Epistemology is a philosophical term that is taken to mean the study of how we come to know things. It is a theory of knowledge (not to be confused with a knowledge of theory), especially concerned with the ways in which we obtain knowledge, the validity of the knowledge obtained and the extent to which this knowledge can be applied.
Epistemology is a jargon term but every time clinicians wish to understand how we make therapeutic decisions or consider the best ways to learn our skills, we are practicing epistemology. In Part I, I reviewed Hogarth’s work on two feedback environments that facilitate different learning and decision-making strategies. Psychotherapy is largely practiced in a wicked feedback environment and, I argue, would benefit from a wicked epistemology. Annie Duke, strategist and former world poker champion has written a book called Thinking in Bets, which I believe contains a number of insights around which to found a such a way of thinking about treatment.
Here are some insights, as applied to psychotherapy (please feel free to write your own):
Decisions ≠ Outcomes: Duke emphasizes that a good decision can lead to a bad outcome and vice versa. It’s important to evaluate clinical decisions based on the information available at the time of making them (i.e., the patient's emotional state, therapeutic relationship), rather than judging them solely based on how things turned out. A bad decision (e.g., a premature confrontation or overly pedantic interpretation) may precede a good outcome (e.g., symptoms may improve). However, there are many intermediate variables that we do not see or consider (e.g., the person could have won a lottery!). One could conclude that this intervention worked or was good, because it preceded a good result. She calls this bias ‘resulting.’
Instead of focusing exclusively on treatment outcomes (which are a good thing to routinely evaluate), we should also be focusing on the quality of our decision-making process and accepting a certain probability of negative outcomes that can follow after good decisions.
Probabilistic Thinking: Duke encourages people to think in terms of probabilities rather than absolutes. Therapeutic change is uncertain, much like a poker game, and developing the ability to see various outcomes (rather than programmatically thinking of textbook dialogues) can lead to more humility and better decision-making. If we assigned probabilities of success to our interventions, we might avoid going ‘all-in’ on decisions that have a higher margin of uncertainty.
Separate Luck and Skill: In therapy, extraneous variables play a significant role. Duke advises separating luck from skill when evaluating outcomes. By attributing success solely to skill and failure solely to patient variables (i.e., fundamental attribution error), we fail to learn and improve from our experiences.
Hindsight/Storytelling Bias: Past events are predictable when we construct a narrative around it. This is often an advantage in supervision—we see how things turned out (which the supervisee does not, in the moment) and thus we are able to construct a post hoc narrative that is theoretically sound and has a high degree of explanatory power. However, how well can this narrative or theory predict future interactions? Critically examining our feedback and narrative deductions for hindsight bias helps avoid the trap of thinking we could have predicted outcomes more accurately, based on past (and not future) events.
Open-mindedness and Humility: Duke emphasizes the importance of being open to updating our beliefs based on new information. This is essential for improving decision-making over time. How often do we update our theoretical knowledge? Are we only looking at convergent/confirmatory sources or also divergent sources of information?
Feedback and Accountability: Seeking feedback from others and holding ourselves accountable for our decisions can lead to better outcomes and continuous improvement.
Embracing Uncertainty: A fundamental attitude of therapeutic change involves embracing the unknown and uncertain. Baird Brightman, a psychologist, once wrote that therapists have 3 biases: 1) to know things 2) to be potent enough to do things and 3) to be seen and a kind, good object. When we therapists are faced with situations where our knowledge is uncertain, or our ability to act is compromised or our intentions are not well-communicated or received, what do we do? Do we revolt against uncertainty and push harder, blame the patient or sink into quiet resignation? What can it look like to stay in uncertainty and moments of hesitation (which I rarely see in most published transcripts)?
If you are a clinician or a client, let me know what you think about this wicked epistemology!
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