How Expert Therapists Use Theoryin Generating Case Conce

Clinical Expertise in Psychotherapy: How Expert Therapists Use TGenerating Case Conceptualizations and Interventions - Springer
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Journal of Contemporary Psychotherapy

On the Cutting Edge of Modern Developments in Psychotherapy
Springer Science+Business Media, LLC 2010

10.1007/s10879-010-9138-0
Original Paper
Clinical Expertise in
Psychotherapy: How Expert
Therapists Use Theory in
Generating Case
Conceptualizations and
Interventions
Ephi J. Betan 1 and Jeffrey L. Binder 1
(1) Clinical Psychology Program, Argosy University, Atlanta, 980 Hammond Drive,
Suite 1000, Atlanta, GA 30328, USA
Ephi J. Betan (Corresponding author)
Email: ebetan@argosy.edu
Jeffrey L. Binder
Email: jbinder@argosy.edu
Published online: 25 February 2010
Abstract
Case conceptualization is a primary skill that may be the linchpin of
clinical practice as it sets the framework for making sense of a
patients difficulties and guides a path toward change. Providing
meaning and structure to often ambiguous and nuanced clinical
information, an apt case conceptualization facilitates the therapists
complex integration of core therapeutic skills to produce expert
performance. Rooted in the cognitive sciences literature on expertise,
we introduce the concept of metabolizing theory to capture expert
http://link.springer.com/article/10.1007/s10879-010-9138-0/fulltext.html
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therapists capacity to use theoretical and clinical knowledge in an

intuitive, flexible manner that responds and adapts to the unique and
complex context of the treatment.
Keywords Expertise Case conceptualization Psychotherapy
Training
When considering the complex, multifaceted, relationally embedded
work of psychotherapy, clinical expertise is a concept that invites a
knowing nod of recognition but defies easy, immediate definition.
Psychotherapy is essentially an encounter between two people, with all
the attendant vagaries of human relationships. As such, it is a highly
ambiguous, variable, and uncertain process that is embedded in
subjective, interpersonal, and cultural contexts. When viewed as a
performance domain, then, expertise in psychotherapy is not defined
simply in terms of problem-solving accuracy, as in chess (de Groot
1965) or physics (Chi et al. 1988), where the solution can be judged as
correct or incorrect by relatively definitive measures. The expert
conduct of psychotherapy is difficult to evaluate because we are not
observing discrete performance skills, singular decisions or solutions,
or concrete outcomes. In working toward a definition of clinical
expertise in psychotherapy, we are challenged to capture the technical
complexity, subjective and cultural implications, and relational
demands of clinical work. Defining and identifying expertise can be
meaningful only if we pay attention to the contexts in which
therapeutic performance occurs.
Certainly, the various approaches to psychotherapy differ in the degree
of structure and direction set by the therapist, emphasis on discrete
observable phenomena (e.g., behavior versus unconscious processes),
and attention to childhood origins of psychological difficulties. Still,
no matter how structured the treatment process is, deciding how to
intervene (the performance skills, as such) to produce desired
therapeutic outcomes is based not only in a comprehensive
understanding of the patients difficulties, but also in the capacity to
use such understanding to adapt flexibly and wisely to what is unique
with each patient. Therefore, although a psychodynamic-relational
perspective informs this paper, our attention to interpersonal,
subjective, and contextual factors in understanding expertise can have
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broader relevance for clinical training and expertise beyond specific

theoretical orientation.
There is relatively little written in clinical psychology on expertise in
psychotherapy and little research on effective training toward expert
therapeutic performance (Binder 2004; Eells et al. 2005) despite the
fact that research has indicated significant variability in therapist
effectiveness and that expertise is a significant factor in treatment
outcome (see Eells et al. 2005 for a summary of this research).
Therapist expertise in and of itself has not received much attention,
overshadowed by the focus on manualized treatments that have been
developed precisely to reduce differences in therapist performance.
Nonetheless, differences in therapist effectiveness emerge even in
well-controlled studies that require adherence to clear, systematic
directives for practice (Eells et al. 2005).
The nature of clinical expertise demands our attention as a key variable
in assessing the effectiveness of psychotherapy. Furthermore, as one
leg of the tripartite definition of Evidence-Based Psychotherapy
Practice (APA Presidential Task Force on Evidence-Based Practice
2006), clinical expertise has been identified as a necessary condition
for effective psychological practice. A number of authors and working
groups (Binder and Wechsler 2010; Kaslow et al. 2004; NCSPP 2007;
Rodolfa 2005; Rodolfa et al. 2005) have identified key competencies
that describe important aspects of clinical work and promote positive
therapeutic outcomes (APA Presidential Task Force on EvidenceBased Practice 2006, p. 276). NCSPP has developed a competencybased core curriculum that highlights the knowledge, skills, and
attitudes necessary for psychological practice (Kenkel and Peterson
2010). This model distinguishes between competency as the capacity to
perform effectively whereas competencies refer to those areas of
professional activity in which one performs with competence.
Generally, the lists of competencies have included these areas of
professional functioning: assessment and diagnosis, case
conceptualization, intervention, consultation, research-evaluation, and
supervision-consultation. Furthermore, each competency is defined as
a cluster of specific knowledge, skills, and attitudes necessary for
effective clinical work in that domain of professional functioning
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(Kaslow 2004; Rodolfa et al. 2005).

The literature on competencies remains mostly descriptive and does
not address the nature and development of the skills that characterize
expertise. Each competency reflects a core component of clinical
practice, but in and of itself, each competency would not be sufficient
for effective clinical work. Psychotherapy is a highly complex
performance domain, and therapeutic competence or, for that matter,
expertise, cannot be understood as static or fixed (Binder 2004) given
the contextual and subjective dimensions that influence the therapeutic
task. Expertise may be best considered an overarching concept that
captures the therapists abilities to (a) perform specific skills in an
effective manner marked by good judgment and flexibility; (b)
actualize in performance the complex reciprocal relationship between
core aspects of professional functioning, and (c) reflect upon, critically
evaluate, and adapt ones performance. Thus, we are characterizing
expertise in terms of judgment and flexibility; integration of multiple,
complex skills; and the capacity to self-evaluate and adapt ones
performance. Expertise is marked primarily by the clinicians capacity
for adaptation and creative use of theoretical understanding and
technical skills in ways that meet the unique needs and interpersonal
style of the patient. We would place expertise at a more advanced level
than clinicians who function at an average acceptable level of
competence. However, as quite a complex construct, we would not
assume that clinical expertise is a categorical construct that we can
classify as present or absent. Instead, it may be useful to understand
expertise as a multifaceted construct that must be assessed on multiple
dimensions.
As a starting assumption, clinical expertise is not merely the
accumulation of knowledge or experience. If this were so, it certainly
would simplify how we define, measure, and facilitate the
development of clinical expertise. However, as researchers on the
relationship between experience and skill have found, experts do have
many years of experience, but not all experienced clinicians are expert
(Chi et al. 1988). An apocryphal saying is: Twenty years of
experience is not the same as one year of experience repeated twenty
times.
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Likewise, knowledge is certainly an aspect of expertise. Clinical

expertise concerns not merely the accumulation of knowledge, but how
the clinician uses knowledge to inform what she does when sitting
with a patient. Expertise requires not only a strong knowledge base,
but also the ability to apply and adapt ones knowledge in a way that is
meaningful to and ultimately helpful for a particular patient in the
context of a unique therapeutic dyad in which distinct subjectivities,
needs, cultural values and influences, and interpersonal modes
intersect. Theoretical knowledge that cannot be made relevant to the
person suffering, and by extension the unique treatment, is not helpful.
We are primarily interested in how expert therapists use theory and
clinical knowledge in making cogent sense and meaning of patients
difficulties and narratives. Thus, our focus is on how expert therapists
use theory to generate case conceptualizations and interventions. In our
view, clinical expertise involves the ability to make use of what one
knows in an intuitive, flexible manner that responds and adapts to the
unique and complex context of the treatment.
Case Conceptualization, Clinical

Inference, Meaning Making
A number of authors recognize case conceptualization as a core skill in
psychotherapy (Eells et al. 2005; Ivey 2006; Kendjelic and Eells 2007;
Persons 2006; Scheiber et al. 2003). Case conceptualization involves
coming to an understanding about what troubles the patient, including
what causes the symptoms and/or distress and what contributes to the
patients vulnerability to struggle in this particular way. Case
conceptualization has been described as a working hypothesis about
what causes, precipitates, and maintains a persons psychological,
interpersonal, and behavioral difficulties. A case conceptualization can
help identify treatment goals and interventions, as well as potential
problems for the treatment (Levenson and Strupp 1997). Ivey (2006)
notes that a case conceptualization goes beyond identifying the
patients difficulties to focus on understanding the nature, origin, and
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meaning of a patients difficulties. Regarding clinical expertise, the

Task Force on EBPP (2006) suggests that, The clinically expert
psychologist is able to formulate clear and theoretically coherent case
conceptualizations (p. 276). The NCSPP competency-based model
also emphasizes the capacity to understand and apply theory to
develop a therapeutic process that promotes the patients well-being
and change as key to competence in intervention (NCSPP 2007).
What allows the clinician to produce cogent, coherent case
conceptualizations? What is involved in the process of generating
these conceptualizations? How does the expert clinician learn or come
to know how to conceptualize? These questions are at the heart of this
paper. The literature offers definitions of what a case conceptualization
is and its components, but does not address the nature and
development of expertise in using theory to generate
conceptualizations.
The ability to conceptualize is a primary skill that may in fact be the
linchpin of clinical practice, when coupled with relational skills and
sensibilities, including a keen understanding of how people struggle to
be in relationships. The process of conceptualizing and the case
conceptualization(s) we develop set the framework for implementing
other skills and activities in clinical practice, including assessment and
diagnostic judgment, meaning making and interpretation, clinical
decision making and intervention, and interpersonal as well as
multicultural sensitivity.
Why place case conceptualization at the heart of expertise, rather than
perhaps diagnostic assessment or interpersonal skills? Assessment may
be considered part of case conceptualization, although these tasks are
often described as distinct components of clinical functioning in the
competencies literature (Kenkel and Peterson 2010). Nonetheless, of
course, there is an obvious link between assessment and case
conceptualization in that how we understand our patient is based on
what we come to know through our assessment. However, our
assessment of the patients difficulties and narratives is an ongoing,
iterative process, and what we assess initially and throughout treatment
very quickly becomes grounded in our emerging case
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conceptualization. Immediately, we make meaning of and draw

inferences about our patients, the problems they have, personality style
and functioning, motivation, and the context of their lives. Our
conceptualization about what troubles a patient subsequently informs
what we assess explicitly, as well as subtly directs our attention to
history, behaviors, and emotions that help elaborate our emerging
understanding.
Our emerging conceptualization of our patients difficulties informs the
interpersonal process of psychotherapy, as well. The therapists
relationship skills are paramount in psychotherapy, without question.
Capacities for empathy, attunement, and accurately reading and
responding to social cues enable the therapist to establish a therapeutic
alliance, which is the foundation of any viable psychotherapy.
However, relational skills alone are not likely sufficient to produce an
effective treatment process, nor change, for the patient. We engage our
patients in a relationship in a particular way for a particular purpose.
How we understand our patients troubles and what will be helpful
informs our relational overtures and clinical interventions.
In short, our conceptual framework invariably directs what we pay
attention to and how we engage in the clinical encounter. In a manner
similar to the concept of illness scripts (Charlin et al. 2007;
Feltovich and Barrows 1984; Schmidt and Rikers 2007), our
conceptual framework organizes our theoretical understanding and
clinical experiences into schemas that we use to understand clinical
data, guide further assessment, and test our hypotheses. Adopted in the
medical expertise literature, illness scripts is a cognitive sciences
concept that refers to the way physicians organize knowledge from
repeated experiences with a disease into knowledge structures that
facilitate recognition, processing, and interpretation of relevant
medical information to establish a diagnosis. These scripts are
activated automatically and allow one to anticipate sequences of
events, set expectations, interpret complex events, and predict
consequences or outcomes (Charlin et al. 2007). The scripts are helpful
in quickly establishing a diagnosis because they capture factors that are
most likely associated with a specific disease (enabling conditions), the
specific problems that characterize the disease (faults), and the typical
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consequences such as complaints and symptoms (Charlin et al. 2000).

In psychotherapy, illness scripts likely enable therapists to tacitly use
their knowledge base to focus immediately on the most relevant
information and make appropriate judgments in the clinical moment
with the patient. For example, an illness script of borderline
personality disorder may include those characteristics that make the
diagnosis more likely (e.g., female, age), specific disturbances that are
paradigmatic of the disorder (such as suicidality, self-injurious
behaviors, intense fears of abandonment, and emotional dysregulation)
and likely complaints, signs or symptoms (e.g., depression, anxiety,
interpersonal difficulties). Such schemas help the therapist organize the
complexity of a patients narrative, clinical presentation, and
interpersonal style into a meaningful and coherent case
conceptualization that, in turn, informs key therapist skills of clinical
observation, clinical judgment, intervention, and interpersonal
engagement. Providing meaning and structure to the often ambiguous
and nuanced array of clinical information, an apt conceptual
framework can guide the therapists complex integration of core
therapeutic skills to produce expert performance.
What capacities are involved in expert case conceptualization? What
does it take to make meaningful observations and conclusions and then
use these conclusions to guide treatment interventions and assess the
treatment process? Here, we turn our attention to how expert therapists
use theory and think about patients differently than novices,
introducing the concept of metabolizing theory to capture the process
by which psychotherapists adapt theoretical and clinical knowledge in
conceptualizing their patients.
Metabolizing Theory
It is generally expected that case conceptualization, or the making
sense of and framing a patients difficulties in a meaningful way that
helps guide a path toward change, is rooted in theorythat is, a
formal, explicit, consensually recognized and adopted theory.
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However, the findings of cognitive sciences research on expert

performances, when applied to psychotherapists, suggests that
therapists may differ in how they use theories. Experts do not apply
knowledge in rote ways or even in the same way that they learned the
information (whether it be basic knowledge, diagnostic algorithms, or
theoretical concepts), but have adapted and extended their knowledge
based on experience (Hatano 1982, 1988). The few studies (Eells et al.
2005; Cummings et al. 1990) investigating therapists case
conceptualizations have found that, compared to those of novice
therapists, expert therapists case conceptualizations were more
comprehensive, elaborated, and complex, as well as showed evidence
of higher levels of abstraction. We would expect that expert therapists
arrive at a cogent case conceptualization with much more ease than do
novices. However, more than speed and facility distinguishes the
expert clinicians case conceptualization. Expert conceptualizations are
likely more sophisticated because expert therapists use theoretical
knowledge and think about patients with greater understanding,
flexibility, creativity, and innovation than do novice therapists.
In conceptualizing, we do not simply plug in information about the
patient where it fits the theory. Instead, the task involves fitting theory
to the unique qualities and circumstances of the patients personality,
life history, interpersonal style, cultural context, and current needs and
difficulties. The path from theoretical knowledge to generating a
conceptual narrative about a patients difficulties demands the ability
to apply generally abstract ideas (often embodied in terms, such as
defense, ego strength, maladaptive cyclical patterns, automatic
thoughts, or cognitive triad) in a way that is uniquely meaningful
and relevant to each patient. Doing so requires not merely familiarity
with theory, but rather the therapist needs to take ownership of the
theoretical concepts and the theorys approach to understanding
symptoms and the way people live their lives interpersonally,
intrapsychically, and emotionally.
Making theory ones own involves what we refer to as metabolizing
the theoryto be so familiar with a theorys key concepts, explanation
of pathology, and mechanisms of change that they become automatic
in ones way of thinking about and approaching unique clinical
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contexts. In learning theory and developing clinical skill, we cannot

merely swallow knowledge wholesale without synthesizing,
assimilating, and transforming it to make it useful to unique and
ambiguous clinical situations. Metabolization is the process of
bringing ideas and concepts to live inside ones mind and psyche so
they become part of self and identity. As a result, the therapists way of
seeing the world and thinking about psychological phenomena
changes, as does the therapists way of being with a patient. The
therapist develops more flexible, varied, and nuanced possibilities for
intervention and relating with a patient as theoretical notions are
integrated with personal style and values in ways unique to the
therapist. We often see this kind of shift begin as students progress
through training. For example, an important developmental shift
occurs when students begin first to recognize that we must listen to
clinical material on multiple levels (e.g., content versus process,
concrete versus symbolic, immediate awareness versus unconscious,
themes, beliefs about self, others, and the world). Expertise is marked
by the therapists ability to listen (and hear) at these levels intuitively.
Theory that has been metabolized is a form of tacit knowledge that
functions automatically and often outside of conscious awareness.
Based on the study of professionals at work in various knowledge
domains, the social scientist Schn (1983) suggests, Competent
practitioners usually know more than they can say. They exhibit a kind
of knowing-in-practice, most of which is tacit (p. viii). When a
therapist exhibits what Schn (1983) referred to as intuitive knowing
in the midst of action (p. viii), we would say the therapist has
metabolized the theory.
Although theory is a fundamental guide in clinical practice, when it is
detached from ones psychological and interpersonal sensibilities, it
can significantly stifle clinical understanding and intervention. Theory
that is not metabolized is not automatically available to guide the
therapists understanding and interventions. Under these conditions,
the therapist labors to make meaning of the patients presentation and
distress within the framework of a theory. The theoretical framework
remains detached from the therapists way of seeing and processing
experiences, and, as a result, theoretical knowledge at early stages of
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training can interfere with rather than facilitate case conceptualization

and treatment. Distracted by their efforts to apply theory, students and
novices fumble in their work with patients, often missing relevant
clinical and interpersonal data as well as opportunities to deepen the
alliance and treatment (Binder 2004).
Initial advances in clinical experience paradoxically may be associated
with diminished performance. Finding that medical residents with 3
4 years experience performed worse than less experienced residents in
diagnosing X-ray pictures, Lesgold et al. (1988) hypothesized that use
of a theory or framework is initially incorrect and may be worse than
having no theory at all. Similarly, Karmiloff Smith and Inhelder (1974)
found that on a block balancing task, children performed more poorly
as their rudimentary theoretical understanding replaced their initial
trial and error approach.
The novice therapist may understand theoretical concepts and
mechanisms but cannot work from within the theory, so to speak. The
novice does not have a sufficient grasp, i.e., metabolization, of the core
of a theory to think and speak in language consistent with a theory
without getting bogged down in jargon. This is not just a matter of how
the novice speaks about the patient and the treatment, but also how the
novice thinks about and conducts the treatment. In contrast, the expert
processes incoming information from the patient automatically and
implicitly from within the theoretical framework; the key components
of the theory are apparent in the structure of how the therapist thinks
about the patient, the types of questions the therapist asks the patient,
the way the therapist focuses interventions, and what the therapist
attends to in the process and sequence of the treatment.
Furthermore, expert clinicians are more likely to understand when
theory may not yet be helpful and that it can take time to gather
sufficient clinical information and experiences with the patient in order
to generate a meaningful case conceptualization. The focus on the
importance of case conceptualization may give the impression that one
must quickly generate a formal case conceptualization. However, it is
equally important to know when to suspend judgments regarding a
patients difficulties and tolerate ambiguity1 that comes with not yet
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knowing what troubles a patient and/or communications that may be

inchoate or nonverbal. Novice clinicians are apt to foreclose their
process of fully understanding a patients difficulties in their generally
unsophisticated efforts to rigidly apply a theoretical construct or
framework. Having metabolized theoretical understanding, experts are
more likely to appreciate the nuances of clinical phenomena, knowing
both when a theory informs understanding and when they simply do
not yet know enough to generate a complex understanding of the
uniqueness of the patients experiences, psychological difficulties, and
relational patterns.
Lessons from the Expertise Literature

Across various knowledge domains, experts use their knowledge
differently than novices. Studies of the development and nature of
medical expertise have found that, compared to novices, expert
physicians are more capable of organizing information, screening out
irrelevant information, recognizing meaningful patterns, fluidly and
automatically retrieving knowledge relevant to the task at hand, and
problem-solving (Bedard and Chi 1992; Bransford et al. 1999; Patel et
al. 1994, 2001; Patel and Groen 1991; Bordage and Zacks 1984). We
might assume, as the medical education literature has often assumed
(Eva 2004), that experts use analytic models of clinical reasoning,
involving careful analysis of obvious signs or evidence (e.g.,
symptoms) to draw conclusions regarding relevant categories (e.g.,
arriving at a diagnosis). In fact, however, it appears that experts engage
in non-analytic reasoning, using prototypes from past experience to
make sense of the current situation (Norman et al. 2007). Furthermore,
studies show that with experience, knowledge becomes encapsulated
whereby higher-level, causal concepts that explain signs and symptoms
allow medical experts to process cases more efficiently (Schmidt and
Rikers 2007). An example of encapsulated knowledge in our field
would be the psychodynamic concept of borderline level of ego
organization that would capture (for those familiar with the concept) a
patients emotional dysregulation, impulsivity, interpersonal
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difficulties, and potential for cognitive lapses. Thinking in terms of

encapsulated concepts allows the therapist to see patterns in patients
symptoms and ways of behaving, thinking, and feelings, generate
coherent case conceptualizations, and plan effective interventions.
Novices are at a disadvantage because they do not have sufficient
clinical experience to help make their knowledge relevant to their work
with patients. As Schmidt and Rikers (2007) describe, When
confronted with a clinical case in this stage of development [i.e., early
medical training], students focus on isolated signs and symptoms and
attempt to relate each of these to the pathophysiological concepts they
have learned. This is an effortful and error-prone process. In addition,
as they do not yet recognise patterns of symptoms that fit together,
processing is detailed (p. 1134). This also is an apt description of
novice therapists and students who struggle to apply theoretical
knowledge in a way that does not distract from being interpersonally
and emotionally engaged with their patients.
Chi et al. (1981), in a now classic study comparing expert and novice
physicists performance on problem solving tasks, found that experts
used underlying theory (labeled deep structure) and novices used
superficial details (surface structure) to categorize information.
Dunbar (1995) also found that expert scientists are more easily attuned
to deep structural features that novice scientists have great
difficulty seeing (p. 386). Others also have found that experts
knowledge base, problem solving, and reasoning tend to be more
abstract, deeper or more theoretical, and more causally interconnected
(Voss et al. 1983a, b, 1988).
This body of literature strongly suggests that experts use theory or
higher-order case conceptualizations to process key information and
arrive at a response to a given task, and that, quite significantly, this
knowledge is gained through experience rather than through academic
study (Schmidt and Rikers 2007). We would emphasize again here
that, based on our observations and the expertise literature, experience
alone does not beget expertise. Rather, expertise develops as the
therapist processes and metabolizes experiences, after integrating or
chunking theoretical constructs that are mentally evoked by concrete
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clinical experiences and the associated action-consequence sequences.

As such, theory becomes a deep structure so that clinical
observations and experiences are automatically organized and given
meaning by a theory-guided conceptual framework. In this process,
knowledge is changed and deepened to become keenly relevant and
useful to the clinician when encountering future clinical situations and
problems.
Adaptive Expertise
A fundamental difference between domain expertise and domain
relevant experience lies in the experts ability to transform and create
his own knowledge. Hatano (1982, 1988; Hatano and Inagaki 1984,
1986) introduced the idea of distinct types of expertise, routine and
adaptive. In this distinction, routine experts are essentially
experienced non-experts (Myopoulous and Regehr 2007) who are
able to apply sophisticated routines or solutions efficiently and
automatically. Hatanos prototype for routine expertise was the abacus
master who is highly skilled in a repetitive, narrow, procedural task.
Hatano (1982) noted that practice in procedural skills may produce
routine experts but usually doesnt facilitate development of
corresponding conceptual knowledge, nor competence under a new set
of constraints even in the same domain (p. 17). In contrast, rather than
merely applying knowledge or acquired skills (no matter how
sophisticated), adaptive experts extend and transform their knowledge
base and are able to transfer their expertise to novel problems. Holyoak
(1991) summarizes the differences this way: Whereas routine experts
are able to solve familiar types of problems quickly and accurately,
they have only modest capabilities in dealing with novel types of
problems. Adaptive experts, on the other hand, may be able to invent
new procedures derived from their expert knowledge (p. 310).
Prepared to learn from new situations, adaptive experts also recognize
when previously held schema are not appropriate for the current
circumstances and adapt accordingly (Hatano and Inagaki 1986; Lin et
al. 2007). Furthermore, adaptive experts may understand why their
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procedures work, and they are able to verbalize the principles

underlying their skills. Thus, the capacity to build and create new
knowledge and to think about the relevance and development about
ones knowledge distinguishes the adaptive expert.
In psychotherapy, experienced (versus expert) therapists may be quite
sophisticated in implementing treatment interventions that are part of
their routine practice (Myopoulous and Regehr 2007). For example,
manualized treatments have become quite popular, and, presumably,
the clinicians who have adopted these treatments in either research or
clinical practice become quite adept at implementing the strategies of
the treatment. Such clinical practice based on manualized treatments
fits the domain of routine expertise because the parameters of problem
definition, case conceptualization, and treatment are defined by the
manual. The supposed benefit of manualized treatments in diminishing
therapist error by prescribing interventions is also a disadvantage with
regard to a therapists capacity to respond adaptively to the unexpected
in psychotherapy. Strict reliance on manualized treatment protocols
may in fact limit knowledge and skills in addressing the novel and
unpredictable circumstances (that pose a new set of constraints as
identified by Hatano) that arise in psychotherapy. Indeed, Binder and
colleagues (Binder 1993; Henry et al. 1993) observed such negative
effects in the Vanderbilt II project, a manualized training program in
time-limited psychodynamic psychotherapy. Although clinicians
adhered to the prescribed techniques, they displayed diminished
interpersonal skills and ability to develop and apply therapeutic
interventions skillfully. The team concluded, A certain anxiety and
defensiveness may appear natural (although unfortunately, likely
countertherapeutic) as therapists struggle to adhere to the precepts of a
not-yet-fully-internalized manual that may contradict established
patterns of intuitive performance. This anxiety and defensiveness
might have been coped with by a greater tendency to adopt an
authoritarian stance, again an unintentional by-product of attempting to
use new interventions (p. 439).
These Vanderbilt II project findings support our ideas regarding the
importance of metabolizing theory such that it becomes part of ones
identity, way of being with patients, mode of relating, and conceptual
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framework. Furthermore, Hatanos and others findings regarding

adaptive expertise lend credibility to our proposition that expert
therapists do not use theory the way they learned it. Having
metabolized the theory (ies), expert clinicians adapt, alter, and deepen
what they have learned based on cumulative concrete experiences in
varied (routine and novel) therapist, patient, and treatment contexts.
Deepening clinical knowledge occurs in a spiral, crossing similar
terrain, but each pass brings greater coherence and complexity in
understanding. It is likely that expert therapists, different from nonexperts or novices, evidence the capacity to learn something new from
every clinical encounter, thereby deepening and changing the
theoretical constructs and interventions that guide their work.
Therapists work at levels and in modes of understanding (relational,
emotional, intuitive, unconscious) that cannot always be put easily into
words, and perhaps ought not to be (knowing when to leave something
unsaid is a judgment informed by a high level of theoretical
understanding). Still, words are the primary medium of communication
with our patients. Expert therapists are skilled at putting words to what
is often implicit, nonverbal, and nuanced in the patients lived
experience and in the relational encounter between therapist and
patient. Theory is a guide, but the therapists understanding comes
from within what the therapist and patient have created together.
Metabolizing theory enables the therapist to transform abstract,
externally defined concepts and knowledge structures into experiencenear, dynamic constructions that capture something meaningful and
immediately felt. Theory is a language for making meaning of the
patients experiences and presentation, but with every patient, the
expert therapist is capable of creating a new, slightly different,
language that is highly relevant.
We would go further to suggest that this capacity to extend and adapt
theoretical and clinical knowledge is the essence of therapist expertise.
The capacity for innovation is core to effective practice for a number
of reasons. Flexibility and innovation move the therapist beyond
theoretical adherence to the capacity to respond to that which is preverbal, nonverbal, implicit, relational, and subjective in the therapeutic
encounter. It is not surprising that seasoned clinicians, no matter the
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orientation, tend to work very similarly to each other in terms of being

attuned to emotionally significant events in therapy (Goldfried et al.
1998; Wiser and Goldfried 1998). Furthermore, adaptive expertise in
psychotherapy is perhaps most evident in the ability of expert
therapists to deal more effectively with complex, interpersonallydifficult encounters typical of the treatment of patients with personality
disorders. Therapy is a human encounter, a relationship that draws two
(or more) people together in ways unique, ambiguous, and uncertain.
We cannot predict fully what will emerge in a therapy, even in highly
structured treatments. There is nothing static about a living human
being, and the psyche and mind are equally active, shifting entities.
Each patient, and therefore each psychotherapy encounter, is unique
and presents new problems demanding creative solutions to further
therapeutic progress. Finding a way to enter into a patients world is
crucial to facilitating key aspects of therapy, including development of
a therapeutic alliance, assessment, and intervention. Interpersonal
skills are paramount, of course, but not enough in the absence of a
coherent and also immediate (metabolized, intuitive) way of
conceptually understanding the person and the encounter between
therapist and patient. Theory needs to be in the background when we
are with patients, but never absent.
The capacity to step back and capture experience and communicate it
to another is at the root of psychological growth in psychotherapy (and
in development in general). On the part of the therapist, this requires
the capacity to reflect and think about the patient and the therapeutic
process on multiple levels at the same time. Although this may appear
to contradict the idea that metabolized theory is intuitive and outside
conscious awareness, expert knowledge and skill can be both intuitive
and explicitly articulated, although at different moments in time. What
may be silently working in the background while sitting with patients
must ultimately be recognized and verbalized by the clinician to bring
ones case conceptualization and intervention skills to an expert level.
The capacity to reflect upon and make explicit ones actions and
internal process (including thoughts and emotional responses) that
guide clinical decisions and behaviors is at the heart of expertise. This
involves making meaning of (conceptualizing) ones own experiences,
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actions, and knowledge.

Hatanos emphasis on the ability to articulate the principles underlying
ones knowledge is very important here. It is not simply the ability to
create or extend knowledge that marks expertise, but also the capacity
to understand why the adaptation (of knowledge) works. We ought to
have a conceptual understanding of what is working and not working
with or for a patient and why this is so. Simply working intuitively
without knowing what you are doing is not expert performance. The
capacity to come to know why an adaptation of an intervention or a
unique clinical stance worked is a distinct aspect of expertise; without
such awareness and articulation, flexibility and creativity are no more
than haphazard (a sure sign of novice performance). Experts, we
believe, spend time reflecting on the treatment and generate new
understandings that guide intervention. Schn (1983) referred to this
capacity as reflection-in-action. Experts think about and evaluate
their use of theories and interventions constantly, and they can critique
their own work. For this reason, expertise in psychotherapy is not
routine or rote, but marked by the evolution of new ideas and meaning
in the therapeutic dialogue, creativity in technical interventions and
relational modes, and the therapists personal growth.
Considerations for Training

How do we facilitate the metabolization of theory to encourage
innovative, flexible, adaptive use of theory and clinical knowledge that
responds to the unique context and interpersonal pulls in
psychotherapy? Can you teach a student to adapt and be innovative
with knowledge she does not quite yet have or grasp? Or would such
efforts produce haphazard learning or poor technique? In order for a
musician to master the art of playing improvisational jazz, she first
must master the basic musical chords (with all the monotony of
practicing chords) before she can improvise. Is this the same in clinical
work?
For example, in teaching ethics, the first author (EJB) tends toward a
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more conservative stance primarily regarding the therapeutic frame.

Although I believe it is extremely important to consider the
interpersonal and subjective contexts when teaching ethics and when
considering ethical implications of clinical work (Betan 1997), I also
believes it is imperative to help students understand that boundaries
(i.e., time, extrasession contact, therapist self-disclosure) protect the
patient and the treatment. As such, I lean toward teaching the scales
firstfor example, I promote limited therapist self-disclosure as we
cannot always be clear about the impact on the patient without further
understanding of why the patient may be asking or why we might feel
the pull toward such disclosure. I also quite intentionally do not assign
readings that highlight therapist self-disclosures (e.g., Fosshage 2007;
Silverman 2006) even though some of these writings from a relational
perspective are quite compelling and cogent examples of meaningful
therapeutic engagement. We fundamentally believe that knowing when
and how to adapt treatment (in ways that may shift boundaries or stray
from traditional interventions) emerges from a broad and in depth
understanding of the therapeutic encounter that comes from learning to
be attuned to the interpersonal and internal (intrapsychic) nuances,
appreciating the complexity of therapeutic process and change, and
having a framework for making sense of what occurs for both patient
and therapist. In other words, clinical sophistication emerges with
experience, but only if we develop the ability to think about the work
and process it within a useful, metabolized conceptual framework.
How do we learn when and how to adapt treatment with flexibility and
responsiveness to the unique patient and context? What facilitates the
capacity to metabolize knowledge and adapt understanding to fit the
patient and treatment contexts? This returns us to our efforts to
understand the nature and development of clinical expertise. These are
tandem questionswhat is clinical expertise and how do we train (for)
such expertise?
Research in education supports the idea that exposing students to
diverse case examples promotes in-depth theoretical understanding and
the ability to transfer knowledge to novel problems (Barnett and
Koslowski 2002; Brown 1989; Catrambone and Holyoak 1989;
Cummins 1992; Gick and Holyoak 1983; Hatano 1982; Holyoak
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1991). Recognizing and comparing differences across cases is an

important component in facilitating the understanding, and therefore
metabolization, of theory and new possibilities for problem solving.
Student therapists may fail to notice important differences because
they repeatedly apply well-worn schemas. Using contrasting cases,
side by side, may help students become more attuned to important
distinctions that would demand alternative explanations and
interventions (Lin et al. 2007). Similarly, exposing student therapists to
a diversity of explanations also increases the capacity to generate new
understanding. In particular, it may be quite useful to have students
first generate their own opinions about a case or potential interventions
before exposing these students to expert opinions. Having already
made their own observations, students can better appreciate the
experts insights, which students would otherwise dismiss as obvious if
they had not already failed to generate such understanding (Lin et al.
2007). Also, it seems to us, in showing how experts think about
clinical cases, students would develop greater awareness of how to
generate and apply theoretical understanding, as well as hone their
abilities to critically evaluate their own knowledge base.
To facilitate metabolization of theory, we must teach student therapists
a way of thinking about clinical material in order to draw meaningful
clinical inferences. We also need to teach students how to use their
knowledge, as well as reflect on what they know and what they do not
know. Clinical knowledge is not a static resource that is merely built
upon with subsequent experience as though having more information
would equate with greater expertise. Experts are actively engaged in
generating their own understanding. Student therapists must be
engaged as well. We can expose students to many case examples and
provide students repeated opportunities to apply theoretical
frameworks. This will help students become sufficiently familiar with
a theory that it becomes automatic in their way of thinking about and
approaching each clinical contextsthat is, they will begin to
metabolize the theory.
In the context of psychotherapy as a highly complex, context-specific
endeavor, it is imperative that therapists have the capacity to extend
their theoretical understanding in a flexible manner to a broad array of
Page 20 of 31
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possibilities. Using case examples that highlight the interpersonal and

subjective contexts of psychotherapy can have a major impact on
students capacities to think about the nuances of the therapeutic
encounter and to think through their intervention decisions within the
framework of their theoretical understanding. Open discussions of case
examples with particular emphasis on generating possibilities
possibilities of meanings and clinical inferences about the patient and
treatment, possibilities for interpersonal engagement, and possibilities
for interventions that might helpcan make theoretical knowledge
especially relevant and also spark students capacity to observe how
they think and process clinical material. It is very important that the
clinical material we use be emotionally meaningfully enough to be an
experiential (rather than a didactic) exercise that stimulates the
students empathy for the patient, personal reactions, attendant
anxieties, and curiosity. Videotapes of therapy sessions, either by
experts or students themselves, can be very helpful tools in providing
students opportunities to conceptualize not only the patients
difficulties, but also what is happening in the clinical encounter. A
process note, in which the student writes down verbatim the dialogue
with the patient (very preferably right after the session and not in
session), is also a good way to encourage critical thinking and
theoretical musing because it forces the therapist to deliberately think
about what the patient may have been trying to communicate.
Videotapes and process notes are preferable to written case
descriptions once students are on practicum for two reasons: (a) a
written case without the context of the dialogue and interpersonal
nuances with the patient does not provide students sufficient clinical
information to generate psychological hypotheses and meanings, and
(b) in a written case conceptualization, the process of thinking about
the patient within a theoretical framework is already completed; this
can circumvent the students process of thinking through and making
meaning of a case.
Based on studies of experts in a number of knowledge domains,
Ericsson and Charness (1999) emphasize the importance of deliberate
practice in the development of expertise. However, as Barnett and
Koslowski (2002) note in their study of adaptive expertise comparing
Page 21 of 31
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business consultants and restaurant managers, In this real-world

domain, where the everyday goal is not to build a specific skill but to
get a job done (unlike domains that are often studied, such as music
and professional sports), it is not clear what deliberate practice would
be, nor is it clear the extent to which either of the expert groups have
engaged in deliberate practice (p. 258). A challenge in applying the
research on deliberate practice is that it is difficult, and perhaps
irrelevant, to zero in on a skill that defines expertise in psychotherapy.
In this paper, we focused on the expert use of theory in generating
cogent case conceptualizations of patients struggles and character
style. This is a complex, multifaceted activity that is one cog in the
wheel of clinical practice. Furthermore, it is impossible to assess case
conceptualization skills separate from the context of the treatment and
the feedback from the patient. Improving performance through
deliberate practice requires immediate feedback. In psychotherapy,
feedback often may be obscure, indirect, delayed, and/or highly
subjective. The nature of information in psychotherapy is as nonverbal
as it is verbal, and often we learn more paying attention to process than
to content. We face another training challenge in how to help students
become attuned to feedback inherent in the treatment process and
develop capacities for and motivation for self-reflection and selfcritique.
Future Directions
It is important to keep in mind the limitations of medical expertise
research when considering the ambiguity, complexity, and
interpersonal dimensions of psychotherapy. The literature on medical
expertise is informative, but the predominant focus on physicians
routine diagnostic activities, and the fact that the studies are often
conducted in laboratory settings with written case descriptions, limit its
relevance. Diagnosis is treated as a discrete task that depends on the
physicians ability to process factual and observable information. It is
safe to say that in psychotherapy, even when the primary task is
assessment, we do more than diagnose by way of matching the signs
Page 22 of 31
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and symptoms to a disease prototype. Furthermore, the nature and

development of clinical expertise in psychotherapy is significantly
more complex than the assimilation of experience into a knowledge
base learned through academic study. The interpersonal dimensions of
therapeutic performance complicate the observation and evaluation of
expertise, because what is appropriate in one context may be quite
wrong in another.
It will be important to develop our own operational and conceptual
definition of expertise, conduct research on expertise specific to
psychotherapy, and generate a conceptual framework for
understanding clinical expertise in a way that accounts for the
multifaceted, fluid, contextual nature of psychotherapy. In addition, we
need to investigate empirically those approaches to psychotherapy
training that are more likely to facilitate students metabolization of
theoretical knowledge and development of adaptive expertise.
We also need to more systematically evaluate the efficacy of training
case conceptualization skills by formally assessing students capacity
for making clinical inferences and applying theoretical constructs
using a systematic, quantifiable approach to clinical diagnosis and case
conceptualization (Betan and Westen 2005). One potential measure for
such a study is the SWAP-200 (Shedler and Westen 2007), a reliable
and valid instrument that provides a means of assessing personality
using clinical judgment and inference. The SWAP-200 is a set of 200
personality-descriptive statements that capture the richness and
complexity of clinical case description. The SWAP-200 item set
includes DSM Axis II criteria and those Axis I criteria relevant to
personality, as well as personality constructs described in extensivelyreviewed clinical and research literatures. SWAP-200 items are written
in jargon-free English close to the data (e.g., Tends to be passive and
unassertive or Expresses emotion in exaggerated and theatrical
ways), and items that require inferences about internal processes are
written in simple and straightforward language (e.g., Tends to blame
others for own failures or shortcomings; tends to believe his/her
problems are caused by external factors or Tends to see own
unacceptable feelings or impulses in other people instead of in
him/herself). The statements provide a standard vocabulary with
Page 23 of 31
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which clinicians can express their observations and inferences and

capture even the most subtle clinical phenomena. Using the SWAP,
therefore, we could assess students abilities to observe, describe, and
conceptualize personality functioning of a patient in a videotaped
treatment. Using such a standardized method would allow comparisons
across students and across points in time for the same student. In
addition, in completing the SWAP, students will (a) be sensitized to the
types of clinical data we hope they would observe in a clinical
encounter; (b) be exposed to a descriptive language for describing
dimensions of personality and salient diagnostic features; and (c) learn
how to organize their clinical observations in a structured way.
Understanding and generating new meanings and modes of relating
that are therapeutic for each unique patient are at the heart of
psychotherapy expertise. We do not know enough about what kinds of
instruction and supervision, exposure to theoretical ideas and clinical
matter, and experiences in conducting psychotherapy contribute to the
capacities to metabolize theoretical understanding, to create new
understandings of people, to intervene in effective ways in each unique
therapeutic context, and to reflect upon ones knowledge and
conceptual understanding of therapeutic process and intervention. To
move forward in studying and facilitating the development of clinical
expertise, we look forward to growing partnerships between cognitive
scientists who study expert performance, psychotherapy process
researchers, therapy trainers, practitioners, and students.
References
American Psychological Association Presidential Task Force on Evidence-Based Practice.
(2006). Evidence-based practice in psychology. American Psychologist, 61, 271285.
CrossRef
Barnett, S. M., & Koslowski, B. (2002). Adaptive expertise: Effects of type of experience and
the level of theoretical understanding it generates. Thinking and Reasoning, 8, 237267.
CrossRef
Page 24 of 31
08/12/14 15:53
Bedard, J., & Chi, M. T. (1992). Expertise. Current Directions in Psychological Science, 1, 135
139.
CrossRef
Betan, E. J. (1997). Toward a hermeneutic model of ethical decision making in clinical practice.
Ethics & Behavior, 7, 347365.
CrossRef
Betan, E. J., & Westen, D. (2005). Evaluating the development of clinical skills in doctoral
students in clinical psychology (unpublished research proposal).
Binder, J. L. (1993). Is it time to improve psychotherapy training? Clinical Psychology Review,
13, 301318.
CrossRef
Binder, J. L. (2004). Key competencies in brief dynamic psychotherapy: Clinical practice beyond
the manual. New York: The Guilford Press.
Binder, J. L., & Wechsler, F. S. (2010). The intervention competency. In M. B. Kenkel & R. L.
Peterson (Eds.), Competency-based education for professional psychology (pp. 105123).
Washington, DC: American Psychological Association.
CrossRef
Bordage, G., & Zacks, R. (1984). The structure of medical knowledge in the memories of
medical students and general practitioners: Categories and prototypes. Medical Education, 18,
406416.
CrossRef
PubMed
Bransford, J. D., Brown, A. L., & Cocking, R. R. (Eds.). (1999). How people learn: Brain, mind,
experience, and school. Washington, DC, USA: National Academy Press.
Brown, A. L. (1989). Analogical learning and transfer: What develops? In S. Vosniadou & A.
Ortony (Eds.), Similarity and analogical reasoning (pp. 369412). Cambridge: Cambridge
University Press.
CrossRef
Catrambone, R., & Holyoak, K. J. (1989). Overcoming contextual limitations on problemsolving transfer. Journal of Experimental Psychology: Learning, Memory, and Cognition, 15(6),
11471156.
Page 25 of 31
08/12/14 15:53
CrossRef
Charlin, B., Boshuizen, H. P. A., Custers, E. J., & Feltovich, P. J. (2007). Scripts and clinical
reasoning. Medical Education, 41, 11781184.
PubMed
CrossRef
Charlin, B., Tardiff, J., & Boshuizen, H. (2000). Scripts and medical diagnostic knowledge:
Theory and applications for clinical reasoning instruction and research. Academic Medicine, 75,
182190.
CrossRef
PubMed
Chi, M. T. H., Feltovich, P. J., & Glaser, R. (1981). Categorization and representation of physics
problems by experts and novices. Cognitive Science, 5, 121152.
CrossRef
Chi, M. T., Glaser, R., & Farr, M. J. (Eds.). (1988). The nature of expertise. Hillsdale, NJ:
Erlbaum.
Cummings, A. L., Hallberg, E. T., Martin, J., Slemon, A., & Heibert, B. (1990). Implications of
counselor conceptualizations for counselor education. Counselor Education and Supervision, 30,
120134.
Cummins, D. (1992). Role of analogical reasoning in the induction of problem categories.
Journal of Experimental Psychology: Learning, Memory, and Cognition, 18(5), 11031124.
CrossRef
De Groot, A. D. (1965). Thought and choice in chess. The Hague: Mouton.
Dunbar, K. (1995). How scientists really reason: Scientific reasoning in real-world laboratories.
In R. J. Sternberg & J. E. Davidson (Eds.), The nature of insight (pp. 365395). Cambridge, MA:
MIT Press.
Eells, T. D., Lombart, K. G., Kendjelic, E. M., Turner, L. C., & Lucas, C. P. (2005). The quality
of psychotherapy case formulations: A comparison of expert, experienced, and novice cognitivebehavioral and psychodynamic therapists. Journal of Consulting and Clinical Psychology, 73,
579589.
CrossRef
PubMed
Ericsson, K. A., & Charness, N. (1999). Expert performance: Its structure and acquisition. In S.
J. Ceci & W. M. Williams (Eds.), The nature-nurture debate: The essential readings (pp. 199
Page 26 of 31
08/12/14 15:53
255). Malden, MA: Blackwell Publishers, Inc.

Eva, K. (2004). What every teacher needs to know about clinical reasoning. Medical Education,
39, 98106.
CrossRef
Feltovich, P. J., & Barrows, H. S. (1984). Issues of generality in medical problem solving. In H.
G. Schmidt & M. L. De Volder (Eds.), Tutorials in problem-based learning: A new direction in
teaching the health professions (pp. 128142). Assen, Maastricht: van Gorcum.
Fosshage, J. L. (2007). Searching for love and expecting rejection: Implicit and explicit
dimensions in cocreating analytic change. Psychoanalytic Inquiry, 27, 326347.
CrossRef
Gick, M. L., & Holyoak, K. J. (1983). Schema induction and analogical transfer. Cognitive
Psychology, 15, 138.
CrossRef
Goldfried, M. R., Raue, P. J., & Castonguay, L. G. (1998). The therapeutic focus in significant
sessions of master therapists: A comparison of cognitive-behavioral and psychodynamic
interpersonal interventions. Journal of Consulting and Clinical Psychology, 66, 803810.
CrossRef
PubMed
Hatano, G. (1982). Cognitive consequences of practice in culture specific procedural skills. The
Quarterly Newsletter of the Laboratory of Comparative Human Cognition, 4, 1518.
Hatano, G. (1988). Social and motivational bases for mathematical understanding. In G. B. Saxe
& M. Gearhart (Eds.), Childrens mathematics (pp. 5570). San Francisco: Jossey-Bass.
Hatano, G., & Inagaki, K. (1984). Two courses of expertise. Research and Clinical Center for
Child Development, 83 (annual report), pp. 2736.
Hatano, G., & Inagaki, K. (1986). Two courses of expertise. In H. W. Stevenson & H. Azuma
(Eds.), Child development and education in Japan (pp. 262272). New York: W.H. Freeman &
Co.
Henry, W. P., Strupp, H. H., Butler, S. F., Schacht, T. E., & Binder, J. L. (1993). Effects of
training in time-limited dynamic psychotherapy: Changes in therapist behavior. Journal of
Consulting and Clinical Psychology, 61, 434440.
CrossRef
PubMed
Page 27 of 31
08/12/14 15:53
Holyoak, K. J. (1991). Symbolic connectionism: Toward third-generation theories of expertise.

In K. A. Ericsson & J. Smith (Eds.), Towards a general theory of expertise (pp. 301335). New
York: Cambridge University Press.
Ivey, G. (2006). A method of teaching psychodynamic case formulation. Psychotherapy: Theory,
Research, Practice, Training, 43, 322336.
CrossRef
Karmiloff Smith, A., & Inhelder, B. (1974). If you want to get ahead, get a theory. Cognition,
3(3), 195212.
CrossRef
Kaslow, N. J. (2004). Competencies in professional psychology. American Psychologist, 59,
774781.
CrossRef
PubMed
Kaslow, N. J., Borden, K. A., Collins, F. L., Forrest, L., Illfelder-Kaye, J., Nelson, P. D., et al.
(2004). Competencies conference: Future directions in education and credentialing in
professional psychology. Journal of Clinical Psychology, 60, 699712.
CrossRef
PubMed
Kendjelic, E. M., & Eells, T. D. (2007). Generic psychotherapy case formulation training
improves formulation quality. Psychotherapy: Theory, Research, Practice, Training, 44, 6677.
CrossRef
Kenkel, M., & Peterson, R. L. (Eds.). (2010). Competency-based education for professional
psychology. Washington, DC: American Psychological Association.
Lesgold, A., Glaser, R., Rubinson, H., Klopfer, D., Feltovich, P., & Wang, Y. (1988). Expertise in
a complex skill: Diagnosing X-ray pictures. In M. T. H. Chi, R. Glaser, & M. J. Farr (Eds.), The
nature of expertise (pp. 311342). Hillsdale, NJ: Lawrence Erlbaum Associates Inc.
Levenson, H., & Strupp, H. H. (1997). Cyclical maladaptive patterns: Case formulation in timelimited dynamic psychotherapy. In T. D. Eells (Ed.), Handbook of psychotherapy case
formulation (pp. 84115). New York: Guilford Press.
Lin, X., Schwartz, D. L., & Bransford, J. (2007). Intercultural adaptive expertise: Explicit and
implicit lessons from Dr. Hatano. Human Development, 50, 6572.
CrossRef
Page 28 of 31
08/12/14 15:53
Myopoulous, M., & Regehr, G. (2007). Cognitive metaphors of expertise and knowledge:
Prospects and limitations for medical education. Medical Education, 41, 11591165.
National Council of Schools and Programs in Professional Psychology (NCSPP). (2007).
Competency developmental achievement levels of the National Council of Schools and Programs
in Professional Psychology. Retrieved August 21, 2009, from http://www.ncspp.info/DALof%20
NCSPP%209-21-07.pdf.
Norman, G., Young, M., & Brooks, L. (2007). Non-analytical models of clinical reasoning: The
role of experience. Medical Education, 41, 11401145.
PubMed
Patel, V. L., Arocha, J. F., Diermeier, M., How, J., & Mottur-Pilson, C. (2001). Cognitive
psychological studies of representation and use of clinical practice guidelines. International
Journal of Medical Informatics, 63, 147167.
CrossRef
PubMed
Patel, V. L., Arocha, J. F., & Kaufman, D. R. (1994). Diagnostic reasoning and expertise.
Psychological Learning Motivation, 31, 137252.
Patel, V. L., & Groen, G. J. (1991). The general and specific nature of medical expertise: A
critical look. In A. Ericsson & J. Smith (Eds.), Towards a general theory of expertise: Prospects
and limits (pp. 93125). Cambridge, UK: Cambridge University Press.
Persons, J. B. (2006). Case formulation-driven psychotherapy. Clinical Psychology: Science and
Practice, 13, 167170.
CrossRef
Rodolfa, E. (ed.). (2005). Competency educationcompetent professionalsethical practice
[Special section]. Professional Psychology: Research and Practice, 36, 347375.
Rodolfa, E., Bent, R., Eisman, E., Nelson, P., Rehm, L., & Ritchie, P. (2005). A cube model for
competency development: Implications for psychology educators and regulators. Professional
Psychology: Research and Practice, 36(4), 347354.
CrossRef
Scheiber, S. C., Kramer, T. A. M., & Adamowski, S. E. (Eds.). (2003). Core competencies for
psychiatric practice: What clinicians need to know: A report of the American Board of
Psychiatry and Neurology, Inc. Arlington, VA, USA: American Psychiatric Publishing, Inc.
Page 29 of 31
08/12/14 15:53
Schmidt, H. G., & Rikers, R. M. J. P. (2007). How expertise develops in medicine: Knowledge
encapsulation and illness script formation. Medical Education, 41, 11331139.
PubMed
Schn, D. A. (1983). The reflective practitioner. New York: Basic Books.
Shedler, J., & Westen, D. (2007). The Shedler-Westen Assessment Procedure (SWAP): Making
personality diagnosis clinically meaningful. Journal of Personality Assessment, 89, 4155.
PubMed
Silverman, S. (2006). Where we both have lived. Psychoanalytic Dialogues, 16(5), 527542.
Voss, J. F., Greene, T. R., Post, T. A., & Penner, B. C. (1983a). Problem-solving skill in the social
sciences. In G. H. Bower (Ed.), The psychology of learning and motivation: Advances in
research theory (Vol. 17, pp. 165213). New York: Academic Press.
Voss, J. F., & Post, T. A. (1988). On the solving of ill-structured problems. In M. T. H. Chi, R.
Glaser, & M. J. Farr (Eds.), The nature of expertise (pp. 261285). Hillsdale, NJ: Lawrence
Erlbaum Associates Inc.
Voss, J. F., Tyler, S. W., & Yengo, L. A. (1983b). Individual differences in the solving of social
science problems. In R. F. Dillon & R. R. Schmeck (Eds.), Individual differences in cognition
(pp. 205232). New York: Academic Press.
Wiser, S., & Goldfried, M. R. (1998). Therapist interventions and client emotional experiencing
in expert psychodynamic-interpersonal and cognitive-behavioral therapies. Journal of Consulting
and Clinical Psychology, 66, 634640.
CrossRef
PubMed
Footnotes
1 We appreciate very much an anonymous reviewers suggestion that tolerating ambiguity is an important
aspect of a therapists functioning that clearly relates to the ability to develop a coherent conceptualization.
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How Expert Therapists Use Theoryin Generating Case Conce

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therapists capacity to use theoretical and clinical knowledge in an

broader relevance for clinical training and expertise beyond specific

(Kaslow 2004; Rodolfa et al. 2005).

Likewise, knowledge is certainly an aspect of expertise. Clinical

Case Conceptualization, Clinical

meaning of a patients difficulties. Regarding clinical expertise, the

conceptualization. Immediately, we make meaning of and draw

consequences such as complaints and symptoms (Charlin et al. 2000).

However, the findings of cognitive sciences research on expert

contexts. In learning theory and developing clinical skill, we cannot

training can interfere with rather than facilitate case conceptualization

knowing what troubles a patient and/or communications that may be

Lessons from the Expertise Literature

difficulties, and potential for cognitive lapses. Thinking in terms of

clinical experiences and the associated action-consequence sequences.

procedures work, and they are able to verbalize the principles

framework. Furthermore, Hatanos and others findings regarding

orientation, tend to work very similarly to each other in terms of being

actions, and knowledge.

Considerations for Training

more conservative stance primarily regarding the therapeutic frame.

1991). Recognizing and comparing differences across cases is an

possibilities. Using case examples that highlight the interpersonal and

business consultants and restaurant managers, In this real-world

and symptoms to a disease prototype. Furthermore, the nature and

which clinicians can express their observations and inferences and

255). Malden, MA: Blackwell Publishers, Inc.

Holyoak, K. J. (1991). Symbolic connectionism: Toward third-generation theories of expertise.

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