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A therapist I was coaching asked me an excellent question. “Should I develop myself to become a specialist in a certain area, with a certain type of diagnostic category and/or population, or should I aim to be really client centered and ‘Rogerian’ to all my clients?”

This is an important question. Should you become a specialist or a generalist?

First, embedded in our culture and thinking, specialisation tend to connote superiority of domain knowledge. The question is, what sort of domain specific knowledge we need to be good at? Conventionally, we often think about specialisation in terms of problem/diagnosis specifications, in specific populations, or specialisation in our pet solutions. But is this the way to go, to be like our medical profession when we have all sorts of anatomical specialisation, from your head to your heart, your stomach to your hip, and from your foot to your toes? (Surgeon and writer Atul Gawande once joked that we got to make sure that we don’t end up with a left foot specialist).

Second, being client-centred or “Rogerian” shouldn’t become a technique that we employ. I mean, even Carl Rogers said that he is not a “Rogerian.” Let’s also not water down what been client-centred truly means, under an umbrella term of “supportive therapy.” In short, let’s not relegate the deep value of being person-centred in our attempts to relate with someone in distress .

The Dangers of Specialisation

One of the dangers that is evolving in the field of medicine is overspecialisation.[1] There seems to be a lack of medical practicers who treating the human body as an inter-related system. For example, go to your family doctor, and many would not be able to tell you much about the relationship between the gut health and how it affects your mental health, much less what to do about it. (An aside: How many would appreciate that a large proportion of more than 70% of serotonin is produced in your gut?). Or, with the best of intentions, doctors are quick to prescribe anti-depressants without a full consideration of the systemic side-effects on weigh gain, reduced sex drive and difficulty in listening to emotions, which impacts clarity in decision making.[2] Personally, trying to find a practitioner in integrative medicine is so difficult. The last doctor I was recommended to by a colleague who practiced more holistically, was so fully booked that she no longer takes on new patients.

If we can afford the luxury to be in a practice where you specialise in treating people with the label of borderline personality disorder—and you are getting good outcomes—good for you. If you specialise treating people with complex trauma—and you are getting good outcomes—good for you. You should continue to serve the population that reaps benefit.

But most practitioners will not be able to afford this level of specialisation, especially those who are not in private practice.

Cognitive Bias

The biggest danger in specialisation is confirmation bias. In his comments about the state of affairs in diagnosing mental illness, former chair of DSM-IV committee turned vocal critique of DSM-V (which cost $25 million to produce), psychiatrist Allen Frances says that there are too much narrow experts within each area of the diagnosis. More worryingly, the DSM-V has inflated mental illness and shrank what constitutes as normal human experience, turning social problems into mental problems. [3]

Attribution creep speaks to the adage where if you hold a hammer, everything looks like a nail. If you specialise in trauma, everyone seems to have small t’s and big T’s. If your specialised in ADHD, nearly all of your child and adolescent, and adult clients seem like that fidgety kid. Besides, unlike randomised clinical trials (RCT) with stringent exclusion criteria (i.e., In most RCTs, if you have more than a specified diagnosis like clinical depression, you will not be included in the trial), ask any seasoned practitioners and they would tell you co-morbidity is more of a norm than a rarity in the real-world.

Once again, we end up with two problematic forms of specialisations:

  1. Specialisation in ill-defined and complex problems, and
  2. Specialisation in our theoretical persuasions

In Praise of Generalists

Most of the time, when we are in a “stuck” clinical situation, it’s often not because of an error in case formulation, or not using a specific treatment protocol well. Instead, we need to get good at core fundamental relational knowledge, not technical content knowledge (See also this post, 3 Types of Knowledge) . Let’s not get lost in our cerebral definitions of human and social problems. Neither should we be cult-like in our pet-solutions.

I wonder about the implications if we come to fully appreciate that our field is more of a “relational” profession, and less of a “clinical knowledge” profession.

I believe that one of the roads we need to take is to to improve our core skills of human connection in order to promote healing and development.

For instance, Tim Anderson and colleagues published a really interesting paper in 2015 (the authors made this available in Researchgate). They found that a therapists relational skills before attending graduate school, was a significant predictor of outcomes and alliance formation. The impact of training was “negligible”.[4]

Being Moved Towards a Path

Maybe you might find yourself being moved towards working specific populations (e.g., kids, geriatrics). This can’t be forced. Follow your natural tendencies and what compels, as this will serve you and others well.

The aim should not be about becoming a specialist. Let’s not become prisoner’s of our own depths.

The aim should be focused on fulfilling a need. If you adopt a routine approach to measuring outcomes session-by-session, you will be able to figure out when you are achieving good results with your clients. Let that guide your professional development path.

So instead of asking “Should I be a specialist in an area?” Maybe the real question should be, “How do I get better at delivering the help for the people that I seek to serve?”

“A human being should be able to change a diaper, plan an invasion, butcher a hog, conn a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, die gallantly. Specialization is for insects.”

~ Robert A. Heinlein, Time Enough for Love

For more, see also the following posts from the archives:

1. What Does General Athleticism Got to Do with Psychotherapeutic Skills?
2. The Iterative Pathway of a Psychotherapist’s Professional Development

[1] I highly recommend this two books, The Mosaic Principle by Nick Lovegrove and Range by David Epstein (a brilliant writer). See also Allen Frances article in the Huffington Post, We Have Too Many Specialists and Too Few General Practitioners
[2] Read Moody Bitches by Julie Holland Your Drug May Be Your Problem by Peter Breggin and David Cohen.
[3] For starters, read this article in Wired Magazine, Inside the Battle to Define Mental Illness. Take one more step and read Allen Frances’ important book, Saving Normal. If you want to dig in a little further around the deep flaws embedded in the DSM-V compilation, read Gary Greenbergs, The Book of Woe.

[4] Anderson, T., Crowley, M. E. J., Himawan, L., Holmberg, J. K., & Uhlin, B. D. (2015). Therapist facilitative interpersonal skills and training status: A randomized clinical trial on alliance and outcome. Psychotherapy Research, 1-19. doi:10.1080/10503307.2015.1049671

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