Case Study 2 — Chapter 26: Learning, Growth Mindset, and Expertise

Amara: The Edge of Competence

Background

End of the second semester. The peer processing group has concluded its three sessions. The cohort is preparing for final papers. Amara's clinical hours stand at 87 — well above the semester's required minimum.

In supervision, Marcus has been shifting the focus. In the first semester, supervision was primarily about establishing the basics: the clinical frame, boundaries, the mechanics of the therapeutic relationship. In the second semester, he has begun pushing on something harder: the quality of Amara's clinical thinking.

The push has arrived in a form Amara did not expect. Not criticism of what she's getting wrong. Interrogation of what she thinks she's getting right.

The Supervision Challenge

Week twelve of the second semester. Amara presents a case: a 28-year-old client she has been seeing for ten weeks, presenting with depression and a pattern of relationships that end when the client becomes emotionally dependent.

She presents the case clearly, her formulation well-organized: anxious attachment, self-defeating relational patterns, possible early abandonment history she is still working to understand.

Marcus listens. Then: "What's the clinical theory you're using?"

Amara: "Attachment theory, primarily. Some CBT for the depressive cognitions."

Marcus: "What does attachment theory tell you about what you should be doing right now — specifically — in sessions ten through fifteen of this treatment?"

Amara starts to answer. She describes the therapeutic relationship as the primary vehicle. She mentions security-building. She mentions working with the internal working model.

Marcus: "What does security-building look like as a specific intervention in session eleven?"

Amara pauses. She knows what it looks like in theory. She can feel the gap between the theoretical account and the specific behavioral description of what she actually does in the room.

She says: "I'm not sure I can describe it specifically. I know what I'm trying to do. I'm less clear on how I would describe the specific intervention."

Marcus: "That's the most honest answer you've given me in two months."

She looks at him.

Marcus: "You're doing something right in the room. I can tell from the clinical outcomes. But you're running on pattern recognition and empathy, and you don't have the theoretical vocabulary to describe what you're doing. That means you can't refine it, you can't transfer it to a harder case, and you can't teach it. You're at the edge of what intuition will carry you."

Amara says: "So what do I do?"

Marcus: "You go back and read. Not overview-level reading — the technical literature on attachment-based interventions. And then you come back here and tell me what, specifically, you're doing in sessions 10 through 15 with this client. Not what you're trying to do. What you're doing."

The Reading

Amara spends two weeks in the library. She reads the technical literature Marcus pointed her to: Fonagy on mentalization-based treatment, Wallin on attachment in psychotherapy, the specific literature on therapeutic interventions with anxious attachment.

The experience is different from the assigned reading she has been doing all semester. This reading has a specific question it is answering: what am I actually doing in the room with this client?

She takes notes differently. Not summaries — she has been writing summaries. This time she writes: "This is what I've been doing. This is what the literature calls it. This is what the next intervention should be."

She discovers, reading Wallin, that what she has been doing — staying present when the client becomes emotionally dependent rather than subtly withdrawing — has a name. It is called "providing a secure base under stress." She has been doing it intuitively because her own experience of secure attachment with Nana Rose gave her a template. She has been doing it without knowing what it was.

She also discovers what she should do next: an explicit relational intervention she had not attempted, involving naming the pattern with the client rather than only working within it.

She writes in her journal: I've been practicing clinical intuition. I need to practice clinical theory. The intuition is real and it's useful. It's also a plateau if I don't understand what's underneath it.

The Return to Supervision

Two weeks later. Amara presents the case again.

She describes what she has been doing — using Wallin's vocabulary this time. She names the specific intervention she is now attempting. She describes the theory and the clinical rationale.

Marcus asks three follow-up questions. She can answer two of them precisely and the third approximately — with a clear acknowledgment that she is approximating.

Marcus: "What changed?"

Amara: "I realized I was operating below the theory. I could do the thing but I couldn't describe it. You were right that I couldn't refine it from there."

Marcus: "How did it feel to read the technical literature instead of the overview?"

Amara: "Harder. But more interesting. The overview reading is too easy — I feel like I'm learning but I'm not working. The technical reading makes me work."

Marcus: "That's the difference between practice and deliberate practice."

She looks at him. "You know about deliberate practice?"

"I've been a clinician for twenty years. I know about plateaus."

The Feedback Problem

One thing Amara has been doing: seeking feedback. From Marcus in supervision. From Dr. Chen in seminar. From her own notes after each session.

What she realizes, in the context of the chapter's framework, is that the feedback she has been getting most is the feedback that was least informative — Marcus's end-of-session supervision summary of her overall clinical work. It was useful; it was not specific enough to guide targeted improvement.

The most useful feedback she has ever received was the single question: "What's the clinical theory you're using, specifically?"

That question told her more about the gap between where she was and where she needed to be than six weeks of positive supervision summaries had. Not because the positive summaries were wrong — her clinical work was generally adequate — but because adequacy is not the level at which development occurs.

She brings this to Marcus: "The most useful supervision is the supervision that's uncomfortable."

Marcus: "Yes."

Amara: "I want to request something. In our remaining sessions this semester and next year: can you challenge my clinical reasoning specifically, rather than evaluating my overall performance? I want to be asked what I can't answer."

Marcus: "I can do that. It will be harder for you."

Amara: "I know."

The Growth Mindset Moment with a Client

Late April. In a session with the client she has been working with for twelve weeks — the client whose 8-week disclosure was the competence growth moment in Chapter 22 — something goes wrong.

Amara makes an interpretation. She names what she thinks is happening in the client's relational pattern. The interpretation is, she thinks, accurate. The client shuts down. Something in the room closes.

She holds it. She does not try to fix it immediately. She asks, after a pause: "I notice something changed just now. I want to check in about that."

The client says: "I don't think you understood what I was saying."

Amara: "Okay. Will you help me understand what I got wrong?"

The client does. Amara's interpretation had been accurate in structure but wrong in timing — the client wasn't ready for it yet. The naming happened before the relationship could hold it.

She does not defend herself. She does not explain that she was technically correct. She says: "That makes sense. I moved too fast. Let me follow your lead."

The session recovers.

In supervision, Marcus asks: "What happened in that session?"

Amara describes it. Marcus asks: "What did you learn?"

Amara: "Accurate isn't the only criterion. The client has to be ready to receive it. The relationship has to be strong enough to hold it."

Marcus: "That's the thing textbooks tell you and supervision is supposed to help you feel in your body."

Amara: "I felt it."

Marcus: "I know. I could tell. That's different from knowing."

Analysis Questions

Marcus's supervision challenge — "what does security-building look like as a specific intervention in session eleven?" — shifts Amara from theoretical knowledge to clinical specificity. The chapter distinguishes between knowing the concept and being able to describe the specific behavior. What is the learning gap Marcus has identified, and why does that gap limit Amara's development in the way he describes?
Amara discovers, through targeted reading, that she has been "providing a secure base under stress" intuitively — based on her internalized template from Nana Rose — without knowing that was what she was doing. The chapter discusses expert intuition as pattern recognition from experience. What is the specific risk of operating from clinical intuition without theoretical vocabulary, and how does Amara's realization that she is "at a plateau" address this?
Amara requests a change in supervision format: "challenge my clinical reasoning specifically, rather than evaluating my overall performance." She is requesting, in essence, feedback that is specific to her deliberate practice targets rather than general evaluative feedback. How does this request connect to the deliberate practice criteria in the chapter? What specifically is she asking Marcus to do differently?
The session where the accurate interpretation lands wrong is a specific type of failure: intelligent failure — it was based on sound reasoning but produced new information (timing matters as much as accuracy; the relationship has to hold the interpretation). How does Amara's response to the failure in the room — not defending herself, not explaining her reasoning, asking "will you help me understand what I got wrong?" — model growth mindset in the clinical context?
Marcus's final exchange: "That's the thing textbooks tell you and supervision is supposed to help you feel in your body." / "I felt it." / "I know. I could tell. That's different from knowing." This distinction — felt experiential knowledge vs. theoretical propositional knowledge — is related to the Dreyfus model's distinction between rule-following and holistic intuitive expertise. What does Marcus mean by "different from knowing," and why does it matter for Amara's development toward expertise?