Agency via Knowledge, pt. 1: A Unifying Therapeutic Theme

Recently I got to present this early version of a project I’ve been developing with some of my colleagues:

Given the surprising amount of positive feedback this poster has gotten from researchers and practicing therapists alike, I’ve been inspired to do a deeper conceptual dive into the “meta-process” we’ve identified. Below is an initial preview of my evolving thoughts on what I believe is a common mechanism of many forms of therapy, and of many paths to psychological growth. I invite any and all feedback as I work to flesh out and refine these ideas for a forthcoming manuscript.

The Thesis

Each of the major therapeutic modalities shares, implicitly or explicitly, 1) a core aim of helping individuals exercise greater agency over their own lives; and 2) an assumption that this is achieved primarily by helping them exercise greater agency over their own working knowledge base.

The Thesis Explained

By “agency,” I mean here the capacity to choose and direct one’s own life. An “agent”, according to Merriam-Webster, is “one that acts or exerts power” or “produces or is capable of producing an effect.” Applied to one’s own life, this means one has and exercises the power to produce life experiences and circumstances of one’s own choosing—be that a particular career, a loving family, a group of trusted friends, a life of serene contemplation or adventuresome travel, a home one is pleased to inhabit, etc. Exercising agency is not the same as being all-knowing or all-powerful, nor does it guarantee that all of one’s chosen goals will be fulfilled. Rather, it means that one does the things that constitute self-authorship and tend to generate success: one is able to choose one’s own goals and strategies based on the information available, and to take action in light of them; to solve problems in flexible and creative ways; to learn from failures and setbacks, and adjust one’s goals and/or strategies accordingly. In short, it means that one is a competent and responsible manager over the overarching project of living one’s life.

By one’s “working knowledge base,” I mean one’s actively maintained, updated, and integrated understanding of whatever aspects of oneself and the world are relevant to managing one’s life. This includes, for example, a working knowledge of what kinds of careers or relationships or lifestyles are possible; what steps, activities, or challenges are involved in pursuing each one; how and why one thinks and feels toward each; one’s strengths and weaknesses; the nature and malleability of human beliefs, emotions, and habits, including one’s own and other people’s; and, indeed, what further knowledge or skills one needs in order to figure all of this out. To have a working knowledge of any of these things means that you can access it when you need it, and that it has fully “sunk in” for you; that is, it has the power to stir your emotions and motivate your actions. To have a working knowledge, as opposed to just any set of beliefs and attitudes that stir and motivate you, is to have done the work of forging your beliefs and attitudes through active engagement with reality—which includes gathering the needed data (both introspective and extrospective), reflecting on it critically, and checking and updating your conclusions through continual experience. This is hard work, and it is work that never stops. It is chosen, self-directed work. For individuals struggling to make sense of deep loss, failure, misfortune, or injustice, it can be very painful work. But it is work that needs doing if one wants the power to envision and enact a more satisfying life. It is agential work. The fundamental task of therapy, I contend, is to inspire and empower this work.

The Thesis Applied

Below are examples of the knowledge work needed to inform and motivate two very different kinds of therapeutic change, along with the role that various therapeutic approaches and techniques might play.

Example 1. Suppose you’ve expressed a desire to quit smoking cigarettes, but you just haven’t been able to do it. What working knowledge would you need in order to inform and motivate this change?

Above all, you would need to really know that the act of smoking hurts you more than it benefits you, all things considered. If you can recite the claim that “smoking is bad for me” but you feel no aversion or dread as you light up your next cigarette, then this knowledge is not really “working” for you yet. To make it real to yourself, you would likely need to:

• Learn about and concretely project some of the negative health consequences involved, as they would impact your life and goals.
• Understand what needs or values your smoking habit is fulfilling for you—whether it is relief from anxiety, opportunities to socialize and connect with other smokers, a sense of pleasure, etc.—and consciously consider whether those values outweigh the costs for you, and/or whether you can fulfill them in other ways. If, upon considering all of these factors, you reach the conclusion that smoking is indeed doing you more harm than good, your affective responses to smoking will likely also shift, and you will be more motivated to work on quitting.
• Even then, you will sometimes lose access to this fresh new knowledge (that the harms of smoking outweigh the rewards for you), which needs time to cement and get integrated into the rest of your working knowledge base. This will especially be true when you encounter cues that make the immediate rewards of smoking so salient to you as to eclipse your knowledge of the long-term harms—such as when you sip the cup of coffee that you always used to enjoy with a cigarette. Thus it helps to limit your exposure to such cues, and to practice intentionally shifting your attention toward other cues that make your new knowledge more accessible.

These processes are covered by the psychoeducation, motivational enhancement, stimulus control, and mindfulness-based components (respectively) of the most well-established therapeutic treatments for smoking cessation.

Example 2. Suppose you find yourself stuck in an abusive relationship of many years. Perhaps you believe “on an intellectual level” that “my life would be better if I ended it,” but you cannot begin to imagine what such a version of your life might look like, nor specify any concrete steps you could take to bring it about. Your belief is at the level of a vague, untested speculation, and is unlikely to motivate you to leave. To turn this belief into “working knowledge,” you would need to do a lot of work to specify, in vivid enough detail, the realistic costs and rewards associated with staying in the relationship versus leaving it. Consider some of the steps this work might involve:

• First you may need to gain awareness of the unadmitted anger and resentment you feel toward your partner, or the unadmitted fear that you would be unable to make it on your own. This is the kind of insight that a psychodynamic therapist might help you gain, both by offering interpretations you had not considered and by strengthening your ability to mentalize—i.e., “to differentiate between internal and external reality and to generate representations of [your] own and other people’s mental states.” A humanistic therapist could also aid you in this task, both by empathically reflecting your emotional states in a way that helps you more fully articulate them, and by providing a safe and supportive space for you to open up to aspects of your experience that might have previously felt too threatening. Lest you also have an implicit belief that abusive relationships are “the only kind I’m capable of,” the corrective experience of a supportive and empathic relationship with your therapist would help you update that aspect of your knowledge base.
• Having consciously admitted your fear that you cannot make it on your own, you might then need to check it against reality, both by considering the evidence you already have available (e.g., your ability to get by on your own prior to this relationship) and by gathering new evidence (e.g., making some independent decisions and seeing how they go). In other words, you may need to do some cognitive restructuring and conduct some behavioral experiments—two of the main building blocks of cognitive-behavioral therapy.
• To do this data-gathering successfully, you may need to learn to tolerate the distress that certain painful conclusions (e.g., “I’ve been needlessly tolerating abuse all this time”) and anxiety-inducing behavioral experiments (e.g., standing up to your abusive partner) would entail. This is where “third-wave” interventions like mindfulness, acceptance and commitment therapy, or dialectical behavior therapy would come in especially handy, as they would offer you ample tools for tolerating and distancing from distress enough to bring your growing knowledge base to bear on your choices.
• Finally, to make a fully informed decision about whether to stay in the relationship or end it, you may need a structured and supportive process for weighing the costs and benefits of each alternative against each other, generating a realistic action plan, and troubleshooting obstacles. Motivational interviewing is a therapeutic technique designed to help you do just this.

Each of these varied therapeutic approaches, I contend, derives its value from the role it plays in helping people engage in the active, non-defensive pursuit and internalization of new knowledge about what is really true and what they really want, so that they are empowered to act accordingly. Stay tuned for my further reflections on what this might mean for psychotherapy researchers and practitioners.