Introduction to Clinical Psychology Clinical Judgment

Process and Accuracy Clinical interpretation or clinical judgment is a complex and inferential process. It involves the patient’s data –samples, observation, signs of some underlying state and correlates- , clinician’s responses, characteristics of clinicians-cognitive structures and theoretical orientations- and situational variables. According to Sundberg, Tyler & Taplin (1973) clinical interpretation may involve 3 different level: - Level I: clinicians know specific experiences and go directly to prediction. Primary purpose is screening. (E.G. SAT & GRE) -Level II: clinicians observe patient’s behaviors and conclude that observed behavior characterizes the patient (Descriptive generalization) Patient is restless =interview tension … or clinicians seek inner determinants or states of the patient (Hypothetical construct). -Level III: clinicians seek a broad understanding of the individual’s determinants in a situation. (e.g. blood responses lead to aggression which leads anticipating future impulsive outbursts or loss of control)

Theory and Interpretation There are 3 different Theoretical approaches in clinical interpretation: Behavioral approach seeks patient’s data based on personal observations, direct reports form the patient. The data used are samples. The interpretation tend to use level I and II. Psychometric approach uses objective test to predict specific criteria. The data used are correlates, standardized test, regression equation. It tend to employ level I and II of interpretation. Psychodynamic approach identifies with inner states or determinants. The data are view as signs (projective test, unstructured interview). The interpretation tends to be level III.

Quantitative versus Subjective approaches Quantitative or statistical approach emphasizes objectivity. It uses formulas and statistical models to make decisions. This approach quantified clinical interpretations but, it not involves clinical decision making at all. Subjective or clinical approach offers useful interpretations and predictions. It is intuitive and experiential. This approach emphasizes individual cases and requires that the clinician be sensitive to sources of information to make inductive and deductive generalizations and predict the outcomes.

The case for a statistical approach Quantitative approach is effective when the outcome or events are known and specific and the clinician are predicting large populations. Statistical techniques uses explicit meaning to predict. Often, clinician make interpretations that seem self-description but, in reality, describe everybody and are not very discriminative (Barnum effect). WHAT OTHER INDIVIDUALS DO THIS ON TV? Quantitative approach can eliminate unreliability in clinical judgment. Quantitative approach may be rejected by many clinician for psychological, ethical reasons and lack of profound indices.

The case for a clinical approach The clinical approach is effective when the sample is relative homogeneous. Certain data only can be discovered through clinical investigation because the data is gatherer. For example suicide. Understanding and describing phenomena are goals of science not only predicting.

Comparing clinical and Actuarial approach Meehl (1954) surveyed studies on clinical vs. statistical prediction and concluded that the predictions made statistically were approximately equal or superior to those made by clinician. Sawyer (1966) concluded that clinical method are useful in the data collection process and this data can be combined by the way of the statistical approach. There is not much evidence to suggest that clinical approach is superior to statistical approach and vice versa in making accurate diagnostic interpretations. Both approach complement each other.

Conclusion Statistical approach is valuable when the outcomes are objective and specific, when the outcomes are large and heterogeneous samples and when there is reason to concerned about bias. Clinical approach is valuable when there is not adequate test for specific areas or events, when the interest in individual case is high, when clinical judgment involves situations or unforeseen circumstances of which statistical test are not available.

Improving judgment and interpretation There are several factors that can reduce the efficacy and validity of clinical judgment. Information processing. The clinician must avoid the tendency to oversimplify and learn to tolerate the ambiguity and complexity. The reading-in syndrome. The clinicians tend to over interpret patient’s symptoms and make predictions that emphasize the negative symptoms. The clinicians should evaluate client’s strengths rather than the psychopathology.

Validation and records. The clinicians’ predictions should be compared with colleague, relatives who know the patient and can help to refine interpretations. Vague reports, concepts and criteria. Vague reports and concepts lead to wrong prediction and lack of validity. Gard (1998) recommends that clinicians use structured interview and rating scales, objective personality test, behavioral assessment methods to predict their clinical judgment.

The effects of predictions. The predictors influence on the behavioral situation. So they may become a error. Prediction to unknown situations. Clinical judgment turns out to be in error when the clinician does not know the situation and environment in which their patients are living or working. However, many times the clinicians must make predictions with vague information about the patient’s environment. Also patient’s behavior may change from one situation to another (personality features).

Fallacious prediction principles. Intuitive predictions can lead into error if clinician are ignoring the statistical prediction related with those predictions. The reliability and validity did not increase as a function of increasing the amounts of test data. A mistake is to believe that the validity of inferences is inevitably correlated with test battery. Influence of stereotyped beliefs. Clinician should avoid tendency to believe that certain diagnostic signs, demographic group may influence inevitably on clinical judgment.

“Why I do not attend case conference” Sick-sick fallacy. Tendency to perceive people unlike ourselves as being sick (maladjusted). Me-too fallacy. Denying the significance of an event in the patient's life because if has also happened to us. Uncle George’s pancakes fallacy. Things that we do could not be maladjusted behavior. Multiple Napoleons fallacy. A mistake is interpreted any patient’s belief as not pathological because although is not real for us, it is real for him/her. Understanding it make it normal fallacy. Understanding patient’s beliefs deprive them of their significance, context.

Communication: the clinical report The clinical report is a communication phase of the assessment process. The nature of referral, the audience to which the report is directed and theoretical persuasion are variables that may affect the clinical reports. Referral source is the major responsibility of the clinical report. It address the referral question-the question about the patient that induce the assessment-. The clinical reports may be sent to referring person and agencies.

Aids to communication The clinical report should be written in a style and language that can be understood by the person to which it is directed. The technical language is tolerated to a colleague. The distinctive characteristics are preferred over the general. This individualized report avoid the Barnum effect explained in previous section. The report should be include high level of detail, mix of abstract generalities, specific behavioral illustrations and some testing details. This avoid fallacies and wrong interpretations.