The Second Leg: Clinical Expertise

1. The Second Leg:Clinical Expertise June 14, 2007

2. Clinical Expertise Defined • Clinical expertise: the ability to use clinical skills and past experience to rapidly identify • each patient's unique health state and diagnosis • individual risks and benefits of potential interventions • personal values and expectations

3. APA EBPP Definition • Relevant issues: • Experts v. novices • Heuristics and biases • Cookbook formulation • Competency v. adaptive knowledge

4. Components of Clinical Expertise • Assessment, diagnostic judgment, systematic case formulation, and treatment planning • Clinical decision making, treatment implementation, and monitoring of patient progress • Interpersonal expertise • Self-reflection and life-long learning • Evaluation of research evidence in basic and applied psychological science • Understanding individual and cultural differences and their effects on treatment • Seeking available resources • Having a cogent rationale for clinical strategies

5. Clinician Biases • Motivated reasoning: people more skeptical when processing information they don’t want to believe (Ditto et al, PSPB, 2003) • fake saliva test indicating presence of a pancreatic enzyme

6. Evidence that Clinical Skills are Important(N=248 consecutive patients)(Wahner-Roedler, et al., J Eval Clin Prac, (2007).

7. Clinician “semantic space” of DSM-II-R Axis I and Axis II disorders

8. Herkov & Blashfield (1995) – hierarchical structure of diagnoses in personality disorder

9. Clinician concepts of PD Shedler & Westen (American Journal of Psychiatry, 2004) • National sample of 797 experienced psychiatrists and clinical psychologists (18.1 postgrad years) • Pick a patient or respond to a ‘hypothetical’ • Sort statements into 8 piles from least descriptive (0) to most descriptive (7)

11. Blashfield and Flanagan JNMD, 1998 “age= 38, gender = female, marital status = single.” (*1*) “A 38-year-old woman was brought to an emergency room after attempting to kill herself by jumping in front of a subway train. (*2*) The woman had flat affect and spoke matter-of-factly during the interview. She said that the driver of the subway train had been her lover and that a major fear of these drivers was that someone would leap in front of their train in a suicidal act. (*3*) This lover had recently stopped seeing the woman after his wife learned of his affair and the wife had physically beaten up the patient in a nightclub. (*4*) The patient is an obese women of at least 250 pounds who works at a mortuary. She has been employed at the mortuary since the death of her mother.(*5*) Her mother and father were divorced when the patient was 15. Initially, the father won custody, but, when the patient kept running away from him, she was permitted to live with her mother. (*6*) She and her mother were very close. The mother contracted cancer, and the patient took care of her until her death. Then the patient requested a job with the mortuary that buried her mother. (*7*) Until recently, the patient had had no social life outside the mortuary. However, while riding the subway, she became fascinated with the voice of one driver and was determined to learn about this man. (*8*) She took leave from her job and managed to learn who the driver was, what his schedule was, and where he lived. She approached him and they became lovers. (*9*)”

12. Previous distributions of PD diagnoses Diagnosis when presented in steps

13. Therapist (Treatment) Skills(Bennett-Levy et al (2006) Behavioural and Cognitive Therapy) • Declarative • Methods • Techniques • Procedural • “When-then” • “How-to” (e.g., reflection, empathy) • Reflectional • Key to skill development

14. Expert and Novice Treaters(Eells et al, (2005), JCCP) • Expert, experienced, and novice tx • Expertise in psychotherapy is “ill structured” rather than “well-structured” as in chess • Psychodynamic and CBT • “Think aloud” case formulations of standard cases • Experts’ formulations were more elaborated, comprehensive, complex, and systematic • Experts treatment plans more directly tied to case formulations • Effect size medium-large

15. Question • If you were doing a study evaluating the relationship between therapist expertise and therapy outcome, how would you measure expertise? • If you were doing a study evaluating the relationship between therapist expertise and the therapy experience (viewed by the patient), how would you measure expertise?

16. What does the literature say… • About the relative importance of therapist, treatment, and patient variables in predicting outcome? • Is there any empirical data on the implications of therapist expertise findings for education and training? • How can supervision be structured to enhance development of expertise?

17. Research Needs(APA, 2005)