Epistemology and Psychotherapy
**A quick note before setting off here. This particular post has been developed in preparation for a presentation I will be doing for a group that I participate in where we explore the overlap of philosophy and therapy. As such, the tone and baseline level of knowledge I’m operating from might be a little different from other posts. Still, I thought it was an interesting topic and relevant to a lot of what I try to explore here. It also seemed like it would be weird to write something about philosophy and psychotherapy and not make it available on this platform.**
Epistemology is one of the central interests of the field of philosophy, with a rich history dating back, in the Western cannon, to the days of the Ancient Greeks. Given epistemology’s central concerns, questions such as what constitutes knowledge, how knowledge is acquired, what are its limitations, etc., it makes sense that philosophy—a discipline concerned with making assertions about fundamental aspects of the human condition—would not only want, but would in fact need, to take knowledge up as an object of concern. After all, at the bases of any kind of assertion, argument, or claim to knowledge, exists some implicit or explicit assumption about why or how one can make that claim in the first place.
One of the most famous and earliest inquiries into the nature of knowledge is Plato’s Allegory of the Cave. In this allegory, Plato describes a set of prisoners who only ever get to experience the objects of the world as shadows cast against a cave wall, visible from the place where the prisoners are chained. Taken up from an epistemological lens, questions can be raised as to whether the prisoners in the cave could be said to “know” the objects in question and to what degree their limited experience of reality is representative of a reality that those not held captive in the cave can access. In the context of the allegory, reason then comes to serve as a method for coming to know objects more accurately (represented in the allegory by attempts to venture out of the cave and into the sunlight). This leads to an early theory of mind, wherein “objects” are taken up as “ideas” that, via epistemology, can only be “known” when the ideas that the mind holds represent a “true” belief.
Aristotle would later offer his own take on epistemology, providing the basis for a longstanding philosophical debate between Idealism and Realism that has served as the basis for most epistemological inquiry in the subsequent centuries. Essentially, where Plato preferred metaphysics and reason, Aristotle argued that all knowledge originates out of, and should be grounded in, a sensory observation of the physical world. Laying the foundation for knowledge based on scientific materiality, rather than abstract thought, Aristotle felt knowledge should be restricted to things which could be perceived, measured, counted, etc. By way of contrast to Plato, Aristotle offered an epistemological framework that placed more value on inductive and empirical approaches to the accumulation of knowledge, whereas Plato’s was centered around the world of ideas and abstraction.
In jumping ahead several centuries, we can observe how this debate between idealism and realism continued to evolve in the context of philosophical thought. Aristotle’s realism was a major influence on the rationalism and empirical advances of the Enlightenment, perhaps best encapsulated by the work of Rene Descartes. In addition to making considerable advances in math and science, Descartes went so far as to try to work out of a framework of rationalism that could be used to answer critical questions related to God and the soul. This focus on a cognitive and empirical basis for all experience, which needed to be verifiable beyond a reasonable doubt, lead to Descartes’ famous maxim “cogito, ergo sum”, or “I think, therefore I am”. Descartes’ belief that all empirical knowledge needed to be built on top of some verifiable truth led him to the conclusion that all that could be known for sure was that he was a “thinking thing”. This belief ultimately led to his elevating the mind and soul as “thinking” and disparaging the material body as “unthinking”. These ideas were ultimately picked up and expanded/commented upon by other Enlightenment-era philosophers inclined to emphasize cognition and reason, such as Locke, Berkeley, Hume, Kant, etc.
This crop of thinkers eventually gave rise to a series of dissenters, beginning with Kierkegaard and traveling through much of the late 19th and early 20th-century continental tradition. These writers attempted to undermine the primacy of cognition and reason by reintroducing the importance of passion, language, and the body into the philosophical tradition. Nietzsche, Heidegger, Sartre, Foucault, Derrida, Deleuze, and their many respective acolytes would all in some way come to criticize the primacy of logic and reason in the human experience and as the only source of knowing for philosophical inquiry.
The question of knowledge bears significant influence on present day approaches to psychotherapy. Though Freud had often claimed an intention for his theories to largely be accepted as a kind of science at some point in the future, with a belief there would be various neurological corelates for the various concepts he developed, psychoanalysis has always been and continues to be rooted in types of observation that extend beyond material observation. The lack of operationalizability of many psychoanalytic concepts has been challenged in recent decades, and there is some good academic work happening at various institutions to develop more of a research basis for psychoanalytic and psychodynamic theory as a practice. However, psychoanalysis has always been mostly satisfied to be a highly idiographic practice, developing its rich theoretical foundations through observation and application in the clinical setting.
For many years, the primacy of the clinical encounter held sway, through psychoanalysis and into the humanistic tradition and its various subcategories (person-centered, Gestalt, and existential psychotherapy). However, this approach began to come under serious scrutiny with the introduction of behavioral and cognitive approaches to therapy. Concerned primarily with accumulating and organizing observational data, these approaches hung their hat on the notion that their underlying principles, and the foundation of knowledge on which they were based, were far more scientific, and therefore verifiable, than the work of psychoanalysis. With the increased involvement of managed-care and academic psychology in clinical settings, this eventually led the way to the “evidence based-treatment” or EBT models we hear so much about today. This pernicious block of letters has become fetishized as a substitute for what some may argue is the real work done in therapy (based more in relational, structural, and phenomenological principles) creating the illusion that there ought to be some manualized and overly deterministic approach to treatment that should be applicable to broad swaths of the public, organized and ordered along lines of scientifically validated categories of psychopathology.
This has largely become the accepted manner of practice and is the pedagogical track along which most psychotherapy training programs in the US operate. A significant amount of standardization in graduate and undergraduate level courses has been attempted to make sure that cognitive and behavioral approaches to psychotherapy make up the bulk of psychotherapeutic training.
My interest is not necessarily in arguing against the utilization of CBT and its many iterations. Rather, what I think gets missed is the limited utility in a purely cognitive-behavioral approach to psychotherapy. I’ve met with many clients who, while “test-driving” therapists, lament having attended an initial session where someone runs them through a battery of questionnaires to determine how depressed or anxious they are, rather than simply having a conversation with them about their daily life and practices. I think there is also a question to be asked about whether CBT can be effective at treating more intensely characterological problems or generating lasting change that helps a client not just understand their “symptoms”, but also the underlying mechanisms of their experienced form of “pathology” (the repetition compulsion I’ve discussed in other posts). I also can’t help but wonder to what degree some of these practices are purely about assuaging the anxieties of the clinician being faced with the challenging proposition of needing to step into the unknown of another person’s suffering, with overly rigid and generalizable theoretical principles serving as a sort of buffer against the real and at times very destabilizing work of the therapeutic encounter.
CBT limits the realm of knowing to the mind. Even the “B” in CBT, though nominally embodied, as it is meant to explore specific actions or behaviors, only understands behavior in the realm of observational data that can be refashioned into intellectual principles and constructs. CBT, in the way it is taught to most clinicians, lacks the sophistication to discuss things like emotional experience, human subjectivity, or embodied phenomenology, all categories that are going to have a remarkable bearing on things like emotion/affect and the ways in which our particular brand of suffering gets structured into our relationship with the world and others.
Another deficit in perspective worth remarking on is that operating in conversation with the ideas posited in Bessel van der Kolk’s classic The Body Keeps the Score. Required reading for those who work out of a trauma model, van der Kolk’s work talks about the embodied nature of the trauma response and the manner in which those suffering from PTSD and other types of complex trauma are compelled into non-conscious reactions to stimuli which carry some kind of reminder of the initial physical, emotional, or interpersonal injury (some classic examples being the former service person who comes apart at an unexpected loud noise or a person with a history of victimization flying into a rage when they feel like their sense of control or safety is being compromised). What does this type of response have to tell us about the process of “knowing”. Most of these folks logically “know” their reaction is incongruent with whatever is provoking that response, but the body (and more specifically their central nervous system) can claim to “know” something different. For many of us, this type of embodied, unconscious knowing can actually be beneficial. It’s ultimate function and purpose is to keep us safe in the face of a detected threat. But what happens when it is put through a set of conditions that, to the rest of us, seem to cause it to become calibrated in a manner that is difficult to understand. Is it right to say that the body in that instance is somehow possessed of incorrect knowledge? Or is it rather that the body could be said to know something more about the limits of human safety that many of the rest of us take for granted?
On a recent podcast I was listening to, the host was talking about a piece of literature a friend shared with him. The topic of the paper was on dissociation, another common response to trauma. The host was talking about the argument of the paper being a challenge to the common, evidence-based approach to what theoretically should happen when a dissociative response shows up in session. The common knowledge intervention is that one should immediately ground the client. That the therapeutic encounter can be a place to experientially work these skills with the client. The reframing being argued for by the podcaster, was that to do this immediately might in fact be premature. The host reflected on—and I share this sentiment—what he called the creativity of the dissociative event. That in a state of dissociation, our first obligation is to attune to that moment and try to listen to what that response is trying to share with us about the client’s lived experience. That dissociation has just as much “value”, information, or—to keep with the themes being developed here—that the dissociative response “knows” something that we would be wise to listen to. This is analogues to some of the ideas developed in the work of Phillip Bromberg and his exploration of self-states, dissociation, and trauma in the work of psychoanalysis, which I would recommend everyone read at some point.
These are just some preliminary concerns. As always, there’s more to be explored here. But I think it’s important, particularly as the lens of what constitutes “good” therapeutic work in the ideas of those trying to wrestle control over the discipline (namely academia, managed-care, and those trying to codify their own particular brand of understanding therapy as the only way to do therapy) to start with a reflection on our epistemological values, and what kind of biases those might be imparting and excluding in this messy and vast realm of what it means to heal another in the context of a human relationship.
