Internet Editor’s Note: Drs. Oddli and Halvorsen recently published an article titled “Experienced Psychotherapists’ Reports of Their Assessments, Predictions and Decision-Making in the Early Phase of Psychotherapy” in Psychotherapy. Read below for their further thoughts on defining psychotherapist expertise.
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I just let it flow naturally in the way we talk, I think. (Psychotherapist)
What does it mean to be an expert psychotherapist? How does expertise develop? How does it relate to experience and knowledge?
The relationship between expertise, experience and knowledge in psychotherapy is a complicated one. Definitions of expertise across various disciplines share an understanding of the phenomenon as reflecting comprehensive knowledge and experience. In the field of psychotherapy, however, the concept of expertise is an object of discussion. Most recently, Tracey, Wampold, Lichtenberg and Goodyear (2014) have raised the question as to the very role of expertise in psychotherapy, timely questioning its relation to psychotherapist experience and treatment outcome.
In the following we will briefly discuss the concept of expertise, before we present some examples of expert-practices. These examples illustrate central questions about how expertise develops, and what kind of training and knowledge may be warranted.
Psychotherapist Expertise and Experience
The positive effect of psychotherapist experience in itself is not unanimously supported (e.g. Hill & Knox, 2013). However, inspecting the nuances of the various research findings, there is no reason to discard the role of experience when we aim at understanding professional practice and the role of the psychotherapist.
For example, some recent studies (Powell, Hunter, Beasly, & Vernberg, 2010; Tschuschke et al., 2014) and a meta-analysis (Keefe, McCarthy, Dinger, Zilcha-Mano, & Barber, 2014), support the effect of psychotherapist experience on outcome.
Furthermore, and in line with the more general expertise-literature, studies suggest that experienced psychotherapists are more flexible, and that they cope better with more complex conditions and severe problems, and form more complex, nuanced and succinct conceptualizations than their less experienced colleagues (Huppert et al., 2001; Kivlighan & Quigley, 1991; Martin, Slemon, Hiebert, Hallberg, & Cimmings, 1989; Miller, Hubble, & Duncan, 2008; Rønnestad & Skovholt, 2013; Tschuschke et al., 2014).
A Question of How
The relationship between expertise and outcome is another complicated issue to disentangle. However, it seems to be some consensus that expertise is characterized by quick, complex and meaningful conceptualizations of the problem in question. Experts are described as those who:
- Organize their knowledge hierarchically and in ways that reflect a deep understanding of the phenomenon.
- Focus on what is relevant, and develop functional rather than merely descriptive accounts of the problem.
- Have the capacity to adjust to new situations, and to reflect upon their knowledge and actions, both generally and in the particular situation (e.g., APA, 2006; Bédard & Chi, 1992; Feltovich, Prietula & Cokely, 2006; Glaser & Chi, 1988).
It is not necessarily the case that the more you do something, the better you become at doing it.
Rather, several studies suggest that it may be how you do what you do, including how you reflect upon your clinical practice that determines how you develop the skills, attitudes and ways of being that is associated with effective practices (e.g. Eells et al., 2011).
Manifestations of Expertise
In the following, we will highlight two central features of expert-practices, which are widely recognized in the expert literature: Implicit processes and intuitive decisions.
Implicit processes and intuitive decisions
Implicit reasoning and intuitive decisions are long-recognized aspects of professional practices (Eraut, 1994; Greenhalgh, 2002; Polanyi, 1958). Much of what a knower does is left unsaid, and reflects other knowledge processes than those involved with deliberative, analytic thinking (e.g., Lieberman, 2000).
Some results from our studies of highly experienced psychotherapists at the University of Oslo may illustrate selected aspects of implicit processes and intuitive decisions in psychotherapy.  Analyses of processes and decisions were made from different observational perspectives, including analyses of treatment sessions and interviews with the psychotherapists  (e.g. Oddli & Halvorsen, 2014; Oddli, McLeod, Reichelt, & Rønnestad, 2014; Oddli & Rønnestad, 2012; Råbu, Binder, Haavind, 2013).
Implicit, intuitive processes were recognized across the various analyses. For example, in the initial sessions, where alliance was rated high, the psychotherapists and their clients hardly ever talked explicitly about goals even though analyses from external observational perspective and retrospective psychotherapist accounts showed that they were clearly working goal directedly (Oddli, McLeod, Reichelt, & Rønnestad, 2014). The same was the case with the decisions about choice of treatment methods.
Even when the psychotherapists had elaborate discussions with their clients about how they previously had tried to solve their problems and their ideas about mechanisms of change, they did not explicitly agree on or decide what should be proper methods and interventions (Oddli & Rønnestad, 2012). One of the therapists said: I think it is an impediment to therapy to start up with lots of general contractual work in the beginning (Oddli & Halvorsen, 2014).
Non-linear, unplanned processes
A noteworthy implication of implicit, intuitive decision-making is that the processes are unplanned and non-linear. In the therapies of our experienced psychotherapists there was a striking lack of structured plans. Decisions were not marked by “first agreement, then action”. The interactions were marked by moment-to-moment adjustments, in which the psychotherapists were seemingly basing their decisions on the flow of the conversation – centered around the particular clients’ accounts and needs, rather than theory-driven questions.
Preliminary results from an analysis of highly experienced versus less experienced psychotherapists, with good and not-so-good outcomes respectively, suggest that this was a characteristic that markedly contrasted the two samples (von der Lippe, Oddli, & Halvorsen, 2014). Similarly, Miller, Hubble and Duncan (2008) have identified such ‘attentiveness to feedback’ as characteristic of ‘the best of the best’ psychotherapists.
In the post-therapy interviews, when the psychotherapists reflected upon their own initial evaluations of the clients and the processes to come, they highlighted how unknowing they were, and how their predictions often failed. Thus, their own understandings were not described in a narrative of planfulness.
In the expertise-literature such non-sequential processes have been recognized as forward-driven strategies (Bédard & Chi, 1992; see also Ells et al., 2011). These strategies involve an open, process-oriented type of problem solving, in which characteristics of the particular problem determine the next move, rather than a predefined goal.
Not surprisingly, such forward-driven strategies are more common among experienced practitioners; they are more risky, as you do not know where you will end up, but also potentially more effective, as long as you have sufficient knowledge to recognize and act upon the particular problem (Bédhard & Chi, 1992).
Forward-driven strategies are also expressed in reflection-pre-action that Rønnestad & Skovholt (2013) have suggested in their extension of Schön’s (1983) distinction between reflection-on-action and reflection-in-action. Reflection-pre-action may also be conceptualized as an aspect of deliberate practice, which Tracey et al. (2014) have highlighted as essential to increase expertise. But as we will describe below, there may be limits to the deliberate and rational approach to decision making.
What Implications Do These Long-Recognized Implicit, Intuitive Processes Have for the Question of How We Develop Expertise, and for the Question of Training?
Tracey et al. (2014) suggest the method of explicit a priori testing of hypotheses as a means to increase expertise. We embrace their call for an approach to the therapeutic endeavor that is based on scientific principles. However, we fear that this particular kind of scientific approach does not fully capture the implicit, intuitive aspects of the therapeutic process.
We suggest the hermeneutic process (e.g., Gadamer, 1975) as a model for understanding the implicit, moment-to-moment, context-sensitive decisions. A hermeneutic perspective implies that preconceptions are subject to constant accommodations according to how the material they engage in unfolds and changes (as with forward-reasoning). These decisions not only include psychotherapists’ rational reasoning and predictions, but also their use of emotional cues, both as perceived of the other and as recognized in themselves, including less conscious, embodied cues (Rennie & Ferguson, 2006).
As we have seen, psychotherapy processes are typically characterized by forward reasoning, , such as that reflected in hermeneutics. It is worth noting that under complex, unpredictable conditions, where quick decisions are needed, as in psychotherapy, intuitive processes have proven effective (Gigerenzer, 2008; Kahneman, 2003; Lieberman, 2000). Furthermore, we should note the studies of cognitive disruption, which suggest that implicit cognitive processes might be disrupted if forced to be verbalized (e.g., Lieberman, 2000; Schooler, 2002).
The same line of reasoning applies to structured feedback-procedures (Howard, Moras, Brill, Martinovich, & Lutz, 1996; Lambert, 2001; Lutz et al., 2006), which seems to be a well-recognized solution to ensure adjustments when therapeutic processes develop negatively. Tracey et al. (2014) point out that even though such structured feedback procedures increase outcome, studies suggest that they do not seem to enhance the development of expertise.
This is not surprising, when we think of the experts’ small-scaled, moment-to-moment adjustments, without words, often based on rapid perceptions of facial expressions and their own emotional reactions. Maybe such skills are not facilitated by structured, large-scale feedback procedures. This does not, of course, mean that such procedures do not have their domains of application or relevance, just that they may not be fit to teach students and psychotherapists all the crucial, small-scale aspects of psychotherapy.
The question that still remains is exactly how the totality of favorable performances, including both the declarative, explicit and the implicit, intuitive ones, might be stimulated during the course as a psychotherapist. It might of course be that intuitive decisions develop both through planful, scientifically rigorous hypothesis testing, and by the help of other approaches based in other forms of epistemology. More research on training and psychotherapist development is warranted to investigate these questions in detail.
Cite This Article
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