Peter Spencer, 2013. Problem solving in an empathic task: an experimental study of expertise and intuition. Reformulation, Winter, p.41,42,43,44.
Research into human cognition has proposed two information processing systems; one of which, an intuitive system, is quick, affective and automatic, and the other, a deliberative system, is sequential, verbal and consciously considered. Models of learning suggest that as we gain experience in any field of practice, what at first requires effort and calculation, latterly becomes accessible to the intuitive system. In this study we used an experimental task derived from therapy materials along with a qualitative analysis, to examine the strength of intuitive and deliberative modes of processing for three groups representing different levels of expertise in the practice of psychotherapy.
In healthcare research, intuition is an often-maligned concept. Quick, affect-led, and seemingly effortless in its operation (Epstein, 2010), it contrasts with the measured, rational-analytic approach championed in a scientist practitioner model (Lilienfeld, 2010). Whilst there is strong evidence that our intuitions can be misleading (for an excellent overview see Kahneman, 2011), processes which outwardly seem rational and deliberative can be similarly prone to errors and biases (Dijksterhuis, 2004; Gigerenzer & Brighton, 2009). There is a need to reappraise the potential benefits of intuition as a clinical resource.
Research in human judgement and decision making has shown that in many fields of expertise, people who have attained mastery are able to mobilise tacit understanding without recourse to conscious processing (Salas, Rosen, & DiazGranados, 2009). Unconscious processing will be of special importance where tasks exceed the capacity of our working memory. Chase & Simon (1973) showed that chess masters do not think many moves ahead as we might imagine; instead, they intuitively respond to the ‘chunks’ of information which they see on the board. Master level players perceive underlying relationships that bind the individual pieces together as meaningful units. This raises an interesting question: do expert therapists have a similar ability to recognise patterns of response within therapy?
Dual-processing models of cognition (Epstein, 2010; Evans, 2010; Kahneman, 2011; Stanovich & Toplak, 2012) propose that there are two routes of thinking that have very different qualities; an intuitive system which is quick, affective, and pre-conscious and a deliberative system which is slower, and deals with conscious appraisal. The present study aimed to use an experimental design examine the relative strength of intuition and deliberation as processing strategies for psychological therapists at three different levels of training and experience; novice (psychology undergraduates), informed (clinical psychology trainees), and sophisticated (ACAT members).
We were interested to discover whether, as with research conducted with chess players, experts in the field of psychological therapy are able to produce strong task performance under conditions which favour intuitive processing.
The experimental task was intended to stimulate the pattern recognition found in cognitive research whilst using therapy materials. In order to examine the qualities of highly empathic therapist-client talk, Shapiro (1976) used a card sort methodology, whereby jumbled-up sections of therapeutic conversations were reconstructed by participants. Borrowing from this study, we used two randomly arranged conversations embedded within an internet survey, comprising of 8 ‘floor holdings’ of speech, which participants had to put back into the correct order. Shapiro (1976) found that his undergraduate participants struggled to perform above chance level with the most empathically attuned conversations. We anticipated that expert therapists would be able to recognise patterns not apparent to naïve participants and that they would be able to perform comparatively well under intuitive conditions.
Participants were randomly allocated to either an intuitive or deliberative condition. In order to stimulate intuitive and deliberative thinking, different sets of instructions were given. In the intuitive condition, participants were asked to go with their gut feeling. In the deliberative condition, participants were asked to take their time and think about their response. It has been found that such ‘strategy instructions’ have been successful in producing different responses in eye tracking (Horstmann, Ahlgrimm, & Glöckner, 2009) and in task performance (Hilbig, Scholl, & Pohl, 2010; Pretz, 2008).
We recruited n=42 Psychology undergraduates, n=101 trainee clinical psychologists, and n-92 members of the Association of Cognitive Analytic Therapy (ACAT). We found that when taking the data from the two tasks together there were no significant results. However, exploratory analysis showed that there was a significant amount of variance between the two tasks, with the second task being much more difficult to reconstruct (t(233) = 13.83, p<.001). Different patterns of response were apparent when examining the two tasks separately.
For Task 1, deliberation was the stronger strategy (F(1,233) = 5.77, p=.017). For Task 2, there were no overall effects. Interestingly however, across the study’s 234 participants there were only 8 fully ‘correct’ reconstructions of Task 2, 5 of these were amongst the sophisticated (ACAT) group under intuitive conditions. Intuition was the stronger strategy for ACAT members when considering responses as correct/incorrect (X2(1,91) = 5.176, p = .023).
Level of expertise within the groups was also considered in analysis. For the informed (trainee) group, year of training (F(2,100)=3.3, p=.041) and intuitive/deliberative instruction (F(1,100)=9.57, p=.003) were significant for Task 1. For Task 2 there were no significant main effects or interactions. Figure 1 demonstrates these findings.
In the sophisticated (ACAT) group, expertise was investigated according to level of accreditation; Trainee (n=22), Practitioner (n=49), and Psychotherapist (n=20). For Task 1 there were no significant effects. On Task 2 however, level of accreditation (F(2,90)=3.4, p=.038) was significant. Scores were higher at more advanced levels of accreditation. Also, the interaction between instruction and accreditation was marginally non-significant (F(2,90)=2.69, p=.074). As can be seen from Figure 2, amongst the sophisticated group it appears that intuition gets better with expertise for Task 2.
So what is different about the two tasks? They are derived from therapy conversations selected as exemplars of different levels of ‘accurate empathy’. On the nine point ‘accurate empathy scale’, Truax and Carkuff (1967) placed the conversation in Task 1 at level 7, and Task 2 at level 9. Shapiro (1976) queried whether impaired performance in reconstructing conversations at higher levels of accurate empathy was due to ‘tacit understandings or knowledge, unique to their relationship and hence inaccessible to outsiders’. The findings above provide a tentative suggestion that for the most highly trained practitioners, there may be an intuitive access to this understanding which is not available to the initiate therapist. For the less empathically attuned conversation (Task 1), therapists beginning their training were able to get equally good results, but show greater reliance upon conscious deliberation to achieve this.
Alongside our experimental study, we were also interested to find out what our participants understood by the terms intuition and deliberation and how they might interact in clinical judgement. Qualitative analysis showed support for theories of dual processing and expertise. Intuition was described as an ‘in the moment’ process, quick and affective, but having a propensity to lead therapists to act on personal biases or dynamic pulls:
I think that the ‘intuition’ is our reading of other factors such as tone, nonverbal communication and something to do with the process of projection and projective identification which we may not be fully aware of.
Deliberation was characterised by slower more effortful processing that takes context, theory and professional standards into account, but has the potential to disrupt the fluidity of therapeutic interaction.
gut instinct understandings have to be balanced by careful thought and deliberation, e.g. as regards timing and consideration of a person’s ZPD or level of vulnerability. if we deliberate too much, we lose the spontaneity and irrationality of human emotions and connections.
A pattern of commentary in relation to expertise emerged which was congruent with the experimental hypotheses: inexperienced or trainee practitioners showed a preference for deliberation and explicit models rather than going with their gut feeling, experienced therapists were pictured as having advanced intuitive resources derived from their access to wealth of experience and training.
I would harbour a guess that the more experienced the clinician, the more their intuitive responses arise instinctively from their historical bank of past deliberations.
Intuition and deliberation were also described as interacting with one another so as to produce clinical judgement which was sensitive of gut feeling whilst being tempered by conscious reflection.
Now there are times when I find I can come to a decision comfortably and more quickly because of the experience. It is almost as if the deliberation process speeds up because I can access the information/experience more quickly so it may seem like it is intuition in the sense of a gut decision but it is informed by experience/previous deliberations etc. Both are informed by each other. This relationship was described as providing mutual fine-tuning so as to increase sensitivity and performance. The relationship was also characterised by tension between intuition and deliberation; deliberation providing a check and balance to the operation of intuitive processes.
We cannot directly apply these results as a more general measure of clinical skill. The experimental task is in no way an adequate reproduction of the therapeutic process. That being said, in this study, and in other studies of expert decision making, performance on such controlled tasks is positively associated with wider expertise in the field. Another key limitation is reliance on the construct of accurate empathy to differentiate the two tasks. There is insufficient theoretical and empirical evidence to be wholly satisfied with this division, it may be that a model of working memory and therapist schemas provides a more fitting explanation but this would require further research. Methodologically, it should be underlined that the study’s findings are derived from exploratory analyses and were not subject to tests for multiple corrections.
The study provides exploratory findings which suggest that psychological therapists may develop expert skills over the course of their career. Being able to quickly interpret the meaning of an exchange and make reasonable predictions from this could confer a great advantage to the expert therapist. It has been suggested that psychological therapy does not give accurate enough feedback to foster genuine mastery (Kahneman, 2011). To the contrary, this empirical study suggests that intuitive strength does develop as training and experience progresses. An important implication is that expertise, which requires considerable investment of time and resources, brings skills and understanding to clinical practice that will likely be absent from the work of practitioners who are technically appropriate but nevertheless inexperienced.
The findings of this study provide some tentative evidence that for the most highly trained and experienced practitioners there may be a cognitive faculty which is able to mobilise quick and non-effortful resources to reach a solution not available to sequential processing. For less experienced practitioners however, deliberation is the stronger strategy. Reflecting on the concepts of intuition and deliberation in clinical judgement, a frequent point of commentary for therapists was on the transition over the course of a career from reliance on effortful retrieval of declarative knowledge to a more intuitive and fluid integration of theory in practice. Further research is needed to confirm the results of this study and to describe the conditions under which intuitive understanding is most and least helpful to clinicians.
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