goals, beliefs, and values. For this process to be effective the client needs to be willing to peruse and express whatever comes into their mind so that they can listen to the idea from outside their head rather than from just inside it. We hypothesize that it is this feature of the therapeutic relationship (providing an opportunity for unrestrained examination by the client) that sets the therapeutic relationship apart from other relationships in the client's life and makes the therapeutic relationship therapeutic.

The therapeutic function of the therapeutic relationship, therefore, arises when an opportunity is created for the client to scrutinize problematic material in a focused, sustained, and uncensored way.

In day-to-day social interactions, people generally filter what they say and phrase things in particular ways in order to achieve certain effects (or goals) during the conversation. For example, they might not want to offend their friend or worry their partner or appear incompetent at work so they portray things accordingly. This process is exaggerated in anxious individuals and has counterproductive effects (Meleshko & Alden, Reference Meleshko and Alden1993). However, in an ideal therapeutic relationship, clients will say whatever comes into their mind and reflect on it after it has been expressed rather than before. In this way clients are able to spend time examining ideas, thoughts, and images that might have otherwise only been in their awareness fleetingly, peripherally, or that which they might not have attended to whatsoever. They might have been thoughts the client was trying to block out and not think about at all. The hierarchical organization of goals can be used to advantage here to help clients become aware of higher-level goals that might be influencing their current state. A simple, brief example of hierarchical goals is illustrated in Figure 5 for the doctor. PCT asserts that the goals of all people are organized hierarchically. A goal to arrive at work on time helps achieve the more essential goal of performing well at work which helps achieve the higher level goal of building a successful career which then helps achieve the goal above that of living the life one wants to live. This hierarchical arrangement is exploited in MOL by directing a client's attention to the higher order but out of focus areas of their life related to the problem that they are currently aware of.

For example, as clients talk about their problems they might say something like ‘That sounds stupid’ or ‘I don't know why I reacted like that’. These statements could be thought of as ‘meta-statements’ in that they are evaluations of what has just been expressed. A therapist with an understanding of PCT would assume that this statement indicates that the client's awareness may have just moved to a more important, more highly valued goal and so, further questioning would be used to direct the client's attention to any background thoughts occurring about this higher level goal. The therapeutic relationship will therefore be therapeutic, when it facilitates a client's detailed exploration of their problem so that attention can be directed to background thoughts that enable awareness of other important goals, thus developing mental flexibility.

The hierarchical arrangement of goals can help therapists prioritize their tasks during treatment delivery. While the establishment of warmth and trust, for example, are important goals, they should be considered a means to an end and not the end in themselves. For example, if one asked ‘Why should warmth and trust be established?’ one could answer with ‘So the client will feel safe to examine all facets of their problem’. Warmth and trust, therefore, are being used to create an environment where the client can freely explore their problem. The reverse, however, does not apply. If one asked ‘Why should I encourage the client to explore freely?’ the answer might be something like ‘So they can become aware of aspects of their problem they previously hadn't considered in much detail and by doing this can find solutions for themselves through cognitive reorganization’. The answer would not be ‘So that warmth and trust will be generated.’ On the other hand, if one asked ‘How can my clients be encouraged to freely examine their problems?’ the answer might be something like ‘By establishing warmth and trust.’ In PCT it is accepted that ‘Why?’ questions tend to move a person's attention up the hierarchy of control systems whereas ‘How?’ questions tend to move attention to lower levels. Encouraging people to investigate their internal experiences, therefore, is one of the most important goals of therapy. ‘Why?’ and ‘How?’ questions can be very useful for therapists as well as clients. Therapists could ask themselves ‘Why?’ about the various strategies they use in order to identify the goals they are seeking to realize in treatment. Moreover, once they have identified important goals they could ask ‘How?’ questions to discover different ways of achieving those goals.

In line with this approach, there is emerging evidence to suggest that the extent to which the client feels ready and able to explore their problem and answer the therapist's questions predicts symptom improvement following a therapy session, over and above the client's perception of the therapeutic alliance. However, both a rating of therapist adherence to the therapy and the client's rating of the working alliance at the end of one session predicted their readiness to talk about their problems at the beginning of the next session (Kelly, Reference Kelly2011). These findings both support the notion of the client's openness and ability to talk freely being important, for therapy, and suggest that a focused form of questioning as part of a structured therapy and the therapeutic relationship facilitate this readiness.

This model can be applied when there appears to be ruptures in therapy. For example, during the conversation, the therapist might get the idea that the client is thinking about what they are going to say next or searching for the right answer (perhaps they have goals about presenting themselves in a particular way to the therapist). This can be addressed quickly and directly by asking questions like ‘Are you thinking of the right way to say what you want to say?’ or ‘Are you wondering what I'm thinking just now?’ Thus, without explicitly focusing on the client's communication, their free expression can be promoted by the questions that are asked. Such questions should focus on experiences in the present moment, increasing the likelihood of clients being able to access the perceptions that are currently occurring in therapy. Reis & Brown (Reference Reis and Brown1999) highlight the importance of ‘preparing’ clients for therapy by the therapist and the client becoming clearer of each other's expectations and, therefore, achieving more convergent perspectives. In the context of this article, treatment preparation could involve the therapist explaining to the client the importance of talking freely and the kind of questions they might ask to help facilitate the client directing their attention to background thoughts.

One client put it succinctly: