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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.
Luis Botella, Sílvia Urbano, & Josep Gallifa
Ramon Llull University
One-third to one-half of American clinicians consider themselves to be either “eclectic” or “integrative” in theoretical orientation—Schottenbauer, Glass,& Arnkoff (2005).
Psychotherapy integration is widely believed by experienced clinicians to improve the effectiveness of psychotherapy—Schottenbauer, Glass,& Arnkoff (2005).
Expert psychotherapists converge in significant beliefs regardless of their preferred theoretical approach—Mahoney & Craine (1991).
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.
Expertise entails also a decrease in novices preference for being directive (vs. reflective).
Psychotherapy integration can be regarded as a product or a process—Schacht (1991).
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).
What are the differences between novice and expert integrative psychotherapists in terms of their knowledge organization?
28 postgraduate students enrolled in an integrative Psychotherapy Master’s course
Mean Age = 25.7
Min = 22.2; Max = 29.9; SD = 2.2
Maximum 50 hs. of clinical experience
9 novices randomly selected among the ones in Study 1
20 practicing psychotherapists, accredited by professional societies belonging to the Spanish Federation of Psychotherapists’ Associations
All of them defining their practice and approach as integrative
Mean Age = 46.3
Min = 42.2; Max = 55; SD = 2.9
More than 15 years of clinical experience;
More than 10 patients per week;
Presentations in international conferences.
9 experts randomly selected among the ones in Study 1
Case Conceptualization Narrative
First person narrative including prototypical examples of 28 key psychotherapy concepts
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)
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…
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.
Participants were asked to:
Therapeutic Approaches Grid
Personal construct grid elicited by comparing and contrasting six main theoretical approaches
Participants were asked to:
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”
Example B (Expert)
Psychoanalytic psychotherapies require a quite serious and profound therapist’s attitude, while systemic therapies are far more playful and irreverent
Novices were also asked to:
Study 1--Concepts Correctly Identified (mean)
Study 1--Concepts Correctly Attributed to their Theoretical Approach (mean)
Experts have more “declarative knowledge” than novices. They identify more techniques as well as their theoretical origins.
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.
Study 2—Constructs Content Clusters (Novices)
Study 2—Constructs Content Clusters (Experts)
Experts use a more complex conceptual map than novices. They use more concepts and organize them in more clusters.
Study 2—Integrative vs. Non Integrative Construct Scorings (means)
Experts differ from novices regarding what approaches they regard as the more/less integrative ones.
Constructivism is regarded by experts (but not by novices) as the more integrative approach.
Psychoanalysis is regarded by experts (but not by novices) as the less integrative approach.
Study 2—Integrative vs. Non Integrative Extreme Ratings (%)
The construct “integrative vs. non integrative” makes more sense and is more salient to experts than to novices.
Study 2—Novices vs. Experts Differentiation and Integration Indices (means)
Novices perceive common factors in all prototypical cases—somewhat differentially however.
Novices perceive specific factors of every approach in every other one—also somewhat differentially.
Novices do not differ from experts in their ability to differentiate approaches.
However, novices differ dramatically from experts in their ability to integrate different approaches.
Expert integrative therapists excel in their domain. Interestingly, their domain is not a single psychotherapy approach, but more than one.
Novice integrative therapists are more knowledgeable about a single approach than about more than one or about factors common to all of them.
Expert integrative therapists organize their knowledge in a way that supports rapid and accurate perception of large meaningful patterns.
Novice integrative therapists have difficulties identifying and perceiving patterns in everyday situations—like a patient’s narrative.
Expert integrative therapists represent events at semantically deeper levels—i.e. they are not only able to differentiate but to integrate them.
Novice integrative therapists tend to represent events in their domain more in terms of surface features—i.e. they differentiate far more than integrate.
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.