Agency via Knowledge, pt. 2: Beyond the “Therapy Wars”

Illustration: Peter Gamlen (from Burkeman (2016), “Therapy wars: the revenge of Freud,” The Guardian: https://www.theguardian.com/science/2016/jan/07/therapy-wars-revenge-of-freud-cognitive-behavioural-therapy)

The psychotherapy field suffers from a serious and persistent lack of theoretical unity. Other scholars have written at length about what might account for this and how severe a problem it poses for the field. Here I want to suggest that reconceptualizing the existing therapeutic frameworks in terms of their promotion of agency through knowledge, as described in my previous post, may be an important step toward establishing a common core, as it would help reconcile some of the seeming conflicts that have kept the field divided.

To take just one example, the field is currently entrenched in a conceptual standoff between those who regard the process versus the content of human thought as more important to target in psychotherapy. Interestingly, therapeutic approaches rooted in the Psychoanalytic and Behaviorist traditions have largely converged in their prioritization of process, albeit in different ways and for somewhat different reasons. The psychoanalytic tradition explicitly views conscious thought content as being at the constant mercy of reality-distorting motives and defenses that operate outside of awareness. As such, any effort to engage directly with this content—such as by offering counter-evidence or checking its logical validity—would just perpetuate the illusion of objectivity created by the patient’s defensive processes, instead of bringing those processes to light. Meanwhile the Behaviorist tradition explicitly regards thoughts as conditioned behaviors controlled by environmental contingencies, leaving no theoretical room for checking their veracity or modifying them based on evidence (e.g., Gross & Fox, 2009). Both traditions thus emphasize the importance of changing the process by which patients relate to their own thoughts: how attached they are to those thoughts, how flexibly they are able to move between or away from them, and so on.  One might say that these traditions emphasize agency while deemphasizing knowledge. 

By contrast, traditional cognitive approaches rooted in “information processing” models of human cognition tend to focus on correcting the distorted content of patients’ thoughts and beliefs, but are less attentive to the different motivations that might energize a person’s thought processes. As such, a cognitive psychologist might err on the side of trying, in effect, to force knowledge on someone who defensively resists it, without first identifying or addressing the source of that resistance. The tendency to view people as mere information processing machines, in other words, may lead to an emphasis on content but an underemphasis on agency in choosing whether and how to engage with such content to begin with.

If we adopt the agency through knowledge model I’m proposing here, the apparent conflict between content- and process-focused approaches would dissolve. Rather, we would come to think in terms of an agential metacognitive process that has working knowledge—i.e., accurate and useful content—as its goal. The motivation to work toward knowledge must itself come from past or current experience of the rewards this work can bring: more effective decision-making, increased confidence in one’s choices, and the sense of vitality that comes from being awake and alive to the full reality of one’s experience. Many existing interventions already get at these ideas in many different ways, using many different terms (such as “willingness,” “acceptance,” “self-congruence,” “metacognition,” and “mindfulness,” just to name a few). Having the unified perspective I’ve proposed here would allow us to develop a common language for what we are really doing when we utilize these various strategies. For instance, we can now speak in terms of summoning the courage to face painful truths, arming oneself with knowledge, doing the work to make one’s knowledge fully real to oneself, valuing one’s need to really know, etc. It would also allow us to be more judicious about when and how to use them, based on an assessment of what working knowledge a patient currently needs in order to make more effective choices in her identified problem area; what information, inspiration, or experience she needs next in order to work toward that knowledge; etc.

In this way, the “agency through knowledge” model can provide us with a parsimonious understanding and vocabulary for the many stages and manifestations of the therapeutic change process. Thus clinicians can learn and capitalize on the distinctive strengths of each therapeutic approach, while keeping in mind the fundamental task that unifies them all.

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