Epistemic styles

Royce (Reference Royce1964) proposed that there are three core ways of knowing (the rational, the empirical, and the metaphorical), which he termed epistemic styles – and that our epistemic style shapes our world view (Royce et al., Reference Royce, Coward, Egan, Kessel and Mos1978). The rational epistemic style involves relating to the world through one’s rational/analytical skills: beliefs are evaluated according to their logical consistency. The empirical epistemic style involves relating to the world according to one’s senses: beliefs are evaluated according to observable evidence. The metaphorical style involves relating to the world through symbolic experience. Rather than analytical or deductive reasoning, this style relies on symbolic experience and analogical reasoning to evaluate beliefs. It is concerned with the ‘construction and transformation’ of meanings (Lyddon, Reference Lyddon1991; p. 589). These concepts are a useful categorisation of broad overlapping cognitive styles. Lyddon suggested these styles correspond to three types of cognitive therapy: the rational approach is epitomised by Ellis’s rational emotional behaviour therapy (REBT), the empirical approach by Beck’s cognitive therapy (CT), and the metaphorical by constructivist cognitive therapy.

Constructivist therapy, according to Michael Mahoney, one of its original advocates, adopts a more proactive (as opposed to traditional CBT’s reactive) view of cognition and the organism, emphasises tacit (unconscious) over conscious core ordering processes, and ‘promotes a complex systems model in which thought, feeling, and behaviour are interdependent expressions of a life span developmental unfolding of interactions between self and (primarily social) systems’ (Mahoney, Reference Mahoney1991; p. 8). Although less well known in the UK, constructivist therapies have taken root in Europe and South America. Constructivist psychotherapies are less structured, problem-focused or goal-directed than standard CBT. Their aim is to facilitate the co-construction of new meanings for the client, usually without pre-conceptions and with a particular interest in selfhood and identity (Mahoney, Reference Mahoney1991; Guidano, Reference Guidano, Neimeyer and Mahoney1995; Neimeyer, Reference Neimeyer2009). In keeping with the metaphorical episteme, methods to change perspective are more experiential and emotion-focused. In the wider psychotherapeutic sphere, psychoanalytical and post-structuralist therapies operate in this epistemological region (for instance psychoanalytical therapists use more symbolic and metaphorical thought processes, whereas CBT therapists rely more on reason and logic; Arthur, Reference Arthur2000). Within the broad church of contemporary CBT, the metaphorical episteme is dominant in third-wave approaches such as acceptance and commitment therapy (ACT: Hayes et al., Reference Hayes, Strosahl and Wilson2003) and mindfulness based cognitive therapy (MBCT: Segal, Reference Segal2001). In Barnard and Teasdale’s interacting cognitive subsystems (ICS) model, on which MBCT is based, there are two routes into emotion, the propositional which involves explicit, conscious beliefs and statements about the world, and the implicational which involves more tacit, metaphorical cognitive processing (Barnard and Teasdale, Reference Barnard and Teasdale1991; Teasdale and Barnard, Reference Teasdale and Barnard1993). Standard CBT focuses on the propositional whereas third-wave CBT is seen to work through targeting the implicational mode.

Rational-empiricist versus constructivist approaches

Mahoney (Reference Mahoney1991) collapsed the rationalist and empirical therapies into a single rationalist category; what research there has been in the area has tended to use this dichotomous distinction: rationalist versus constructivist. Therapist epistemic style distinguishes personal construct therapists from CBT therapists (Winter and Watson, Reference Winter and Watson1999), predicts therapist allegiance to different models (Neimeyer and Morton, Reference Neimeyer and Morton1997) and is associated with clients’ preference for particular types of counselling (Neimeyer, Reference Neimeyer1993). Of more interest to the purposes of this paper, epistemic style also seems to be associated with the type of techniques therapists employ: more rationalist therapists use techniques such as thought and belief challenging, whereas those with a more metaphorical style use more constructivist techniques (Lee et al., Reference Lee, Neimeyer and Rice2013; Toska et al., Reference Toska, Neimeyer, Taylor, Kavas and Rice2010).

Each epistemic style is a lay form of a more formal epistemology. Rationalist philosophy has its origins in Stoicism in the ancient world, and the writings of Descartes, Leibniz and Spinoza during the enlightenment. Murguia and Díaz identify the influence of Stoicism, Buddhism, Taoism and Existentialism on the writing of Albert Ellis, Beck and David Burns (Murguia and Díaz, Reference Murguia and Díaz2015). Surprisingly, Murguia and Díaz do not acknowledge the English philosophers, Locke and Hume, who emphasised the senses as the source of acquisition of knowledge about the world, and so established Empiricism. Constructivism and CBT third-wave have their origins in a range of philosophical traditions both Eastern – (Buddhism) and Western (Kant and Schopenhauer) (Mahoney and Granvold, Reference Mahoney and Granvold2005). Although Stoicism is traditionally seen as underpinning second-wave CBT and Buddhism third-wave, Carona (Reference Carona2022) has noted similarities in the themes addressed by both philosophies.

Pragmatism

There is, however, another epistemological position that is not considered by Royce or Mahoney – pragmatism. Pragmatism is associated with the works of the American philosophers C.R. Pierce, William James and John Dewey. It is concerned with the way the individual engages with the world and considers truth as relevant in as much as it helps us to deal with the world. It rejects metaphysics and concepts of universal truths. In its most simplistic form, ‘Truth is what works’ (James, Reference James2013). I would argue that much of our lay epistemology and indeed the ‘clinical epistemology’ of CBT therapists is pragmatic. Beliefs and behaviour change because we find they are no longer useful to us, and CBT very effectively demonstrates this through behavioural experiments. For instance, in CBT for body dysmorphic disorder, the therapist does not focus on proving the distorted beliefs about body image are untrue, but rather helps the client test the utility of their beliefs that certain behaviours (e.g. social avoidance, mirror gazing) are beneficial to them. Some techniques in CBT use a concept of objective truth as their touchstone, appealing to logic or evidence (e.g. disputation or reality testing); others are more pragmatic, presenting the utility of the belief as the criterion of ‘truth’ (e.g. evaluating costs and benefits); while others, from the more constructivist/metaphorical epistemic style, explore alternative perspectives without referring to an underlying reality base (e.g. asking ‘What would you say to a friend?’ does not directly challenge thoughts but opens possibilities for a new view to emerge). These three epistemic positions (rational-empiricist, pragmatist and constructivist; see Fig. 1) can provide a helpful frame for choosing cognitive interventions and we will consider their clinical applications later in the paper.

Figure 1. Three epistemic bases for changing beliefs.

Cognitive versus behavioural techniques

Cognitive techniques have also been criticised on the grounds that they are no more effective than simpler behavioural methods, and that cognitive change is not the mechanism for change in CBT. For instance, clinical improvement often occurs before cognitive change (see for instance Blease, Reference Blease2015). A recent network meta-analysis of 45 studies of depression found that CR, behavioural activation (BA) and full CBT were equally effective and superior to waiting list and treatment as usual controls (Ciharova et al., Reference Ciharova, Furukawa, Efthimiou, Karyotaki, Miguel, Noma, Cipriani, Riper and Cuijpers2021) suggesting equivalence of techniques. For the anxiety disorders, there is evidence for the value of CR in combination with exposure for social phobia. Mattick and colleagues found that CR+exposure was more effective than exposure or CR alone (Mattick et al., Reference Mattick, Peters and Clarke1989). Cognitive restructuring and other techniques may produce change by working on different processes. For instance, imagery rescripting and CR are both effective in treating social anxiety, but CR may have a greater effect on fear of negative evaluation (Norton and Abbott, Reference Norton and Abbott2016). The evidence for cognitive restructuring compared with exposure in post-traumatic stress disorder (PTSD) is varied. Some studies have found an equivalence (Marks et al., Reference Marks, Lovell, Noshirvani, Livanou and Thrasher1998); some have shown superiority of exposure (Foa et al., Reference Foa, Hembree, Cahill, Rauch, Riggs, Feeny and Yadin2005) and some superiority of combined CR and exposure (Bryant et al., Reference Bryant, Moulds, Guthrie, Dang and Nixon2003; Bryant et al., Reference Bryant, Moulds, Guthrie, Dang, Mastrodomenico, Nixon, Felmingham, Hopwood and Creamer2008). Grunert et al. reported the failure of prolonged exposure with two industrial injury victims (Grunert et al., Reference Grunert, Smucker, Weis and Rusch2003). Rather than separate CR and exposure, the more sophisticated interplay of techniques as used in the Ehlers and Clark model (Ehlers and Clark, Reference Ehlers and Clark2000) may be the most effective (Grey et al., Reference Grey, Young and Holmes2002). In this approach cognitive restructuring is incorporated into the exposure (reliving) itself (Ehlers and Clark, Reference Ehlers and Clark2000; p. 338).

Cognitive restructuring versus cognitive defusion

Consistent with Brewin and Teasdale’s criticisms that thought challenging does not really ‘hit the spot’ when it comes to changing emotion, studies have compared cognitive restructuring with cognitive defusion (CD) techniques as used in ACT. The latter focus on cognitive processes and support clients in accepting and decentring from thoughts instead of engaging with them. These studies have shown a degree of equivalence but also differential effects on various measures. For instance, in a non-clinical sample of people high in self-criticism, brief CR and CD interventions delivered though mobile apps are both more effective than waiting list in reducing self-criticism, distress and dysfunctional attitudes, and increasing decentring and self-compassion (Levin et al., Reference Levin, Haeger, An and Twohig2018). In another study, participants were asked to ruminate about a saddening autobiographical event and then taught a CR, CD or distraction technique to manage the ruminations (Yovel et al., Reference Yovel, Mor and Shakarov2014). CR and CD both reduced distress. For the CR condition improvement was associated with change in appraisal but not acceptance, and vice versa for CD.

Focusing on cognitive content as well as cognitive process and behaviour is still a valuable skill in CBT and should not be abandoned for a number of reasons:

1. (1) Cognitive restructuring is a key component of evidence-based CBT approaches and has equivalence to other techniques.

2. (2) Cognitive restructuring may work through different mechanisms and may produce different outcomes compared with other techniques (see above).

3. (3) There may be individual differences (as yet little studied) in preference and response to cognitive interventions.

4. (4) Cognitive restructuring probably works best when woven into formulation-based treatments where the sequence of identifying beliefs, questioning them through verbal discussion, testing them through behavioural experiments and reviewing the outcome, is a core feature (Grey et al., Reference Grey, Young and Holmes2002).

5. (5) In order to persuade a client to engage in a behavioural task or experiential technique we are inevitably inviting then to consider a new way of relating to the world. Whether it is through psychoeducation or a thought experiment, this involves a conversation that questions their beliefs.

Useful or helpful?

Figure 2 depicts the validity-helpfulness matrix. Thoughts and beliefs that are unrealistic and unhelpful can be questioned directly using reality testing. Cognitions that are realistic but unhelpful are best addressed using the pragmatic method, while thoughts and beliefs that are realistic and helpful can be recognised and supported. In the fourth quadrant, beliefs are unrealistic but seem to be helpful. For instance, someone with multiple sclerosis may hold an optimistic belief that a cure could be found for their condition in their lifetime, or someone living in poverty might speak of how they might win the lottery. These beliefs may help people to carry on the struggle. Rather than being rigidly rational, the therapist needs to be compassionate and flexible in their approach. The costs and benefits of wishful thinking can be taken into account: is the positive thinking helping them cope or hindering? The patient with multiple sclerosis may say that this hope allows them to get up every morning, but on the other hand they may be spending so much time researching cures that it has a negative effect on their family. The person longing for a lottery win may spend so much time dreaming of the magic solution they do not plan how to manage their debt. These strategies may be helpful in the short term but deleterious in the long term.

Figure 2. Realistic vs helpful beliefs.

Time perspective

Here the therapist asks the patient to imagine themselves at a different period in their lives. For someone with depression this may be a time when they were well. When asked a question like, ‘What would you have said to me about this situation when you were well?’, the depressed person is often able to say that they would have seen their situation more positively, would have felt able to cope and would not have felt that it indicated something was wrong with them. This shift of perspective can engender hope that things can be different. It also activates memory networks of times when things were better, and so may help move the person from the depressive mode into the euthymic mode (Beck, Reference Beck and Salkovskis1996). Questions can be asked about how the person coped in the past with challenges, what strengths and resources did they bring to bear on the situation? We can also ask questions about the future such as ‘What will life be like in 1 year, 5 years’ time?’. For suicidal patients or patients with PTSD the future is foreshortened and hopeless. Imagining future scenarios can help generate the idea that a future is possible (Williams, Reference Williams, Scott, Williams and Beck2003; see for instance pp. 220–223).

Others perspective

This is one of the commonest questions after the question ‘What’s the evidence?’. Here we ask the client to move position so they imagine someone else in their situation – ‘What would you say to a friend?’. They are usually able to be much more compassionate when they think of someone else in their situation. This allows for discussion of the double standards we apply, as well as possibly acting at the more experiential, implicational level. The feelings of empathy, compassion and warmth felt towards a friend in need may induce a felt sense that can be directed towards the self. ‘What would a friend say to you?’ offers a similar alternative compassionate perspective.

Changing focus

Shifting attentional focus is a key technique in the treatment of anxiety disorders, e.g. moving from an internal focus to an external focus in social anxiety. It can be helpful for people facing adversity in two ways. Firstly, it is possible to become stuck in one mode of coping. A patient with cancer may spend so much time worrying about their illness, searching for cures, etc. that they do not live their life. Alternatively, they may put all their attention on everyday life as a way of distracting themselves from the emotional impact of the disease. Balancing coping is a way of refocusing. Secondly, we have a tendency to try to use coping strategies that have worked for us in the past even if they are not applicable in the present. We can find ourselves trying to control what we can no longer control, e.g. a patient with an incurable illness may want to plan the future for their partner; or a recently disabled person may focus on all the things she can no longer do and ignore what they still can do.

The perspective of values

ACT’s emphasis on helping people move in the direction of their values clearly fits into the constructivist paradigm. Some of these interventions can be used within mainstream CBT. Again, in the area of adversity, people may genuinely no longer be able to do some of the things they used to do. Identifying what was valuable about the activity and finding alternative ways to follow values and work towards goals can open up new possibilities.