Enhancing Clinical Judgment in Psychology: Addressing Biases and Improving Outcomes

1. Issues in Assessment III PSYC 4500: Introduction to Clinical PsychologyBrett Deacon, Ph.D.October 1, 2013

2. Announcements • Grades posted on course website • A note about response paper grades

3. 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/

4. 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

5. 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

6. 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

7. 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

8. 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

9. Why I Do Not Attend Case Conferences (Meehl, 1973; http://www.tc.umn.edu/~pemeehl/099CaseConferences.pdf) • What is a case conference?

10. 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”

11. 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.

12. 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?

13. 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?

14. 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

15. 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

16. 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

17. 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.

18. Evidence-Based Psychological Practice Best available research evidence EBPP Patient preferences and values Clinical expertise

19. 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?

20. The Role of Clinical Judgment and Evidence-Based Practice • Three-legged stool vs. pyramid?