‘Epistemic Injustice’ in Therapy?

Most of the time I spend scrolling through Twitter is probably time I won’t ever get back, but the other day I ‘overheard’ an interesting conversation between two academics on what one said was psychological therapy’s primary aim: constructing a sense of dignity, and the other academic voicing the opinion that in fact, therapy often risks having the opposite effect. It also introduced me to the work of philosopher José Medina on ‘epistemic injustice’ – which I will write about in another blogpost.

I will quote Nev Jones’s Twitter thread before adding my thoughts:
“I fear I’m still not great at this in Tweet form but let me try. Again very important to my argument is that these are risks, not inevitabilities. (1) when, to quote José Medina, “the epistemic agency of an informant qua informant is…subordinated to that of the inquirer’s” Or, as he continues “at the service of the inquirer’s questions, assessments and interpretations” — in which case there can be no full & equal “epistemic cooperation”. [Here one might discuss at length how this does/doesn’t play out in eg in CBTp-style ‘reality testing’]. Then there is the issue of communicative “reversibility” and “reciprocity” which JM frames as central to equal epistemic exchanges. Reciprocity seems more fundamentally absent from the traditional therapeutic relationship but again a point one could debate at length…JM then underscores the interactional relationship between hermeneutic & testimonial injustices, viz “interpretive gaps are formed & maintained [when] those who are struggling to make sense are persistently not heard & their inchoate attempts at generating new meaning… unanswered”. To continue “because of difficulties in hearing and interpreting certain things — because of hermeneutical I sensitivities — people’s credibility gets undermined. Testimonial and hermeneutical insensitivities [thus] converge and feed each other.” “[Once] hermeneutical gaps are formed…they handicap our communicative lives and are hard to eradicate.” I will stop there and say that said gaps of course emerge at multiple levels of discourse—dyadic exchanges and also the more macro levels of clinical knowledge generation.” (bold font added by me)

I’ve recently started my own therapy, and this was something I felt almost immediately – the quite unsettling one-sidedness of the therapeutic relationship. Nev Jones and José Medina raise the possibility that this inequality might be more damaging than beneficial, if it perpetuates the sense that the patient is ‘at the service of the inquirer’s questions, assessments and interpretations.’

I can think of two things that might reduce the risk of this happening:
1) The therapist should undergo their own in-depth therapy so that they truly understand how it feels to be on the other side of the power structure. Only then can they properly empathise with how their patient might be feeling during this organised, and often expensive, form of self-disclosure.
2) We can think of Jessica Benjamin’s psychoanalytic Recognition Theory (also see her book ‘Beyond Doer and Done To‘) which describes how analyst and analysand can meet and speak as equals joined by the ‘Third’. Benjamin’s work centres around achieving that ‘reciprocity’ that may or may not be present in the therapeutic encounter.

To expand on Benjamin’s theory – she argues that the therapeutic encounter should be understood as dynamic, and with a two-way directionality, both analyst affecting the analysand, and vice versa. One way the analyst could highlight this ‘two-wayness’ would be by telling the analysand how what they are hearing is making them feel. Only when the analysand starts to see themselves as a being who makes an impact on other people’s subjective experiences can they regain the sense of agency that will help them recover. The risk this runs is that the analyst must make sure that they don’t then steer the conversation too much onto their own thoughts and feelings – it should always be based in the intersubjective encounter.

This is related to what I think might be the fundamental hurdle and balancing act implicated in the therapeutic encounter – the therapist must somehow help the patient regain a sense of agency, while at the same time not ‘blame’ them for the problem they came in with in the first place. The therapist needs to communicate: that what happened to you wasn’t your fault, but now you must find the strength and agency towards repairing that ‘damage’. It aligns with an interesting and complex picture of free will and responsibility, that I am yet to understand fully…

Coaches or Clinicians?

I’ve recently started training to become a Psychological Wellbeing Practitioner in an IAPT (Improving Access to Psychological Therapies) service, and what that means is that I will soon be able to deliver Low Intensity Cognitive Behavioural Therapy to ‘clients’ with mild to moderate common mental health problems such as depression and anxiety.

The training is delivered 2 days per week by lectures and seminars from University College London, and the remaining 3 days per week I spend working at my IAPT service doing assessments and low-intensity treatments.

One thing in particular that we learnt in the first week threw myself and my fellow Trainees: the fact that we should not think of ourselves as therapists or clinicians, but as coaches. We didn’t do so big-headedly, but in our previous role (when we were doing Triage Assessments and offering people Step 2 Guided Self-Help, or Low Intensity CBT), we always thought that Step 2 was a sort of CBT-lite, and so the Step 2 clinician was therefore a sort of therapist-lite.

Also, when I was learning about IAPT as an outsider, I was wrongly led to believe that the program is training ‘therapists’ not coaches. David Clark says so himself in his ‘IAPT at 10: Achievements and Challenges’ post, he writes (under the dramatic title ‘A revolution in mental health’), that to overcome the shortage of psychological therapy available to people suffering from common mental health problems, ‘the NHS has trained over 10,500 therapists and deployed them in new psychological therapy services’ (emphasis added). This is misleading, and I often find evidence of IAPT’s main advocates (usually people with a stake in the game), claiming more for the service than it deserves. I think Clark and others should be more cautious in over-selling IAPT, because it will eventually lead to disappointment when people’s expectations aren’t managed.

Thanks to that misinformation, when I used to allocate people whom I had triaged to Step 2 treatments, I always sold it as a ‘guided cognitive behavioural therapy over 6 weeks, for 30 minute sessions’. But now that we are training to be those Step 2 ‘clinicians’, we find that we are not that at all, and what we offer isn’t Cognitive Behavioural Therapy, but rather a life-coaching session.

But – I agree with this. We shouldn’t think of ourselves as clinicians or therapists because we don’t have those skills – we aren’t taught about what happens within the therapeutic relationship, and how to more supportively guide our clients through more long-lasting psychic change. I think it also serves to prevent us from feeling also like counsellors, whose role is to sit and listen to the client as they talk about whatever they feel like getting off their chest. By reminding us that we are there to encourage behaviour change (and that’s essentially it), it makes a lot of sense to call us coaches.

Having said that, however, it’s now clearer to me just how difficult I’m going to find this year in how it jars with my fundamental values and assumptions as to how psychological therapy should be. It’s odd, and I must try to check it, but I have an almost instinctual aversion to CBT and the phrase ‘evidence-based treatment’. Aaron Beck (the founder of CBT), gives me an uncomfortable feeling, I can’t help but think he’s getting something terribly wrong, or turning something complex into something robotically simple (to its detriment). I don’t have enough learning or experience to quite put into words what exactly I distrust about Beck’s cognitive approach, and I know that it has changed and improved a lot since his day so I’m probably being hugely unfair to modern practitioners of CBT, but I have read a couple of things recently that have started to confirm my uncomfortable feeling about it…

The first was a blog post by philosopher and clinical psychologist Richard Gipps, on how Beck’s turn away from psychoanalytic psychotherapy was caused by his own misunderstanding of the theory, rather than with any fundamental flaw in the approach itself.

And the second was a journal article by Michael McEachrane on the flawed assumptions that Cognitive Therapy is based on to do with what it really means to ‘think that p‘.

I’m tempted to share these two articles with the other Trainees on my course to see what they think, but I don’t want to be the bad, critical one in the bunch.

And, I do understand why IAPT uses the CBT model so religiously. The aim of IAPT is to ‘democratise psychological therapy’ – it wants to make it accessible on the NHS, and this I fervently agree with. Unfortunately, however, CBT is the only kind of therapy that can be made ‘efficient’ and ‘wide-spread’ in this way, because it’s less about the relationship that the client has with their therapist, and more about the ‘tools’ that they learn from them. So, the therapists can be quickly and inexpensively trained, because it’s not really about them and their skills.

Research has shown that this can be effective (with about a 50% recovery rate; not bad, not good?), but the jury’s out as to how long those benefits last for, and I have a feeling that the main function of having Step 2 low-intensity treatments available on the NHS isn’t so much for the good they do, but as a sifting mechanism for finding out who are the really serious cases on the waiting list who need longer-term therapy. Without Step 2, we would have one big, long waiting list for CBT Proper (Step 3), and that wouldn’t be good for anybody.