Issues in Assessment III

PSYC 4500: Introduction to Clinical Psychology

Brett Deacon, Ph.D.

October 1, 2013

Announcements

• Grades posted on course website

• A note about response paper grades

In the News

• NY Times Editorial: “Psychotherapy’s Image

Problem” by Brandon Gaudiano, Ph.D. http://www.nytimes.com/2013/09/30/opinion/psychotherapys-image-problem.html?nl=todaysheadlines&emc=edit_th_20130930&_r=2

&

• Psychotherapy client’s blog: “Bad Therapy” A

Disgruntled Psychotherapy Client Speaks Her

Piece” http://disequilibrium1.wordpress.com/

From Last Class

• Maryanne’s experience with equine therapy at

the Sheridan VA

• Factors that affect therapist’s ability to learn

from their own experience and make more

accurate clinical decisions (predictions)

• Biases in clinical judgment

• Nature of feedback in mental health practice

From Last Class

• Issues discussed in last class:

• Assessment data is interpreted in context of

one’s own preconceived notions

• Confirmation bias

• Overconfidence

• We rarely get accurate, objective feedback

about our judgments

Biases in Clinical Judgment

• Availability bias – relying on information that

most easily comes to mind

• We vividly recall instances of accurate

judgment (the “hits”) and overestimate their

frequency

Experience and Clinical Judgment

• Experience creates the “illusion of learning”

• We see an unrepresentative sample of patients

• Examples:• Alcoholism is a chronic disease because all the

alcoholics in my clinic keep relapsing

• Alcoholics cannot control their drinking because the patients in my practice don’t seem to be able to control their drinking

Experience and Clinical Judgment

• We create contexts in which our judgments

cannot be wrong

• Hospitalizing an ambiguously suicidal patient

• Awarding custody to one parent over the

other

Why I Do Not Attend Case Conferences (Meehl, 1973; http://www.tc.umn.edu/~pemeehl/099CaseConferences.pdf)

• What is a case conference?

Why I Do Not Attend Case Conferences (Meehl, 1973; http://www.tc.umn.edu/~pemeehl/099CaseConferences.pdf)

• Classic paper on clinician biases. Examples:• 1. Forgetting the base rate problem (using high base rate

predictor to predict low base rate outcome)

• 2. Explaining away symptoms because “anybody would act the same way under the circumstances”

• 3. “I’ve had that experience before as well, so the client must be normal”

• 4. “Uncle George’s pancakes” fallacy (that symptom isn’t a problem; my Uncle George did the same thing)

• 5. I had a client with that same symptom, and he wasn’t psychotic (_____ heuristic?)

• 6. “My client is a unique individual so group-level research doesn’t apply”

Why I Do Not Attend Case Conferences (Meehl, 1973; http://www.tc.umn.edu/~pemeehl/099CaseConferences.pdf)

• Why do clinicians make less accurate predictions than a

statistical equation, even when they are provided with the

results of statistical prediction and allowed to copy them?

• 7. Clinicians make “Broken leg” exceptions

• A professor sees a movie every Friday night. This Friday

morning, the professor breaks his leg. Will he see a movie

this Friday night?

• Deviating from the usual, empirically-based prediction that

the professor will see a movie this Friday is a bona fide

broken leg exception.

• Meehl argued that most exceptions therapists make are not

bona fide broken leg exceptions.

Broken Leg Exceptions: Treatment of PTSD in the VA System

• Prolonged exposure is the most effective treatment for PTSD, approximate 70% success rate

• Used with less than 20% of veterans with PTSD, and as primary treatment in 1% of cases (Foy et al., 1996)

• Not using prolonged exposure is a false broken leg exception

• Why might clinicians make what they think are broken leg exception in this case?

Our Clinician Survey

• Surveyed 182 community therapists who report providing exposure therapy to their anxious clients

• We asked therapists to rate the likelihood they would exclude an anxious client from exposure therapy based on 25 client characteristics

• Most common reasons for exclusion:• Client has a comorbid psychotic disorder• Client is emotionally fragile• Client is reluctant to participate in exposure

• Are these bona fide broken leg exceptions?

Our Clinician Survey

• Our most interesting results:

• Correlation between general tendency to exclude clients from exposure therapy and:

• Therapists’ fear of anxiety: r = .32 (p < .001)

• Therapists’ negative beliefs about the unethicality, intolerability, and dangerousness of exposure therapy: r = .53 (p < .001)

• Take-home message: reasons for excluding clients from exposure have more to do with therapist biases than empirically based broken leg exceptions

Improving Clinical Judgment

• How can we improve clinical judgment, or at least reduce the likelihood of making mistakes?

• Suggestions:

• Search for alternative explanations

• Understand the impact of base rates

• Decrease reliance on memory

• Increase reliance on scientific findings

• Increase opportunities for accurate feedback

Improving Clinical Judgment

• Take-home messages:

• Clinical judgment is affected by numerous biases to which all of us are subject (regardless of advanced scientific training)

• “Thinking like a scientist” involves recognizing these biases and taking steps to control for them:

• Humility, not overconfidence

• Favoring clinical judgment over scientific evidence is a recipe for inaccurate predictions

Clinical Judgment and Evidence-Based Practice in Psychology (EBPP)

• APA’s (2006) definition of EBPP: Evidence-based practice in psychology (EBPP) is the integration of (a) the best available research with (b) clinical expertise in the context of (c) patient characteristics, culture, and preferences.

Evidence-Based Psychological Practice

Best available research evidence

Patient preferences and values

Clinical expertise

EBPP

Clinical Judgment and Evidence-Based Practice in Psychology (EBPP)

• What are the implications of our discussion of clinical judgment for HOW the three components of EBPP should be integrated?

The Role of Clinical Judgment and Evidence-Based Practice

• Three-legged stool vs. pyramid?