This article was downloaded by: [Tel Aviv University] On: 18 March 2013, At: 01:56 Publisher: Routledge

Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Child Sexual Abuse

Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wcsa20

Treatment of Individuals and Families Affected by Child Sexual Abuse: Defining Professional Expertise
Sheri Oz
a a

Machon Eitan Treatment Center for Sex Trauma Survivors and Their Families, Kiryat Motzkin, Israel Version of record first published: 19 Jan 2010.

To cite this article: Sheri Oz (2010): Treatment of Individuals and Families Affected by Child Sexual Abuse: Defining Professional Expertise, Journal of Child Sexual Abuse, 19:1, 1-19 To link to this article: http://dx.doi.org/10.1080/10538710903485609

PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditions This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

Journal of Child Sexual Abuse, 19:119, 2010 Copyright Taylor & Francis Group, LLC ISSN: 1053-8712 print/1547-0679 online DOI: 10.1080/10538710903485609

1547-0679 1053-8712 WCSA Journal of Child Sexual Abuse, Abuse Vol. 19, No. 1, Dec 2009: pp. 00

TREATMENT AND PRACTICE ISSUES

Treatment of Individuals and Families Affected by Child Sexual Abuse: Defining Professional Expertise
Expertise S. Oz in Treating Child Sexual Abuse

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

SHERI OZ

Machon Eitan Treatment Center for Sex Trauma Survivors and Their Families, Kiryat Motzkin, Israel

In this paper, the concept of expertise as defined in various professions is applied to psychotherapy and more specifically to the field of childhood sexual abuse. Given the dearth of research in this area, exploration of the issue is accompanied by reviewing the curriculum vitae of a number of recognized experts in the field. The paper concludes with a call for the recognition of childhood sexual abuse as a specialized field requiring specialized training both at the graduate level and in continuing postgraduate education. KEYWORDS child sexual abuse, professional training, expertise, specialization, psychotherapy Professionals and nonprofessionals alike are coming to terms with the growing recognition that there are large numbers of sexually traumatized citizens within our communities. Some of them enter therapy for specific treatment of symptoms resulting from sexual trauma; in this case they may seek recognized experts in the field. Others begin therapy with generalized complaints and look for referral to a generalist practitioner. Still others experience symptoms that they do not regard as possible consequences of sexual trauma, such as substance abuse, relationship problems, generalized anxiety, depression, or behavior problems at school, work, home, etc., and
Received 9 October 2008; revised 9 May 2009; accepted 8 September 2009. Address correspondence to Sheri Oz, Machon Eitan Treatment Center for Sex Trauma Survivors and Their Families, Harav Kook 13, 26361 Kiryat Motzkin, Israel. E-mail: ozsheri@ ymail.com 1

S. Oz

they or their families seek help from a professional dealing with the presenting problem. Two questions arise from this situation: (a) who are these recognized experts in treating sexual trauma issues and what are the criteria for defining them as such, and (b) are these generalist or non-sextrauma specialists competent enough to identify and treat sexual trauma issues if they arise over the course of therapy? The psychotherapy field in general has undergone a series of changes in the past decade or so that relates to these questions. Six trends in the literature can be identified. First, there is growing emphasis in the literature regarding empirically validated treatment methods. A debate rages regarding the degree to which practitioners should prefer research-supported techniques over unresearched approaches to therapy that may be traditional, innovative, or some combination of both (Beutler, 2004; Ravitz & Silver, 2004; Sanderson, 2002). Second, the development of professional standards and codes of ethics comprise efforts to regulate the professions of counseling, psychotherapy, and social work (Nair, Ardila, & Stevens, 2007; Schofield, 2007). Third, sensitivity to cultural backgrounds of clients and therapists are now considered essential to any clinical training program (Schofield, 2007). Fourth, a growing number of specializations within the general field of counseling, psychology, and social work have been emerging (Nair et al., 2007), and fifth, along with this, the need to integrate services among the various service providers has been recognized (Whittington & Bell, 2001; Xyrichis & Lowton, 2008). Finally, professional associations are defining minimum standards for training and certification in a number of general clinical programs and specializations (Whittington & Bell, 2001). At the same time, there are attempts to determine the natural course of professional development following formal training from novice to expert in order to inform formal academic and postacademic training programs (Fouad, 2003). A literature search produces articles exploring these issues for health and mental health professionals in a variety of specialist fields. In the child sexual abuse (CSA) literature, attention has been given primarily to the specialized training required of forensic investigators, training of allied professionals (nursing, teaching, etc.) with the goal of increasing their efficacy and confidence in fulfilling their role as mandated reporters of suspected abuse, and empirically testable therapeutic approaches (usually some form of cognitive behavioral therapy). What seems to be lacking is attention to the specialized training required of those who guide the victims/survivors and their families through the maze of legal and other protection proceedings following report (many of whom work in child advocacy centers or other agencies) and the clinical work toward psychological healing and rehabilitation when cognitive behavioral therapy (CBT) is inappropriate or insufficient for the particular victim/survivor or family. This oversight can seriously impede the ability of clinicians to confidently provide services for this population. In the absence of clearly defined standards of care and insufficient training in sexual trauma therapy, some

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

Expertise in Treating Child Sexual Abuse

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

practitioners may refuse to treat clients who were sexually abused, and others may inadvertently harm their clients in some way (Read, Hammersley, & Rudegeair, 2007; Regehr & Glancy, 1997). Issues concerning expertise will be discussed in this paper. In addition, a rationale will be provided for recommending that the CSA field be designated as a unique specialization within the world of clinical practice requiring proficiency in clearly defined areas of competence that may lead to expertise. Based on a survey of how diverse specialties handle the question of expertise, the term CSA expert will be explored. Given the lack of research in this area, an informal review of the curriculum vitae of 29 American, commonly recognized experts in the field provides a point of departure for understanding the depth and span of the knowledge base that informs the work of leaders in the field. From this, we can perhaps understand the basic training requirements for promoting the development of competent CSA practitioners.

WHO IS AN EXPERT?
How do we define who is an expert in any particular field? Is expertise determined by number of years practicing (Benner, Tanner, & Chesla, 1996; Rassafiani, Ziviani, Rodger, & Dalgleish, 2005), or is there a relationship between practice style and being an expert (Embrey, Guthrie, White, & Dietz, 1996; King et al., 2008)? Do successful client outcomes identify the expert (Resnik & Jensen, 2003), or is it as Meichenbaum (2004) facetiously suggested, the ability to choose your patients carefully (p. 50)? Are personality factors more predictive of the therapists for whom experience leads to expert status versus those who remain experienced but average (Spengler et al., 2009)? Is the expert an individual recognized as such by his or her peers (King et al., 2008)? Exploration into the nature of expertise apparently began with de Groots research (as cited in Gobet & Chassy, 2008) on expert versus novice chess players just after World War II. He determined that the distinguishing factor between novice players, experts, and master players was the ability of the latter two groups to intuitively know the right moves by drawing on a vast store of recognizable patterns of board configurations rather than devising a strategy by use of thought and analysis. Simon and Chase (1973) conducted experiments that led to the understanding that over time and with practice, the individual learns relevant patterns, and this material is stored in memory as chunks. In the 1980s, Dreyfus and Dreyfus (1986) applied these observations to the development of a theory of expertization that contradicted the common sense notion that the expert operates with a more elaborate set of rules or more involved analysis than the beginner. In fact, they claimed that while the beginner needs to learn and practice the application of unambiguous

S. Oz

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

rules, as knowledge and skills increase, patterns emerge and the expert develops an intuitive sense of what comes next, what fits, etc. for novel situations that arise. Furthermore, the expert is more able to handle ambivalence and complicating factors (Epstein & Hundert, 2002). Therefore, extrinsic knowledge at some point becomes intrinsic, and experts are unable to describe the rationale informing their judgments and decisions. They reflect on their performance to further improve their intuitive capabilities without returning to the analytic processes that characterize the beginner stage (Dreyfus & Dreyfus, 2004). The startling fact that experts cannot be expected to be able to explain why they do what they do means that they are not necessarily good mentors. Perhaps this is the origin of the well known pejorative, Those that can, do, and those that cannot, teach. Those experts who are able to effectively pass on their skills to novices, then, likely have a natural inclination toward teaching and have perhaps developed their teaching skills in the same way they developed expertise in their primary profession. Ericsson and Charness (1994) proposed that experts in all fields, whether chess, sport, music, business, etc., achieve mastery by means of deliberate practice over about 10 years of essentially full-time preparation (p. 738). Aside from determination, what are the other characteristics that experts have in common that contribute to their development as experts? This will be explored first for the helping professions.

EXPERTISE IN THE HELPING PROFESSIONS

Benner and colleagues (1996) applied Dreyfus and Dreyfuss (1986) observations to the field of nursing, adding that the element of emotional responses to patients needed to be considered as well. Over years of practice, these responses became part of the expert nurses inner archives from which they would draw when applying their skills, and this formed the basis for developing professional expert intuition (Benner & Tanner, 1987). Gobet and Chassy (2008) compiled findings from the nursing field as well and characterized expert performance as being comprised of five elements: (a) rapid perception of patterns of data (chunks or templates, which are larger than chunks), (b) emotion as an important resource for information, (c) comprehension of the context (i.e., a holistic grasp of the situation), (d) intrinsic decision making, and (e) intuitions that are usually correct. If expertise is defined as consistently superior performance on a specified set of representative tasks (Ericsson & Charness, 1994, p. 731), and expert therefore means more successful, then outcome studies should provide a way to explore the nature of the expert in comparison with the nonexpert. Seeking to do just that in the field of physical therapy, Resnik and Jensen (2003) found that in comparison with average practitioners, experts:

Expertise in Treating Child Sexual Abuse

(a) had more eclectic academic and work backgrounds, (b) were curious and more passionate about their work, (c) recognized their limitations and continually sought opportunities to learn more, (d) consulted with peers more often, (e) reflected on and analyzed their own functioning, (f) observed their patients in situations outside of the clinical session (e.g., getting out of their cars, removing shoes, etc), and (g) regarded patients as responsible for their own health, thus they provided patients with enough information to ensure informed choice within a conjoint decision-making approach. Similar factors were found by King and colleagues (2007, 2008) in their study of expertise for pediatric rehabilitation therapists. These factors can also be seen as corresponding with factors defined by earlier theoreticians (e.g., Dreyfus & Dreyfus, 1986; Simon & Chase, 1973) as indicators of expertise in other fields. The participants in these two studies had consistently better therapy outcomes; therefore, presumably, their intuitions were usually correct. Experts in Resnik and Jensens (2003) study had more varied academic and work backgrounds (item a, listed previously). This corresponds with the tendency for experts to expose themselves throughout life to everincreasing sources of knowledge (Sullivan, Skovholt, & Jennings, 2005), thereby expanding the templates/patterns of data available to them. In some cases, the professional may be experienced in certain aspects of professional practice even before beginning formal studies, such as through after-school work, volunteering, or personal experience with family tragedy or serious illness (Ruth-Sahd & Tisdell, 2007). Item a, together with items b and c listed previously, can also be understood as corresponding with Ericssons (2002) concept of deliberate practice, or pushing the limits and challenging oneself to see more, know more, and understand more. The fourth item (d) listed previously, making observations of patients in situations outside of the therapy hour, corresponds with Gobet and Chassys (2008) point that experts take a holistic view of patients, seeing the patient in context. Again, this may result from the natural tendency of experts and potential experts to push themselves to broader and deeper learning, which results in systemic understanding as more interconnecting templates are stored in memory (Ericsson & Charness, 1994). Perhaps some of them may have studied in family and marital therapy programs. Consulting with peers and self-reflection (items e and f ) are ways in which experts continue to seek additional perspectives in order to avoid getting stuck in one way of perceiving situations (Dreyfus & Dreyfus, 2004) and challenge themselves to further improve their skills (Ericsson, 2002). Item g, regarding patients as partners in the therapeutic endeavor, raises an interesting issue: Is this a skill or an attitude? A study in which psychiatrists scored very low in shared decision-making with their patients (Goossensen, Zijlstra, & Koopmanschap, 2007) may help illustrate this point. The psychiatrists in this study claimed that they intuitively feel if the patient is able and interested in participating actively in their treatment (p. 54). The

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

S. Oz

authors cited similar results in research reports for psychiatrists in various countries and for other medical specialties. Whether or not doctors are correct in their assumption that patients do not want to be more involved in decision making should be verified empirically before it is accepted as a truism. If doctors are in fact wrong (as Goossensen and colleagues suspected), then either they are not developing expertise in this aspect of doctor-patient communication or they have an attitude that precludes taking the possibility seriously. While qualitative research with nonmedical practitioners has suggested that working collaboratively with patients distinguishes the experts from the experienced nonexperts (King et al., 2007; Sullivan et al., 2005), the connection is not clear. Perhaps experts have more confidence in their skills and are therefore less wary of being disagreed with and more open to sharing responsibility with patients. Perhaps some aspect of their training has instilled a more egalitarian rather than authoritarian attitude. Therefore the question of whether this is a skill or an attitude and whether or not it can be taught remains unanswered. Given the postmodern trend toward empowering patients/clients, this point is most important. Although rapid perception of data patterns and intrinsic decision making were not empirically examined in the studies cited previously, they have been explored in other fields. In physics (Chi, Feltovich, & Glaser, 1981) and in mathematics (Paige & Simon, 1996), experts were shown to quickly discern the principles salient to solving the problem at hand, as opposed to novices who went through a more superficial, rule-based progression. Thus, while experts spend more time gathering initial data, they more quickly conceptualize the problem parameters and are eventually more accurate in the generation of solutions. Interestingly, studies have shown that years of experience are not necessarily salient to performance ability (Eels, Lombart, Kendjelic, Turner, & Lucas, 2005; King et al., 2007, 2008; Resnik & Jensen, 2003). Spengler and colleagues (2009) confirmed that there is minimal seniority effect on diagnostic and prognostic accuracy for psychologists. Some senior clinicians may be thought to be experts since they perform routine procedures with great skill. However, when presented with unique or unexpected complications where standardized approaches are not sufficient, some will excel and others will not; the former are the experts (Ericsson, 2007).

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

Models of Expertise in Psychotherapy

Meichenbaum (2004) outlined the core tasks performed by expert psychotherapists as being the following: (a) developing a therapeutic relationship, (b) adapting relationship and intervention approaches to the particular client situation, (c) educating clients about the nature of the problem and possible solutions, (d) instilling hope and promoting coping skills, (e) empowering

Expertise in Treating Child Sexual Abuse

clients, and (f) preparing them for potential relapses. For the trauma client, the additional skills required include: (a) ensuring client safety and stabilization, (b) conducting traumatic memory resolution, (c) helping clients find meaning in their lives and meaningful relationships, and (d) promoting the avoidance of revictimization. Therapists of most theoretical orientations would likely agree that these are the essential components of effective therapy, applied in the unique fashion of each approach (see also, Manring, Beitman, & Dewan, 2003). In fact, these skills were found to be pertinent for expert physiotherapists (King et al., 2007). However, Meichenbaum has claimed that it is still unclear how expert therapists actually carry out these core tasks. The how has been suggested by Jennings and Skovholt (1999). They claimed that expert therapists learn to function well in three essential areas, referred to as CER: (a) cognitive, or the acquisition of a knowledge base along with the ability to think about theories; (b) emotional, or the emotional maturity described by Goleman (1995) for which he coined the term emotional intelligence; and (c) relational, or the ability to engage clients in a safe yet challenging and productive relationship (see also, Sullivan et al., 2005). The cognitive component of the CER model is the most easily quantifiable. Students submit to the term papers, final examinations, and thesis defenses that have characterized evaluation procedures for generations and then they happily leave this behind at the end of their formal studies or professional licensing. When studying the expert therapist, the evaluation of cognitive expertise is accomplished more indirectly, and this will be further discussed. The association between the emotional component of the CER model and psychotherapeutic processes remains to be studied. The relational component has been explored mainly with the aim of showing the correlation between the quality of the therapeutic alliance and successful attainment of therapeutic goals. There are many tools available for assessing the therapeutic relationship, and Summers and Barber (2003) have recommended using such tools as a measure of relationship skills during psychotherapy training. However, these have not been used in expert therapist research. The 10 domains comprising a measure of therapist competence in cognitive analytic therapy (Bennett & Parry, 2004) evaluate all three aspects of the CER model, and with modification, this tool may be applicable to the assessment of practitioner expertise in most therapeutic schools. Some studies have explored the relationship between competence in cognitive-behavioral therapy and adherence to manualized procedures as well as how this relates to clients successful completion of therapy (e.g., Milne, Baker, Blackburn, James, & Reichelt, 1999). However, other studies have shown that the situation is more complex than it appears, and expert therapists may decide not to follow the therapy protocol when the client has needs other than what the protocol could address (Barber et al., 2006;

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

S. Oz

Levitt, Neimeyer, & Williams, 2005; Milne, Claydon, Blackburn, James, & Sheikh, 2001). In light of our earlier discussion of expertise in general, this adaptability, continual reflection, and ability to put aside inappropriate rules are what we would expect of the expert therapist. Furthermore, Barber, Sharpless, Klostermann, and McCarthy (2007) have cautioned that to date, studies have not in fact measured therapist competence or expertise since we do not yet know how to accurately operationalize these factors in psychotherapy.

Beginning Efforts in Studying Expertise in Psychotherapy

Research exploring the nature of the expert helper in nonpsychotherapy professions has defined experts as those with more successful outcomes (Resnick & Jensen, 2003), those who perform well on decision-making tasks (Rassafiani, Ziviani, Rodger, & Dalgleish, 2009), or those nominated as experts by peers (Jennings & Skovholt, 1999). Some of these studies sought to discern those qualities that distinguish experts from non-experts (e.g., Ronnestad & Skovholt, 2003). In psychology, however, this approach has not been taken, and the studies identifying experts have mostly sought to evaluate the effectiveness of certain techniques. For example, Linehan and her colleagues (2006) considered experts in treating difficult clients to be those who were named as such by directors of local clinical agencies with no criteria mentioned. Spengler and colleagues (2009) discussed the issue of defining experts on the basis of peer nomination or reputation. An exception to this is the work of Eels and colleagues (2005). They compared case formulation skills between novice therapists (graduate students), therapists who were experienced (over 10 years of practice) but not experts in case formulation, and experts (taught or wrote about case formulation). The latter group differed significantly from the former two groups in quality of formulations.1 Similarly, in exploring how therapists deal with problems of values in psychotherapy, Levitt and colleagues (2005) picked experts on the basis of the number of published works, being leading proponents of therapy approaches, and having received awards for their contribution to the field. This of course means that therapists being labeled as experts are those who have decided to contribute outside the therapy room as well as in it. Practitioners who devote themselves solely to helping clients without simultaneously contributing publicly to development of the profession may have expertise that differs in important ways from that of their more visible counterparts. However, it is difficult to tap into this resource. Clinical decision making in the expert therapist (one aspect of the cognitive component of the CER model) is an area that has not been investigated in psychotherapy, and it has important bearing on the field. Rehabilitation therapists (King et al., 2007) and pediatric physical therapists (Embrey et al., 1996) talked about decisions made during therapy sessions

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

Expertise in Treating Child Sexual Abuse

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

while viewing tapes of their sessions. The recorded interviews were coded in order to distinguish the different qualities of decision making and modes of interaction with clients among therapists of varying degrees of experience. King and colleagues (2007) found that expert rehabilitation therapists spent more time exploring client needs and needs of the clients family and this enabled them to fashion intervention strategies that were more likely to be successful over the long term. In both studies, more experienced therapists worked intuitively, had more naturally integrated social interactions with the children as they worked, adapted their approach to developments within sessions, and had a higher frequency of self-monitoring. It is logical to assume that these qualities would also be true of expert psychotherapists. Approaching this topic from another angle, Rassafiani and colleagues (2009) first categorized occupational therapists with 4 to 16 years experience on the basis of accuracy and consistency of clinical judgments measured by the Cochran-Weiss-Shanteau (CWS) Index. They then looked for similarities and differences between low and highly skilled decision makers, where only 4 were in the high performance group (could be considered experts) and 14 in the low. The former were more intuitive and drew on a larger information base than the latter. Interestingly, years of experience did not distinguish between the groups. The CWS, therefore, shows promise as a way to more objectively distinguish experts from experienced nonexperts. It could perhaps be applied to studies of psychotherapy expertise exploring emotional maturity and relational skills, which have yet to be studied.

THE QUESTION OF EXPERTISE IN CHILD SEXUAL ABUSE

If competence and expertise in psychotherapy in general are still in the early stages of serious investigation, then the situation in the field of psychological treatment for victims/survivors of child sexual abuse (CSA) is even less developed. A literature search for experts in child sexual abuse pulled articles on expert witnesses, expert forensic investigators (mostly medical), and training mandated reporters to gain expertise in recognizing signs of abuse in children and adolescents. These areas may have been promoted particularly in the United States as a result of the spread of child advocacy centers that house multidisciplinary teams (MDTs) composed of medical practitioners, social workers, and representatives of the prosecution and/or the police (Dixon, 2005). These centers, however, provide first-response interventions only and do not generally conduct ongoing therapy for victims or their families; they often refer clients to clinicians in the community. The importance of first-response teams is not in question. No less important is access to ongoing high quality therapeutic services after legal files have been opened and either prosecuted or closed for any number of reasons. Minor and adult survivors of sexual trauma as well as members of

10

S. Oz

their families (the secondary victims in these cases) usually need the help of qualified practitioners in order to heal from the trauma of the abuse and the aftermath of the disclosure. Sadly, it has been suggested that many therapists and even their supervisors are not sufficiently trained to work with this population (Knight, 2004; Wells, Trad, & Alves, 2003). Who, then, are the expert therapists in the CSA field?

Use of Experts in CSA Research

Two studies that explored clinical decision making in working with CSA survivors used experts to elucidate decisions therapists must make in early stages of therapy. In the first study (e.g., Kessler, Nelson, Jurich, & White, 2004), the experts were experts in marital and family therapy and not necessarily in sexual trauma. However, the second study (e.g., Kessler & Goff, 2006) drew on specialists in adult CSA survivor therapy. In this study, Kessler and Goff defined their experts as having three years experience when one-third of the caseload consisted of CSA survivors or five years experience when one-quarter of the caseload included CSA survivors. In addition, the clinician had either published at least two professional works on the topic, had at least five years experience teaching CSA survivor therapy, or had been a primary presenter at two or more national conventions or workshops. Given that the expertise literature talks about deliberate practice during 10 years of essentially full-time preparation (Ericsson & Charness, 1994, p. 738), the above standard for defining CSA experts is inadequate. Yet in spite of the low threshold for defining an expert, the final sample actually included practitioners with clinical experience ranging from 1132 years, where for over 1028 years, on average, 50% of their caseloads included survivors. If research claims to use experts, then the definition of expert must conform to the expertise literature.

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

Characteristics of Commonly Recognized CSA Experts

How do clinicians commonly recognized as experts in the field of CSA therapy fare with respect to criteria delineated by researchers who study the nature of expertise (e.g., Dreyfus & Dreyfus, 2004)? A serious limitation here is that in contrast with the chess master, for example, the work of the therapist does not occur in an open theater for all to see. Acquiring taped sessions for research also involves complex ethical and moral issues since the content of therapy sessions is sensitive and potentially shame-inducing. Furthermore, studying the cognitive processes of the expert therapist in hypothetical situations, which is the basis of some studies, does not necessarily reflect the virtuosity of the expert therapist in actual sessions. Perhaps we can gain some evidence of the nature of the CSA expert by examining curriculum vitae (CVs) of CSA experts.

Expertise in Treating Child Sexual Abuse

11

The curriculum vitae of some recognized expert clinicians2 were located on the Internet. Other experts were asked specifically if they would provide their CVs. Because the availability of their CVs on the Internet was not necessarily intended by all of those experts so displayed, their identities remain anonymous in this paper. Twenty-nine CVs were included for this article (three experts declined participation, five others did not respond to e-mail queries, and seven did not fulfill all of the predetermined criteria listed subsequently). Note was made of major areas of study for all formal degrees, topics of continuing education if listed, employment history (including primary place of work and workshops and trainings given in various venues), organizational commitments, and published writings. All of the experts met the following criteria: (a) over 15 years experience in CSA-related work; (b) published numerous pieces either in refereed journals, books chapters, or entire books; (c) trained other clinicians, whether through university courses, professional conferences, or specialized workshops; (d) served as consultants for agencies or other clinics; and (e) were reviewers for professional journals in CSA-related fields. In other words, each had been recognized as having had impact in shaping the field (Levitt et al., 2005). Almost twice as many of the experts primarily treated adults and adolescents versus children and adolescents. Almost all more readily identified with victim therapy than offender treatment. Perhaps surprisingly, several worked currently or in the past with both victims and offenders. Some of these professionals worked in an academic environment (while seeing clients as well), while others were occupied primarily as practitioners and trainers outside academia. Those with academic careers had far more publications than those who taught and provided training in other venues. This can be attributed to workplace demands and not necessarily to the natural proclivity of academics to write more prolifically. It is interesting to note the broad academic backgrounds of a number of these experts. Only a minority, in fact, took a straight line from undergraduate to doctorate studieseither medicine to psychiatry or psychology to clinical psychology. The remainder was divided between those who perhaps did not know their career direction early on and those who anticipated a totally different path for themselves. They studied child development, sociology, education, philosophy, literature, languages, history, fine arts, anthropology, or journalism before embarking on postgraduate studies in social work, psychology, family therapy, or rehabilitation. For some, the clinical training constituted a second postgraduate career, and a number of the sample worked for several years in a different field before changing professions. Current interests were unrelated to career paths. Those who sought expertise in a singular field, such as a particular population (offenders, male victims, suffering borderline personality disorder, etc.) or a particular

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

12

S. Oz

therapy approach, as well as those who maintained an extensive range of interests (research and teaching in areas unrelated to abuse or in multiple clinical approaches to recovery from abuse), could be found in either the direct-route or indirect-route groups. Experts who completed their formal education (either at the masters or doctorate level) prior to 1990 can be perhaps regarded as self-didactic in the CSA field. Until then, there were virtually no university courses in the United States on the subject, and information was disseminated at professional conferences. These earlier professionals came to the CSA field through various avenues (as shown by their CV-reported history of publications and/or courses and workshops given). For example, one professional explored approaches to the self, followed by studying the impact of trauma (disaster, illness) on self, and then dissociation and CSA. Another engaged in university student counseling, followed by an interest in the counseling of women, and then CSA. Another went from parenting, to child abuse in general, to CSA. Those who moved directly into specializing in abuse issues, even if their formal studies ended before 1990, generally worked for several years as a doctor, social worker, or teacher before entering graduate studies and likely were exposed to abuse issues in these occupations. It is unclear what brought those in unrelated fields, such as anthropology or journalism, to make the dramatic switch to child abuse studies in a second masters degree. Clinicians who completed their postgraduate work in the later 1990s had the benefit of scholarly articles and colleagues already growing wellversed in CSA issues. However, they did discover that many of the research areas were still new territory waiting for exploration. It is only new graduates emerging from programs in recent years who must wade through a literature rich with material, thereby standing on broad shoulders of those who laid the groundwork in the field. This will likely affect the nature of tomorrows experts versus those we recognize today. A few of the experts listed continuing education studies, and those who did learned eye-movement desensitization and reprocessing (EMDR), art therapy, play therapy, gestalt, neurolingquistic programming (NLP), marital and family therapy, and more. All the professionals were members in multiple professional organizations, taking an active part by joining the boards or committees. It is assumed that these recognized experts have also been successful in their clinical work, something that has not been proven directly but rather can be implied by the continuing invitations to provide clinical training at professional meetings and various agencies. We have seen here that some recognized experts in CSA have demonstrated drive and versatilitythey are scholarly, engage in clinical work, spend time teaching and training in a variety of settings, and donate their time to professional societies. These activities likely ensure that they

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

Expertise in Treating Child Sexual Abuse

13

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

constantly face new challenges and engage in ongoing self-education and mutual enrichment with peers (deliberate practice, continued exposure to new learning, possibly with ever-expanding holistic/systemic understandings). They likely fulfill the criteria for expertise as set forth by Dreyfus and Dreyfus (2004), Ericsson and Charness (1994), Resnick and Jensen (2003), and Skovholt, Jennings, and Mullenback (2004), and do not merely constitute a group of experienced clinicians with public images. In order to explore how these experts fulfill other criteria for expertise, one would have to gain access to their thought processes and discern to what degree they function intuitively, with rapid pattern recognition based on the integration of a broadly based spectrum of knowledge as opposed to applying systematized rules and generalizations. Such material may be available at case consultations whereby a systematic examination of the way in which these practitioners respond to other therapists dilemmas may be instructive. Additionally, one would need to explore their self-reflection processes and their recognition of personal limitations. Some well-known therapists have been open about the fact that they continue to engage in ongoing peer supervision, which is an indication that they continue to examine their own performance.

Social Environments of Todays CSA Experts

The majority of todays recognized experts in CSA have been working in the field mainly since the 1970s or 1980s, while some have joined the ranks in the 1990s, and a few have risen in the past few years. A major difference between the veteran and more recent professionals lies in the context within which they found themselves cutting their professional teeth. The earlier clinicians matured professionally during a time in which Freudian theory still reigned supreme and at the beginnings of mandated abuse reporting laws, modern feminism, family therapy, posttraumatic stress disorder, the recognition of battered children and battered wives, and the rediscovery of childhood sexual abuse as a real and not fantasized event.3 Practitioners in a variety of settings were confronted with narratives of abuse, and many were enthusiastic about exposing the problem, sharing information with colleagues, and helping a sick, traumatized society. They began to research, write, and instruct others from the point at which their eyes and ears were opened and in the direction in which their experiences and intuition took them. The CVs in the available sample hinted at the possibility that todays veteran experts learned from one another rather than from mentors of a previous generation. It is perhaps not surprising, then, to find that many of them have practiced clinically with children, adolescents, and adults, some with both victims and offenders, with individuals, and

14

S. Oz

with families. In other words, they have been more generalist than specialist within the CSA field. The more recently educated experts obtained their clinical training after the false-memory backlash stung professionals with a ferocity that made them take a few steps back and work more cautiously. At the same time, postmodernitys not-knowing stance, cognitive-behavioral therapy, empirically supported approaches, and emerging gender and cultural sensitivities characterized the environments in which they were being trained. With a rapidly growing professional literature that no one individual can digest alone, specialization within the field of CSA may be anticipated in the future.

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

A DESIGNATION OF EXPERTISE IN CHILD SEXUAL ABUSE The Argument for Specialization in CSA
Since, according to the expertise literature, the expert has a broad academic and experiential background and a holistic view of the field in which he or she works, training of future practitioners will best provide students with exposure to an expansive range of study. These are areas encompassed by the early pioneering CSA experts, which they discovered on their own, but which should not be left to contemporary trainees to find by chance. Given an exponentially growing knowledge base, there now exists both a considerable wealth of research and clinical literature and a growing number of conferences and conference tracks dealing specifically with CSA. It is possible, then, that the time has come for a specialization in CSA in the same way that professionals specialize in family and marital therapy, gerontology, and other subspecialties within psychology and social work. Specialized training would promote community awareness of the fact that CSA clinical work is a distinct field. Agencies dealing with child protection would then be more likely to hire professionals who come preequipped with the appropriate academic background. Clients who know they need help with recovery from abuse could then more easily identify those who are properly and adequately trained. For clients who do not know at the start of therapy that abuse underlies their presenting problems, therapists could either more confidently refer the client to a CSA specialist even after a bond has been formed and with less risk of debilitating abandonment trauma, or they could embark on specialized training in order to take up the challenge offered by this particular client. In other words, the definition of a CSA specialization with appropriate training would ensure competent and safe therapy interventions for the CSA victims/survivors and their families who seek professional help.

Expertise in Treating Child Sexual Abuse

15

Anticipated Challenges in Developing Specialist CSA Training Programs

Some questions need to be addressed when applying lessons learned from the expertise literature and the informal review of expert CVs undertaken in this paper. For example, how can a balance be found between the need to teach competence in empirically validated therapy approaches and the need to prepare trainees to understand when to adhere to protocols and when to set them aside? How can one promote the institution of professional standards in practice and in training without suppressing the creativity of trainees and the development of expert intuition? Without sacrificing depth, how can one instruct trainees in the breadth of areas to which todays experts were exposed over a lifetime, given the enormous amount of knowledge currently available? Do we offer trainees subspecialties within the CSA field, or do we train professionals to be competent in the various areas available? How much time is required for the acquisition of the skills required for competence? Should such training be offered as a postgraduate degree program or as specialized training following the postgraduate degree?

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

SUMMARY
The expertise literature, originally examining chess players, lists criteria for distinguishing between the expert practitioner in any field and the novice or experienced-but-average performer. Empirical studies have shown that these criteria apply equally well to some helping professions (such as nursing and physical therapy), with the additional consideration of emotional data as an important aspect of expert functioning. Psychotherapy has models for explaining competence and expertise, but the research has not yet examined the application of expertise criteria to clinical work. In fact, many studies that purport to use experts do not define expertise according to the criteria accepted in the expertise literature. It may be possible to examine competence and expertise in psychotherapy using the clinical models and rating scales developed based on the expertise criteria. This may provide a basis for developing standards for evaluation of competence and expertise that could be applied to the development of training programs in various fields of psychotherapy and social work. Expertise in CSA therapy has received no attention to date. The CVs of 29 recognized experts in the field reveal trends in the career paths of experts that correspond with criteria of expertise as defined in the expertise literature. This, together with an understanding of the social context in which these experts grew professionally and in which we find ourselves now, suggests that a new specialization in CSA needs to be designated and practitioners appropriately trained.

16

S. Oz

NOTES
1. This contradicts the adage about teachers and suggests that teachers are more expert than others in the specific area in which they provide instruction. This is logical, given that teachers are practicing their specific skill countless times in preparing lessons, lecturing, writing exams, grading papers, etc. It does not mean that teachers can necessarily expertly apply the skill in real-world situations in which the therapist functions unless they are actively practicing therapists focusing on this skill. 2. A clear selection bias occurred here as the names chosen were those with which the author was familiar. With over 20 years experience in the field, the author considers herself well-read in both historic and contemporary clinical CSA literature and therefore offers this unscientific review as an interesting point of departure on which later methodologically rigorous studies can be based. 3. Child sexual abuse has had a complex history of discovery and suppression (Olafson, Corwin, & Summit, 1993) partly because of the extreme positions it engenders in both professions and the lay public (Myers, 1994).

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

REFERENCES
Barber, J. P., Gallop, R., Crits-Christoph, P., Frank, A., Thase, M. E., Weiss, R. D., et al. (2006). The role of therapist adherence, therapist competence, and alliance in predicting outcome of individual drug counseling: Results from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Psychotherapy Research, 16, 229240. Barber, J. P., Sharpless, B. A., Klostermann, S., & McCarthy, K. S. (2007). Assessing intervention competence and its relation to therapy outcome: A selected review derived from the outcome literature. Professional Psychology: Research and Practice, 38, 493500. Benner, P. E., & Tanner, C. A. (1987). How expert nurses use intuition. American Journal of Nursing, 87, 331. Benner, P. E., Tanner, C. A., & Chesla, C. A. (1996). Expertise in nursing practice: Caring, clinical judgment and ethics. New York: Springer Publishing Company. Bennett, D. & Parry, G. (2004). A measure of psychotherapeutic competence derived from cognitive analytic therapy. Psychotherapy Research, 14, 176192. Beutler, L. E. (2004). The empirically-validated treatments movement: A scientistpractitioners perspective. Clinical Psychology: Science and Practice, 11, 225229. Chi, M. T. H., Feltovich, R. J., & Glaser, R. (1981). Categorization and representation of physics problems by experts and novices. Cognitive Science, 5, 121125. Dixon, C. (2005). Best practices in the response to child abuse. Mississippi College Law Review, 25, 73100. Dreyfus, H. L., & Dreyfus, S. E. (1986). From Socrates to expert systems: The limits of calculative rationality. In C. Mitcham & A. Huning (Eds.), Philosophy and technology II: Information technology and computers in theory and practice (pp. 111130). Dordrecht, Holland: D. Reidel Publishing Company. Dreyfus, H. L., & Dreyfus, S. E. (2004). The ethical implications of the five-stage skill-acquisition model. Bulletin of Science, Technology & Society, 24, 251264. Eels, T. D., Lombart, K. G., Kendjelic, E. M., Turner, L. C., & Lucas, C. P. (2005). The quality of psychotherapy case formulations: A comparison of expert, experienced, and novice cognitive-behavioral and psychodynamic therapists. Journal of Consulting and Clinical Psychology, 73, 579589.

Expertise in Treating Child Sexual Abuse

17

Embrey, D. G., Guthrie, M. R., White, O. R., & Dietz, J. (1996). Clinical decision making by experienced and inexperienced pediatric physical therapists for children with diplegic cerebral palsy. Physical Therapy, 76, 2033. Epstein, R. M., & Hundert, E. M. (2002). Defining and assessing professional competence. Journal of the American Medical Association, 287, 226235. Ericsson, K. A. (2002). Attaining excellence through deliberate practice: Insights from the study of expert performance. In M. Ferrari (Ed.), The pursuit of excellence through education (pp. 2156). Hillsdale, NJ: Erlbaum. Ericsson, K. A. (2007). An expert-performance perspective of research on medical expertise: The study of clinical performance. Medical Education, 41, 11241130. Ericsson, K. A., & Charness, N. (1994). Expert performance: Its structure and acquisition. American Psychologist, 49, 725747. Fouad, N. A. (2003). Career development: Journeys of counselors. Journal of Career Development, 30, 8187. Gobet, F., & Chassy, P. (2008). Towards and alternative to Benners theory of expert intuition in nursing: A discussion paper. International Journal of Nursing Studies, 45, 129139. Goleman, D. (1995). Emotional intelligence. New York: Bantam Books. Goossensen, A., Zijlstra, P., & Koopmanschap, M. (2007). Measuring shared decision-making processes in psychiatry: Skills versus patient satisfaction. Patient Education and Counseling, 67, 5056. Jennings, L. & Skovholt, T. M. (1999). The cognitive, emotional, and relational characteristics of master therapists. Journal of Couseling Psychology, 46, 311. Kessler, M. R. H., & Goff, B. S. N. (2006). Initial treatment decisions with adult survivors of childhood sexual abuse: Recommendations from clinical experts. Journal of Trauma Practice, 5, 3356. Kessler, M. R. H., Nelson, B. S., Jurich, A. P., & White, M. B. (2004). Clinical decision-making strategies of marriage and family therapists in the treatment of adult childhood sexual abuse survivors. The American Journal of Family Therapy, 32, 110. King, G., Bartlett, D. J., Currie, M., Gilpin, M., Baxter, D., Willoughby, C., et al. (2008). Measuring the expertise of pediatric rehabilitation therapists. International Journal of Disability, Development and Education, 55, 526. King, G., Currie, M., Bartlett, D. J., Gilpin, M., Willoughby, C., Tucker, M. A., et al. (2007). The development of expertise in pediatric rehabilitation therapists: Changes in approach, self-knowledge, and use of enabling and customizing strategies. Developmental Neurorehabilitation, 10, 223240. Knight, C. (2004). Working with survivors of childhood trauma: Implications for clinical supervision. The Clinical Supervisor, 23, 81105. Levitt, H. M., Neimeyer, R. A., & Williams, D. C. (2005). Rules versus principles in psychotherapy: Implications of the quest for universal guidelines in the movement for empirically supported treatments. Journal of Contemporary Psychotherapy, 35, 117129. Linehan, M. M., Comstois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., et al. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs. therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63, 757766.

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

18

S. Oz

Manring, J., Beitman, B. D., & Dewan, M. J. (2003). Evaluating competence in psychotherapy. Academic Psychiatry, 27, 136144. Meichenbaum, D. (2004). What expert therapists do: A constructive narrative perspective [Electronic version]. International Journal of Existential Psychology & Psychotherapy, 1, 5055. Milne, D. L., Baker, C., Blackburn, I. M., James, I., & Reichelt, K. (1999). Effectiveness of cognitive therapy training. Journal of Behavior Therapy & Experimental Psychiatry, 30, 8192. Milne, D. L., Claydon, T., Blackburn, I., James, I., & Sheikh, A. (2001). Rationale for a new measure of competence in therapy. Behavioural and Cognitive Psychotherapy, 29, 2133. Myers, J. E. B. (1994). The literature of the backlash. In J. E. B. Myers (Ed.), The backlash: Child protection under fire (pp. 86103). New York: Sage Publications. Nair, E., Ardila, R., & Stevens, M. J. (2007). Current trends in global psychology. In M. J. Stevens & U. P. Gielen (Eds.), Toward a global psychology: Theory, research, intervention and pedagogy (pp. 69100). Mahwah, NJ: Lawrence Erlbaum Associates. Olafson, E., Corwin, D. L., & Summit, R. C. (1993). Modern history of child sexual abuse awareness: Cycles of discovery and suppression. Child Abuse and Neglect, 17, 724. Paige, J. M., & Simon, H. A. (1996). Cognitive processes in solving algebra word problems. In B. Kleinmuntz (Ed.), Problem solving (pp. 51118). New York: Wiley. Rassafiani, M., Ziviani, J., Rodger, S., & Dalgleish, L. (2005). How many years clinical practice is required to become an expert occupational therapist? The Journal of Japanese Association of Occupational Therapists, 24. Retrieved April 24, 2008, from http://espace.library.uq.edu.au/view/UQ:8217. Rassafiani, M., Ziviani, J., Rodger, S., & Dalgleish, L. (2009). Identification of occupational therapy clinical expertise: Decision-making characteristics. Australian Occupational Therapy Journal, 56(3), 156166. Ravitz, P., & Silver, I. (2004). Advances in psychotherapy education. Canadian Journal of Psychiatry, 49, 230237. Read, J., Hammersley, P., & Rudegeair, T. (2007). Why, when and how to ask about childhood abuse. Advances in Psychiatric Treatment, 13, 101110. Regehr, C., & Glancy, G. (1997). Survivors of sexual abuse allege therapist negligence. Journal of the American Academy Psychiatry and the Law, 25, 4958. Resnik, L., & Jensen, G. M. (2003). Using clinical outcomes to explore the theory of expert practice in physical therapy. Physical Therapy, 83, 10901106. Ronnestad, M. H., & Skovholt, T. M. (2003). The journey of the counselor and therapist: Research findings and perspectives on development. Journal of Career Development, 30, 544. Ruth-Sahd, L.A., & Tisdell, E.J. (2007). The meaning and use of intuition in novice nurses: A phenomenological study. Adult Education Quarterly, 57, 115140. Sanderson, W. C. (2002). Why we need evidence-based psychotherapy practice guidelines. Medscape General Medicine, 4. Retrieved April 25, 2008, from www.medscape.com/viewarticle/445080.

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

Expertise in Treating Child Sexual Abuse

19

Downloaded by [Tel Aviv University] at 01:56 18 March 2013

Schofield, M. (2007). Best practice self-regulation model for psychotherapy and counselling in Australia: Final report. Victoria, Australia: Psychotherapy and Counselling Federation of Australia. Simon, H. A., & Chase, W. G. (1973). Skill in chess. American Scientist, 61, 393403. Skovholt, T. M., Jennings, L., & Mullenback, M. (2004). Portrait of the master therapist: Developmental model of highly-functioning self. In T. M. Skovholt & L. Jennings (Eds.), Master therapists: Exploring expertise in therapy and counseling (pp. 125146). Boston, MA: Pearson. Spengler, P. M., White, M. J., Aegisdottir, S., Maugherman, A. S., Anderson, L. A., Cook. R. S., et al. (2009). The meta-analysis of clinical judgment project: Effects of experience on judgment accuracy. The Counseling Psychologist, 37(3), 350399. Sullivan, M. F., Skovholt, T. M., & Jennings, L. (2005). Master therapists construction of the therapy relationship. Journal of Mental Health Counseling, 27, 4870. Summers, R. F., & Barber, J. P. (2003). Therapeutic alliance as a measurable psychotherapy skill. Academic Psychiatry, 27, 160165. Wells, M., Trad, A., & Alves, M. (2003). Training beginning supervisors working with new trauma therapists: A relational model of supervision. Journal of College Student Psychotherapy, 17, 1939. Whittington, C., & Bell, L. (2001). Learning for interprofessional and inter-agency practice in the new social work curriculum: Evidence from an earlier research study. Journal of Interprofessional Care, 15, 153169. Xyrichis, A., & Lowton, K. (2008). What fosters or prevents interprofessional teamworking in primary and community care? A literature review. International Journal of Nursing Studies, 45, 140153.

AUTHOR NOTE
Sheri Oz, MSc, earned her degree in couples and family therapy at the University of Guelph, Canada. She is the founder and director of Machon Eitan, a private clinic in Israel, offering treatment to victims, offenders, and their families and developing prevention programs in the community to combat child sexual abuse.