On the nature of expertise in family therapy

Background: While family therapy has been demonstrated to be an effective intervention, practitioners in the field face a number of challenges that provide the impetus for this project. Therapists commonly report feeling confused by the theoretical debates and the demands placed on them by empirically supported treatments, and there is also significant variability between clinicians in quality of practice and within their individual practice. While the therapist variable is consistently recognised as the most robust predictor of outcomes, there is a paucity of research on how this variable exemplifies skilled performance and expertise, and gaps in understanding of the therapist's contribution to therapeutic change. Method: This investigation examines elite practice to develop an understanding of the perceptual-affective-cognitive mechanisms underpinning the habits of mind, which mediate expertise in the naturalistic practice of family therapy. Two in-depth studies were used; the first investigating procedural knowledge and the second focusing on the dynamic thinking process. Six novice and seven elite family therapists contributed narratives of complex and straightforward cases in Study 1, and narratives of in-themoment mental events while conducting family therapy (using video assisted recall) in Study 2. The case narratives were analysed using modified grounded theory and open coding, with each study generating four categories of mental events associated with good practice. A novice and elite practitioner comparison of these categories was then conducted to find patterns of convergence within and divergence between the groups. Results: The study of procedural knowledge identified four categories of habits of mind mediating expertise; a) Mental preparation; b) Deliberate monitoring; c) Quality of engagements; d) Using emotions and managing the emotional climate. The study of dynamic thinking processes generated four categories of in-the-moment perceptualaffective- cognitive mental activity; a) Therapy as a balancing act; b) Sensing relationships; c) Noticing and promoting micro-changes; d) Engaging in reflection and evaluation. Elite practitioners demonstrated high convergence in all these categories, while novices exhibited higher variability and less consistency. Conclusion: Relational-emotional expertise, clinical expertise and reflective practices emerged as over-arching features of expertise in family therapy. Some novices demonstrated some of the elite-like mental processes and, like elite practitioners, engaged in high levels of self-reflection and meta reflective practices, generated family specific mental models that linked the relational process with clinical symptoms, and established an emotional place in the matrix of relationships. The elite practitioners developed an emotional-intuitive understanding, and used relational-clinical practices to facilitate changes in collaboration with their client-family.