clinical psychology

1. THE PROCESSTHE PROCESS ANDAND
ACCURACY OF CLINICALACCURACY OF CLINICAL
JUDGEMENTJUDGEMENT
Lecture 23Lecture 23

2. Clinical Judgment is enough to suggestClinical Judgment is enough to suggest
that clinicians use inferential processesthat clinicians use inferential processes
that are often far from objective. Thethat are often far from objective. The
process, accuracy, and communication ofprocess, accuracy, and communication of
clinical judgment are still very oftenclinical judgment are still very often
extremely per­sonalized phenomena.extremely per­sonalized phenomena.
The discussion of clinical judgment willThe discussion of clinical judgment will
begin with its basic element­­­­begin with its basic element­­­­
InterpretationInterpretation..

3. INTERPRETATIONINTERPRETATION
 Interpretation is the most important singleInterpretation is the most important single
activity engaged in by the clinician”.activity engaged in by the clinician”.
 ClinicalClinical interpretationinterpretation or judgment is aor judgment is a
complex process. It involvescomplex process. It involves
• StimuliStimuli
• It also involves the clinician's response.It also involves the clinician's response.
• It also involves the characteristics ofIt also involves the characteristics of
clinicians.clinicians.
• Finally, situational variables enter into theFinally, situational variables enter into the
process.process.

4. THE THEORETICAL FRAMEWORKTHE THEORETICAL FRAMEWORK
 Clinical psychologists strive to discover theClinical psychologists strive to discover the
etiology, or originsetiology, or origins,, of psychological problemsof psychological problems
and to understand patients.and to understand patients.
 Clinical problems can be conceptualized in aClinical problems can be conceptualized in a
variety of ways (for example, psychodynamic,variety of ways (for example, psychodynamic,
behavioral, and cognitive).behavioral, and cognitive).
 By adopting a particular theoretical perspective,By adopting a particular theoretical perspective,
clinicians can evaluate interpretations andclinicians can evaluate interpretations and
inferences according to their theoreticalinferences according to their theoretical
consistency and can also generate additionalconsistency and can also generate additional
hypotheses.hypotheses.

5. Patient data can be viewed in several ways.Patient data can be viewed in several ways.
 SAMPLES:-SAMPLES:-First, one can view such data asFirst, one can view such data as
samples.samples. Observations, test scores, testObservations, test scores, test
responses, or other data are seen as samplesresponses, or other data are seen as samples
of a larger pool of information.of a larger pool of information.
 SIGNS:-SIGNS:-A second way in which patient dataA second way in which patient data
can be interpreted is as signs of somecan be interpreted is as signs of some
underlying state, condition, or determinant.underlying state, condition, or determinant.
 CORRELATES:-CORRELATES:-A third view of patient dataA third view of patient data
emphasizes their status asemphasizes their status as correlatescorrelates of otherof other
things.things.

6. LEVELS OF INTERPRETATIONLEVELS OF INTERPRETATION::
Sundberg, Tyler, and Taplin (1973) have describedSundberg, Tyler, and Taplin (1973) have described
three levels of inferences or interpretations.three levels of inferences or interpretations.
 LEVEL 1LEVEL 1 interpretation generally involves littleinterpretation generally involves little
in the way of inference and certainly nothing in thein the way of inference and certainly nothing in the
way of a sign approach.way of a sign approach.
 This simple yet efficient approach can dispenseThis simple yet efficient approach can dispense
with high-level clinicians.with high-level clinicians.
 it can be handled by technicians, computers, orit can be handled by technicians, computers, or
machinesmachines
 Level I interpretations can often be used with largeLevel I interpretations can often be used with large
populationspopulations

7.  LEVEL IILEVEL II interpretations involve two kinds’interpretations involve two kinds’
inferences.inferences.
 Sundberg etal call first kind of inferenceSundberg etal call first kind of inference
descriptivedescriptive generalization-----generalization-----still at thestill at the
descriptive level.descriptive level.
 Example: a patient who fidgets, smokesExample: a patient who fidgets, smokes
cigarettes during the interview, and stammerscigarettes during the interview, and stammers
the clinician may make a descriptivethe clinician may make a descriptive
generalization----interview tension.generalization----interview tension.
 The second kind of inference is a hypotheticalThe second kind of inference is a hypothetical
construct that suggests an inner state and takesconstruct that suggests an inner state and takes
the clinician a bit beyond descriptivethe clinician a bit beyond descriptive
generalization.generalization.

8.  LEVEL IIILEVEL III interpretations take cliniciansinterpretations take clinicians
beyond level II primarily by being morebeyond level II primarily by being more
inclusive and better integrated.inclusive and better integrated.
 For example, ‘blood’ responses on theFor example, ‘blood’ responses on the
RorschachRorschach  sign of underlyingsign of underlying
aggression that may lead to futureaggression that may lead to future
impulsive outbursts or loss of control.impulsive outbursts or loss of control.

9. THEORY AND INTERPRETATIONTHEORY AND INTERPRETATION
Three very broad interpretive classes.Three very broad interpretive classes.
BEHAVIORAL CLINICIANS:-BEHAVIORAL CLINICIANS:-
 The strict behaviorist avoids makingThe strict behaviorist avoids making
inferences about underlying states andinferences about underlying states and
instead concentrates oninstead concentrates on thethe behavior of thebehavior of the
patient.patient.
 These data are regarded as samples.These data are regarded as samples.
Interpretation is Largely at Level I and II,Interpretation is Largely at Level I and II,
although more recently some behavioralalthough more recently some behavioral
clinicians have begun to show an inter­est inclinicians have begun to show an inter­est in
Level III interpretationLevel III interpretation

10.  A second group of clinicians pride themselvesA second group of clinicians pride themselves
on being empirical and objective.on being empirical and objective.
 ThisThis psychometric approachpsychometric approach to interpretation,to interpretation,
as we shall see a bit later, is especially usefulas we shall see a bit later, is especially useful
when the criteria being predicted are crisp andwhen the criteria being predicted are crisp and
well articulated.well articulated.
PSYCHODYNAMIC APPROACH:-PSYCHODYNAMIC APPROACH:-
 The psychodynamic ap­proach strives toThe psychodynamic ap­proach strives to
identify inner states or determinants.identify inner states or determinants.
 Data from projective tests, unstructured clinicalData from projective tests, unstructured clinical
interviews and other sources are viewed asinterviews and other sources are viewed as
signs of an underlying state.signs of an underlying state.
 Interpretation tends to itched at Level III.Interpretation tends to itched at Level III.

11. QUANTITATIVE VERSUS SUBJECTIVEQUANTITATIVE VERSUS SUBJECTIVE
APPROACHESAPPROACHES
 Quantitative or statisticalQuantitative or statistical approachapproach,, emphasizesemphasizes
objectivity and is presumably free from fuzzyobjectivity and is presumably free from fuzzy
thinking.thinking.
 This enables clinicians to determine the correlationThis enables clinicians to determine the correlation
between any two characteristics.between any two characteristics.
 A multivariate prediction model could then beA multivariate prediction model could then be
constructed and tested.constructed and tested.
 Example of variablesExample of variables: ego strength, the: ego strength, the
experience of the therapist, marital satisfaction, andexperience of the therapist, marital satisfaction, and
interpersonal trust.interpersonal trust.

12.  Clinicians have to be sure that they have correctlyClinicians have to be sure that they have correctly
weighted various predictor scores before they canweighted various predictor scores before they can
generalize very far.generalize very far.
 These statistical techniques permit a mechanicalThese statistical techniques permit a mechanical
application that does not involve clinical decisionapplication that does not involve clinical decision
making at all once the formulas have beenmaking at all once the formulas have been
established.established.
 The quantitative, statistical approach, then, requiresThe quantitative, statistical approach, then, requires
that the clinician keep careful records of the data,that the clinician keep careful records of the data,
observation and related material so that clinicalobservation and related material so that clinical
interpretations and judgments can be quantified.interpretations and judgments can be quantified.

13.  Subjective or clinical approachSubjective or clinical approach,, whichwhich
adherents claim is the only method to offer trulyadherents claim is the only method to offer truly
useful interpretations and predictions.useful interpretations and predictions.
 The emphasis is on the application of judgmentThe emphasis is on the application of judgment
to the individual case.to the individual case.
 The classical notation is that "clinical intuition"The classical notation is that "clinical intuition"
is not readily amenable to analysis andis not readily amenable to analysis and
quantification.quantification.
 It is a private process in which cliniciansIt is a private process in which clinicians
themselves are sometimes unable to identifythemselves are sometimes unable to identify
the cues in a patient's testthe cues in a patient's test

14.  For example, in the course of a RorschachFor example, in the course of a Rorschach
administration, a patient said, "This looks likeadministration, a patient said, "This looks like
a Christmas tree." What did this mean?a Christmas tree." What did this mean?
Perhaps nothing. Or perhaps it indicated aPerhaps nothing. Or perhaps it indicated a
career in forestry. Or perhaps it suggested ancareer in forestry. Or perhaps it suggested an
underlying sadness or depression.underlying sadness or depression.
 Interpretation involves a sensitive capacity toInterpretation involves a sensitive capacity to
integrate material.integrate material.

15.  The astute clinical psychologist pays atten­tionThe astute clinical psychologist pays atten­tion
to the wide range of events that characterizeto the wide range of events that characterize
the patient's behavior.the patient's behavior.
 A clinician must function a bit like the detective.A clinician must function a bit like the detective.
 There are individual differences in clinicalThere are individual differences in clinical
sensitivity.sensitivity.
 For every instance of brilliant and sensitiveFor every instance of brilliant and sensitive
clinical inference, there probably lurks in theclinical inference, there probably lurks in the
unrecalled recesses of memory an equallyunrecalled recesses of memory an equally
impressive misinterpretation.impressive misinterpretation.

16.  Clinical interpretation involves the sensitiveClinical interpretation involves the sensitive
integration of many sources of data into aintegration of many sources of data into a
coherent picture of the patient.coherent picture of the patient.
 It also fulfills a hypothesis­generating function.It also fulfills a hypothesis­generating function.
 Clinicians should explicate the manner in whichClinicians should explicate the manner in which
they make the leap from cues to conclusions. Itthey make the leap from cues to conclusions. It
is not enough to be good clinicians.is not enough to be good clinicians.
 There is also a responsibility to pass on theseThere is also a responsibility to pass on these
skills to others.skills to others.

17. COMPAIRING CLINICAL ANDCOMPAIRING CLINICAL AND
ACTURIAL APPROACHESACTURIAL APPROACHES
 Over the years, many studies have compared theOver the years, many studies have compared the
relative accuracy of clinical and actuarial methods.relative accuracy of clinical and actuarial methods.
COMPARISON STUDIES: The Regression equationCOMPARISON STUDIES: The Regression equation
 Study of Sarbin (1943)--Study of Sarbin (1943)-- contrasted the prediction ofcontrasted the prediction of
academic success of college freshmen made by aacademic success of college freshmen made by a
clerk employing a regression equation with theclerk employing a regression equation with the
predictions made by several counselors.predictions made by several counselors.
 The regression equation predictors were aptitude testThe regression equation predictors were aptitude test
scores and high school rank.scores and high school rank.

18.  Meehl (1954) surveyed a number of theMeehl (1954) surveyed a number of the
studies available on clinical versusstudies available on clinical versus
statistical, prediction and concluded that instatistical, prediction and concluded that in
"all but one ... the predictions made"all but one ... the predictions made
actuarially [statistically] were eitheractuarially [statistically] were either
approximately equal or superior to thoseapproximately equal or superior to those
made by a clinician" .made by a clinician" .
 Sawyer (1966) regarded data collected bySawyer (1966) regarded data collected by
interview or observation as clinical data.interview or observation as clinical data.

19.  One of the most frequently cited studies of clinicalOne of the most frequently cited studies of clinical
versus statistical prediction was reported byversus statistical prediction was reported by
Goldberg(1965).Goldberg(1965).
13 Ph.D. level staff-members and 16 pre-doctoral13 Ph.D. level staff-members and 16 pre-doctoral
trainees were asked to maize lodgments regarding thetrainees were asked to maize lodgments regarding the
diagnostic status of more than 800 patients, based ondiagnostic status of more than 800 patients, based on
these patients' MMPI scores.these patients' MMPI scores.
 Statistical predictions involved the application of aStatistical predictions involved the application of a
variety of algorithms.variety of algorithms.
 A variety of additional, updated reviews of the studiesA variety of additional, updated reviews of the studies
pitting clinical versus statistical prediction havepitting clinical versus statistical prediction have
uniformly demonstrated the superiority of statisticaluniformly demonstrated the superiority of statistical
proceduresprocedures

20. OBJECTIONS TO THESE FINDINGSOBJECTIONS TO THESE FINDINGS
 Dawes (1994) has outlined several of the majorDawes (1994) has outlined several of the major
objections to large body of evidence supportingobjections to large body of evidence supporting
the superiority of statistical prediction, alongthe superiority of statistical prediction, along
with response, such objection.with response, such objection.
 First, critics argue that several of the individualFirst, critics argue that several of the individual
studies reviewed con-tained research designstudies reviewed con-tained research design
flaws that may have affected the findings.flaws that may have affected the findings.
 The second objection concerns the expertise ofThe second objection concerns the expertise of
the judges/clinicians in these studies.the judges/clinicians in these studies.

21.  A third objection is that the predictive tasksA third objection is that the predictive tasks
were not representative of predictionwere not representative of prediction
situations facing clinicians (that is, notsituations facing clinicians (that is, not
ecologically valid).ecologically valid).
 Dawes (1994) goes on to suggest that muchDawes (1994) goes on to suggest that much
of the negative reaction to the findings is aof the negative reaction to the findings is a
function of our human need to believe in afunction of our human need to believe in a
high degree of predictability in the world.high degree of predictability in the world.
 This appears to be both a cognitive and anThis appears to be both a cognitive and an
emotional needemotional need

22. BIAS IN CLINICALBIAS IN CLINICAL
JUDGMENTJUDGMENT

23. Bias exists when accuracy of clinical judgment orBias exists when accuracy of clinical judgment or
prediction varies as a function of some client or patientprediction varies as a function of some client or patient
characteris-tic, not simply when judgments differcharacteris-tic, not simply when judgments differ
according to client characteristics.according to client characteristics.
 A higher percentage of women than men are judged toA higher percentage of women than men are judged to
suffer from major depression would not indicate a biassuffer from major depression would not indicate a bias
against women. However, finding that a higheragainst women. However, finding that a higher
percentage of women than men are given thispercentage of women than men are given this
diagnosis when the same symptoms are presenteddiagnosis when the same symptoms are presented
would indicate bias.would indicate bias.
 GarbGarb (1997) recently reviewed the empirical evidence(1997) recently reviewed the empirical evidence
for race bias, social class bias, and gender bias infor race bias, social class bias, and gender bias in
clinical judgment.clinical judgment.
 Interestingly, he found that many conventionally heldInterestingly, he found that many conventionally held
beliefs about these types of bias were not supported.beliefs about these types of bias were not supported.

24.  For example, there was little support for theFor example, there was little support for the
beliefs that :beliefs that :
 lower-socioeconomic-class patients are judgedlower-socioeconomic-class patients are judged
to be more seriously disturbed.to be more seriously disturbed.
 Women patients are judged to be moreWomen patients are judged to be more
disturbed.disturbed.
 Black and Hispanic patients who haveBlack and Hispanic patients who have
psychotic mood disor-ders are more likely to bepsychotic mood disor-ders are more likely to be
misdiagnosed.misdiagnosed.
 Middle-class patients are more likely to beMiddle-class patients are more likely to be
referred for psychotherapy.referred for psychotherapy.
 Black patients are more likely to be prescribedBlack patients are more likely to be prescribed
anti-psychotic medicationsanti-psychotic medications

25.  Garb (1997) made the followingGarb (1997) made the following
recommendations to help clinicians overcomerecommendations to help clinicians overcome
these and other biasthese and other bias
 (1) Be aware of and sensitive to the biases that(1) Be aware of and sensitive to the biases that
have been documented in the literature.have been documented in the literature.
 (2) Attend to the diagnostic criteria in diagnostic(2) Attend to the diagnostic criteria in diagnostic
manuals.manuals.
 (3) Whenever possible, use statistical(3) Whenever possible, use statistical
prediction rules instead of clinical judgment orprediction rules instead of clinical judgment or
predictionprediction

26. EXPERIENCE AND TRAININGEXPERIENCE AND TRAINING
 Empirical evidence does not support theEmpirical evidence does not support the
position that increased clinical experienceposition that increased clinical experience
results in increased accuracy in prediction.results in increased accuracy in prediction.
 Why is it that we do not see evidence for theWhy is it that we do not see evidence for the
effect of clinical experience in clinicaleffect of clinical experience in clinical
psychology and other mental health fields?psychology and other mental health fields?
There are several possibilities (Dawes, 1994).There are several possibilities (Dawes, 1994).
 First,First, the accuracy of predictions is limited bythe accuracy of predictions is limited by
the available measures and methods that arethe available measures and methods that are
used as aids in the prediction process.used as aids in the prediction process.

27.  Second,Second, we often cannot define precisely what we arewe often cannot define precisely what we are
trying to predict.trying to predict.
 Third,Third, we tend to remember our accurate predictionswe tend to remember our accurate predictions
and to forget our inaccurate ones.and to forget our inaccurate ones.
 There is not much evidence to suggest that oneThere is not much evidence to suggest that one
profession is superior to another in making accurateprofession is superior to another in making accurate
diagnostic judgments.diagnostic judgments.
 The important thing is to ensure that clinicalThe important thing is to ensure that clinical
psychologists are as well prepared as' they can be, aspsychologists are as well prepared as' they can be, as
well as to train clinical psychologists to use the-bestwell as to train clinical psychologists to use the-best
available measures and techniques for a givenavailable measures and techniques for a given
prediction situation.prediction situation.

28. The clinical approach is especially valuableThe clinical approach is especially valuable
when:when:
 Information isInformation is neededneeded about areas or events.about areas or events.
 Rare,Rare, unusualunusual eventsevents of a highlyof a highly
individualized nature are to be predicted' orindividualized nature are to be predicted' or
judged.judged.
 TheThe clinicalclinical judgmentsjudgments involveinvolve instancesinstances forfor
whichwhich no statistical equationsno statistical equations have been devel­have been devel­
oped.oped.
 The role of unforeseenThe role of unforeseen circumstances couldcircumstances could
nenegategate the efficiency of a formula.the efficiency of a formula.

29. The statistical approach is especiallyThe statistical approach is especially
valuable when:valuable when:
 The outcome to be predictedThe outcome to be predicted is objectiveis objective
and speand specific.cific.
 The outcomes for largeThe outcomes for large, heterogeneous, heterogeneous
samples are involved, and interest in thesamples are involved, and interest in the
individual case is minimal.individual case is minimal.
 There is reason to be particularlyThere is reason to be particularly
concerned about human judgmental errorconcerned about human judgmental error
or bias.or bias.