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Cognitive Complexity and Case Formulation in Psychotherapy Experts vs. Novices: Implications for Psychotherapy Integration. Luis Botella, Sílvia Urbano, & Josep Gallifa Ramon Llull University Barcelona. 1.

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slide1

Cognitive Complexityand Case Formulation inPsychotherapy Experts vs. Novices:Implications forPsychotherapy Integration

Luis Botella, Sílvia Urbano, & Josep Gallifa

Ramon Llull University

Barcelona

slide3

One-third to one-half of American clinicians consider themselves to be either “eclectic” or “integrative” in theoretical orientation—Schottenbauer, Glass,& Arnkoff (2005).

slide5

Psychotherapy integration is widely believed by experienced clinicians to improve the effectiveness of psychotherapy—Schottenbauer, Glass,& Arnkoff (2005).

slide7

Expert psychotherapists converge in significant beliefs regardless of their preferred theoretical approach—Mahoney & Craine (1991).

slide8

Expertise entails an increasing acknowledgement of clients’ variables, therapists’ personality, and the quality of the therapeutic relationship as the most important factors in psychotherapy outcome.

slide14

The development of expertise involves a progression from a superficial and literal understanding of problems (a qualitative mark of the cognition of novices) to an articulated, conceptual, and principled understanding (a qualitative mark of the cognition of experts).

slide15

What are the differences between novice and expert integrative psychotherapists in terms of their knowledge organization?

participants novices
Participants--Novices

Study 1

28 postgraduate students enrolled in an integrative Psychotherapy Master’s course

participants novices1
Participants--Novices

Study 1

Mean Age = 25.7

Min = 22.2; Max = 29.9; SD = 2.2

participants novices2
Participants--Novices

Study 1

14.29% Men

85.71% Women

participants novices3
Participants--Novices

Study 1

Maximum 50 hs. of clinical experience

participants novices4
Participants--Novices

Study 2

9 novices randomly selected among the ones in Study 1

participants experts
Participants--Experts

Study 1

20 practicing psychotherapists, accredited by professional societies belonging to the Spanish Federation of Psychotherapists’ Associations

participants experts1
Participants--Experts

Study 1

All of them defining their practice and approach as integrative

participants experts2
Participants--Experts

Study 1

Mean Age = 46.3

Min = 42.2; Max = 55; SD = 2.9

participants experts3
Participants--Experts

Study 1

35% Men

65% Women

participants experts5
Participants--Experts

Study 1

More than 15 years of clinical experience;

More than 10 patients per week;

Ph.D;

Publications;

Presentations in international conferences.

participants experts6
Participants--Experts

Study 2

9 experts randomly selected among the ones in Study 1

method instruments
Method--Instruments

Study 1--CCN

Case Conceptualization Narrative

First person narrative including prototypical examples of 28 key psychotherapy concepts

method instruments1
Method--Instruments

Study 1--CCN

Behavior Therapies (e.g., positive reinforcement)

Cognitive Therapies (e.g., overgeneralization)

Humanistic Therapies (e.g., unconditional positive regard)

Psychoanalytic Therapies (e.g., CCRT)

Systemic Therapies (e.g., triangulation)

Constructivist Therapies (e.g., rigid superordinate construct)

method instruments2
Method--Instruments

Study 1--CCN

I would really like to say a few things to my mother.

I was left with so many things to say and so many feelings to express after she divorced! But now it’s too late… she’ll never understand me even if I try, so I’ve quit trying… but the truth is that it still hurts…

UNFINISHED BUSSINESS

method instruments3
Method--Instruments

Study 1--CCN

There are no shades of grey with me; either you’re with me or against me. Love me or leave me, but what I do I do it 100% and 24/7, and if someone does not want to follow me, he’d better get out of my way. If you’re not part of the solution you’re part of the problem; and the last thing I need right now are problems.

ABSOLUTISTIC THINKING

method instruments4
Method--Instruments

Study 1--CCN

Participants were asked to:

  • Identify the key concepts that the narrative illustrates, and
  • Identify the theoretical approach to which each concept belongs
method instruments5
Method--Instruments

Study 2--TAG

Therapeutic Approaches Grid

Personal construct grid elicited by comparing and contrasting six main theoretical approaches

method instruments6
Method--Instruments

Study 2--TAG

Behavior Therapies

Cognitive Therapies

Humanistic Therapies

Psychoanalytic Therapies

Systemic Therapies

Constructivist Therapies

method instruments7
Method--Instruments

Study 2--TAG

Participants were asked to:

  • Compare two approaches;
  • Elicit what do they have in common (or what makes them opposite if that was the case);
  • Elicit the opposite pole of the personal construct in (b);
  • Repeat the comparison with other two approaches (nine comparisons in total);
  • Score each approach in each bipolar construct.
method instruments8
Method--Instruments

Study 2--TAG

Example A (Novice)

In my opinion cognitive and behavior therapies are similar because both of them are directive, and the opposite of “directive” would be “non-directive”

method instruments9
Method--Instruments

Study 2--TAG

Example B (Expert)

Psychoanalytic psychotherapies require a quite serious and profound therapist’s attitude, while systemic therapies are far more playful and irreverent

method instruments11
Method--Instruments

Study 2.1

Novices were also asked to:

  • Read six prototypical case studies (one of each of the main approaches already mentioned);
  • Rate them in a list of 19 common factors;
  • Rate them in a list of six specific factors (each one being the main “active ingredient” of each approach);
results
Results

Study 1--Concepts Correctly Identified (mean)

results1
Results

Study 1--Concepts Correctly Attributed to their Theoretical Approach (mean)

slide43

Experts have more “declarative knowledge” than novices. They identify more techniques as well as their theoretical origins.

slide44

Being able to identify theoretical concepts in the patient’s narrative is not only “declarative”, it’s also procedural . So, experts are also more skillful—not only more knowledgeable.

results2
Results

Study 2—Constructs Content Clusters (Novices)

results3
Results

Study 2—Constructs Content Clusters (Experts)

slide48

Experts use a more complex conceptual map than novices. They use more concepts and organize them in more clusters.

results4
Results

Study 2—Integrative vs. Non Integrative Construct Scorings (means)

slide51

Experts differ from novices regarding what approaches they regard as the more/less integrative ones.

slide54

Constructivism

Psychoanalysis

Constructivism

Psychoanalysis

results5
Results

Study 2—Integrative vs. Non Integrative Extreme Ratings (%)

slide56

The construct “integrative vs. non integrative” makes more sense and is more salient to experts than to novices.

slide57

Integrative?

Integrative?

results6
Results

Study 2—Novices vs. Experts Differentiation and Integration Indices (means)

Diff.

Int.

Diff.

Int.

slide61

Novices perceive common factors in all prototypical cases—somewhat differentially however.

slide62

Novices perceive specific factors of every approach in every other one—also somewhat differentially.

slide64

However, novices differ dramatically from experts in their ability to integrate different approaches.

in summary
In summary…

Expert integrative therapists excel in their domain. Interestingly, their domain is not a single psychotherapy approach, but more than one.

in summary1
In summary…

Novice integrative therapists are more knowledgeable about a single approach than about more than one or about factors common to all of them.

in summary2
In summary…

Expert integrative therapists organize their knowledge in a way that supports rapid and accurate perception of large meaningful patterns.

in summary3
In summary…

Novice integrative therapists have difficulties identifying and perceiving patterns in everyday situations—like a patient’s narrative.

in summary4
In summary…

Expert integrative therapists represent events at semantically deeper levels—i.e. they are not only able to differentiate but to integrate them.

in summary5
In summary…

Novice integrative therapists tend to represent events in their domain more in terms of surface features—i.e. they differentiate far more than integrate.

slide72

The will to want to step out of your current comfort zone.

The courage to give it a try.

Perseverance to learn the skills required.

Persistence so to practice until you master them. Humility in order to continue learning without becoming complacent.

Generosity to become a good teacher so others can learn too.