Week 2 - Decision making in the Assessment process

W: Chapter 2 - Judging and Deciding

What does the basic outline of the assessment process look like?

• Clinician gathers information using the Empirical cycle.

• Clinician integrates this information into a diagnostic conclusion and discussion with the client.

What is a common risk during the assessment process?

Selecting assessment instruments just because they are available.

More information is always better.

• True or False?

False; more (irrelevant) information can distract you from the main question.

• First figure out what you want to learn, then pick a reliable tool that can give you the answer.

Clinicians should be careful in the selection of assessment instruments by…

• Considering their psychometric quality.

• Considering whether they can yield an answer to the question.

What is a question that tends to be skipped in the assessment process?

Whether the client’s complaints indeed point to a mental disorder, since behavior that may look typical for one kind of disorder, could also be a normal reaction to something else.

Deciding about a treatment — Whether it is necessary. What are the 2 options?

1. Refraining from treatment

   • Psychotherapeutic treatments can have adverse consequences and pharmacological treatments (e.g. wrong medication) can be harmful.

2. Treatment is necessary

   • Decide which treatment to use.

   • Use treatments with the most empirical evidence, provided the client agrees.

What are external influences that play a role in clinicians’ judgement about the client’s complaints?

Clinicians decide where the problems originated and how they should proceed.

• External influences: who the clinician is, what kind of person the client is, and the context of the problem.

Personal characteristics of the clinician (e.g. personal opinions, interpretations) can affect diagnostic judgements.

• What is the Sick-sick fallacy?

The tendency of clinicians to see things that they cannot personally relate to as disturbed.

• Ex. I brush my teeth after every meal, while the client does it only in the evenings → there is something very wrong with him.

Personal characteristics of the clinician (e.g. personal opinions, interpretations) can affect diagnostic judgements.

• What is the Me-too fallacy?

The tendency to see things that others do the same way as normal.

• Symptoms and complaints that are better understood by clincians are also assessed as more normal by them.

  • Ex. The client and I both go to sleep at 3AM, so this behavior is absolutely normal.

What are examples of client characteristics that are not related to the client’s complaints that can also influence the diagnostic judgement?

• Skin color

• Gender

• Social class

• etc.

Particularly the assessment of personality disorders is affected by gender and race.

What happens when a clinician works with a particular target group?

They are better able to recognize similar problems earlier, but on the other hand, may also be more inclined to opt for that diagnosis.

• Can be seen as context-related tendency to over-pathologize.

What does context-related tendency to over-pathologize lead to?

• False-positives = wrongly-assigned diagnoses.

  • False-negatives = missed diagnoses.

Intuition

Automated (experiential) knowledge.

• It is as good as the knowledge on which it is based.

Heuristics

Experience-based rules of thumb, or shortcuts in thinking.

What is the difference between using heuristics and using intuition?

When using heuristics, we leave parts of the information out of consideration; with intuition, we use all information but in a ‘canned’ form.

Another difference is that when using heuristics, we do not use all the information, whereas intuition is based on previously acquired information and observed associations that are combined by experience into one immediate response.

What is 1 advantage and 2 disadvantages of using heuristic and intuitive decision strategies?

• Advantage: Using these strats. is efficient since it is often not possible to do a complete analysis of a diagnostic situation in clinical practice.

• Disadvantage: It is risky because important information can be ommitted, the knowledge underlying intuition can be wrong, and thinking may more in the wrong direction.

Heuristics and intuition belong to which system?

Efficient System 1 reasoning.

• When using heuristics, people stop searching for more information once they are satisfied with the current outcome.

What biases can come up when using the System 1 reasoning?

Pre-judgements: judgements made before all relevant information is known.

Representativeness heuristic

• What bias comes out of this?

Making a judgement based on how representative or comparable a case is with a category of cases.

• May result in confirmation bias, meaning that we easily find confirmation for our own judgement.

Dual process theories of reasoning

State that a judgement or a decision can be made relying on one of two different systems that operate in parallel.

• System 1 is activated first = the Associative or reflective system.

  • These processes are mostly unconscious and use pattern recognition.

• System 2 is activated in the second instance if system 1 was not adequate enough = the Analytical or reflective system.

  • Leads to more accuracy but is slow.

  • It relies on our working memory, works serially and can only handle one problem at a time because of this.

Attribute substitution

When using heuristics in judging and decision making, a problem can be replaced with a similar problem that is easier to solve.

• You replace the ‘probability’ attribute with an ‘imaginability’ attribute.

  • You replace a difficult question with an easier question.

Downside of using heuristics

It can lead to biases.

Bias

Occurs when something is judged before the relevant information is processed.

• There is no awareness of these errors or biases when heuristics are applied automatically and unconsciously.

Clinical intuition

Is the result of long-term, dedicated, explicit learning that leads to domain-specified intuitions.

What are the 2 types of heuristics in clinical practice?

1. Memory heuristics

2. Attention-based heuristics

   • Representative heuristics

   • Use of prototypes

3 types of Memory heuristics

• Availability heuristic

• Anchoring and adjustment

• Positive test strategy

Availability heuristic

Judgements are based on how easily information is available to you. The easier the information is available in memory, the more conveniently you remember it.

• Clinicians recall examples of disorders they are familiar with much more easily than disorders they have not seen so often.

  • The recency effect plays a role in this.

What does using the availability heuristic lead to?

• Overestimation of the probability of a diagnosis in cases of high familiarity.

• Underestimation in the case of low familiarity.

With the availability heuristic, When it is about the future, counterfactual, or hypothetical events or questions, answers cannot be retrieved from memory.

• What do clinicians then use?

The event is mentally stimulated (stimulation heuristic). The easier the event is to simulate, the higher the estimation of the probability of that event.

Anchoring and adjustment heuristic

A random starting value, the anchor, has a disproportionally great influence on the final judgment.

• Also happens among clinicians. In those cases, the anchor may be a previous judgment by a colleague or a referral letter of the general practitioner, and the final judgment stays close to this anchor.

When does the anchoring effect mainly occur?

It mainly occurs in the assessment phase when important information needs to be combined.

• Additionally, clinicians will assess a client as psychologically healthier when they are used to working with clients who have more serious symptoms.

According to Popper’s philosophy of science, a good theory…

Should be falsifiable.

• The more something does not appear to be wrong, the more likely that it is right.

Disconfirming strategy

The process of actively searching for falsifying information.

• However, people often do the opposite and use a positive test strategy.

Confirmation bias and/or ‘self-fulfilling prophecy’

Refers to one finding what they expect to find.

Overconfidence

Is too risky as people tend to think that they are right more frequently than they actually are.

Positive test strategy examples

4 Attention heuristics

• Representativeness

• Prototypes

• Affect heuristic

• Recognition heuristic

Representative heuristic

Means replacing a difficult question with an easier one. Using this strategy, clinicians can give a quick answer through pattern recognition.

• Because relatively few examples are needed to recognize a pattern, a diagnosis can be given quickly.

• This diagnosis can be correct if the complaints are representative of the disorder, but it can also be wrong and contain invalid information.

  • BUT: The valid and relevant information, like prevalence, is often insufficiently included in the judgment.

    • If complaints seem representative of a rare disease, it should be judged as unlikely, yet often it is not.

Illusory correlations

Correlations that have not been proven but are easily imaginable.

Prototypes

Characteristics examples of typical representations of a disorder.

What is risky regarding clinicians using prototypes?

Every clinician sees different clients and therefore develops different prototypes.

What is a “solution” regarding prototype use?

Using dimensions instead of categories to classify disorders; this acknowledges that different disorders cannot be clearly distinguished from each other.

Trait-specified personality disorder (PD-TS or TGPS)

Using domains/dimensions for the classification of personality disorders.

Affect heuristic

When a judgment is formed based on the feelings evoked by a situation or person, rather than the content.

• This response is given quickly and automatically.

Which heuristic has characteristics of both memory and attention heuristic types?

Affect heuristic

What is 1 advantage and 1 disadvantage of Affect heuristic?

• Advantage: efficiency

• Disadvantage: biased view

  • A negative mood causes information to be more likely to be interpreted negatively.

Difference in clinicians with positive mood vs. negative mood

• Positive mood = More likely to use intuition.

• Negative mood = More likely to use logical reasoning.

Recognition heuristic

Making a choice is related to memory: what is recognized first is chosen.

• ex. Clinicians choose a diagnosis or treatment that they know.

One-reason decisions

Only one cue is used.

• f.e. Clinicians only check one typical symptom before deciding on a diagnosis.

Canned knowledge

The knowledge acquired after experience in clinical practice.

• Automatic responses to a clinical situation (‘clinical intuition’) are based on this knowledge.

Examples heuristics

Which system is used in teams?

System 2 thinking: the team spends time on weighing alternatives, arguing openly, and challenging what appears to be self-evident.

Tolerance of feeble inferences

(e.g. irrelevancies). Means that any inference (derivation, interpretations) is permissible, which is not good.

• Everyone’s input should be of equal value.

Groupthink

Occurs when individuals no longer speak up or are heard individually, but the group seems to think as one person.

• BAD, good ideas are lost in the uniformity of a group.

  • Can be avoided by staying ‘vigilant’.

Delphi technique

It consists of successive rounds of giving anonymous opinions and anonymous group discussions until everyone agrees.

• Disadvantage: duration.

Causal modelling principle of John Morton

Distinguishes between biology, cognition-emotion, and behavior.

Expert intuition

Quickly observing and having holistic understanding of the situation without realizing how that happens.

According to normative decision science, what are the 4 steps needed to optimize the result of a decision?

1. Collecting all possible information.

2. Weighing.

3. Combining it correctly.

4. Drawing a logically correct conclusion.

Syllogistic reasoning

In psychological assessment, Reasoning in which a conclusion is made on the basis of (usually two) premises/assumed statements.

• Ex. All children with ADHD are restless, James is not restless, therefore James does not have ADHD.