1. Issues in Assessment III PSYC 4500: Introduction to Clinical Psychology Brett 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& 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/ 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 )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 )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 )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 Patient preferences and values Clinical expertise EBPP

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?