A contextual perspective of clinical judgement in couples and family therapy: is the bridge too far?

A contextual perspective of clinical judgement incouples and family therapy: is the bridge too far?

David C. Iveya, Michael J. Scheelb andPeter J. Jankowskic

This paper reviews the clinical judgement literature and discusses itsapplicability to the practice of couples and family therapy. Key findingsand conceptual foundations are highlighted. A contextual perspective isadvocated to guide future investigations and to enhance the generalizabil-ity of the literature to the real-life experiences of therapists. Suggestionsfor theory development and future research are provided.

The ascribed importance of therapist judgement to the clinical andcounselling practices of psychology, psychiatry, social work,marriage and family therapy, and other mental health disciplines isperhaps best exemplified by the burgeoning numbers of textsdevoted to interviewing and assessment. Articles and volumes arepublished at an exponential rate detailing the evaluative, diagnos-tic and treatment planning arts employed by mental health practi-tioners. Such attention is paralleled in formal training andcontinuing educational experiences. Over the course of a typicaltherapist’s career, substantial time and energy is invested in activi-ties designed to enhance his or her ability to accurately and effi-ciently determine the nature of client concerns and appropriateplans for intervention. Practitioners are consequently impressedearly on in their development with the critical, if not central roleof clinical acumen. Therapists commonly subscribe to the premisethat client outcomes are, in the main, attributable to their personalproficiency in assessment and treatment decision-making.Amplified by the growing influence of managed care, practitioners

The Association for Family Therapy 1999. Published by Blackwell Publishers, 108 CowleyRoad, Oxford, OX4 1JF, UK and 350 Main Street, Malden, MA 02148, USA.Journal of Family Therapy (1999) 21: 339–3590163–4445

1999 The Association for Family Therapy and Systemic Practice

a Marriage and Family Therapy Program, Texas Tech University, Box 41162,Lubbock, TX 79309–1162, USA.

b Department of Educational Psychology, University of Utah.c Marriage and Family Therapy Program, Texas Tech University.

often experience trepidation, derived both internally and exter-nally, associated with their evaluative and intervention planningskills.

Despite the apparent availability of numerous resources, prag-matic guidance geared towards the enhancement of practitionerjudgement is generally limited. In contrast to the proliferation ofdiagnostic guides, instruments and procedures, few materialsaddress in depth the means by which therapists personally incorp-orate and employ the presented clinical information. The numer-ous articles and texts that examine the processes of interviewingand assessment often overlook the complex perceptual, processingand higher-order mental tasks required of therapists. The resourcesthat specifically address clinical judgement are themselves often oflimited utility due to their poor correspondence with the real-lifeactivities and needs of therapists. Their applicability is underminedby their failure to account for the individual differences betweentherapists and the unique demands presented by each clinical situ-ation. Due to the absence of clearly defined and pragmaticresources, practitioners, by and large, rely heavily on personal expe-rience to acquire clinical judgement skills. As a result, many fail togain confidence regarding their abilities while others are at a loss torecognize areas of weakness and avenues for development.

These concerns are nowhere better demonstrated than in thefield of couples and family therapy. Practitioners who work withcouples and families find very few practical resources to enhancetheir evaluative and clinical decision-making skills. The apparentsimple and straightforward process of determining client concerns,problem severity, treatment needs and intervention modality isoften in actuality a cumbersome and stressful enterprise. Dilemmasregarding whom to include in treatment, which methods to use andwhat the focus of intervention should be present particularlycomplex demands for the couples and family therapist.

As a means to determine the basis for the apparent limitedresources, the current discussion examines the applicability of theexisting clinical judgement literature to practice. Specifically, thispaper addresses whether an oversight has occurred in the study ofclinical judgement with respect to the practice of couples andfamily therapy. For the purposes of this discussion, clinical judge-ment will initially be defined as the perceptual, evaluative and deci-sion-making processes engaged in by practitioners in an attempt tounderstand clients and to provide assistance relevant to identified

340 David Ivey et al.


problems. Such processes encompass an infinite and interactingarray of perceptions, actions, feelings and cognitions (Mahoney,1988). Couples and family therapy will refer to a therapeuticapproach that is based in a systemic orientation. Following a briefreview of the clinical judgement literature, conclusions will beoffered pertaining to the status and relevance of the existing find-ings. Implications for a systemic orientation, underlying philosoph-ical and epistemological assumptions, and suggestions for futureresearch will be presented. It will be argued that a contextualperspective presents a means to resolve the identified concerns. Inparticular, we will suggest that through the development and appli-cation of contextually informed models of clinical judgement usefulmethods for the enhancement of the practitioner’s ability to effec-tively integrate clinical information and to make therapeuticchoices will be most likely to evolve.

The study of clinical judgement

Interest in the perceptual, diagnostic, prognostic and treatmentdecision-making activities of mental health clinicians can be tracedthroughout the history of counselling and psychotherapy (Bieri etal., 1966). Concerted enquiry was not realized however until some-what recently. The contemporary phase of clinical judgementresearch is limited to a span of four decades. Meehl’s (1954, 1957)discussions of the comparative utility of subjective or intuitiveprocessing of clinical information (clinical) versus statistical ormechanical information-processing (actuarial) mark the startingpoint from which systematic scientific enquiry spawned.

The results of clinical judgement research obtained during thecontemporary era generally provide discouraging evidence(Goldberg and Werts, 1966; Little and Schneidman, 1959; Meehl,1954; Oskamp, 1965). In a now classic study using the Bender-Gestalt Test, Goldberg (1959) found that the judgement accuracy ofpsychologists failed to exceed that of secretaries. Oskamp (1965)found that judgement accuracy did not relate to training in a studycomparing the assessments of clinical psychologists and nonclinicaljudges utilizing detailed case history information. The performancelevels in both studies barely exceeded chance.

Kendall (1973) found that psychiatrists’ ability to make validdiagnoses for psychological problems was not related to length ofexperience. Similar results were reported for the ability to predict

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patient assaultiveness on an inpatient psychiatric unit in a studyinvolving thirty psychologists and psychiatrists (Werner et al., 1983).It was found that the validity of clinical prediction was not signifi-cantly related to total years of experience or to length of experiencein acute inpatient settings. Gardner et al. (1996) found that actuar-ial predictions of violence by patients diagnosed with mental illnessoutperformed predictions by clinicians. Evidence from studiesinvolving projective (Levenberg, 1975; Silverman, 1959; Turner,1966; Wanderer, 1969; Watson, 1967) and objective personality testdata (Graham, 1967; Oskamp, 1967; Walters et al., 1988) generallysupport the absence of a relationship between training, experienceand judgement validity. Similar findings have been produced instudies involving the specialized practices of neuropsychology(Faust et al., 1988), social work (Berman and Berman, 1984) andcounselling (Pain and Sharpley, 1989).

These studies provide but a small sample of the availableevidence. Findings consistently support the contentions forwardedby the early scholars that clinical judgement is unreliable, minimallyrelated to confidence and experience, relatively unaffected by thetype or amount of information available, and rather low in validityon an absolute basis (Goldberg, 1968).

Conceptual developments

Of the three primary theoretical orientations underlying thecontemporary study of clinical judgement (Rock et al., 1987), andtheir many variants (Cooksey, 1996), the information-processingperspective has been dominant. The tenets of information-process-ing theory have remained the principal source to guide investiga-tions and remain the primary conceptual lens through whichavailable findings are interpreted and applied. Consequently, thehistory, status and evolution of the clinical judgement literaturecannot be fully appreciated without consideration of the assump-tions of the information-processing model.

The information-processing perspective can be generally catego-rized as mechanistic and rationalistic. It emphasizes the inward andlinear flow of information from the environment to the sense organsand subscribes to the notion that knowledge is a product of sequen-tial and selective processing. Information-processing models main-tain that sense data are useful to the extent that accurate and validcognitive representations of an objective environmental reality are



developed. Variability in judgement is assumed to occur as a resultof faulty or incorrectly utilized methods for integrating and synthe-sizing information (Anderson, 1990; Merluzzi et al., 1981; Turk et al.,1988).

Hogarth’s (1987) conceptual model provides what is perhaps thebest example of the information-processing perspective applied tothe study of human judgement. The model contends that judge-ment occurs through a system of linear feedback initially derivedfrom the environment. At the heart of the model are three infor-mation-processing activities: acquisition, data processing andoutput. Judgement output results in an action and an environmen-tal outcome that in turn may serve as additional feedback into thejudgement system.

Numerous potential sources of variability in clinical perceptionhave been identified through investigations based in the informa-tion-processing perspective. Kahneman et al. (1982) suggest thatefficient processing of information requires the use of decisionrules, termed heuristics. One source of variability in perception andjudgement is the clinician’s use of heuristics with the heuristics ofavailability, representation and anchoring believed to be commonlyemployed in clinical decision-making (Turk et al., 1988).

The availability heuristic is utilized in estimations related tofrequency, probability and causality. Objects or events are judged tobe frequent, probable or causal, to the extent that they are readily‘available’ in memory (Tversky and Kahneman, 1973).

Reliance on the availability heuristic often proves efficient anduseful as long as availability is related to the actual frequency of theevents or objects in question. However, many factors that are notrelated to frequency, such as vividness and recency, can influenceavailability. Reliance on availability when other factors are moreinfluential can therefore result in perceptions and conclusions thatpoorly correspond to the situation being observed (Nisbett andRoss, 1980).

The representativeness heuristic involves the application of‘goodness of fit’ criteria to problems of categorization. This processallows individuals to reduce several inferential tasks to judgementsof similarity. In using the representative heuristic, objects areassigned to conceptual categories on the basis of their perceivedsimilarity (Kahneman and Tversky, 1971).

As is the case with the availability heuristic, the representativenessheuristic is efficient and useful under many circumstances.



However, when the representativeness heuristic is used as the onlyjudgement strategy and when the known features of an object orcategory are insufficient to allow sound classification, error is quitelikely. Under these circumstances, the use of statistics for thefrequency or base rates of the categories in the population provesmore effective. The under-utilization of base-rate informationversus single-case information can lead to significant limitations incategorical judgements (Nisbett and Ross, 1980).

The third heuristic, anchoring, refers to the tendency to rely onpreliminary information as a basis for subsequent judgements anddecision-making. Kahneman et al. (1982) suggest that after individ-uals form preliminary judgements about a situation, they routinelyfail to make necessary adjustments to their original impressions.Once judgement occurs, subsequent information fails to exert asmuch influence as may realistically be desired (Nisbett and Ross,1980).

There are two additional sources of variability in clinical judge-ment. First, the illusory correlation refers to a tendency to perceiveevents in terms of causal relations, even when it is evident that therelation between events is incidental and the attributed causalityillusory (Tversky and Kahneman, 1980). Second, the confirmationbias relates to the tendency to seek confirmatory evidence whentesting hypotheses while underemphasizing or dismissing discon-firming evidence (Lord et al., 1979).

Conclusions and considerations for couples and family therapy

Despite substantial conceptual and empirical developments in thestudy of clinical judgement, the findings, by and large, remainpoorly integrated by the clinical community. Practitioners arecommonly unaware or uninterested in the available evidence or, asis reflected by the continuance of the clinical versus actuarialdebate (Dawes et al., 1989; Einhorn and Hogarth, 1982;Kleinmuntz, 1990), dismiss findings due to the assumption thatempirical efforts are adversarially motivated and insensitive toactual clinical contexts. Although the advance of cognitive scienceand the semi-recent cognitive revolution in psychotherapy haveenhanced the sensitivity of clinicians to the variable and subjectivenature of perception, therapists generally receive limited practicalassistance with respect to clinical judgement from the empiricalliterature. The research community appears to contribute to the



problem by its preoccupation with diagnostic (in)validity andadherence to an objectivistic and mechanistic conceptual base.Consequently, practitioners find few tangible resources. Theabsence of pragmatic guidance is particularly apparent for couplesand family therapists. In contrast to the intense attention, albeitmechanistically oriented, within the individually oriented literature,the processes employed by couples and family therapists to compre-hend client concerns and to make decisions regarding treatmenthave received limited empirical scrutiny. As a result, practitionersworking with couples and families receive minimal assistance fromthe empirical literature to enhance their abilities in these importantareas.

Oversight versus paradigmatic differences

It could be argued that the evident absence of attention to clinicaljudgement in couples and family therapy is the product of negli-gence. A more viable explanation contrasts this conclusion andsuggests that the apparent breach is the result of incongruencebetween the paradigms underlying the mainstream clinical judge-ment literature and the discipline of couples and family therapy.The contemporary study of clinical judgement has been deficitfocused and mechanistic (Holt, 1988; Sarbin, 1986).

The term ‘mechanistic’ is drawn from Pepper’s (1942) fourworld hypotheses: formism, mechanism, organicism and contextu-alism. Pepper’s hypotheses, also known as root metaphors, world-views and paradigms, were conceived as four broad categorieswithin which the means employed by individuals to make sense oftheir world and their personal experiences could be classified. Eachworld hypothesis or paradigm consists of a set of ontological, epis-temological and anthropological axioms. More recently within theadult cognition literature, Pepper’s two analytic world hypotheses offormism and mechanism have been combined into a single mecha-nistic paradigm (Botella and Gallifa, 1995; Johnson et al., 1988;Kramer et al., 1992). Formism assumes the existence of universalforms or types through which all entities can be classified andunderstood.

The root metaphor of the integrated mechanistic worldview isthat the world functions like a machine and as such can be reducedinto its parts and understood in isolation from the whole. A mecha-nistic view is based on the ontological assumption that the universe



is composed of discrete and inherently stable component parts thatare linearly related in a sequence of cause–effect interactions.Mechanistic epistemology asserts that reality is external to theknower and that objectivity and separation characterize the rela-tionship between the knower and reality. Anthropologically, indi-viduals are assumed to be reactive, passive and determined by theirenvironment, yet separate.

Similar axioms can be found underlying the positivist philosophyof science (Lincoln and Guba, 1985), rational cognitive schools oftherapy (Mahoney, 1988) and other modernist psychotherapies(Anderson, 1996; Hoffman, 1990). A positivist philosophy ofscience assumes the presence of a single, tangible reality, externalto the investigator that can be objectively understood throughexamination of isolated and linear associations (Lincoln and Guba,1985). Such a philosophy has long been dominant in the behav-ioural sciences, and more particularly with regard to the study ofclinical judgement.

Rationalist cognitive therapies, as well as other modernistapproaches, assume that a single, stable and external reality exists.Knowledge, behaviour and change are conceived as linearly causedwith clinical outcomes being derived from a logical validation of accu-rate and adaptive perceptions, cognitions and behaviour (Mahoney,1988). Numerous scholars (Amudson et al., 1993; Anderson, 1996;Gonzalez et al., 1994; Hoffman, 1990; Loos and Epstein, 1989;Mahoney, 1988; O’Hanlon, 1993) have delineated the pragmatic clin-ical implications from a modernist clinical stance. Modernist modelsof therapy represent an attempt to discover the objective truth andthe underlying or ‘real’ problems of clients. The focus for interven-tion is understood to be an inherent and covert structural deficiencyof the individual or system. Client problems, from a modernistperspective, are seen as dysfunctions, pathologies or aberrations fromestablished normative standards. Causal explanations or diagnosticformulations for such problems are derived from the expert andremoved knowledge and skills of the therapist. As a consequence,clinicians operate from within a hierarchical, isolated and objectiveposition of power and privilege (Amundson et al., 1993).

The incongruence between the mechanistic worldview and theroot metaphors underlying the field of couples and family therapycan be traced from the earliest forays of the emerging discipline.The pioneers of the 1950s have been described (Nichols andSchwartz, 1991) as disillusioned psychoanalysts who offered a



contextually based view of the human condition, in reaction againstthe prevalent modernist assumptions of their era. Psychoanalysishas itself been referred to as the ‘first wave’ of psychotherapy, char-acterized by a pathology and reductionism focus (O’Hanlon, 1994).The ‘second wave’ of psychotherapy abandoned linear–causalexplanations and adopted a circular view wherein concern withintrapsychic pathology was replaced with attention to adaptability,interaction and context. Despite the guiding influence of the organ-ismic systems root metaphor provided by Bertalanffy (1968, 1969),mechanistic assumptions persisted among many of the earlymodels. The proliferation of constructivist and feminist viewsduring the 1980s led to a ‘third wave’ that challenged the remain-ing mechanistic allegiance apparent within the major schools ofcouples and family therapy (O’Hanlon, 1994).

Unfortunately, the conceptualization and study of clinical judge-ment has not evolved in the same way. Although the limited clinicaljudgement research conducted in couples and family therapy canbe considered compatible with the ‘second wave’, mechanisticassumptions remain pervasive. Judgement has been examinedalmost solely in terms of accuracy, itself operationalized as thedegree of concordance between clinician perceptions and pre-established diagnoses. The utility of much of the existing literatureis consequently dependent on the ‘validity’ of the adopted diagnos-tic categories. The employed methods typically seek to determinethe presence or absence of clinician deficiency through exposure tovarious case or test materials. The methods tend to emphasize theoutcome assessment of psychopathology and to de-emphasize adap-tive adjustment, context, process and relationship factors.

A fundamental departure from the paradigm underlying thecontemporary practice of couples and family therapy is evident.The available evidence is derived from studies whose methods andconceptual foundations do not lend well to the organismic systemsorientation. When reviewing the couples and family therapy litera-ture with sensitivity to this explanation, it becomes evident thatconcern with clinical judgement and decision-making has beenprominent throughout the history of the couples and family ther-apy discipline and was in actuality an impetus to the field’s birth.Difficulty in recognizing its prominence rests in the divergence interms and concepts between those used in the existing mechanisti-cally based clinical judgement literature and those of the couplesand family therapy field.



A contextualist perspective

An alternative to the mechanistic conceptualizations of clinicaljudgement is needed in order to guide future research efforts andto enhance the utility of the literature (Holt, 1988; Sarbin, 1986).We suggest that a contextualist perspective offers a suitable alterna-tive that is particularly compatible with the discipline of couples andfamily therapy. Just as the mechanistic paradigm can be seen as anintegration of two root metaphors, the contextualist paradigm isbest depicted as a blend of the world hypotheses of organicism andcontextualism. The root metaphor of organicism views the world tobe a dynamic, living organism composed of a system of complexand interrelated processes. The contextualist paradigm can be char-acterized by a constructivist epistemology in contrast to the posi-tivist epistemology of the mechanistic paradigm (Berzonsky, 1994;Botella and Gallifa, 1995).

The integrated contextualist paradigm, akin to relativist anddialectical models (Kramer et al., 1992) and Perry’s (1970) contex-tual relativism, views reality to be unique to each individual’sperspective, experience and situation. This view epistemologicallyasserts that reality is internal to the knower and that the relation-ship between the knower and reality is subjective and relative.Individuals are assumed to be proactive, creative, and both influ-enced by and embedded within their environment. The knoweroperates from a position of reflexivity (Kitchener, 1983) with anawareness of one’s place in the social context and the reciprocalinfluence of self on the context and vice versa. Reflexivity involvesrecognition of the limits of knowledge, certainty and the criteria forknowing (Kitchener, 1983). Internal personal constructions ofknowledge can be understood to be created through the dialecticalintegration of seemingly contradictory information (Labouvie-Vief,1994).

Similar principles can be found within the post-positivist philoso-phy of science (Lincoln and Guba, 1985), constructivist models oftherapy (Mahoney, 1988), and other postmodernist schools. Withineach of these areas reality is seen as plural, subjective andconstructed. The individual is understood in context both as aninfluencer and as influenced by multiple, reciprocal and simultane-ous factors. Postmodern clinical approaches seek to generate alter-native truths and multiple descriptions of client problems.Problems and solutions are co-constructed in contrast to modernist



reliance on expert and hierarchical diagnoses and interventions bythe clinician. Problems may be understood as developmentaldiscrepancies between current adaptive capacity and immediatecontextual demands (Mahoney, 1988). An inherent emphasis onclient strengths, resources and initiative typifies postmodernmodels. The therapist functions as a learner, co-researcher andparticipant observer, assuming a persistent position of curiosity ornot knowing coupled with recognition of the limits of clinicianknowledge and ability. The therapeutic process can be character-ized by collaboration and mutual reliance. The therapist is open todisclose assumptions and thoughts and operates from a second-order perspective that is sensitive to the dynamics of the thera-pist–client system (Amundson et al., 1993).

A contextualist model of clinical judgment

Although the proposed alternative does not abandon the contribu-tions from investigations based in the mechanistic paradigm, acontextualist perspective offers a means to conceptualize theprocess of clinical judgement in a manner that dramatically departsfrom the established literature. This alternative draws from fieldsnot traditionally employed by clinical judgement scholars with thefield of hermeneutics providing a primary contribution.

Gadamer’s pivotal work laid the foundation for expanding thescope of hermeneutics beyond the interpretation of literary texts toinclude the process of interpretation in the human sciences(Bontekoe, 1996). His contribution challenged the allegiance tothe positivist philosophy traditionally characteristic of hermeneuticsand argued that interpretation may better be conceived as a conver-sation between text and reader. He asserted that interpretation isembedded within the relationship between reader and text andcoined the term ‘horizon’ to refer to the contexts in which both thereader and text are situated. The reader’s horizon is composed of afore-structure of preconceived ideas, assumptions, values andbeliefs from which the reader is unable to transcend to a position ofobjectivity. The fore-structure serves as a starting point of interpre-tation that influences the direction of the process. The text’s hori-zon is likewise composed of presuppositions and values (Bontekoe,1996).

Gadamer proposed that interpretation or understanding resultfrom the fusion of the horizons of reader and text. As such,



understanding of a phenomenon can be seen as a product ofmutual collaboration or co-construction. Although the hermeneu-tic process can be shut down when one of the parties refuses toallow the other to inform his or her fore-structure and the emerg-ing interpretation, understanding is potentially continuously evolv-ing. The conversation between reader and text is a dialogue ofquestion and answer with the evolution of new questions becomingcentral in the process of co-construction.

We suggest as well that a constructivist perspective (Neimeyer,1995), conceived within the contextualist paradigm, will advancethe conceptualization of clinical judgement in relationship-oriented therapy. Constructivism is best defined as a metatheory.Constructivism comprises a family of theories that are related onthe basis of a set of shared assumptions. Constructivist metatheoryassumes that cognitive processes are proactive in nature. In contrastto mechanistic models, mentation is assumed to be active, anticipa-tory, multilayered and generative. Utility is emphasized over objec-tivism and human knowledge is recognized to be peripherallyconstrained. Individual human systems are viewed to be self-organizing in a manner that protects and perpetuates theirintegrity (Mahoney et al., 1995).

From this view, clinical judgement can be conceptualized as theconstruction of meaning that is co-created among members of thetherapeutic system (for example, therapist, family members, observ-ing team). Meanings are construed through a reflexive process.Tomm (1987, 1988) explains reflexivity as an inherent aspect ofrelationships among meanings within belief systems that guidecommunicative actions. Reflexive communication is viewed asrecursive and circular. New meanings are co-created through thelanguage of therapy. Judgements then for systemic family andcouples therapy are dynamic concepts rather than static objectivetruths. The traditional use of reflecting teams in couples and familytherapy provides an example of an approach that endorses acommunal process of meaning-making or clinical judgement.Through dialogue, reflecting teams, often in concert with the clientsystem, seek to develop multiple and potentially contrasting defini-tions of presenting problems and response.

Similar conceptualizations can be found within the adult cogni-tive literature. King and Kitchener’s (1994) reflective judgementmodel is based on the assumption that the processes required tosolve ill-structured problems depart fundamentally from those



necessary in hypthetico-deductive reasoning. According to Kingand Kitchener, reflective thinking refers to a judgement processthat is based on the active processes of construction experienced bythe knower. They contend that knowledge is uncertain and compre-hension is dependent on context. From their model, alternativeperspectives and interpretations are considered and incorporatedwith judgements being tentative and open to ongoing revision. Astrong parallel is as well presented by Baxter-Magolda’s (1992)concept of contextual knowing.

A contextualist view of clinical judgement no longer adheres toprimary concern with the internal subjective processes of the clini-cian. Judgement is seen as an interactional, evolving, relational, co-constructive process. The notion that a therapist can develop acorrect judgement is eschewed. Rather, it is accepted that in orderto understand, multiple and potentially conflicting views must beintegrated. An observing system reality (the notion that we can onlyknow our own construction of others and the world) is preferredover an observed system reality (the notion that we can know theobjective truth about others and the world) (Hoffman, 1990). Thetherapist in an observing system format diminishes his or her roleas expert or judge concerning the clients’ realities while retaining aposition that facilitates the process of forming meanings within thesystem. An observing system perspective attends to how knowledgeis constructed. The constructed reality that can be thought of as aclinical judgement receives contributions from each individualperspective within the therapeutic system. In addition, the processof communication among system members produces a newchanged reality rather than the application of an objectified pathol-ogy, such as a DSM diagnosis, contrived solely by the therapist.

A hermeneutic framework incorporates the concepts of heuris-tics and biases from the mechanistically based literature andconceptualizes them as a component of the clinician’s horizon. Theformation of a judgement can thus be understood as the process offusing the horizons of therapist and client through dialogue orconversation in which the judgements of the clinician and clientremain open to change, are offered tentatively, and are continu-ously informed by recognition of social and cultural contexts and bynew information and evolution. The value or quality of clinicaljudgement is not understood in terms of validity and not deter-mined by the degree of correspondence between clinician viewsand objective external classification schemes. Utility of a clinical



judgement can be assessed by the co-constructed answer to thequestion: Do perceptions of the problem and client lead to resolu-tion of identified concerns, satisfaction with treatment, andenhanced client independence and welfare? In contrast to tradi-tional mechanistic studies of clinical judgement, contextual modelsattend primarily to the relationship and interactions between ther-apist and client. Much of the existing mechanistic clinical judge-ment literature is potentially informative in this regard given therange of findings that highlight various perceptual and ideationalprocesses of clinicians that may well serve to shape the form andnature of therapeutic relationships.

Is the bridge too far?

It can be argued that the study of clinical judgement is itself incom-patible with the theoretical foundations underlying the field ofcouples and family therapy. It can also be argued that attempts toincorporate the existing, mechanistically derived, clinical judge-ment literature are futile given the paradigmatic distinctions previ-ously addressed. Of the numerous associated philosophicalquestions and dilemmas, one appears particularly important. Doesthe information-processing model and the positivist philosophy ofscience more generally have to be dismantled in order for a contex-tualist-organismic model to be built? In other words, must themechanistically oriented literature be disregarded or is their bene-fit available from the existing findings and concepts for clinicianswhose orientation is contextual?

We suggest that the existing findings can and should be inte-grated. To disregard findings derived from an alternative perspec-tive is at odds with the tenets of contextualism. A contextualist viewembraces diversity in views and recognizes the presence of differ-ences as an opportunity for the expansion of knowledge. Weendorse the methodological pluralism advocated by Sprenkle andMoon (1996) and suggest that a parallel conceptual lens is needed.Although differences and alternative explanations should be exam-ined and highlighted, the advance of the literature will not occursimply through the denigration or dismantling of competing find-ings and concepts. Rather, the growth of knowledge requires atten-tion to new and potentially adversarial ideas.

How then can findings based in a mechanistic philosophy be inte-grated? A considerable dilemma is involved given that many of the



assumptions and principles underlying the existing literature arethemselves contrary to the basic tenets of a contextualist perspec-tive. We suggest that the concept of translation is useful to addresssuch concerns and will employ this language metaphor to explainour position. Concern regarding the mutual exclusiveness of alter-native paradigms can be examined in terms similar to the dilemmasencountered in attempting to learn a new language. Can someonewhose native language is Russian learn to speak Chinese? If he orshe becomes fluent in Chinese, will he or she necessarily losefluency in Russian or in some manner become less Russian? Does aninterest in Chinese reflect a disregard for Russian? Must he or shedismantle their proficiency with Russian in order to acquire fluencyin Chinese?

We contend that the acquisition of knowledge requires the ongo-ing development of new languages, in one form or another, andthat the exchange of information between any two individualsnecessitates translation. Although certain concepts and termsfound in one language may not have a corresponding term inanother, efforts should be given to developing a dialogue asopposed to attempts to further one’s personal perspective via thedenigration of a perceived competitor. The maturation of multilin-gual ability does not require the abandonment or alteration ofone’s worldview or identity, although such openness could be adesirable consequence. Multilingualism is in this sense not synony-mous with eclecticism but rather represents an effort to understandindividuals whose native form of perceiving and relating differsfrom one’s own. Inasmuch as multilingualism is embraced, stridesin the pursuit of knowledge would seem likely.

Despite its utility, the concept of translation is insufficient toresolve the difficulties presented by efforts to integrate contextualand mechanistic views. We consider three additional possibilities inour approach. First, integration might be feasible should oneperspective be subsumed within the other. Although intuitively wecan envision aspects of mechanism to exist within a broader contex-tualist view, this notion does not adequately constitute the form ofintegration to which we aspire. Borrowing again from the conceptof multilingualism, to adopt this approach would be synonymouswith the assumption that one language exists as a subset or minorform of another. As a consequence, such an approach to integra-tion would likely result in inattention to aspects of the subsumedlanguage which could not be construed within the bounds of the



larger. A second possible approach might rely on a hermeneuticmetaphor through which the mechanistic and contextual perspec-tives are viewed as texts in conversation with one another. Thisprocess may ultimately lead to a new reading or interpretation thatis a blend or integration of the pre-existing views. The last alterna-tive draws from Labouvie-Vief’s (1994) conceptualization of inte-grated thinking. From this approach, mechanistic and contextualviews reciprocally define one another by being held in simultaneousopposition to the other within a dialectical whole.

Our sense of integration is best represented by the third alterna-tive. As an example using the lingual metaphor, while an individualcan be fluent in both Chinese and Russian, he or she is capable ofusing only one language at a time. When conversing in onelanguage, the other is held in dialectical opposition to it within theperson’s mind. As a consequence, both languages are present butnot spoken simultaneously.

Suggestions for future study

A three-fold process is needed in order for translation and integra-tion to occur within the research community. The three compo-nents are comprised of familiarization, dialogue and collaboration.Theoreticians and investigators from each school of thought shouldseek to inform themselves of the concepts and findings developedthrough works based in alternative paradigms. For instance, schol-ars who identify with a positivist perspective should acquaint them-selves with the assumptions and models presented within thecontextual perspective and vice versa. Unfortunately, contributionsfrom a contextual perspective are in short supply. While mechanis-tic models and concepts have been available throughout themodern era of clinical judgement research, contextual models areessentially non-existent. We suggest that qualitative studies may besuitable to advance the initial development of contextual theoriesof clinical judgement. Dialogue and ultimately collaboration willnot be possible until such time that a contextual perspective is artic-ulated.

When conceptualized from a contextualist perspective, the studyof clinical judgement exhibits numerous distinctions from the exist-ing literature. A contextual view contrasts the existing mechanisticemphasis on judgement validity. Contextual models attend tocontext, reciprocal processes and information exchange. As a



result, investigations based in this perspective avoid preoccupationwith outcomes and the individual deficiencies of practitioners.Although attending to outcomes, factors associated with individualand group differences and the utility of therapist views, contextualstudies principally seek to describe the involved processes.Contextual investigations are concerned with the interacting rolesof various therapist, client, cultural and situational factors in theformation and expression of clinical judgement. The study of clini-cal judgement from a contextual perspective consequently empha-sizes process and description over diagnosis and classification.

We also suggest that efforts are needed within the scientificcommunity to more fully collaborate with the community of practi-tioners. The paradigmatic breach referenced throughout this paperappears as much to relate to the state of relations between scientists,or those who would study the work of clinicians and practitionersmore so than a simple discrepancy in worldviews. The study of clin-ical judgement requires close consultation and partnership withindividuals who grapple with the real life demands of clinical prac-tice.

Suggestions for clinicians

Integration is needed as well within the clinical community. Wesuggest that it is insufficient and potentially negligent for practi-tioners to summarily dismiss the existing clinical judgement find-ings principally based on the assumption that the evidence andconceptual models are irrelevant due to paradigmatic discrepan-cies. Although one’s conclusions would unlikely be a literal exten-sion from the available literature, a clinician’s ability to engage in acircular and contextual approach may be readily advanced by famil-iarization with the existing mechanistically oriented literature. Forpractical reasons, if for no other, it is advisable as well for clinicianswho identify with a contextual perspective to be conversant with themechanistic worldview in application to clinical practice. Withoutsuch familiarity, a productive dialogue would seem less viablebetween the clinician and multiple other individuals who have astake in the client’s presentation and access to therapy. Many indi-viduals who may exert considerable influence over the client’s abil-ity to receive clinical assistance may assess the need, efficacy andjustification for services from a mechanistic perspective.

Integration within the clinical community can be accomplished



by familiarization, dialogue and collaboration, not only with otherpractitioners and practice policy-makers, but also with the researchcommunity. We encourage practitioners to assume a share ofresponsibility for the advance of knowledge with respect to thestudy of clinical judgement and other aspects of the behaviouralsciences. Practitioners can do so by participation in research as wellas by personal contributions in theory development and study.Advocation of research by practitioners may promote the muchneeded reconciliation between the applied and scholarly commu-nities with respect to this particular area of enquiry.

Although a breach has occurred, the bridge is not too far.Concern is invariably promoted by efforts to span two seeminglydistant worlds. While concern may seem foremost the consequenceof questioning the viability of the bridge, more significant a sourceof tension rests in the possibility for change. Could integration andthe subsequent redefinition of the processes of clinical judgementpose such a threat? Might application of a contextual lens weakenthe foundations on which contemporary mental health practicerests? Regardless, further exploration of such processes is clearlyneeded both for the advancement of knowledge and of clinicalpractice.

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A contextual perspective of clinical judgement in couples and family therapy: is the bridge too far?