BY:
American Psychologist ●
May–June 2006
Clinical expertise refers
to competence attained by psychologists through education, training, and
experience that results in effective practice; the term is not meant to refer
to extraordinary performance that might characterize an elite group (e.g., the
top 2%) of clinicians.
Clinical expertise is
essential for identifying and integrating the best research evidence with
clinical data (e.g., information about the patient obtained over the course
of treatment)
in the context of the patient’s characteristics and preferences to deliver
services that have the highest probability of achieving the goals of therapy.
Psychologists are trained as scientists as well as practitioners.
An advantage of psychological training is that it fosters a
clinical expertise informed by scientific expertise, allowing the psychologist
to understand and integrate scientific literature as well as to frame and test
hypotheses and interventions in practice as a “local clinical scientist”
(Stricker & Trierweiler, 1995).
Cognitive scientists have found consistent evidence of enduring and significant
differences between experts and novices undertaking complex tasks in several domains
(Be´- dard
& Chi, 1992; Bransford, Brown, & Cocking, 1999; Gambrill, 2005).
Experts recognize meaningful patterns and disregard irrelevant
information, acquire extensive knowledge and organize
it in ways that reflect a deep understanding of their domain, organize their
knowledge using
functional rather than descriptive features, retrieve knowledge relevant to the task
at hand fluidly and automatically, adapt to new situations, self-monitor their
knowledge and
performance, know when their knowledge is inadequate, continue to learn, and generally attain
outcomes commensurate with their expertise.
However, experts are not infallible. All humans are prone to errors and biases.
Some of these stem from cognitive strategies and heuristics that are generally
adaptive and
efficient. Others stem from emotional reactions, which generally guide adaptive
behavior as well but can also lead to biased or motivated reasoning (e.g., Ditto &
Lopez, 1992;
Ditto, Munro, Apanovitch, Scepansky, & Lockhart, 2003; Kunda, 1990).
Whenever psychologists involved in research or practice move from
observations to inferences and generalizations,
there are inherent risks of idiosyncratic interpretations, overgeneralizations,
confirmatory biases, and similar errors in judgment (Dawes, Faust, &
Meehl, 2002;
Grove, Zald, Lebow, Snitz, & Nelson, 2000; Meehl, 1954; Westen & Weinberger,
2004).
Integral to clinical expertise is an awareness of
the limits of one’s knowledge and skills and attention to the heuristics and
biases—both cognitive
and affective—that can affect clinical judgment. Mechanisms such as
consultation and systematic feedback from the patient can mitigate some of these biases.
The individual therapist
has a substantial impact on outcomes, both in clinical trials and in practice
settings (Crits-Christoph
et al., 1991; Huppert et al., 2001; Kim, Wampold, & Bolt, in press; Wampold & Brown,
2005).
The fact that treatment outcomes are systematically related to the provider of the
treatment (above and beyond the type of treatment) provides strong evidence for the
importance of
understanding expertise in clinical practice as a way of enhancing patient outcomes.
Components of Clinical Expertise
Clinical expertise encompasses a number of
competencies that promote positive therapeutic outcomes. These
include
(a) Assessment, diagnostic judgment, systematic case formulation,
and treatment planning;
(b) Clinical decision-making, treatment implementation,
and monitoring of patient progress;
(c) Interpersonal expertise;
(d) Continual self-reflection and acquisition of skills;
(e) Appropriate evaluation and use of research evidence in both basic
and applied
psychological science;
(f) Understanding the influence of individual and cultural
differences on treatment;
(g) Seeking available resources (e.g., consultation,
adjunctive or
alternative services) as needed; and
(h) Having a cogent rationale for clinical strategies.
Expertise develops from clinical and scientific
training, theoretical understanding, experience, self-reflection, knowledge of research,
and continuing
professional education and training. It is manifested in all clinical
activities, including but not limited to forming therapeutic alliances; assessing patients and
developing systematic case formulations, planning treatment, and setting goals; selecting
interventions and applying them skillfully; monitoring patient progress and
adjusting practices
accordingly; attending to patients’ individual, social, and cultural contexts;
and seeking available resources as needed (e.g., consultation, adjunctive or
alternative services).
Assessment, diagnostic judgment, systematic case formulation,
and treatment planning.
The clinically expert psychologist is able
to formulate clear and theoretically coherent case conceptualizations,
assess patient
pathology as well as clinically relevant strengths, understand complex patient
presentations, and make accurate diagnostic judgments. Expert clinicians revise
their case conceptualizations
as treatment proceeds and seek both confirming and disconfirming evidence.
Clinical expertise also involves identifying and helping
patients to acknowledge psychological processes that contribute to
distress or dysfunction.
Treatment planning
involves setting goals and tasks of treatment that take into consideration the unique
patient, the
nature of the patient’s problems and concerns, the likely prognosis and expected
benefits of treatment, and available resources. The goals of therapy are developed in
collaboration with the patient and consider the patient and his or
her family’s worldview
and sociocultural context.
The choice of treatment strategies requires knowledge of
interventions and the research that supports their effectiveness as well as research relevant
to matching interventions to patients (e.g., Beutler, Alomohamed, Moleiro, &
Romanelli, 2002;
Blatt, Shahar, & Zurhoff, 2002; Norcross, 2002).
Expertise also requires knowledge about psychopathology; treatment process; and patient
attitudes, values, and context—including cultural context—that can affect the
choice and
implementation of effective treatment strategies.
Clinical decision-making,
treatment implementation, and monitoring of patient progress.
Clinical expertise entails the skillful and
flexible delivery of treatment. Skill and flexibility require knowledge
of and proficiency
in delivering psychological interventions and the ability to adapt the
treatment to the particular case.
Flexibility is manifested in tact, timing, pacing, and
framing of interventions; maintaining an effective balance between consistency
of interventions and responsiveness to patient feedback; and
attention to acknowledged and unacknowledged meanings, beliefs, and emotions.
Clinical expertise also entails the monitoring of patient
progress (and of changes in the patient’s circumstances— e.g., job loss, major
illness) that may suggest the need to adjust the treatment (Lambert, Bergin, &
Garfield, 2004).
If progress is not proceeding adequately, the psychologist
alters or addresses problematic aspects of the treatment (e.g., problems in
the therapeutic relationship or in the implementation of the goals of the treatment)
as appropriate.
If insufficient progress remains a problem, the therapist considers
alternative diagnoses and formulations, consultation, supervision, or referral.
The clinical expert makes decisions about termination in timely ways by
assessing patient progress in the context of the patient’s life, treatment goals, resources,
and relapse potential.
Interpersonal expertise.
Central to clinical expertise is interpersonal skill, which is manifested
in forming
a therapeutic relationship, encoding and decoding verbal and nonverbal
responses, creating realistic but positive expectations, and responding
empathically to the patient’s explicit and implicit experiences and concerns.
Interpersonal expertise involves the flexibility to be clinically
effective with patients
of diverse backgrounds. Interpersonally skilled psychologists are able to
challenge patients in a
supportive atmosphere
that fosters exploration, openness, and change.
Psychological practice is, at root, an interpersonal relationship between
psychologist and patient. Each participant in the treatment relationship exerts
influence on its process
and outcome, and the compatibility of psychologist and patient(s) is particularly
important. Converging sources of evidence indicate that individual health care
professionals affect the efficacy of treatment (American Psychological
Association, 2002).
In psychotherapy, for example, individual-therapist effects
(within treatment) account for 5%–8% of the outcome variance (Crits-Christoph et al.,
1991; Kim et al., in
press; Project MATCH Research Group, 1998; Wampold
& Brown, 2005). Decades of research also support the contribution of an
active and motivated patient to successful treatment (e.g., Bohart & Tallman,
1999; Clarkin & Levy, 2004; W. R. Miller & Rollnick, 2002; Prochaska,
Norcross, & DiClemente, 1994).
With the development of interactive electronic technology
(e.g., telehealth), many community-wide psychological interventions or other
approaches do not necessarily involve direct, face-to-face contact with a
psychologist. However,
these interventions, to be effective, also engage the patient actively in the
treatment process and attend in a flexible manner to individual variations among
targeted groups.
The clinical expert fosters the patient’s positive engagement
in the therapeutic process, monitors the therapeutic alliance, and attends
carefully to barriers to engagement and change. The clinical expert recognizes
barriers to progress and addresses them in a way that is
consistent with theory
and research (e.g., exploring therapeutic impasses with the patient, addressing
problems in the therapeutic relationship).
Continual self-reflection and acquisition of
skills
Clinical expertise requires the ability to reflect on one’s own experience,
knowledge, hypotheses, inferences, emotional reactions, and behaviors and to use that
reflection to modify one’s practices accordingly. Integral to clinical expertise is an
awareness of the limits of one’s knowledge and skills as well as a recognition of the
heuristics and biases (both cognitive and affective) that can affect clinical judgment
(e.g., biases that can inhibit recognition of the need to alter case
conceptualizations that areinaccurate or treatment
strategies that are not working).
Clinical expertise involves taking explicit action to limit the effects of these biases.
Developing and
maintaining clinical expertise and applying this expertise to specific patients entail
the continual incorporation of new knowledge and skills derived from
(a) research and theory;
(b) systematic clinical observation, disciplined inquiry, and
hypothesis testing;
(c) self-reflection and feedback from other sources (e.g.,
supervisors, peers, patients, other health professionals, the patient’s significant others
[where appropriate]);
(d) monitoring of patient outcomes; and (e) continuing
education and other learning opportunities (e.g., practice
networks, patient
advocacy groups).
Evaluation and use of research evidence.
Clinical expertise in psychology includes
scientific expertise. This is one of the hallmarks of psychological education
and one of the advantages of psychological training.
An understanding of scientific method allows psychologists to
consider evidence from a range of research designs, evaluate the internal and
external validity of individual studies, evaluate the magnitude of effects across
studies, and
apply relevant research to individual cases.
Clinical expertise also comprises a scientific attitude toward
clinical work,
characterized by openness to data, clinical hypothesis generation and testing,
and a capacity to use theory to guide interventions without allowing theoretical
preconceptions to override clinical or research data.
Understanding the influence of individual,
cultural, and contextual
differences on treatment. Clinical expertise
requires an awareness of the individual, social, and cultural context of the
patient, including but not limited to age and development, ethnicity,
culture, race, gender,
sexual orientation, religious commitments, and socioeconomic status (see the
Patient Characteristics, Culture, and Preferences section).
Clinical expertise allows psychologists to adapt
interventions and construct a therapeutic milieu that respects the
patient’s worldview,
values, preferences, capacities, and other characteristics (Arnkoff, Glass,
& Shapiro, 2002; Sue & Lam, 2002).
APA has adopted practice guidelines on multicultural
practice, sexual orientation, and older adults to assist psychologists in tailoring
their practices to patient differences (American Psychological Association,
2000, 2003, 2004).
Seeking available resources as needed
(e.g., consultation,
adjunctive or alternative services).
The psychologist is cognizant that accessing additional resources can
sometimes enhance the effectiveness of treatment. When research evidence
indicates the value
of adjunctive services or when patients are not making progress as expected,
the psychologist may seek consultation or make a referral. Culturally sensitive
alternative services
responsive to a patient’s context or worldview may complement psychological
treatment. Consultation for the psychologist is a means to monitor—and correct, if
necessary— cognitive and affective biases.
A cogent rationale for clinical strategies.
Clinical expertise requires a planful
approach to the treatment of psychological problems. Although clinical practice is often eclectic or
integrative (Norcross & Goldfried, 2005), and many effects of psychological treatment
reflect nonspecific
aspects of therapeutic engagement (e.g., changes that occur through development of an empathic
relationship; Lambert et
al., 2004; Weinberger, 1995), psychologists rely on well-articulated case
formulations, knowledge
of relevant research, and the organization provided by theoretical
conceptualizations and clinical experience to craft interventions designed to
attain desired outcomes.
Some patients have a well-defined issue or disorder for which there is a body of
evidence that strongly supports the effectiveness of a particular treatment. This
evidence should
be considered in formulating a treatment plan, and a cogent rationale should be
articulated for any course of treatment recommended. There are many problem
constellations, patient populations, and clinical situations for which treatment evidence
is sparse.
In such instances, evidence-based practice consists of using clinical
expertise in
interpreting and applying the best available evidence while carefully monitoring
patient progress and modifying
treatment as appropriate
(Hayes, Barlow, & Nelson-Gray, 1999; Lambert, Harmon, Slade, Whipple, & Hawkins,
2005; S. D. Miller,
Duncan, & Hubble, 2005).
Future Directions
Although much less research is available on clinical
expertise than on psychological interventions, an important foundation is
emerging (Goodheart, 2006; Skovholt & Jennings, 2004; Westen & Weinberger,
2004). For example, research on case formulation and diagnosis suggests that
clinical inferences, diagnostic
judgments, and formulations can be reliable and valid when structured in ways that
maximize clinical
expertise (Eells, Lombart, Kendjelic, Turner, & Lucas, 2005; Persons, 1991;
Westen & Weinberger, 2005).
Research suggests that sensitivity and flexibility in the administration of therapeutic
interventions produces better outcomes than rigid application of manuals or
principles (Castonguay,
Goldfried, Wiser, Raue, & Hayes, 1996; Henry, Schacht, Strupp, Butler,
& Binder, 1993; Huppert et al., 2001).
Reviews of research on biases and heuristics in clinical judgment have
suggested procedures that clinicians might use to minimize those biases (Garb, 1998).
Because of
the importance of therapeutic alliance to outcome (Horvath & Bedi, 2002;
Martin, Garske, & Davis, 2000; Shirk & Karver, 2003), an understanding of the personal
attributes and interventions of therapists that strengthen the alliance is essential for
maximizing the quality of patient care (Ackerman & Hilsenroth, 2003).
Mutually respectful collaboration between researchers and expert practitioners will
foster useful and systematic empirical investigation of clinical expertise. Some of
the most
pressing research needs are the following:
● Studying the practices
of clinicians who obtain the best outcomes in the community, both in general
and with particular
kinds of patients or problems;
● Identifying
technical skills used by expert clinicians in the administration of
psychological interventions that have proven to be effective;
● Improving the
reliability, validity, and clinical utility of diagnoses and case formulations;
● Studying conditions
that maximize clinical expertise (rather than focusing primarily on limits to clinical
expertise);
● Determining the
extent to which errors and biases widely studied in the literature are linked to
decrements in treatment outcome and how to modify or correct those errors;
● Developing
well-normed measures that clinicians can use to quantify their diagnostic judgments,
measure therapeutic progress over time, and assess the therapeutic process;
● Distinguishing
expertise related to common factors shared across most therapies and expertise specific
to particular treatment
approaches; and
● Providing clinicians
with real-time patient feedback to benchmark progress in treatment and clinical support tools to adjust
treatment as needed.
References
American Psychologist May–June 2006, , Copyright 2006 by the
American Psychological Association 0003-066X/06, Vol. 61, No. 4, p275, 276, 277
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