Psychotherapy is fraught with ambiguities, contradictions, uncertainty and trade-offs. The psychologist Robin Hogarth introduced the concepts of "kind" and "wicked" feedback to describe distinct environments that optimize for different methods of decision-making and learning. When it pertains to giving and receiving good therapy, we need to better understand the environment in which therapy occurs.
Kind Feedback Environment:
In a kind feedback environment, the relationship between actions and outcomes is clear and reliable. When you make a decision or take an action, the resulting feedback is accurate, timely, and directly linked to your choices. Kind environments are typically conducive to learning and improvement because you can easily trace the cause-and-effect relationship between what you did and what happened as a result.
I love chess, and though this game can become incredibly complex and strategic, it is mostly competed within a kind feedback environment. Each move directly affects the subsequent state of the game, and the outcomes are clear and attributable to specific decisions. This type of environment allows for an epistemology based on actions resulting in known outcomes, and clear and immediate feedback.
Wicked Feedback Environment:
Conversely, in a wicked feedback environment, the relationship between actions and outcomes is uncertain, noisy, and/or delayed. Feedback in these environments is ambiguous (did my intervention work?), and its challenging to determine the direct impact of your decisions on the outcomes. Good clinical decisions, for example, can sometimes result in ‘bad’ outcomes e.g., exacerbation of anxiety, defenses; souring of a desire to work together. Because it is harder to draw direct inferences from our results, it harder to learn and improve.
In psychotherapy, feedback can be wicked. Many factors are at play, and outcomes are influenced by multiple variables beyond our control (e.g., patient variables, environmental stressors, random variations in mood, etc.). This uncertainty makes it difficult to pinpoint the effectiveness of our decisions and can lead to challenges in learning from experience. Even recall can be a challenge, as our memories are notoriously selective. Therapists can try to get direct feedback by watching videos of their own treatments but even this does not eliminate all of the ambiguity, variability and uncertainty that can occur in the next session. Theoretical models are helpful but do not alter the feedback environments in which therapists work.
An epistemology that can succeed in these environments is one that favors probabilistic thinking (i.e., what are the odds that X intervention will lead to Y response?), attributing outcomes to both circumstance and effort, is suspicious of narrative/theoretical over-reach, is open-minded to new learning/updating knowledge and premises, embracing uncertainty and seeking feedback from multiple sources.
In Part II of this post, I apply the insights of strategist and former world poker champion, Annie Duke, to developing this “wicked” epistemology that I believe is necessary for better clinical decision-making.
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