Clinical

Decision Making
in Mental Health
Practice

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 Clinical
Decision Making
in Mental Health
Practice
Edited by Jeffrey J. Magnavita

American Psychological Association

Washington, DC

Final_Magnavita Title.indd 2 5/18/15 5:02 PM

Copyright © 2016 by the American Psychological Association. All rights reserved. Except
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Library of Congress Cataloging-in-Publication Data

Clinical decision making in mental health practice / edited by Jeffrey J. Magnavita. —

First edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4338-2029-8 — ISBN 1-4338-2029-3
I. Magnavita, Jeffrey J., editor. II. American Psychological Association, issuing body.
[DNLM: 1. Mental Disorders—diagnosis. 2. Mental Disorders—therapy. 3. Decision
Making. 4. Evidence-Based Practice. 5. Psychotherapy—methods. WM 141]
RC454.4
616.89—dc23
2015004772

British Library Cataloguing-in-Publication Data

A CIP record is available from the British Library.

Printed in the United States of America

First Edition

http://dx.doi.org/10.1037/14711-000
 This book is dedicated to the memory of Vincent Stephens, MD,
a loyal friend, consummate psychiatrist, and passionate psychotherapist.
 CONTENTS

Contributors................................................................................................ ix
Foreword ..................................................................................................... xi
Gerald P. Koocher
Preface ....................................................................................................... xiii
Chapter 1. Overview and Challenges of Clinical Decision
Making in Mental Health Practice .................................. 3
Jeffrey J. Magnavita
Chapter 2. Clinical Expertise and Decision Making:
An Overview of Bias in Clinical Practice ...................... 23
Jeffrey J. Magnavita and Scott O. Lilienfeld
Chapter 3. A Dual Process Perspective on the Value of Theory
in Psychotherapeutic Decision Making ......................... 61
Jack C. Anchin and Jefferson A. Singer

vii
Chapter 4. Clinical Practice Guideline Development
and Decision Making ................................................... 105
Lynn F. Bufka and Erin F. Swedish
Chapter 5. Developing Clinical Practice Guidelines
to Enhance Clinical Decision Making ......................... 125
Steven D. Hollon
Chapter 6. Using Technology to Enhance Decision Making ........ 147
Franz Caspar, Thomas Berger, and Lukas Frei
Chapter 7. Clinical Decision Making When the
Stakes Are High ...................................................... 175
Jeffrey J. Magnavita
Chapter 8. Use of Empirically Grounded Relational Principles
to Enhance Clinical Decision Making ......................... 193
Ken L. Critchfield and Julia E. Mackaronis
Chapter 9. Integrating Ongoing Measurement Into
the Clinical Decision-Making Process
With Measurement Feedback Systems......................... 223
Thomas L. Sexton and Adam R. Fisher
Chapter 10. Clinical Decision Making and Risk Management ....... 245
Steven A. Sobelman and Jeffrey N. Younggren
Chapter 11. Teaching Clinical Decision Making ............................ 273
Gregg Henriques
Index ........................................................................................................ 309
About the Editor ...................................................................................... 321

viii CONTENTS
 CONTRIBUTORS

Jack C. Anchin, PhD, University at Buffalo, State University of New York

Thomas Berger, PhD, University of Bern, Bern, Switzerland
Lynn F. Bufka, PhD, American Psychological Association, Washington, DC
Franz Caspar, PhD, University of Bern, Bern, Switzerland
Ken L. Critchfield, PhD, James Madison University, Harrisonburg, VA
Adam R. Fisher, MA, Indiana University, Bloomington
Lukas Frei, MSc, University of Bern, Bern, Switzerland
Gregg Henriques, PhD, James Madison University, Harrisonburg, VA
Steven D. Hollon, PhD, Vanderbilt University, Nashville, TN
Gerald P. Koocher, PhD, ABPP, DePaul University, Chicago, IL
Scott O. Lilienfeld, PhD, Emory University, Atlanta, GA
Julia E. Mackaronis, PhD, VA Puget Sound Health Care System–Seattle
Division, Seattle, WA
Jeffrey J. Magnavita, PhD, ABPP, Glastonbury Psychological Associates,
Glastonbury, CT
Thomas L. Sexton, PhD, ABPP, Indiana University, Bloomington
Jefferson A. Singer, PhD, Connecticut College, New London
Steven A. Sobelman, PhD, Loyola University Maryland, Baltimore
Erin F. Swedish, MA, Toledo, OH
Jeffrey N. Younggren, PhD, ABPP, Professor, UCLA David Geffen School
of Medicine, Los Angeles, CA
ix
 FOREWORD
GERALD P. KOOCHER

One of my favorite quotations appears in a collection of proverbs

written by Goethe in 1819: “Es ist nichts schrecklicher als eine tätige
Unwissenheit.” This translates roughly as, “Nothing is more dangerous than
ignorance in action,” or more literally, “Nothing is more dangerous than
active un-knowing-ness.” Sadly, this maxim too often seems overlooked in
clinical decision making by psychotherapists. In many ways the complexity
of influences on human behavior makes this state of affairs understandable.
Our behavior flows from our biology and our life experiences in all the rich
combinations that genetics, environmental influences, relationships, and
the passage of time impose. Those who have sought to practice psycho-
therapy (i.e., to improve the behavior of people who become distressed or
distressing to others) have often evidenced struggles with the same complex
variability as they attempt to bring about “cures.”
Ask psychotherapists about the ethics underlying their work and they
tend to become philosophers. Writing on the ethics of their craft, psycho-
therapists have referred to the practice of therapy as a science, an art, a source
of honest and nonjudgmental feedback, the systematic use of a human rela-
tionship for therapeutic purposes, and a means of exploring one’s ultimate

xi
values. Less flattering descriptions from within the profession have included
a house of cards, the purchase of friendship, a means of social control, and
tradecraft.1 My personal favorite definition of psychotherapy came from the
secretary of the historic Boulder, Colorado, conference on the training of
psychologists, who satirically noted, “We have left therapy as an undefined
technique which is applied to unspecified problems with a nonpredictable
outcome. For this technique we recommend rigorous training.”2
In this context of complexity and radically different perspectives
Magnavita and his colleagues have compiled an impressive guide to making
sound clinical decisions in psychotherapy practice amid an array of potential
distractions. The readings guide us through decision-making biases, help us
base decisions on sound evidence, point us to existing guidelines, advise us on
the use of technology, help us to consider risk management, and advise us in
teaching. The result is a major resource to help us avoid the dangers of our own
biases and blind spots in a quest to avoid acting on Unwissenheit.

1Koocher, G. P., & Keith-Spiegel, P. (2008). Ethics in psychology and the mental health professions. New York,
NY: Oxford University Press.
2Lehner, G. F. J. (1952). Defining psychotherapy. American Psychologist, 7, 547.

xii FOREWORD
 PREFACE

Bias is inherent in just about every part of our lives and is often an
unacknowledged but influential part of clinical practice. Understanding our
propensity for bias will go a long way toward enhancing our clinical decision-
making. Try this story, for example:
A father and his son are in a car accident. The father is killed and the son
is seriously injured. The son is taken to the hospital, where the surgeon
assesses the situation and declares, “I cannot operate because this boy is
my son.” Why is that so?1
The answer to this brainteaser, which as many as 75% of those who hear it
cannot solve, is that the boy’s mother is the surgeon. Gender bias is deeply
ingrained.
This volume represents a new and exciting area for me after more than
3 decades of clinical practice and clinical research spent viewing videotapes
of psychotherapy sessions ultimately trying to decide on the optimal course
of action. My efforts, which I have compiled and published in a series of

1Grant, A., & Sandberg, S. (2014, December 6). When talking about bias. New York Times, p. 46.

xiii
volumes and articles, involve working to distill the essential elements of
psychotherapy. The latest of my books is Unifying Psychotherapy: Principles,
Methods, and Evidence From Clinical Science,2 written with my collaborator
and friend Jack C. Anchin, who shares a passion for clinical work and the
scholarly and scientific search for the unifying principles and components of
clinical science and psychotherapy. My current work represents a departure
from my early interests in the treatment of personality disorders, integrative
and unified models of psychotherapy, and personality theory.
It was Eileen Bonetti’s infectious belief in and knowledge of decision
analytics that brought my awareness to this topic and sparked my curiosity and
interest in decision making. Clinicians, as well as all health professionals, are
involved in a continual process of decision making, basing critical decisions
on various streams of information, from the microprocesses in interpersonal
relationships to the results of meta-analytic studies on the efficacy of various
treatment approaches. It became apparent after an extensive review of the
decision-making literature that clinical practitioners can benefit from this
important body of work; the result is this volume.
I was also inspired to explore this exciting field following my experience
serving on the Clinical Practice Guideline Advisory Steering Committee
that the American Psychological Association initiated to begin the impor-
tant process of developing clinical practice guidelines. What became appar-
ent to me is that many components of clinical practice are not supported by
empirical evidence with which to guide decision making. One example is
how we determine the length or frequency of sessions. We continue to use the
50-minute session as the standard unit for delivering psychotherapy, yet I am
aware of no empirical evidence that examines the influence of various session
lengths and formats on outcome. How, then, do you make decisions such as
that one when there is no empirical evidence on which to draw? Mostly we
rely on clinical lore, assuming that Freud had it right when he framed psycho-
therapy in sessions of 50-minute duration. I think we can improve how we
respond clinically by examining our biases.
This volume would not have happened without the support and col-
laboration of many people. I have been actively engaged with a number
of friends, scholars, and clinicians over the years who have influenced and
sharpened my thinking and improved my own decision-making processes. I
want to especially thank Jack C. Anchin and Steven A. Sobelman for their
friendship and collaboration over the years. We have taken on a number
of exciting projects and spent many hours trying to figure out how to make

2Magnavita, J. J., & Anchin, J. C. (2013). Unifying psychotherapy: Principles, methods, and evidence from

clinical science. New York, NY: Springer.

xiv PREFACE
clinical science and psychotherapy more effective. Steve has taught so
many of us about the value of technology bringing us digital immigrants to
the 21st century. Together we founded the Unified Psychotherapy Project.
I also thank William C. Alder, Frank Knoblauch, John Santopietro, Peter
Tolisano, and Anne Shapiro, all part of my core professional support and
friendship group over the decades. I remember Vincent Stephens, an impor-
tant member of our core group, whose loss we deeply mourn. I also express
my appreciation for the collaboration and friendship over the years to
Gregg Henriques, Kenneth L. Critchfield, Jay L. Lebow, Andre Marquis,
Jeffrey E. Barnett, Rosie Adam-Terem, Craig N. Shealy, David M. Allen,
Michael Alpert, Kristin A. R. Osborn, Lori Calabrese, and many others who
have influenced my work and collaborated with me in patient care. I acknowl-
edge the many people I have had the privilege of working with on the road
to achieving more abundance in their lives who have trusted me with their
concerns. Finally, I thank my partner, Anne G. Magnavita, and my daughters
Elizabeth, Emily, and Caroline for more than they will ever know.

PREFACE xv
 Clinical
Decision Making
in Mental Health
Practice

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 1
OVERVIEW AND CHALLENGES
OF CLINICAL DECISION MAKING
IN MENTAL HEALTH PRACTICE
JEFFREY J. MAGNAVITA

You have made a decision to begin reading this volume, Clinical Decision
Making in Mental Health Practice, on the basis of certain information that
influenced your decision to pick up this copy, open it, and begin reading at
this moment. Other decision-making processes will determine whether you
become engaged in the topic and continue reading the book or lose interest
and decide to redirect your valuable resources elsewhere. You will not be dis-
appointed if you continue with the book; the contributors herein are well
informed and offer useful information and wisdom as well as new ways of
thinking to improve your decision making from various perspectives.
Perhaps, in the back of your mind, you have been preoccupied and per-
plexed by a complicated individual, couple, or family you are treating, and
this may have unconsciously attracted you to the title of this volume. Maybe
your challenging case didn’t fit your personal internal heuristics, or “rules of
thumb”—mental shortcuts on which we often base our decisions that are
sometimes reliable but, unchecked, are prone to errors of thinking. Clinicians

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Clinical Decision Making in Mental Health Practice, J. J. Magnavita (Editor)
Copyright © 2016 by the American Psychological Association. All rights reserved.

3
probably utilize hundreds or more of these heuristics in daily practice. For
example, one that comes to mind is how I view poor eye contact as a marker
of anxiety about emotional closeness and intimacy. In spite of the fact that
you may be highly trained in a particular model of treatment or well versed
in a number of evidence-based approaches and deem yourself a well-trained
and competent or even “expert” clinician, you may be uncertain about how
to proceed with treatment in certain situations. Developing expertise is not a
straightforward proposition of attaining the appropriate education, training,
and practice—more is required of us. We have a duty to those we treat for
continuous improvement. Some of your cases may not be progressing in the
manner you anticipated or expected, possibly creating a crisis of confidence.
For example, a patient may have dropped out of treatment and harmed himself
or someone else, showing deterioration in functioning instead of improving.
None of us likes to face these disappointing outcomes. Often treatment doesn’t
unfold as depicted in the textbooks or manualized versions of treatment so
ubiquitous these days. Treatment is often in the moment, and our responses
require trust in our intuition. With certain cases, you may be perplexed, con-
fused about how to proceed, and worried about how to make appropriate deci-
sions when there are few empirical data to guide you. You may find yourself
trying harder with a favored approach because you have already invested a
lot of time and energy in pursuing a particular course of action. I found this
to be a common response while in training in brief dynamic therapy and
afterward as a supervisor. I noticed that it was not uncommon for trainees to
increase their effort with a particular method, such as defensive restructuring,
when they were not getting the desired results. Instead of trying a different
method, they might resort to what is best described as “hammering”—
looking for the results viewed in the master therapist’s videos by doing more
of the same approach. An increase in the frequency and intensity of a method
all too often would lead to iatrogenic reactions and premature termination.
In one of my cases, a patient walked out of the session, and there were others
who never returned.
Although one psychotherapeutic strategy may work wonderfully with
many patients, with others, increasing our efforts and investment in a tried-
and-true strategy may prove ineffective or worse. In such a situation, trainees
may fall prey to the sunk-cost effect, which occurs when one continues to
invest in something in which he or she has already made an investment of
time and energy (Kahneman, 2011). In economics and business, we can see
that people often invest more money in a failing venture in an attempt to
recoup their losses. This may also be true for some addictive behaviors. Those
readers who treat gamblers know this narrative all too well. You have heard
people say that after they lost all of their money they used their credit card to
try to get back what they lost—this is the sunk-cost effect in operation. We

4 JEFFREY J. MAGNAVITA
may also witness the sunk-cost fallacy (Kahneman, 2011) in the treatment
context. This is a type of bias that can occur after we invest our resources in
pursuing a particular approach to treatment and then find ourselves trying to
apply this approach to all our patients instead of using tools of differential
treatment selection and finding the approach that best fits the patient and
his or her situation. This may be when it is warranted to seek a consultation
or to get a trusted colleague’s perspective.
We are also prone to want to present our best selves to the public. This
is evident when you attend treatment conferences where cases are presented.
Almost everyone presenting audiovisual tapes of their therapy sessions at
these conferences shows their best work. We select videotapes of patients
demonstrating great process and outcome. This selection bias may have
serious consequences for trainees, as it surely did when I was in training. This
often leads to what decision researchers term confirmation bias—we honor
data that support our approach and dismiss that which calls what we do into
question (Kahneman, 2011). Viewing positive treatment outcomes proves
the veracity of the approach being demonstrated, and ignoring treatment fail-
ures intensifies this effect. How would the field evolve if instead we presented
our worst outcomes or compared our best with our worst outcomes at these
conferences? Would the learning process progress more rapidly by a study of
errors and mistakes instead of only ideal treatments?
You may have made assumptions about patients in your clinical prac-
tice on the basis of diagnostic labels accrued from previous therapists,
resulting in an anchoring bias—placing too much weight on one aspect or
trait, which reduces the utility of predicting (Tversky & Kahneman, 1974).
What biases do you notice when a referring clinician describes a patient
as “psychopathic,” “borderline,” “narcissistic,” or “a pedophile”? Which
one of these labels has greater emotional activation? I think I can predict
which one does. Emotional responses can bias our judgment, compromising
our decision making. Diagnostic labels serve as anchors that may color our
thinking and influence our decision making on the basis of very limited infor-
mation, thereby leading to reliance on a representative heuristic (Kahneman,
2011), whereby we prematurely arrive at conclusions without sufficient data,
using too few data points. We may hastily assume that a very slender indi-
vidual suffers from an eating disorder. The sheer complexity or uniqueness
of some of our cases may leave us uncertain of both diagnosis and treatment
approach.
Without an understanding of decision theory we are more likely to fall
prey to various traps in our thinking or to biases of which we are unaware
but that nevertheless influence us. Decision theory allows us to be aware of
the underlying processes from which we derive our decisions. The quality of
evidence from which we make decisions is essential, and efforts to remain

OVERVIEW AND CHALLENGES 5

doubtful and question our thinking are imperative. We should strive to falsify
our hypotheses instead of proving them correct. Kahneman (2011) implored
us in this regard to not “expect this exercise of discipline to be easy—it requires
a significant effort of self-monitoring and self-control” (p. 153). Reading the
remainder of this volume will enhance your awareness of potential errors in
decision making as well as various perspectives to consider when making dif-
ficult clinical decisions.
Wouldn’t it be nice if our patients fit the prototypes we learned in
school? Clinical practice is messy and at times chaotic. Patients are not
exactly like the prototypes described in our textbooks, and treatment manuals,
although helpful, necessarily attempt to simplify and organize information
into useful knowledge. Our patients are more likely to present us with com-
plicated physical and emotional symptoms, relational disturbances, and chal-
lenges in their current lives, along with histories of abuse and neglect as well
as other developmental challenges. Heuristics and cognitive templates are
essential. We navigate the world using pattern recognition tools based on
schema and theory, but we must be cognizant that these can be error prone.
These sources are often useful starting points, but clinical expertise is more
than just textbook knowledge; it includes the ability to use the best infor-
mation available in an unbiased manner and convert this information into
knowledge. Transforming data and information into knowledge and wisdom
usually requires extensive practice with relevant feedback to adjust our prac-
tice. Understanding the differences among data, information, knowledge,
and wisdom is helpful when one is besieged with multiple sources of informa-
tion (Mayer-Schonberger & Cukier, 2013). These categories are explored in
Chapter 2 in this volume.
We may at times rely on our intuitive or rapid decision-making strate-
gies, and at other times we may seek a more deliberative approach, gath-
ering as much data as possible first (Kahneman, 2011). You may already
view yourself as an “expert” clinician and not feel the need to learn more
about decision making, and if this is the case, you may have fallen prey to a
common prejudice, overconfidence bias, which is the tendency to overestimate
one’s ability. Most clinicians view themselves as at least average or better in
their psychotherapeutic ability even while being aware that it is statistically
impossible for almost everyone to be average or above (Walfish, McAlister,
O’Donnell, & Lambert, 2012). Even when psychotherapists receive feedback
about patients’ conditions worsening, many continue to assess themselves as
effective and discount the feedback as inaccurate or inconsequential. The
practice of discounting information that does not match our internal self- or
worldview can be dangerous. Why are we so prone to this type of bias to the
point of ignoring patients who are deteriorating as a result of our treatment,
making it difficult in some cases to prevent negative outcomes (Lambert,

6 JEFFREY J. MAGNAVITA
2010)? These questions and many others can be understood through the lens
of decision analytics that are based on advances in decision theory and through
empirical investigation of various ways that we make decisions and the traps
we can fall into.
A certain amount of energy will be required to master the material in
this volume. Some readers may consider the deliberative system of think-
ing “lazy” and would rather defer to their intuitive “fast” response system
(Kahneman, 2011), which will have already biased readers with informa-
tion regarding the stickiness of the title, status of the publisher, the names
of the editor and contributors, endorsements, or even the attractiveness of
the cover. Your personal biases will influence how effortfully you engage with
and learn the material presented in this volume. Your hidden biases may
also determine whether as a result of reading this book your clinical decision
making is enhanced and clinical efficacy improved. You have made a decision
to continue reading this volume, and as the volume editor, this pleases me
because there is so much information in the remaining chapters that you will
find useful and practical. Your decision to invest resources in this volume was
made using two very different but interrelated styles of thinking—one fast
(you may have impulsively picked the book off a shelf in a bookstore respond-
ing to some intuitive sense that it might be worthwhile) and the other slow
(you may have carefully read an advertisement and deliberately called on an
internal book-buying algorithm). You probably are unaware, or only vaguely
aware, of what influenced your decision to allocate your precious resources of
money and time that could be spent in other activities. Take a few minutes
to consider what factors influenced you, but try to remember that I already
made some suggestions that may have created a recency effect. Just as you
made this decision for reasons of your own, I decided that the topic of deci-
sion making and its application to mental and behavioral health was worth
the allocation of my resources. I am confident that it has been, although I
admit I may have succumbed to attributional bias—justifying to myself that
this is an important topic that is worth my effort (Heider, 1958). Maybe you
received a brochure online or in the mail, read a book review that piqued
your interest, were exploring a related topic and found this book, or were
attracted to the cover at the annual convention or on the shelf in a book-
store. At some level of awareness you weighed the cost–benefit outcome of
investing your resources, made a decision, and followed a course of action
about which I am pleased. All of these responses, and many more, are
heavily influenced by hidden biases associated with two main systems for
decision making, one tending to be more cognitive and the other more
emotionally derived. These systems exert a powerful influence on just about
every aspect of clinical decision-making practice and research and more
broadly on every decision you make.

OVERVIEW AND CHALLENGES 7

 THE MOST ADVANCED OF THE DECISION MAKERS

Humans are the most evolved, advanced decision-making species, and

yet we are extraordinarily prone to biases and cognitive errors that result in
less-than-optimal outcome. We all exercise decision-making processes from
birth. Early on we orient to our mother’s voice and smiling face. Our brains
evolve to adapt to the decision demands of our environment and the rela-
tional matrix. Connections in our neural circuits are pruned so that those
not necessary are eliminated, and resources can strengthen connections that
will enhance our adaptation and capacity for decision making. We need to
be able to make decisions rapidly to ensure our survival. Our limbic system,
evolved to respond to danger, can easily go haywire, responding when there
is no imminent threat, the result of unprocessed trauma (van der Kolk, 2014).
No one has to tell us to escape a house on fire or avoid dangerous activities—
we are unconsciously wired for rapid detection of and response to danger
(Bargh, 2013). This is the neural foundation for rapid decision making and
for our survival. These primal defensive structures are part of our reptilian and
early mammillary brain development. Threat detection offers quick template
matching and attention to environmental cues that are novel and unfamiliar
and therefore potentially threatening. Trauma results when our limbic sys-
tems cannot process information because it has been overwhelmed and
fragmented, and thus our decision making falters. We often perceive danger
where none exists and live in state of hyperarousal, good for responding to
threat but not so good for most decisions. This type of rapid decision making,
when it does not go awry, is well suited for many situations, and when it
is activated in the right circumstances is something to behold. Remember
Chessey Sullenberger, the pilot who landed US Airways Flight 1549 in the
Hudson River when both engines were put out of commission after the plane
collided with geese? This is a truly remarkable example of someone operat-
ing with this type of intuitive, rapid response system based on many years of
training and experience. He didn’t have time to refer to a flight manual, nor
would there be one that could tell him what he should do—he just did it.
But intuition can also be dead wrong in many cases. The bleeding of patients
with cholera seemed intuitive to 18th-century physicians—even though
what they really needed in order to survive was hydration.
We have also developed an advanced deliberative and demanding style
of decision making with the evolution of higher cortical structures. As we
discussed, the process of your decision making about investing in this book
began before you picked it up and opened it or read the dust jacket or viewed
it online.
The goal of this volume is to provide you with a foundation in decision-
making theory and offer you some critical tools to enhance the efficacy of

8 JEFFREY J. MAGNAVITA
clinical decision making, especially in situations of uncertainty, which are so
common in clinical practice where our ability to predict is often so limited.
This volume will introduce you to the rapidly advancing science of decision
analytics and review the decision biases that affect us all. More important,
this volume will explore the application of decision theory through a number
of interrelated topics relevant to clinical practice, research, training, and
behavioral health care administration. Decision theory is influencing just
about every scientific discipline, including mathematics, sociology, behav-
ioral economics, computer science, and many others, and yet even though
psychologists have conducted most of the essential research, many psycho-
logists are not familiar with this topic. Because mental health professionals
have been slow to absorb these groundbreaking new interdisciplinary devel-
opments, it is my hope that reading this book will be a step in remedying
this lack of knowledge by exposing you to the advantages of using deci-
sion theory as a framework for clinical practice. I hope that you will con-
tinue to read and absorb the concepts in this volume and that that this
knowledge will provide you with a foundation in decision analytics. This
deeper appreciation for the value of decision theory and related topics will
help you achieve better therapeutic results by increasing your awareness
of the biases that detract from optimal decision making. This volume also
offers strategies and approaches that will mitigate these biases and thus
enhance your decision-making skills and optimize the outcomes of all your
decisions.

PILLARS OF EFFECTIVE DECISION MAKING

Five pillars of effective decision making are presented in this volume,

each offering important information and perspectives to optimize decision
making. These are (a) access to high-quality empirical evidence, (b) develop-
ing clinical expertise, (c) using sound theoretical constructs, (d) including
ethical considerations, and (e) foundation in decision theory.

Access to High-Quality Empirical Evidence

One pillar of effective decision making rests on a foundation of evidence

derived from science and clinical experience (Hollon et al., 2014). The best
available evidence optimizes decisions (Gawande, 2009; Lilienfeld, 2012).
Unfortunately, we do not usually have perfect information with which to
make clinical decisions. Psychology is still a relatively young scientific
discipline, and the complexity of the subject is enormous. It is only rela-
tively recently in scientific time, over the past 5 decades or so, that we

OVERVIEW AND CHALLENGES 9

have established that psychosocial treatments for a variety of behavioral
and mental disorders are effective. And even more recent is the begin-
nings of an evidence base showing the efficacy of a spectrum of approaches.
Even so, the adoption of evidence-based treatments has been slow. Rosen
et al. (2004) found that fewer than 10% of mental health providers at six
sites surveyed provided evidence-based treatment for posttraumatic stress
disorder.
The science to practice lag for [evidence-based practices] is, in fact,
longer (and in many cases, far longer) than the typical lengthy lag
time of 15 to 20 years identified for medical interventions by the Insti-
tute of Medicine (2001) in the seminal report Crossing the Quality
Chasm: A New Health System for the 21st Century. (Karlin & Cross,
2014, pp. 19–20)
Clinicians’ effectiveness at decision making ranges (as one would expect) on
a normal curve. Some clinicians are more expert in their decision making,
whereas others tend to regularly fall prey to common biases that reduce effec-
tiveness. Little is known about what constitutes expert clinical practice, but
one thing that is essential is the knowledge and ability to make decisions in
the face of uncertainty.

Developing Clinical Expertise

Another pillar of effective decision making is expertise, the definition

of which is not straightforward (Kahneman & Klein, 2009). It has been
described, for example, as “(a) reputation, (b) performance, or (c) client
outcomes” (Tracey, Wampold, Lichtenberg, & Goodyear, 2014, p. 219).
Behavioral and mental health professionals are consulted because of our
perceived expertise based on our specialized knowledge of human behavior
and methods of change. Expertise, however, goes beyond having informa-
tion about the domains that encompass a scientific–professional discipline
(Norcross, Hogan, & Koocher, 2008). Information by itself is available
to anyone who has access to the Internet, but clinical decision-making
skills are needed to distill and crystalize information into useful knowledge
(Ariely, 2008). Much more is required to hone these skills. Several factors
interfere with expertise, “including the cognitive and information processes
of therapists, therapist’ failure to engage routinely in deliberate practice,
the inaccuracy of therapists’ self-appraisals of their competence, and the
lack of accurate feedback that affects learning” (Tracey et al., 2014, p. 220).
The public is somewhat skeptical that the study of human behavior is
scientific (Lilienfeld, 2012). This skepticism should not be limited to the sci-
ence of psychology. A recent issue of The Economist titled “How Science Goes

10 JEFFREY J. MAGNAVITA
Wrong” (2013) challenged the assumption that science is self-correcting.
Daniel Kahneman was quoted in an open letter challenging the widely accepted
concept of priming (the notion that decisions we make are influenced by
irrelevant events presented right before a choice is made) in psychological
research as poorly founded, and many studies trying to replicate findings
that seemingly support priming have failed to show support. Jerome Kagan
(2012), in his book Psychology’s Ghosts: The Crisis in the Profession and the
Way Back, challenged many of the assumptions that serve as the basis for
contemporary psychology. The assumptions that we make and may hold dear
influence a cascade of treatment issues from diagnostic labels to the treat-
ments that follow. Kagan illustrated the assumptions, often unexamined and
based on limited evidence, that guide our conceptualizations and approach
to treatment. He held that a biological bias may prematurely lead clinicians
toward suggesting a pharmacological approach, on the basis of a belief that
genetic predispositions have led to certain symptom constellations. Kagan’s
view is that although psychopharmacological treatment for mental disorders
is fraught with biases, it continues to dominate the clinical landscape even
though most psychotropic medication “can be likened to a blow on the
head and resemble the cocktail of drugs used with many cancers that kill
both healthy and cancerous tissues” (p. 209). American Psychological
Association initiatives to develop clinical practice guidelines (Hollon
et al., 2014) based on the most robust accumulated evidence should assist
the public, behavioral and mental health consumers, policymakers, and
other scientific disciplines in being assured that psychology is indeed a sci-
ence and one that may be moving to a unifying framework (Magnavita &
Anchin, 2014).

Using Sound Theoretical Concepts

A theoretical framework provides a map with which to test reality and

therefore represents a fundamental pillar for decision making (Magnavita &
Anchin, 2014). Theories evolve over time as new advances are made and
the utility of the theory is time tested. Theoretical formulations are a type
of decision-analytic process that encourages testing hypotheses and gathering
data to test the validity of the construct. Theories address how the interrelated
component domains of the biopsychosocial model interact and shape human
behavior. Theories limited to one domain are prone to attributional biases and
theories, which are too general and are difficult to test. Theories of the mind,
personality, psychopathology, and behavior should be congruent and increas-
ingly based on findings from neuroscience as well as effectiveness in the con-
sulting room.

OVERVIEW AND CHALLENGES 11

Ethical Considerations

An ethical framework is another pillar of effective decision making.

An ethical examination of our actions and treatments can prevent us from
being subject to the various types of biases that are discussed in this volume.
An ethical framework serves as an important system of checks and balances
when making complicated clinical decisions, and a strong ethical foun-
dation for our decision making provides many safeguards to our patients
and ourselves. Understanding how easily we are influenced by our biases
can keep us from engaging in practices that are inert or, in the worst case,
destructive.

Knowledge of Clinical Decision Making

Who would not like to improve their clinical outcomes or assist stu-
dents and trainees in attaining the best results? The National Institute of
Mental Health (1999) identified the incorporation of patient and provider
decision making as an important research agenda for improving mental
health interventions. In an effort to improve quality of mental health
care, the Institute of Medicine (2001) suggested that the study of decision-
making theory (Roberto, 2009), concepts, and preferences is imperative.
Probably one reason you are reading this volume is that you want to maxi-
mize your clinical expertise or assist others in doing so by adding to your
knowledge base, thus increasing your effectiveness in your own and your
students’ treatment of behavioral and mental health disorders. Clinical
decision making is the foundation of behavioral and mental health prac-
tice, yet most clinicians receive very little formal training in this complex
activity. Clinical decision making requires a depth and range of knowledge
that requires years of education, training, and supervision, yet this critical
activity is not systematically taught. I hope this volume serves as an agent
of change by bringing decision making to the forefront of science, practice,
and education. Decision making has characteristics of both intuitive and
deliberative modes (Stanovich, 2010). Both are necessary, and neither can
operate without the other. The most profound responsibility a clinician
has is discerning which interventions are beneficial and which may prove
inert or even harmful for those who seek our assistance. A series of “correct”
decisions can have a potentially profound impact on improving the lives
of those in our care. A series of “incorrect” decisions can have dire results:
Patients may fail to improve or will deteriorate, and in extreme cases the
outcome may be death. The science and theory of clinical decision making
is the focus of this volume.

12 JEFFREY J. MAGNAVITA
 DECISION MAKING: THE KEY TO EVIDENCE-BASED PRACTICE

Providing a high-quality evidence-based practice informed by the best

information through the lens of clinical expertise requires a foundation in
how to make optimal decisions given the many choices available. Evidence-
based practice represents the new era of contemporary health care: combin-
ing the best available evidence with clinical expertise. “Evidence-based
practice in psychology (EBPP) is the integration of the best available
research with clinical expertise in the context of patient characteristics,
culture, and preferences” (APA Presidential Task Force, 2006, p. 273).
All clinicians would likely agree that practice should be based on the best
evidence. The evidence base for the treatment of behavioral and mental
health disorders is growing, but it remains inadequate in the face of the
extreme complexity and uncertainty in most domains of clinical science.
We need to find and utilize the best evidence available from divergent
credible sources and combine it with an appreciation of decision theory
and deliberative decision analytics. We all make decisions, and we usually
believe that what we decide is logical and that the consequences will be
beneficial for those who seek our services. But decision theory requires us to
constantly examine and challenge our beliefs and, more important, be alert
for the common decision traps humans are likely to fall into. Thus we often
find ourselves “down the rabbit hole” without understanding how we fell
into such a state of upside-down reality.

THE BIRTH OF DECISION THEORY

The formal study of decision theory was initially applied to economic

analysis. Frank Knight (1921/2006) distinguished between risk when the
probability of an outcome can be calculated and uncertainty when there is no
way to determine the probability of an outcome. Later, John von Neumann
and Oskar Morgenstern (1944) developed game theory, which deals with
how people make decisions using unknown variables. Daniel Kahneman and
Amos Tversky (see Kahneman, 2011), over many decades of collaboration,
researched and described many facets of decision theory.
Decision theory has evolved since the 1950s from the fields of psychol-
ogy and economics and has been applied in healthcare research since the
1960s. Theoretical perspectives in decision-making research encompass
a wide variety of prescriptive approaches; for example, judgment and
information processing analysis, decision analysis, and natural decision
making. (Wills & Holmes-Rovner, 2006, p. 9)

OVERVIEW AND CHALLENGES 13

The landmark work in this field that should be standard reading for all clini-
cians and social scientists is Thinking Fast and Slow by Kahneman (2011), who
was awarded a Nobel Prize for his contributions in economics.

ENCODING AND DECODING OUR ENVIRONMENT:

USING SCHEMATA AND PROTOTYPES
FOR DECISION MAKING

I have already discussed the evolutionary basis for and some of the neural
circuits involved in decision making. Our brains have evolved to perceive,
filter, organize, and respond to a potentially overwhelming amount of envi-
ronmental stimuli. Without strategies to organize this incoming information
and develop internal patterns or templates, we would be rendered helpless. We
encode information and store it for later use maintaining internal schemata,
which are prototypes we use to compare current situations with past situations
and look for a match. We learn by encoding and storing new information and
then decode what comes in by seeing how it matches our internal representa-
tion. Most decisions are made automatically without having to strain our men-
tal resources: This is the fast thinking mode. “The mental work that produces
impressions, intuitions, and many decisions goes on in silence in our mind”
(Kahneman, 2011, p. 4). This type of decision making represents what is often
experienced as intuitive and real but as prone to error. We activate the slow
thinking system to prevent the fast one from ruling our lives. We help patients
learn how and when to apply slow thinking with respect to their therapeutic
endeavors, regardless of the approach and what it is termed.

ASSESSING AND MANAGING RISK

Assessing risk in the face of uncertainty and even chaos by optimizing

our choices is fundamental to decision making. In many important areas we
are woefully inadequate at predicting human behavior. There is no area in
which this is more visible than in the failure to predict the kinds of extreme
violence that we have witnessed in schools in the United States beginning
with the Columbine massacre. How could we let these events happen? If
there were so many signs of trouble, how did we fail to notice? The unfor-
tunate answer is that we are not good at predicting who will be violent. In
a perfect world, where we have access to high-quality information, decision
making is probabilistic. In the clinical setting, where there is often a dearth
of empirical evidence, there is a need to be vigilant to the forms of biases
and cognitive traps that influence our approach to making decisions. Almost
every aspect of clinical practice is influenced by how we make decisions.

14 JEFFREY J. MAGNAVITA
 SHARED DECISION MAKING

Decision making in clinical practice should be shared and collabora-

tive. There are various perspectives through which to examine clinical deci-
sion making. Much of what has been presented so far is decision making
with the locus being the clinician. We may also consider shared decision
making, which is dyadic or triadic in that there are interpersonal and larger
system processes that are in operation, with multiple stakeholders. Various
aspects of decision making are critical to improving mental and behavioral
health care. Clinical decision making examines the thought processes that
are incorporated by the clinician in practice. Patient decision making is a
relatively new area of investigation. “How patients make decisions, the test-
ing of interventions to support effective decision making, and the devel-
opment of measures of patient decision making have only recently begun
to be studied for mental health contexts” (Wills & Holmes-Rovner, 2006,
p. 10). Shared decision making involves a partnership between the patient
system and provider system. It requires a collaborative approach in which the
patient’s preferences are considered and information is shared to enhance
decision making (Adams & Drake, 2006).

DECISION ANALYTICS

Most forward-thinking executives have fully adopted decision analytics

as an essential tool. A recent article in the Harvard Business Review was titled
“How to Make Smarter Decisions” (2013).
Techniques from the field of decision analysis formalize the question of
whether (provisionally) to adopt or reject an intervention. Decision
analysis identifies the set of consequences of concern to the decision
maker that might result from each available option (for example, the
therapeutic effects and side effects associated with a drug, its direct
costs, and its impact on social costs such as productivity losses) and
determines their associated probabilities. Aggregating these probability-
weighted consequences using an appropriate common metric yields an
expected net impact for each option. (Claxton, Cohen, & Neumann
2005, p. 95)

Health care as a whole (with mental health soon to follow) will be seeing a
greater reliance on the use of aggregated data to inform decision making, which
will certainly have an economic impact in terms of who will get reimbursed
and at what level. This trend is being fueled by computer technology, which is
allowing us to mine data as never before.

OVERVIEW AND CHALLENGES 15

 BIG DATA AND DECISION MAKING

Technological advances have led to new possibilities for using big data
for making decisions, which will inevitably change how behavioral and mental
health care is delivered. This trend is in large part being driven by the expan-
sion of the Internet along with powerful computer processing to change the
fundamental ways we gather and process information. “The fruits of the infor-
mation society are easy to see, with a cellphone in every pocket, a computer
in every backpack, and big information technology systems in back offices”
(Mayer-Schonberger & Cukier, 2013, p. 8). Since the beginning of the era
of information technology, humans have generated more information than
had been heretofore produced in the cumulative history of our species (Lehrer,
2009). “From sciences to healthcare, from banking to the Internet, the sectors
may be diverse yet together they tell a similar story: the amount of data in the
world is growing fast, outstripping not just our machines but our imaginations”
(Mayer-Schonberger & Cukier, 2013, p. 8). This has important implications
that are beyond the scope of this volume, so I suggest that those interested read
Big Data by Viktor Mayer-Schonberger and Kenneth Cukier (2013), which
presents an in-depth review of the trend and its implications.

ORGANIZATION OF THIS VOLUME

This volume offers a range of topics that will introduce the reader to
the field of decision making in mental health practice. Decision making
influences every aspect of clinical practice and is increasingly important for
behavioral and mental health clinicians, as well as all health care providers,
because of the inherent uncertainty in many aspects of clinical science.
Many decisions are made that do not derive from an empirical evidence base
and that necessitate a comfort with uncertainty. The topics covered in the
remainder of this volume provide a sample of some of the important areas
with which clinicians, researchers, and educators should be familiar. Decision
theory and decisional research are far ranging and rapidly expanding into
exciting areas such as big data and data mining that will influence all aspects
of health care in the future. There is also an accelerating trend in all areas of
health care to develop guidelines that practitioners, patients, policymakers,
and others can use to optimize treatment of physical and behavioral health
disorders.
The current chapter, Chapter 1, has introduced the topic of decision
making in an effort to provide a brief overview of the subject of this volume
and to highlight some of the essential constructs, common biases in deci-
sion making, and the five pillars of effective decision analytics. In Chapter 2

16 JEFFREY J. MAGNAVITA
(“Clinical Expertise and Decision Making: An Overview of Bias in Clinical
Practice”), my coauthor Scott O. Lilienfeld and I present an overview of
decision analytics and the biases and traps of which clinicians and researchers
should beware. This chapter provides a solid foundation in some of the
important topics related to decision making, along with a brief compendium
of common traps or errors to which we are subject when making clinical
decisions. Decision-making theory is included in a robust body of literature
that emanates from research from many disciplines. The fundamentals of
decision analytics and the biases that present danger are critical aspects of
optimal clinical practice. In Chapter 3 (“A Dual Process Perspective on the
Value of Theory in Psychotherapeutic Decision Making”), Jack C. Anchin
and Jefferson A. Singer explore the importance of theory in decision making,
an essential tool that has been evolving and becoming more sophisticated
over the course of clinical science history. Theory presents a way of organiz-
ing and understanding clinical phenomena, offering a road map for decision
making if used appropriately. In Chapter 4 (“Clinical Practice Guideline
Development and Decision Making”), Lynn F. Bufka and Erin F. Swedish
introduce the science and processes that go into the development of treat-
ment guidelines. These cutting-edge developments include both exciting and
somewhat controversial trends and the safeguards that ensure that clinical
practice guideline development is as scientifically valid and transparent as
humanly possible. After reading the chapter by Bufka and Swedish, the next
question you might ask is what to do with this information. Clinical prac-
tice guidelines are all well and good, but we want to know how they help us
treat behavioral and mental health disorders. In Chapter 5 (“Developing
Clinical Practice Guidelines to Enhance Clinical Decision Making”),
Steven D. Hollon explains how using an evidence base can enhance clini-
cal decision making and how clinicians can maximize their effectiveness by
referring to practice guidelines. In Chapter 6 (“Using Technology to Enhance
Decision Making”), Franz Caspar and coauthors show the importance of
technology in clinical decision making. Technology is fundamentally chang-
ing who we are as a species and providing us with multiple options to enhance
our decision making. The number of technological developments available to
us seems to steadily increase, and having knowledge of these can increase our
decision making skills. In Chapter 7 (“Clinical Decision Making When the
Stakes Are High”), I present a model of collaborative decision making that
was developed while working in close collaboration with a psychiatrist treat-
ing complex clinical presentations. Clinical decision making is most chal-
lenging when the stakes are high, when cases may not have a simple solution
and hence involve a high level of risk and potential harm. In Chapter 8 (“Use
of Empirically Grounded Relational Principles to Enhance Clinical Decision
Making”), Ken L. Critchfield and Julia E. Mackaronis show how relational

OVERVIEW AND CHALLENGES 17

principles offer a vital approach to clinical decision making. Having evidence
for the effectiveness of a particular treatment approach is certainly impor-
tant, but having an understanding of evidence-based principles adds another
significant dimension. In Chapter 9 (“Integrating Ongoing Measurement
Into the Clinical Decision-Making Process With Measurement Feedback
Systems”), Thomas L. Sexton and Adam R. Fisher describe how client feed-
back can be used to improve treatment outcome. As I have discussed, decision
making is about assessing probabilities and managing risk. Receiving ongo-
ing feedback about how a patient is responding to treatment is immensely
useful for monitoring treatment and altering one’s approach in a responsive
fashion. This is certainly going to be a part of most practice situations in the
future. In Chapter 10 (“Clinical Decision Making and Risk Management”),
Steven A. Sobelman and Jeffrey N. Younggren offer an important perspective
on how understanding risk can enhance clinical management. Formal train-
ing in decision making is not yet part of graduate curricula in behavioral and
mental health programs. Most of what is taught is done through a mentoring
relationship. So the time seems right to begin to develop formal curricula
and advanced training in decision analytics for behavioral and mental health
professionals. In Chapter 11 (“Teaching Clinical Decision Making”), Gregg
Henriques offers his novel approach to this area of the field.
The chapters in this volume are arranged in a sequence that walks the
reader through a variety of interrelated topics. The wealth of information in
the chapters will allows readers to see how pragmatic decision theory is and
how applicable it is to just about everything we do in clinical practice and
life in general. Learning to apply these tools is also very useful for financial
decision making and will assist in any major decision, especially when there
is uncertainty among various options.

SUMMARY

This volume, Clinical Decision Making in Mental Health Practice, applies

the theory and research of decision analytics to the field of behavioral and
mental health with a particular focus on how to improve clinical decision
making. Decision theory is an exciting development that began as an attempt
to deal with making decisions in situations of uncertainty, which has direct
relevance to health care and mental health practice and training. There are
basically two types of thinking that are called upon in making decisions. One
is fast, intuitive, and emotional, excellent when rapid responses are vital to
outcome. The other is slow or “lazy” in that a great deal of cognitive effort is
required in order to consider the information and determine probabilities of
outcomes from various choices. According to Kahneman (2011), both the

18 JEFFREY J. MAGNAVITA
fast and the slow systems of thinking must flexibly interact and can balance
each other to maximize outcome. There are a number of biases that occur
without our knowledge when we rely too much on the fast response system.
These errors can be avoided by developing knowledge of various types of
biases that are common to problem solving.
The chapters that follow will take you along a fascinating path that
you will find has direct bearing on just about every aspect of your clinical
practice, regardless of the setting or the types of decisions that you must
make. Enhancing our decision-making skills and knowledge will advance the
practice of behavioral and mental health treatment and allow us to adapt and
thrive in the new era of health care that is emerging in this country and the
world. Thank you for deciding to read this chapter, and I hope you will decide
that this volume is worth your investment.

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OVERVIEW AND CHALLENGES 21

 2
CLINICAL EXPERTISE AND DECISION
MAKING: AN OVERVIEW OF BIAS
IN CLINICAL PRACTICE
JEFFREY J. MAGNAVITA AND SCOTT O. LILIENFELD

At a recent dinner party, a guest told a story about an older mentor

who said, “Kid, I smoke and drink, and now the doctor who told me to stop
smoking is dead, and another one after him who said to stop drinking is also
dead.” And so the guest mused, “Why should I stop smoking and drinking?”
This is an illustrative example of flawed reasoning—in this case, the failure to
follow Bayesian logic. The mentor is ignoring probability and base rates—the
frequency of a condition or event: Smokers have a high incidence of lung
cancer. The decisions we make are guided by many factors, and sometimes as
in the case of the smoker, these may have dire consequences. We have excel-
lent data on the relationship between smoking and health risk. Clinicians are
continuously making decisions, some of which are also prone to biases, which
also can have unfortunate consequences.
What guides clinicians in making complex decisions? Do expertise and
intuition account for better treatment outcomes? What biases are we prone to

http://dx.doi.org/10.1037/14711-002
Clinical Decision Making in Mental Health Practice, J. J. Magnavita (Editor)
Copyright © 2016 by the American Psychological Association. All rights reserved.

23
when making decisions, and how can we avoid these? Clinicians and research-
ers alike routinely fall prey to errors in this type of thinking and many others
that can have dire consequences, but as clinical experts we have a responsi-
bility to avoid these cognitive traps. Clinicians have a “duty to know,” which
refers to an “epistemic duty . . . best enacted through a critical knowledge of
the scientific method in psychology and the relevant scientific literature”
(O’Donohue, Lilienfeld, & Fowler, 2007, p. 4). For example, we must try
to avoid missing a high-risk marker for self-destructive behavior, pushing a
patient too hard or fast in treatment, failing to corroborate information with
other family members, selectively including and excluding certain studies in
a meta-analysis, and so forth. Complex decisions are often influenced by hid-
den biases that can lead to faulty reasoning. These decision biases bear major
implications for almost every aspect of clinical practice and research, and it
is thus imperative for clinicians to be knowledgeable about them.
There are some “great” ideas and guiding principles every mental health
practitioner should know (Lilienfeld & O’Donohue, 2007). Advances in clini-
cal science over a century have led to a substantial body of information, includ-
ing robust theoretical constructs, empirical evidence in a variety of domains,
accumulated clinical experience, and evidence from related disciplines, which
serve as the foundation for and as a guide to decision making in clinical practice
(Magnavita & Anchin, 2014). However, accumulated experience or knowledge
alone does not necessarily result in expertise (Tracey, Wampold, Lichtenberg,
& Goodyear, 2014). “Expertise in any endeavor requires, among other things,
a considerable amount of dedicated practice” (Ruscio, 2007, p. 40). The
10,000-hour rule suggests that to become expert at a complex endeavor, one
must practice at least 10,000 hours to achieve mastery (Gladwell, 2008).
And yet, clinical expertise requires more than this extensive knowledge base
and much practice; we also must be wise enough to know how, and when,
to apply what we know. “To be effective clinical scientists, we must base our
actions and decisions on reliable knowledge. We should not simply guess or
believe, but instead know how nature, in this case human nature, actually
operates to influence behavior” (O’Donohue et al., 2007, p. 4). Accumulated
knowledge does not necessarily determine how to proceed in the consulting
room. Expertise requires training and experience in making complex deci-
sions, which in part derives from training and clinical experience, combined
with effective supervision and feedback. The empirical evidence on whether
more experienced psychotherapists get better outcomes is equivocal. There
is some evidence that experienced psychotherapists do have an advantage
in the face of complexity over less experienced ones (Oddli & Halvorsen,
2014), but other evidence suggests that expertise does not play a role in out-
come (Beutler, 1997; Okiishi, Lambert, Nielsen, & Ogles, 2003). Expertise
does not arise solely from experience because there is no guarantee that we

24 MAGNAVITA AND LILIENFELD

are not doing the wrong thing over and over again. Genuine expertise results
from extracting the relevant information from experience and applying it in
the appropriate situation (McKnight & Sechrest, 2003) as well as avoiding the
biases that are common in decision making, which are reviewed later in this
chapter. Regular high-quality feedback is also critical to developing expertise.
In spite of extensive training, clinicians and researchers are often subject to
cognitive errors or systematic sources of irrationality that impair decision mak-
ing. We are all vulnerable to inherent bias-generative errors, and according to
Daniel Ariely (2010), “we are not only irrational, but predictably irrational—
that our irrationality happens the same way, again and again” (p. xx). The
intersection of decision-making processes and clinical expertise influences all
aspects of behavioral and mental health practice.
This chapter explores the relationship between expertise and decision
making, with specific focus on providing an overview of the essential prag-
matic aspects of decision making essential to ethical and effective practice,
fulfilling our epistemic duty. We begin with a description and explanation of
evidence-based practice and clinical expertise.

CLINICAL EXPERTISE: A NECESSARY COMPONENT

OF EVIDENCE-BASED PRACTICE

Clinical expertise is an essential component of providing quality evidence-

based mental and behavioral health care. Access to knowledge does not con-
fer expertise. Let us first consider the meaning of expertise. A review of the
literature on clinical expertise highlights various ways of conceptualizing
expertise, including reputation, performance, and client outcomes (Tracey
et al., 2014). Tracey et al. (2014) endorsed Shanteau’s (1992) definition of
expertise as improvement over time. Expertise is an important component
of an evidence-based practice. “Evidence-based practice in psychology (EBPP)
is the integration of the best available research with clinical expertise in the
context of patient characteristics, culture, and preferences” (APA Presidential
Task Force on Evidence-Based Practice, 2006, p. 273). Norcross, Hogan, and
Koocher (2008), in their volume Clinician’s Guide to Evidence-Based Practices,
wrote: “We all recognize that clinical practice should be predicated on the
best available research integrated with the clinician’s expertise within the
context of the particular patient” (p. xi). The best available information
must be filtered through clinical expertise and grounded in the pragmatics of
decision analytics, which are examined in this chapter and throughout this
volume.
The APA Presidential Task Force on Evidence-Based Practice (2006)
described clinical expertise “as competence attained by psychologists, through

CLINICAL EXPERTISE AND DECISION MAKING 25

education, training, and experience that results in effective practice” (p. 275).
Clinical expertise includes
identifying and integrating the best research evidence with clinical data
(e.g., information about the patient obtained over the course of treat-
ment) in the context of the patient’s characteristics, culture, and prefer-
ences to deliver services that have the highest probability of achieving
the goals of therapy. (p. 275)
What is not clearly articulated in this definition is the central role of decision
analysis. “Decision analysis identifies the set of consequences of concern to
the decision maker that might result from each available option” (Claxton,
Cohen, & Neumann, 2005, p. 95). Decision analytics bridge the gap between
clinical practice and valid sources of information by offering heuristics to max-
imize the decision-making capabilities of the clinician to enhance treatment
process and outcome.
Professional psychologists and other mental health clinicians must acquire
an extensive knowledge base derived from various domains and related disci-
plines, including, but not limited to, psychopathology, neuroscience, develop-
mental psychology, theories of personality and psychotherapy, evidence-based
treatments, statistics, research methodology, and diagnostics systems as well
as various modalities of treatment. This foundation of knowledge and special-
ized language, along with pattern recognition skills, which are not common
in everyday life, confers “expertise.” Effectively combining these domains
of information into a useful knowledge base requires sophisticated decision-
making processes that are largely free from cognitive errors. Unfortunately,
we are often not cognizant of errors in thinking that bias our decisions and
can easily gravitate toward a style of thinking that requires little effort and
may conflate our self-perception about our competence. Clinicians are noto-
rious for believing in the veracity of our approaches and often not question-
ing the clinical dogma of one approach or another. As Roberto (2009) noted,
“Our cognitive limitations lead to errors in judgment—not because of a lack
of intelligence, but simply because we are human. Systematic biases impair
the judgment and choices that individuals make” (p. 31). “True experts, it is
said, know when they don’t know” (Kahneman & Klein, 2009, p. 524).
Abundant psychological research, including groundbreaking work by
scholars Tversky and Kahneman (1973), Kahneman, (2011), and Stanovich
(2010), has illuminated the inherent traps that arise from widely held cogni-
tive, affective, and perceptual biases. These often useful heuristics that we
draw on for rapid decision making can nevertheless become “traps” when
they are misused. A controversial form of this type of flawed decision mak-
ing is racial profiling. Heuristics are mental shortcuts or “rules of thumb”;
more formally, they constitute methods of thinking that allow us to process

26 MAGNAVITA AND LILIENFELD

information rapidly, which in some cases can be useful and even indispens-
able for making rapid decisions under conditions of uncertainty. However,
when we are unaware of how these heuristic devices affect our thinking,
or when we incorporate them when more systematic effort is required, our
problem solving can be impaired. Even expert clinicians and researchers are
prone to biases that strongly affect their clinical decision making and slide
toward “lazy,” less rigorous, thinking (Kahneman, 2011); indeed, the two
authors of this chapter are just as susceptible to these biases! But what makes
us lazy, Fiske and Taylor (1991) argued, is that we are “cognitive misers” when
it comes to effortful thinking; we use heuristics to save resources. For many
decisions it is not necessary to use effortful modes of analysis. As we shall see,
these rules of thumb can be extremely useful for certain purposes, but require
vigilance when used. Only by being aware of these biases or cognitive traps
in decision making can we combat the inherently human tendencies toward
thrift and minimize the risk of falling into decision-making traps.

THE PRAGMATICS OF DECISION MAKING

One of the leading figures in the scientific study of decision making,

Keith Stanovich (2010), wrote, “Nothing could be more practical or useful
for a person’s life than the thinking processes that help him or her find out
what is true and what is best to do” (p. 2). Clinicians, regardless of whether
their discipline is psychology, social work, psychiatry, nursing, or medicine,
must process enormous amounts of data and information, distilling them
into coherent diagnostic formulations followed by a logical course of action,
which are modified and corrected as new information is gleaned. Often impor-
tant decisions have to be made quickly, so these heuristics can be invaluable
because they allow us to implement the “thin slice”—a type of rapid pattern
recognition (Ambady & Rosenthal, 1992; Gladwell, 2005). Because there will
almost always be a high degree of uncertainty in human behavior, the natural
world, and clinical science, we cannot always respond in an optimal manner,
and at times mistakes occur. Developing an understanding of cognitive biases
that may lead to faulty decision making and understanding how to minimize
these errors can improve clinical expertise and increase wisdom.
In his book How Doctors Think, Groopman (2007) wrote, “Experts
studying misguided care have recently concluded that the majority of errors
are due to flaws in physician thinking, not technical mistakes” (p. 24). As
the old saying goes, “The operation was a success but the patient died.” In
spite of endorsing an evidence-based approach, such as following a manual-
ized treatment approach, a patient may worsen or not return, prematurely
discontinuing treatment. These situations may require and capitalize on our

CLINICAL EXPERTISE AND DECISION MAKING 27

expertise. Although most psychotherapists generally have a positive view of
treatment manuals (Najavits, Weiss, Shaw, & Dierberger, 2000), research is
equivocal about whether clinicians who too closely adhere to a treatment
manual have better or worse outcomes (Hogue et al., 2008). It is clear that
sophisticated treatment must go beyond a cookbook approach, and thought-
fully constructed therapy manuals recognize what Kendall, Gosch, Furr, and
Sood (2008) termed “flexibility within fidelity.” At this point in time, the
preponderance of research seems to suggest that outcome is improved when
adherence is maintained. Nevertheless, there are times when strict adher-
ence to any approach is contraindicated and clinical judgment based on deci-
sion theory must supersede blindly enforcing a particular treatment approach
(see also Grove & Meehl, 1996, for a discussion of the “broken leg” scenario
in clinical judgment and prediction). As Groopman described the complex-
ity of information processing, “Throughout the day we are detecting frequen-
cies hundreds of times, using our language modules repeatedly, inferring the
thoughts of others constantly, and so on—all of which are adaptive and serve
personal goal satisfaction” (p. 141). Given the complexity of clinical prac-
tice, our clinical expertise can be strengthened and our results optimized by
learning the basics of decision analysis and the cognitive traps to which we
are prone. As we shall discuss, certain types of decision making are best suited
for particular situations.

ACKNOWLEDGING THE UNCERTAINTY

IN DECISION ANALYTICS

In our chaotic and unpredictable world, many of the decisions we make

represent our best efforts to deal with greater or lesser degrees of uncertainty.
It is important to acknowledge the uncertainty in the world and be skepti-
cal when it comes to any evidence we analyze. We should always be asking
ourselves, “What do the data say, and what is the evidence?” The more risk
involved in a decision, the greater the importance of incorporating principles
of decision analytics to reduce unnecessary bias in our response. It is not
always prudent to “trust your gut or your judgment” when making decisions.
For example, incorrectly diagnosing a patient may have severe consequences;
failure to provide the appropriate diagnosis may lead to undertreatment or
inappropriate treatment. Misguided interventions can in turn predispose a
patient to destructive behavior; similarly, placing a patient on a potentially
harmful medication that is not required would be erroneous and possibly
iatrogenic.
Problems encountered in clinical practice will demand differing
approaches to decision making. A patient who seems to be in a high level of

28 MAGNAVITA AND LILIENFELD

limbic arousal may call for quick action as opposed to a patient with Bipolar I
disorder, for example, who refuses to take a mood stabilizer. It is essen-
tial to understand how we make decisions and what types of problems are
best addressed through rapid processing as opposed to a more deliberative
approach. Similarly, individuals can be described as either high or low on
the polarity of emotional versus rational decision makers: Some may say that
they just “know in their heart” what is right, whereas others “use their heads”
when making decisions.

RATIONALITY AND EMOTIONALITY:

TWO APPROACHES TO DECISION MAKING

There are two basic processes we incorporate in our decision making,

which Lehrer (2009) described as rational and emotional (see also Kahneman,
2011). The first, based largely on logic, uses rationality by accumulating appro-
priate information, weighing findings, testing hypotheses, and using feedback
to modify them. This type of systematic thinking tends to be rational, language
based, and linear and requires a great deal of effort. The second type tends to
be based largely on unconscious emotional (“gut”) reactions and intuitions
and often bypasses rational thinking. This type of decision making generally
requires much less effort and is used to navigate many situations in which
effortful thinking may not be required (Epstein, 1994).
Each type of problem solving has an important place in clinical deci-
sion making, and when the types are properly combined they can most effec-
tively enhance our judgments. When we fall prey to biases that are inherent
to each of these systems, our clinical decision making can be hindered and our
expertise compromised, resulting in less than desirable outcomes or iatrogenic
effects. When this occurs, we should ideally monitor the process and then use
feedback we gather to make adjustments.
For example, when formulating a treatment plan for a patient with a
particular clinical presentation, we systematically weigh options, predict the
benefits of each, discuss patient preferences, and determine a course of treat-
ment. Thus, a patient who presents with suspicious features might have a
paranoid personality disorder; alternatively, his or her clinical presentation
may stem from other sources. Reviewing the prevalence of paranoid person-
ality disorder in the general population, we would find the base rate to be
rather low. Determining base rates for clinical phenomena is a critical aspect
of psychodiagnosis and other clinical tasks, which represents a logical, rational
approach. There will be times when we need to respond on a largely emotional
level, which is more intuitive and rapid. This often occurs in the moment-
to-moment process of clinical work. For example, we may make a suggestion

CLINICAL EXPERTISE AND DECISION MAKING 29

to a patient or summarize what he or she is describing and notice that he or
she is grimacing. Our intuitive sense is that we have created a rupture in the
alliance to which we may respond before we even consciously process what
occurred—for example, by asking whether we said something that offended
our client. In his book Blink, Malcolm Gladwell (2005) wrote, “The part of
our brain that leaps to conclusions like this is called the adaptive unconscious,
and the study of this kind of decision making is one of the most important new
fields in psychology” (p. 11). In addition, in his book Strangers to Ourselves:
Discovering the Adaptive Unconscious, Timothy Wilson (2002) discussed how
much of what occurs in our minds lies outside of conscious awareness. Hassin,
Uleman, and Bargh (2005), in their volume The New Unconscious, also pre-
sented compelling evidence for the scope of unconscious processing and sug-
gested that transference and countertransference phenomena are rooted partly
in these ubiquitous template-matching processes. Much of what occurs in the
moment-by-moment process in psychotherapy may capitalize on bringing this
system to conscious awareness so that practitioners can exert greater agency
over their schema-driven responses.
Objective and rational processes are valuable in clinical decision mak-
ing, but sometimes even these more deliberate processes are prone to uncon-
scious bias. Our internal state also influences our decision-making processes.
“The [clinician’s] internal state, his state of tension, enters into and strongly
influences his clinical judgments and actions” (Groopman, 2007, p. 36).
Effective decision making requires an optimal level of anxiety; too much
anxiety may compromise rational thinking, but too little anxiety may not be
optimal. Research has increasingly identified neurobiological correlates of
the inefficiencies of effective decision making. For example, neuroscientific
findings suggest that when individuals are confronted with a financial expert,
regions of the brain linked to decision making become less active. Similarly,
when we see the same phenomena repeatedly, our brain uses less energy to
process it (Berns, 2008). When we find information that supports our deci-
sions, we tend to experience an increase in dopamine similar to consum-
ing chocolate, having sex, or falling in love (Hertz, 2013, p. SR6). We like
it when what we believe is affirmed. “But there are moments,” according to
Gladwell (2005), “particularly in times of stress, when haste does not make
waste, and our snap judgments and first impressions can offer a much better
means of making sense in the world” (p. 14). Clinicians often report that they
are at their best when their intuitive sensing is operative. This may create
a state that Mihaly Csikszentmihalyi (1990) described as flow. There exists
much folklore regarding these concepts in the clinical community. “Good”
therapists are often described as working intuitively and thereby capitalizing
on the information discerned through the filter of the “nonconscious” system.
Recent neuroscientific research shows evidence of neural networks that allow

30 MAGNAVITA AND LILIENFELD

for the rapid intuitive processing of implicit information, a process referred to
as mentalization (van Overwalle & Vanderkerckhove, 2013). At the same time,
subjective experience, although accurate in some interpersonal situations, may
not be suitable for most decisions, so one must use data to substantiate these
informal impressions.

ELEMENTS OF OPTIMAL DECISION MAKING:

DATA, INFORMATION, KNOWLEDGE, AND WISDOM

Optimal decision making involves forecasting outcomes in the face of

uncertainty. The use of intuition, a relatively rapid form of decision making,
is subject to error, but it can sometimes be a useful clinical aid. Effective
decision making involves gathering relevant information, considering and
evaluating alternatives, making judgments that are relatively free of biases,
and appraising the outcomes of our decisions. What are the basic elements of
decision making? Stanovich (2010) wrote this succinct description:
Decision situations can be broken down into three components: (a) possi-
ble actions, (b) possible events or possible states of the world, and (c) evalu-
ations of the consequences of possible actions in each possible state of
the world. Because there are almost always one or more possible future
states of the world, any action can be viewed as a gamble—the conse-
quences of the gamble are unknown because the future state of the world
is unknown. (p. 9)
Clinical expertise may be viewed as a form of wisdom because having
access to a plethora of information does not confer wisdom, as we now expe-
rience in the digital–Internet age. One very intelligent professional, while in
treatment with the first author, reported that when she looks up her symptoms
on the Internet she has almost every possible disorder described. It is therefore
helpful to differentiate among the hierarchy of classes of knowledge on which
we base our decisions, and it is important to differentiate among the classes of
knowledge relevant to decision making. The hierarchy of knowledge, referred
to as DIKW (data, information, knowledge, wisdom), is a useful framework
with which to organize classes of information and has been used extensively
in business, technology, and information science (Rowley, 2007; Zins, 2007).
Although the originator of this system is unknown, numerous scholars have
described similar constructs in the literature (Russell Ackoff was one of the
leading proponents of this system; Ackoff, 1967). Each level of the system,
similar to Maslow’s (1954) hierarchy of needs, is posited to be a precursor for
the next level. The hierarchy of knowledge includes the elements described
in the following paragraphs.

CLINICAL EXPERTISE AND DECISION MAKING 31

Data

Data are discrete units of information that are not yet organized on the
basis of observations or facts. For example, a list of names and telephone
numbers and discrete observations from a research study are classified as data.
There is no inherent usefulness to data because they become useful only when
they are coherently and systematically organized. Computers rely on enormous
quantities of nonprocessed bytes encoded as 0 or 1 units, or data, that when
organized into code become useful. Never before in the history of our species
have we had the capability to amass such voluminous amounts of data. These
“big data” that most often comes from the Internet is a new frontier for infor-
mation technology. “Today, every e-mail, instant message, phone call, line of
written code and mouse-click leaves a digital signal” (Lohr, 2013, p. 4). This
constitutes a revolution in data gathering that is beginning to fundamentally
transform the world. Data patterns are being mined and used to enhance
innovations in health care and business. “Digital technology also makes it
possible to conduct and aggregate personality-based assessments, often using
online quizzes or games, in far greater detail and numbers than ever before”
(Lohr, 2013, p. 4). This emphasis on mining big data is leading to an ever
greater reliance on data-driven decision making. The future of clinical deci-
sion making will almost certainly be shaped by innovative uses of big data.

Information

When data have been endowed with some meaning and have been orga-
nized into a useful form, they are called information. A phone book is an exam-
ple of information because the data (names and phone numbers) are organized
in a way to be easily accessed. The development of clinical practice guidelines,
discussed in Chapter 4 in this volume, exemplifies what should eventually be
useful information that when accessed by clinicians and the public will serve
to reduce uncertainty. Anyone will be able to read the guidelines, a source of
information, but applying them will require more than simply assimilating
the information provided—expertise is necessary.

Knowledge

When information is synthesized, it becomes knowledge. For example,

a knowledgeable practitioner should be able to appropriately apply the infor-
mation that is provided in the form of clinical practice guidelines. In contrast,
such application is unlikely to take place for those untrained in the domains
discussed at the beginning of the chapter, which serve as a foundation for
employing this information.

32 MAGNAVITA AND LILIENFELD

Wisdom

The ability to use knowledge to increase our effectiveness is known as

wisdom. The highest level of clinical expertise reflects a substantial knowl-
edge base and the ability to effectively use decision analytics to make the
best choices in the face of uncertainty. Scott Miller and colleagues studied
ostensible “supershrinks” and found that they worked hard at deliberate
practice, which entails actively planning, considering strategies, tracking
and reviewing process, and adjusting the intervention (Miller, Duncan, &
Hubble, 2008). The downside of deliberate practice is that it is not inherently
motivating and increases costs. Lambert (2010) has conducted extensive
research showing that expert therapists are more likely than other therapists
to respond to information regarding the therapeutic process and accurately
self-assess compared with less effective psychotherapists, who tend to over-
rate their skill. When we make the effort to understand different types of
decision making—one “fast” and one “slow”—we can learn how to use these
modes to our advantage.

THE DUAL PROCESSORS OF DECISION MAKING:

FAST AND SLOW THINKING

As suggested earlier, abundant research has accrued over many decades

supporting the presence of two types of decision-making processes or styles
that have evolved in humans to assure our survival and enhance adaptation
(Stanovich & West, 2000). An understanding of the way we think is essential
for optimizing our decision making. It is imperative to know what type of
system is called for in clinical situations that require us to process informa-
tion and make complex decisions. In his book Thinking, Fast and Slow, Nobel
Prize–winning psychologist Daniel Kahneman (2011) presented two sys-
tems that are operative when we think. Keith Stanovich and Richard West
(2000) classified these two modes into System 1 and System 2 thinking. In
his book Rationality and the Reflective Mind, Stanovich (2011) argued that
System 1 is rapid, intuitive, and emotional, and System 2 is slower, logical,
and more deliberately algorithmic. Although Stanovich now uses the terms
Type 1 and Type 2 when referring to these systems, we use Kahneman’s more
familiar System 1 and System 2 designations in this chapter. It is worthwhile
to develop an understanding of the strengths and weaknesses of both systems
so that we are aware of how each may be useful in clinical decision making
and of the biases inherent in System 1 (Kahneman, 2011, p. 79). Fortunately,
the biases have been well researched and articulated and are discussed later
in this chapter. The two systems described in greater detail in the following

CLINICAL EXPERTISE AND DECISION MAKING 33

section are interactive and can effectively work together, but awareness of
how these operate is critical to avoid thinking traps.

System 1—Essential for Survival but Notorious for Bias

Operating automatically with little or no voluntary control, System 1

is the rapid processor or the fast thinking system (Kahneman, 2011). It is
easy to be seduced by System 1 thinking, which is relatively effortless, non-
conscious, and utilizes intuition. Most of us fall prey to the ease of use and
overconfidence of thinking fast, and therein is the problem. This system gen-
erates complex patterns of ideas, drawing effortlessly on feelings and impres-
sions, often responding efficiently and effectively. However, System 1 is most
efficient when responding to short-term predictions and does less well with
longer term predictions. This mode of thinking is essential when we have to
rapidly assess the environment for threat, such as in fight–flight responses,
and for falling in love, or swiftly reacting to a potentially violent patient.
However, the modern world is “simply littered with Type 1 traps” (Stanovich,
2010, p. 141), which can lead to costly decisions such as buying on impulse,
amassing credit card debt, and taking on predatory mortgages, to name a few.
When we need to be deliberate and analyze information to make a decision,
System 1 often falls short, although, as we shall note, many important aspects
of clinical practice incorporate and may benefit from System 1 processing.
Clinicians often refer to this type of fast thinking as intuition based on clinical
expertise and gut feelings (Kahneman & Klein, 2009).
Clinical expertise is a hard-earned and valuable commodity for practi-
tioners that is derived from extensive training and experience. It is helpful to
understand how expertise often relies on intuition. We must understand the
strengths and limitations of intuition and the circumstances under which it
is most effectively utilized because intuition, when unchecked, can be prone
to bias. Kahneman (2011) wrote,
Expert intuition strikes us as magical, but it is not. Indeed, each of us
performs feats of intuitive expertise many times each day. Most of us
are pitch-perfect in detecting anger in the first word of a telephone call,
recognize as we enter a room that we were the subject of the conversa-
tion, and quickly react to subtle signs that the driver in the next lane is
dangerous. (p. 11)
This wisdom comes from having a sound knowledge base and relevant
experience derived from seeing multiple cases in clinical practice. Emerging
from this intuitive and deliberative information-processing experience are
complex pattern-recognition skills and useful clinical heuristics to guide
treatment (Kahneman & Klein, 2009). Clinicians often rely on intuition in

34 MAGNAVITA AND LILIENFELD

the face of uncertainty. Sometimes, we may try to justify a gut feeling with a
“rational veneer” (Ariely, 2010, p. 53). However, as Paul Meehl (1954) noted
in his landmark volume, Clinical Versus Statistical Prediction,
Four decades of research consisting of over 100 research studies have
shown that, in just about every clinical prediction domain that has ever
been examined (psychotherapy outcome, parole behavior, college gradu-
ation rates, response to electroshock therapy, criminal recidivism, length
of psychiatric hospitalization, and many more), actuarial prediction has
been found to be superior to clinical prediction. (pp. 84–85)
So does adding clinical to actuarial prediction improve our results? The
answer appears to be clear: As Stanovich (2010) noted, “Clinical prediction
does not work” (p. 84). Predicting human behavior is not precise and never
will be, so we employ heuristics, which sometimes improve our decisions.
Nevertheless, there are rare exceptions. Meehl (1954) described “bro-
ken leg” cases, in which extremely low base rate events that are too rare to
be incorporated into the formula should lead us to overrule this formula.
For example, if an empirically derived actuarial formula tells us that a cli-
ent is extremely unlikely to attempt suicide, but the client informs us that
he is about to kill himself and has recently bought a gun, we should prob-
ably disregard the formula and act quickly. Nevertheless, these cases are rare
exceptions. In the substantial majority of cases, we are better advised to trust
the output of statistical prediction rules that have been derived from actual
output data. As Kahneman (2011) noted,
Most impressions and thoughts arise in your conscious experience with-
out knowing how they got there. You cannot trace how you came to the
belief that there is a lamp on the desk in front of you, or how you detected
a hint of irritation in your spouse’s voice on the telephone, or how you
managed to avoid threat on the road before you became consciously
aware of it. The mental work that produces impressions, intuitions, and
many decisions goes on in the silence of your mind. (p. 4)
In Blink, Malcolm Gladwell (2005) popularized the term thin slicing,
which was coined by Ambady and Rosenthal (1992) to describe this rapid,
intuitive style of processing information. For example, the first 3 minutes of
marital dialogue is highly predictive of whether a couple will divorce (Carrère
& Gottman, 1999).Clinicians who have not developed the capacity to rapidly
respond to stimuli at an unconscious level are handicapped. We call this skill
clinical intuition and recognize it in others as a “gift,” but “supershrinks” may
in fact be differentiated from others by their deliberative focus on improving
performance (Miller et al., 2008). We contend, however, that although clini-
cal intuition is important for effective mental and behavioral health practice,
its output must be checked continually against another more logical system.

CLINICAL EXPERTISE AND DECISION MAKING 35

System 2—The “Lazy” Processor

More effortful than System 1, System 2 utilizes a higher level of mental

activity and requires “agency, choice, and concentration” (Kahneman, 2011,
p. 21). This system draws heavily on our cognitive resources and can lead to
ego depletion. In fact, more energy is used by the nervous system for System 2
processing. Nonetheless, System 2 is notoriously “lazy” and reluctant to do
more than is necessary. According to Kahneman, we tend to find the cognitive
effort required of System 2 unpleasant and too effortful, leading us to avoid
the demands necessary and often defaulting to the less effortful System 1
style of processing information. The type of thinking outlined by Stanovich
(2011) requires us to approach our decision analysis much more slowly, using
computational skills that he termed algorithmic. As we become more skilled
in a task, it is less effortful but still requires engagement. Actuarial prediction
is predominantly a System 2 process, whereas clinical prediction is predomi-
nantly a System 1 process.

Relying on Both System 1 and System 2

Clinicians generally and understandably favor System 1 decision mak-

ing, which is the rapid pattern recognition type necessary for navigating
the often enormous multitude of decisions that are faced on a moment-to-
moment basis in clinical practice. Researchers, in contrast, tend to favor
System 2 decision making, which relies on using systematically derived data
and well-substantiated conclusions. There is often much saber rattling and
polarization among devotees of these two types of decision making. Some
clinicians appear to believe that data derived from research studies are not
especially useful in clinical decision making, whereas some researchers appear
to believe that many clinicians ignore the fact that actuarial prediction typi-
cally outperforms clinical decision making based on expertise. Nevertheless,
such polarization is largely unnecessary. In the heat of the therapy session,
clinicians must of course rely on their intuitions; they must “use their heads.”
At the same time, such intuitions should be guided and double-checked by
systematic data.

CLINICAL VERSUS ACTUARIAL PREDICTION

What we observe in the world is a complex mixture of random and

systematic factors, in large part driven by the former (Stanovich, 2010).
Our reluctance to acknowledge the role of chance in predicting outcomes

36 MAGNAVITA AND LILIENFELD

can decrease our ability to predict events accurately. Stanovich (2010)
wrote,
Research on the issue of clinical versus actuarial prediction has been
consistent. Since the publication of Paul Meehl’s classic book Clinical
Versus Statistical Prediction, four decades of research consisting of over
100 research studies have shown that, in just about every clinical pre-
diction domain that has ever been examined (psychotherapy outcome,
parole behavior, college graduation rates, response to electroshock ther-
apy, criminal recidivism, length of psychiatric hospitalization, and many
more), actuarial prediction has been found to be superior to clinical pre-
diction. (pp. 84–85)

In a more recent meta-analytic study, the actuarial or statistical predic-

tion was about 10% more accurate than the clinical prediction. This seems
to be the case regardless of types of judgment and amount of experience. In
a few studies, clinical prediction was slightly more accurate, although it is
not clear whether these findings are replicable. Interestingly, when clinical
interview data are included, the accuracy of prediction typically deteriorates,
suggesting that such data can dilute the validity of clinicians’ information
appraisal (Grove, Zald, Lebow, Snitz, & Nelson, 2000). Stanovich (2010),
citing Gawande (1998), noted that
the clinicians in these studies believed their experience allowed them
to make better predictions than those that can be made from quantified
information in the client’s file. In fact, their “insight” is nonexistent and
leads them to make predictions that are worse than those they would
make if they relied only on the public, actuarial information. It should be
noted, though, that the superiority of actuarial prediction is not confined
to psychology but extends to many other clinical sciences as well—for
example, to the reading of electrocardiograms in medicine. (pp. 85–86)

Why then are many clinicians opposed to actuarial prediction? Clini-

cians commonly cite a number of reasons for eschewing actuarial prediction
(Grove & Meehl, 1996). In many cases, it seems that we exhibit the very biases
presented in this chapter. Indeed, Meehl’s ideas were met with hostility and
disbelief from the clinical community. Kahneman (2011) wrote that they were
under the influence of “an illusion of skill” and commented, “On reflection,
it is easy to see how the illusion came about and easy to sympathize with the
clinicians’ rejection of Meehl’s research” (p. 227).
Some clinicians may assume that the quality of their judgments should
override statistical evidence. Kahneman (2011) noted, “Psychologists who
work with patients have many hunches during each therapy session, antici-
pating how the patient will respond to an intervention, guessing what will

CLINICAL EXPERTISE AND DECISION MAKING 37

happen next” (p. 227). Much of what happens on a moment-by-moment
basis in the clinical situation seems to substantiate clinician intuition.
Psychotherapists practice and hone their skills over many years and develop
a keen sense of what will transpire in the therapeutic process. Certain clini-
cians are clearly superior to others in their competence level. However, they
typically are not good at making predictions about longer term future events;
these are best handled by actuarial prediction.

THE BASICS OF CRITICAL DECISION MAKING:

PATTERN RECOGNITION AND DECISION MAKING

Clinical decision making begins at the point of first contact with the
patient, when we initiate our pattern-detection process. During the first con-
tact, the clinician has to make multiple decisions that involve comparisons
with internal schema. The clinician rapidly matches internal templates when
considering decisions such as who should attend the initial session (patient,
couple, family, significant others), proposed duration of the session, how much
should be discussed on the phone, and many other issues that immediately
must be contemplated and decided on. Science in large part is about finding
patterns in nature. One way we make clinical decisions is to draw from the
depth and range of information and clinical experience we have amassed and
compare external reality with internal patterns that we have constructed.
Specifically, clinicians utilize prototypes as a form of template to help
compare cases and organize decision making. Essentially, we use these heu-
ristics to make predictions. When we make a diagnostic formulation, we do
so in part to predict the course of a disorder, the client’s response to treat-
ment, and therapeutic strategies that optimize outcome. Each strategy we
employ in treatment is based on an implicit or explicit decision to achieve a
therapeutic goal. For example, the regulation of anxiety is a central aspect of
the treatment process (Faust, 2007). We are continually matching patterns
derived from past experience with our current ones, and thereby compar-
ing and evolving our mental maps. If anxiety is too high, a patient may be
flooded, whereas if it is too low, there may be little motivation to change and
treatment may stagnate. This process of anxiety management often occurs
with the fast processing of System 1, but anxiety regulation should be based
on extensive knowledge and drawn from clinical experience. Groopman
(2007) described this as occurring “within seconds, largely without any con-
scious analysis; it draws most heavily on the doctor’s visual appraisal of the
patient” (pp. 34–35). This is not a “linear, step-by-step combining of cues”
but the mind acting like a magnet, assimilating data from many domains of
the patient (pp. 34–35).

38 MAGNAVITA AND LILIENFELD

 Intuition is fundamentally a complex pattern-recognition process
whereby we use cues from a situation that we match to these internalized pat-
terns or schemas (Roberto, 2009). In using intuition, we must guard against
our tendency to find nonexistent patterns in the world and thus impose them
on everything. Our propensity to perceive order in disorder and sense in
nonsense is basically adaptive because it is an attempt to reduce the chaos
and randomness of the world (Stanovich, 2010, p. 81). At the same time,
we may falsely assume a pattern in events that are random. This sometimes
leads to false positives, in which we perceive a pattern (e.g., a connection
between certain ineffective intervention techniques and outcomes in our
clinical practice) that does not exist. Prototypes, although an essential ele-
ment of clinical decision making, can also lead to errors in thinking. We may
ignore or selectively reinterpret information that does not fit our prototype
and thereby increase the probability of clinical errors.

TYPES OF ERRORS THAT INFLUENCE DECISION MAKING

Heuristics are essentially rules of thumb or shortcuts in thinking that

allow us to reduce the complexity in our world and reduce the effort of
constantly attending to and responding to every detail in our environment
(Groopman, 2007, p. 35). They can be useful but are notoriously error
prone. In their classic work, Tversky and Kahneman (1973) explored the
topic of heuristics, which enable us to respond rapidly to uncertainty but
also have associated dangers. Developing our awareness of the dangers will
serve as an important check and balance to System 1 thinking. Familiarizing
ourselves with the most common types of cognitive biases optimizes our
decision making by helping us avoid common errors. The following sec-
tions offer a basic overview of many of these heuristics and their associated
biases (we refer the reader to the references provided to attain a deeper
appreciation).

Anchoring Bias

Anchoring bias refers to a tendency to allow an initial reference point

to unduly influence or distort our estimates. Anchoring is often based on
an arbitrary reference point (Ariely, 2010). This anchoring phenomenon is
prevalent in economics and can lead to arbitrary coherence, whereby arbi-
trary anchor points can nevertheless influence our future decisions. Ariely’s
(2010) research in behavioral economics showed “that our first decisions res-
onate over a long sequence of decisions” (p. 38). In this way, random anchor-
ing effects may have sway on the way we make future decisions.

CLINICAL EXPERTISE AND DECISION MAKING 39

 This effect can exert a strong influence on our clinical conceptualiza-
tion and interfere with proper decision analysis. This bias is often present
when someone presents a patient or a case and uses a powerful anchoring
label, such as borderline or narcissistic. Receiving a new referral from a col-
league along with his or her case formulation may result in falling into a trap
whereby we fail to perform our own systematic investigation of the case.
When a diagnosis is communicated before we form our own opinion, it is too
easy to heavily weight one piece of evidence such as “the patient engages in
parasuicidal behavior” when she merely scratched her arm lightly with a pin.

Attributional Bias

Attributional bias refers to people’s tendency to minimize their errors and

maximize the errors of others (Heider, 1958). Gottman (1999) reported on this
phenomenon in couples, in which negative traits in a partner are frequently
exaggerated. When working with a team of other providers, we may inaccu-
rately assess our contribution as a positive component of the treatment process
and that of other providers as a lesser and/or more negative component.

Availability

Availability is a heuristic whereby we estimate the likelihood of an event

or phenomenon using the ease with which relevant examples are recalled
(Tversky & Kahneman, 1973). A clinician who has recently seen a number of
patients with posttraumatic stress disorder (PTSD) might diagnose a troubled
patient with PTSD even in the absence of an identified traumatic event. He
or she may further miss the fact that the patient suffers from hyperthyroidism,
given that this medical condition is often not readily accessible in memory
(Schildkrout, 2011). Availability, if misused, can lead to distorted pattern rec-
ognition (Groopman, 2007). We generally have easy access to memories of
occurrences that are especially vivid, rare, and emotionally activating (Nisbett
& Ross, 1980). For example, many clinicians have formed a schema for mul-
tiple personality disorder (now termed dissociative identity disorder) based on
the sensational and now largely discredited (see Nathan, 2011) case of Sybil
(Schreiber, 1973). Cases such as Sybil’s can adversely affect the judgment
of clinicians by heightening the ease of recall, resulting in biased judgments
(Ruscio, 2007).

Confirmation Bias

In confirmation bias, we look for information that supports our beliefs

and affirms our perspective while neglecting or selectively reinterpreting

40 MAGNAVITA AND LILIENFELD

evidence that contradicts this perspective. In a sense, this tendency reduces
cognitive dissonance (Festinger, 1957; Tavris & Aronson, 2007). An example
of this type of bias is implicit in a report that I have heard many times from
patients in alcohol treatment. Patients are asked whether they are alcoholic,
and if they say no, the clinician may inform them that this “denial” confirms
the diagnosis. Such “confirmation bias” is probably a variant of the anchoring
bias we discussed earlier because it leads us to be overly influenced by initial
information. We tend to avoid integrating information that challenges our
beliefs and also cherry-pick features that fit our prototype (Groopman, 2007,
p. 65). Selectively gathering data that support our initial views and interpret-
ing data in a manner that confirms our beliefs tends to reduce the accuracy
of our decision making.
Magnavita and Anchin (2014) gave an example of a troubling trend
in psychotherapy. In certain cases, a psychotherapist who held a belief that
most women had endured sexual abuse would frequently ask leading ques-
tions when a particular constellation of symptoms was present, with the
assumption that these symptoms were the result of childhood sexual trauma.
If a patient responded by saying that she had not experienced sexual abuse,
the clinician would often take this as a sign of repression, which he or she
felt provided strong corroborating evidence for the assumption of abuse.
Confirmation bias may also explain my friend’s thinking about smoking and
drinking, discussed in this chapter’s opening paragraph. Hertz (2013) wrote,
Smokers often persist with smoking despite the overwhelming evidence
that it’s bad for them. If their unconscious belief is that they won’t get
cancer, for every warning from an antismoking campaigner, their brain is
giving a lot more weight to that story of the 99-year-old lady who smokes
50 cigarettes a day but is still going strong. (p. SR6)
Clinicians are often subject to confirmation bias when they have strong
allegiance to a particular approach to psychotherapy. One can observe this
phenomenon at psychotherapy conferences in which presenters show video-
tapes of patients’ treatment, most of which depict impressive results. However,
it is well known that many of these psychotherapists have also experienced
many treatment failures, which are very rarely shown. This bias is not limited
to clinicians; researchers are more likely to publish and advertise their posi-
tive findings than their negative findings (Rosenthal, 1979).

Gambler’s Fallacy

Gambler’s fallacy refers to our tendency to see a link between past and
present events when in fact they are independent (Stanovich, 2010). For
example, if you flip a coin once and get heads, the chance that you will flip

CLINICAL EXPERTISE AND DECISION MAKING 41

the coin and get tails is independent of the first flip because the probability
of outcome remains the same. In other words, random events don’t have
memories. “Two outcomes are independent when the occurrence of one does
not affect the probability of the other” (Stanovich, 2010, p. 79). Much to
the delight of casino owners, those who play games of chance are often taken
in by the faulty assumption that the probability of a number coming up at
a particular time is based on the previous occurrence. As Stanovich (2010)
observed,
Psychologists, physicians, and marriage counselors often see couples who,
after having two female children, are planning a third child because, “We
want a boy, and it’s bound to be a boy this time.” This of course, is the
gambler’s fallacy. The probability of having a boy (approximately 50%) is
exactly the same after having two girls as it was in the beginning (roughly
50%). The two previous girls make it no more likely that the third baby
will be a boy. (p. 80)
Clinicians often inaccurately perceive patterns in random events and
are likely to develop narratives to explain the occurrence of these events, a
tendency that should be vigilantly guarded against. It is often very tempt-
ing to forget that even though two events are occurring together on a
regular basis, this does not imply causality. Other unknown factors may
be at play.

Endowment Effect

People have a tendency to be biased toward the status quo, a phenom-

enon termed the endowment effect (Stanovich, 2010). “Endowment effects
result from loss aversion and are a special case of even more generic sta-
tus quo biases, where the disadvantages of giving up a situation are valued
more highly than the advantages of an alternative situation” (Stanovich,
2010, p. 37). Clinical science has been notorious for reifying orthodoxy that
often emerges from the beliefs and practices of charismatic psychotherapists.
Psychoanalysis, among many other paradigms, has long been criticized for
its orthodoxy (Masson, 1984, 1990). An example in psychotherapy of the
endowment effect is that for almost a century the length of a session was
based on the 50-minute psychoanalytic hour. Interestingly, the authors of this
chapter are aware of no research support for this treatment frame. Not only
have psychotherapists continued this tradition without much critical scru-
tiny, but it also became the unit of time (plus or minus 5 minutes) preferred by
insurance companies. Of course, a few psychotherapists have experimented
with adjusting the length of a session, but most clinicians rely on the status
quo without consideration of alternatives.

42 MAGNAVITA AND LILIENFELD

Egocentrism

We have a propensity to attribute credit to ourselves for an outcome

that is perceived as deserving less credit than we would receive from an out-
side party. Clinicians fall into the trap when they believe that a particular
intervention produces a positive result, which may be better explained by
extraneous factors such as passage of time or extratherapeutic experiences.
One empirical investigation revealed that 25% of clinicians rated themselves
in the top 10%, and none viewed themselves as below average (Walfish,
McAlister, O’Donnell, & Lambert, 2012). We psychotherapists can poten-
tially ward off falling into this thinking bias, clinically referred to as narcis-
sism, which results when egocentrism is excessive, if we keep in mind that we
are notorious for overestimating our effectiveness.

Failure to Attempt to Falsify Hypotheses

Consistent with the literature on confirmation bias that we have already

reviewed, more than 4 decades of research have demonstrated that we tend
not to acknowledge data that falsify our focal hypotheses (Stanovich, 2010).
We have difficulty assessing information that points to alternative hypotheses.
Stanovich (2010) wrote,
Thus, the bad news is that people have a difficult time thinking about
the evidence that would falsify their focal hypothesis. The good news
is that this thinking skill is teachable. All scientists go through training
that includes much practice at trying to falsify their focal hypothesis,
and they automatize the verbal query “What alternative hypothesis
should I consider?” (p. 90)

This bias in thinking may explain why practitioners often strongly advocate
and employ a specific approach to treatment, even if this treatment is not
compellingly supported by research.

Fixed Frames

We rely on mental models or metaphors to map our world. In her book

Of Two Minds: An Anthropologist Looks at American Psychiatry, Luhrmann
(2000) explored the gulf between psychological and biological psychia-
try. Each of these perspectives represents a powerful frame that drives case
conceptualization and treatment decisions. The preferred frame of the psy-
chiatrist selected would heavily influence the outcome of a patient who
consulted that psychiatrist. One patient would leave with a prescription for

CLINICAL EXPERTISE AND DECISION MAKING 43

medication and the other five-times-a-week psychoanalysis. Most clinicians
are aware of the power of reframing, such as describing phenomena in a more
positive or negative way. The manner in which we frame an event may affect
the outcome. As F. Scott Fitzgerald (1936/1993) wrote, “The test of a first-
rate intelligence is the ability to hold two opposite ideas in mind at the same
time and still retain the ability to function” (p. 69).
Often the clinical process requires a holding of dialectic polarities.
Physicians as well as psychologists frame cases all the time and are susceptible
to the influence of this bias (Groopman, 2007). We often receive referrals
using this shorthand way of communicating: A referring clinician might say
that he or she is referring a patient with a borderline personality disorder,
attention-deficit/hyperactivity disorder, or posttraumatic stress disorder to
another clinician. The clinician looks through the lens of his or her own
expertise and, on this basis or his or her experience, communicates that a
given patient is alcoholic. This bias may limit our desire to look at the patient
and his or her presentation through a different lens. In Chapter 3 in this vol-
ume, Anchin and Singer examine the importance of theory in decision mak-
ing. Our theory of the world, of change, and of psychotherapy has tremendous
influence on our decision making.
Mental health clinicians, even those who are extensively medically
trained, can succumb to a number of errors in thinking arising from framing.
For example, mental health clinicians are generally biased to see symptoms
through a psychological frame. But consider that Graves’ disease, a variant
of hyperthyroidism, may cause anxiety and depression and may be related to
Parkinson’s disease as well as many other physical conditions (Schildkrout,
2011). Being overly attached to a frame may not allow us to consider alter-
natives. The manner in which we frame a problem is rooted in part in our
attitudes and beliefs. Patients viewed as having a biologically as opposed to
psychologically based disorder are more likely to be treated psychopharmaco-
logically (Ahn, Proctor, & Flanagan, 2009). This reflexive decision may have
serious consequences for unified treatment because it may lead to an artifi-
cial division between mind and brain, which are merely different levels of
analysis of the same phenomenon. The attitudes and beliefs we hold must be
thoughtfully examined and considered. For example, data show that when a
clinician perceives that a mental disorder has a biological basis as opposed to
a psychological one, there is likely to be less stigma attributed to the patient
with the perceived biologically based mental disorder (Ahn et al., 2009). If
persons with behavioral or mental disorders are held accountable for their
disturbances, they are more likely to be referred to psychotherapy than medi-
cation. It is also interesting that emotions lead to differential appraisals of
violence—fear increases pessimism, and anger optimism (Lerner, Gonzalez,
Small, & Fischhoff, 2003).

44 MAGNAVITA AND LILIENFELD

Hindsight Bias

Hindsight bias is well known to sports fans as “Monday-morning quarter-

backing.” More formally, hindsight bias leads us to believe that we could have
successfully predicted an outcome even when we would not have been able
to do so. When looking back, we tend to erroneously judge events as being
more predictable than they were. This error can result in overconfidence.
For example, a practitioner might persuade himself after a client attempts
suicide that he “saw it coming” or “knew it all along.” As a consequence, he
may overestimate his capacity to successfully forecast suicide attempts, which
could be dangerous to his clients.

Ignoring Alternative Hypotheses

Stanovich (2010) described a famous psychology study that exemplifies

the problems that can emerge when we ignore alternative hypotheses. The
Barnum effect, a term coined by psychologist Paul Meehl, is based on the
famous circus entrepreneur P. T. Barnum’s observation that “there’s a sucker
born every minute.” In an introductory psychology class demonstration (con-
ducted on many occasions by this chapter’s second author), the students are
given an individualized report of their personality with highly generalized
statements such as “At times you are extraverted, affable, and sociable, but at
other times you are wary and reserved” based (for example) on a graphologi-
cal analysis of their handwriting. The students then rate the accuracy of the
description on a scale of 1 to 10. More than 50 years of studies have yielded
average ratings from 7 to 9. Following the ratings, students are instructed to
compare their descriptions with those of their classmates and to discover,
much to their chagrin, that the descriptions are all identical (see Furnham &
Schofield, 1987, for a review).
It is easy to be misled in this regard as a clinician and important to
be cognizant of these influences. For example, most clinicians have to use
extensive resources to attain training in various approaches to treatment; this
process can be daunting. Deciding whether to seek advanced training in the
variety of approaches can be overwhelming because the claims made by the
progenitors of the interventions tend to be seductively appealing. We may
attend a seminar in which a prominent therapist presents videotape demon-
strating what appears to be a genuine transformation in the patient. This may
lead to entering a costly training program to advance one’s expertise, even
though there may be limited evidence to support such an approach. Many of
the biases that we have reviewed may come into play and enhance a clini-
cian’s allegiance to a particular approach to psychotherapy in which much
investment has been made and beliefs become self-perpetuating.

CLINICAL EXPERTISE AND DECISION MAKING 45

Illusory Correlation

We often assume statistical associations between statistically unrelated

variables, especially when these associations are intuitively plausible (Chapman
& Chapman, 1967). For example, we might falsely assume a correlation between
highly conflictual parental subsystems and the likelihood of certain psychologi-
cal symptoms in children. Recent evidence, however, has failed to document a
consistent link between levels of marital adjustment and behavior problems in
children (Hindman, Riggs, & Hook, 2013).

Inverting Conditional Probabilities

Another form of faulty decision making results from our tendency to

invert probabilities. As Stanovich (2010) stated,
It has been found that both patients and medical practitioners can some-
times invert probabilities, thinking mistakenly, that the probability of
disease, given a particular symptom is the same as the probability of the
symptom, given the disease (as a patient you are concerned with the
former). (p. 75)
For example, an inexperienced clinician may erroneously believe that a
client with an elevated Scale 2 (Depression) on the Minnesota Multiphasic
Personality Inventory—2 (MMPI–2) is likely to meet criteria for major
depression. In fact, although many or most patients in the throes of major
depression exhibit elevated MMPI–2 Scale 2 scores, the substantial majority
of patients with elevated Scale 2 scores are not clinically depressed.

Narrative Fallacy

We humans are marked by a tendency to weave together facts and obser-

vations into what seems to be a coherent narrative, even when the facts are not
meaningfully related. Storytelling is a powerful device that can make events
appear more plausible by adding details (Tversky & Kahneman, 1983). We
may become seduced by a story if it appears to explain seemingly unconnected
details; in turn, we may not sufficiently explore rival explanations. We may
have many useful narratives that can be explanatory. In fact, the ultimate nar-
rative that we use is theory, which is discussed in Chapter 3 in this volume.

Overconfidence Bias

It is well known that most professionals (e.g., physicians, psychothera-

pists, economists, lawyers) tend to overestimate their knowledge and ability,

46 MAGNAVITA AND LILIENFELD

especially with respect to difficult tasks. Research shows that clinicians also
tend to be overly confident about the accuracy of their decision making and
expertise, although researchers are by no means immune to this tendency
either. Overconfidence among clinicians has been substantiated by Lambert’s
(2010) research, which demonstrated that clinicians frequently underesti-
mate the proportion of negative outcomes among clients in their caseloads.
Following other authors, Lambert described this phenomenon as the Lake
Woebegone effect, from Garrison Keillor’s fictional town described on his pro-
gram A Prairie Home Companion, in which all the children are above average.
Again, the results from Walfish et al. (2012) are revealing in that when a
group of therapists was asked to rate their skill level, 25% assessed themselves
at the 90% level compared with their peers; none rated himself as below aver-
age. Attending to patient feedback is critical to reducing overconfidence.
Even if we believe that psychotherapy is progressing well, we need to consider
that our patients’ perceptions might be different.

Recall Bias

Memory is not always a sound source of reliable information. Wheelan

(2013), the best-selling author of Naked Statistics: Stripping the Dread From
the Data, wrote,
We have a natural human impulse to understand the present as a logi-
cal consequence of things that happened in the past—cause and effect.
The problem is that our memories turn out to be “systematically fragile”
when we are trying to explain some particularly good or bad outcome in
the present. (p. 122)
For example, psychoanalysis has been widely criticized for its tendency to
look to the past for causal explanations of current disorders. Part of the chal-
lenge here is that patients in treatment may erroneously “recall” events that
seem to confirm the psychoanalyst’s hypotheses, thereby reinforcing poten-
tially mistaken lines of inquiry.

Recency Effect

We tend to place too much emphasis on evidence that we have recently

encountered. This recency effect results from an overuse of the availability
heuristic. For example, if our psychotherapy client has been distressed but
largely emotionally stable over the course of the past few months, yet was
angry and affectively labile in her most recent session, we may overestimate
the likelihood that she has borderline personality disorder.

CLINICAL EXPERTISE AND DECISION MAKING 47

Representative Heuristic

This mental shortcut operates by the rule of “like goes with like” (Tversky
& Kahneman, 1974). There are “virtues” to judging information on the basis
of our impressions. In many cases, reliance on stereotypes (e.g., the extent to
which a client reminds us of our prototype of the modal patient with schizo-
phrenia) is more accurate than sheer guessing (Kahneman, 2011, p. 151).
Nevertheless, this tendency can lead to errors in the clinical context. We may
assume that a client with bipolar disorder who reminds us of a previous client
with borderline personality disorder has the latter condition; as a consequence,
the client may receive inappropriate or inadequate treatment. However, it is
tempting to predict unlikely events even when the base rates are low. This error
can lead to the phenomenon of base rate neglect, a corollary of the overuse of
the representativeness heuristic. For example, if a client who acts differently on
different occasions reminds us of our prototype of dissociative identity disorder,
we may jump too readily to assign this diagnosis, forgetting that the prevalence
of this condition in the general population is probably extremely low.

Sunk-Cost Effect

We tend to escalate our commitment to a course of action in which we

have made a substantial prior investment of resources. Instead of considering
another approach or modality of treatment when the patient is not progressing
adequately, we might suggest that he or she continue with the same approach
but come more frequently. The therapeutic process can be susceptible to this
form of escalating commitment. For example, trainees in various approaches
to psychotherapy often persist and escalate their effort using a favored
method of psychotherapy, such as cognitive, affective, or defense restructur-
ing (Magnavita, 2005). They believe in the efficacy of their interventions and
have put a lot of effort into learning them. Unfortunately, following a course
of action without attention to patient feedback often results in poor outcome
or premature termination. In some cases, patients have walked out of sessions
when the therapist relentlessly persists with a particular method.

Selection Bias

Where and from whom we gather our data influences our analyses. Most
psychologists have been trained to recognize the inherent problems when
samples are not obtained by random selection. This bias can be introduced
in many ways. For example,
A survey of consumers in an airport is going to be biased by the fact that
people who fly are likely to be wealthier than the general public; a survey

48 MAGNAVITA AND LILIENFELD

 at a rest stop on Interstate 90 may have the opposite problem. (Wheelan,
2013, p. 118)
Clinicians in forensic (prison) settings, for example, must remain cognizant
of the fact that their clients have higher rates of childhood physical abuse
than do individuals in the general population. If they do not, they may over-
estimate the extent to which physical abuse causes criminal behavior in the
general population.

Survivorship Bias

Another factor that can bias our thinking is the fact that in datasets
from clinical and research settings, dropout rates are often high. Those who
remain in treatment may not be representative of the population. Wheelan
(2013) wrote, “If you have a room of people with varying heights, forcing the
short people to leave will raise the average height in the room, but it doesn’t
make anyone taller” (p. 123). In psychotherapy, the clients who remain in
treatment are typically those who are benefiting from it. If we do not take
survivorship bias into account, we may overestimate our effectiveness as
therapists.

Publication Bias

There is general agreement that there is a crisis in science, including

psychological science. A recent edition of The Economist examined “How
Science Goes Wrong” (2013) in a front-page article. One major source of
concern is publication bias (Rosenthal, 1979), which seems to be rampant
in a number of disciplines. In psychiatry, especially in the subfield of psycho-
pharmacology, the results of studies in many instances have been biased by
the pharmaceutical industry, which has often overstated the efficacy of cer-
tain medications for psychological disorders (Whitaker, 2010). Publication
bias assumes various forms; the most common is a tendency for journals to
publish only research that shows novel findings, positive findings, or both.
The pharmaceutical industry has been accused of publishing research that
supports the efficacy of their products and squelching findings that are less
flattering. This tendency can exert a negative downstream effect. For exam-
ple, when meta-analytic studies eventually challenged many of the accepted
findings regarding the efficacy of selective serotonin reuptake inhibitors, the
results were very different when unpublished negative results were included
(see Chapter 5 in this volume). Researchers are under so much pressure to pro-
duce groundbreaking results that few are interested in replicating studies that
have yielded significant effects, which results in a lack of replication of many
key findings (Pashler & Wagenmakers, 2012). Unfortunately, psychology

CLINICAL EXPERTISE AND DECISION MAKING 49

is not immune from similar problems with careerism and publication bias
(Kagan, 2012).

ENHANCING CLINICAL DECISION MAKING

All clinical practice involves explicit and implicit prediction (Faust,

2007, p. 51). Much of what is decided in clinical practice cannot be derived
directly from research evidence. However, Kahneman (2011) observed that
when we have doubts about the veracity of evidence, we must not let judg-
ment stray too far from the base rates. He cautioned, “Don’t expect this exer-
cise of discipline to be easy—it requires a significant effort in self-monitoring
and self-control” (p. 153).
Balancing the two primary systems of thinking is essential to effective
clinical decision making, as Gladwell (2005) wrote: “Truly successful deci-
sion making relies on a balance between deliberate and instinctive thinking”
(p. 141). We should write down and compare what is known with what is
unknown (Roberto, 2009, p. 87). It is important to keep in mind epistemol-
ogy, or the nature of knowledge, given that we have a limited understanding
of the mind and how it goes wrong. As a consequence, we should continu-
ally be striving to combat confirmation bias and allied biases by questioning
the veracity of everything we consider to be true. In the final section of this
chapter we conclude by presenting some of the safeguards that can be used to
avoid cognitive traps and enhance our clinical decisions.
Tracey et al. (2014) summarized some important ways to enhance clini-
cal decision making:
(a) adopting a Bayesian approach by looking at base rates, (b) obtaining
quality information (e.g., relying on valid measures rather than impres-
sions), (c) relying less on memory, (d) recognizing personal biases and
their effects, (e) being aware of regression to the mean where less extreme
behavior follows extreme behavior, and (f) adopting a disconfirming, sci-
entific approach to practice. (p. 224)
In the following, we elaborate on the first two of these recommendations,
followed by an additional recommendation: tolerating uncertainty.

Adopting a Bayesian Approach

Probabilistic thinking offers rules to follow, which provide a basis for

decision making (Stanovich, 2010). “Decision-making is a very complex
endeavor, something that we engage in all the time, some decisions more
high stakes than others, but oftentimes decision-making can perplex us”

50 MAGNAVITA AND LILIENFELD

(Roberto, 2009, p. 9). Intuition can lead us astray by drawing from outdated
patterns or challenging our relied-on rules of thumb. Bayesian analysis uses
a mathematical approach to making decisions based on the numerical prob-
ability of various potential outcomes. A basic understanding and incorpora-
tion of Bayesian reasoning is crucial to accurate decision making. Bayes’s
rule states that the “diagnosticity of evidence must be weighted by the base
rate” (Stanovich, 2010, p. 59). Diagnosticity refers to the validity of the infor-
mation, which in studies of psychiatric diagnosis is obtained by drawing on
conditional probabilities (true positive rate, false positive rate, true negative
rate, false negative rate). Stanovich (2010) wrote that
when the case evidence gives the illusion of concreteness—people
combine information in the wrong way. The right way is to use Bayes’
rule, or, more specifically, insight from Bayes’ rule. . . . It is enough that
people learn to “think Bayesian” in a qualitative sense—that they have
what might be called “Bayesian instincts,” not that they have necessarily
memorized the rule. (p. 59)
For example, if a test is known to have a high percentage of false positive
results, and is applied to a group with a low base rate, there is a low likelihood
that the test will overdiagnose psychopathology in that sample. Stanovich
(2010) wrote that if nothing else is understood about Bayesian reasoning, the
acknowledgement of base rates is all that is essential but “of course, greater
depth of understanding would be an additional plus” (p. 59). He believes that
this type of “qualitative understanding” affords us the opportunity to make
“guesstimates,” which are approximate and close enough to prevent serious
errors in practice (p. 59). The importance of a Bayesian approach to decision
making is to remind us not to ignore the statistical influence of base rates
when calculating probabilistic decisions.

Mining Quality Information

The access to information that is available with the Internet and search
engines is fundamentally changing human social memories and transcend-
ing some of the limitations of human cognition (Wegner & Ward, 2013).
Most clinicians now have access to high-quality information that has never
been so readily available and can be easily used to enhance decision making
by using Boolean operators—search commands—to access relevant data-
bases (Norcross et al., 2008). In Chapter 5 in this volume, Hollon discusses
the steps involved in generating structured questions in the development
of clinical practice guidelines. These are called PICOTS, a mnemonic that
stands for populations, interventions, comparisons, outcomes, time, and
settings.

CLINICAL EXPERTISE AND DECISION MAKING 51

 Clinical science has advanced to the stage at which we now have a
number of treatment approaches that have been substantiated as effective for
a range of mental and behavioral disturbances. As Karlin and Cross (2014)
noted,
Over the past 30 years, psychotherapeutic interventions have been
developed and empirically validated for a wide range of psychological
conditions, including conditions that not too long ago were considered
untreatable, such as posttraumatic stress disorder. (p. 19)
However, a serious problem with dissemination remains. The science-
to-practice lag time for evidence-based practices is, in fact, longer (and in
many cases, far longer) than the typical lengthy lag time of 15 to 20 years
identified for medical interventions by the Institute of Medicine (2001) in its
seminal report Crossing the Quality Chasm: A New Health System for the 21st
Century (pp. 20–21).
Where possible, rely on established empirically based algorithms. As
computer technology and the capacity to effectively mine big data advances,
there will be an increasing trend to rely on algorithms. It is well documented
that even experts are typically inferior to algorithms, so the hostility that
many hold needs to be addressed through education. Kahneman (2011), sum-
marizing the work of Paul Meehl, noted that some clinicians have a natural
antipathy to algorithmic thinking because it goes against many of the beliefs
that clinicians hold dear. “The research suggests a surprising conclusion: to
maximize predictive accuracy, final decisions should be left for formulas,
especially in low-validity environments” (p. 225). An example of a classic
algorithm developed by the pediatrician Virginia Apgar in 1953 is still used
today to assess newborns’ health using a rating of five variables (heart rate,
respiration, reflex, muscle tone, and color). This simple rating is credited for
significantly reducing infant mortality (Kahneman, 2011). A very pragmatic
algorithm identified by John Gottman (1999), called the Four Horsemen of
the Apocalypse, is highly predictive of the demise of a marital relationship.
The “four horsemen” are partners’ criticism, defensiveness, contempt, and
stonewalling. When these warning signs are observed in a couple, on average
they divorce following 5.6 years, much sooner than other couples. Clinical
algorithms such as Gottman’s are easy to use and helpful, not only as predic-
tive tools but as educational tools for clients in treatment.

Tolerating Uncertainty: Assuming a Reflective Stance

As we have discussed, uncertainty in the face of complexity is an unavoid-

able part of clinical practice. We encounter three types of uncertainty in clini-
cal practice. The first concerns not having mastered the material necessary to

52 MAGNAVITA AND LILIENFELD

guide our decision making—continuous learning is essential as the field of clin-
ical science is rapidly advancing. The second concerns acknowledging the limi-
tations of the evidence base on which we rely to inform our decision making.
In terms of the exponential number of variables and their interrelationships, it
is highly unlikely that the field will ever have perfect knowledge or anything
close to it. Therefore, many clinical questions will remain murky because of
lack of information—we must be able to effectively function in situations of
less than perfect knowledge. In fact, clinical advances often emerge from these
states of unknowing. The third type of uncertainty concerns a combination
of the first two, whereby clinicians cannot distinguish between their lack of
mastery or ineptitude and limitations of their knowledge (Groopman, 2007,
p. 152). Groopman (2007) argued that a tendency for many practitioners to
deny uncertainty often leads to a closed mind and suboptimal decision making.
There are many aspects of decision-making theory and research that we
can incorporate into our clinical processes with the goal of increasing mind-
fulness and thereby honing our clinical decision-making skills. Assuming a
“mindful” stance when making decisions and acknowledging our feelings can
be like an “emotional thermostat” recalibrating our decision analysis (Hertz,
2013, p. SR6). Kahneman (2011) suggested that “continuous vigilance” when
making all decisions is not practical and that “the best we can do is a compro-
mise: learn to recognize situations in which mistakes are likely and try harder
to avoid significant mistakes when the stakes are high” (p. 28). The more
aware we are of our cognitive biases, including those discussed in this chapter
and this volume, the greater chance we have of guarding against these cogni-
tive and perceptual traps. Actively identifying the biases present in our work
enhances the value of our expertise by balancing System 1 and System 2 pro-
cesses inherent in most decision making. It is important to keep in mind that
“conscious doubt is not in the repertoire of System 1; it requires maintaining
incompatible interpretations in mine at the same time, which demands men-
tal effort. Uncertainty and doubt are the domain of System 2” (Kahneman,
2011, p. 80).
There may be a partial antidote, however. Kahneman (2011) wrote, “To
derive the most useful information from multiple sources of evidence, you
should always try to make these sources independent of each other” (p. 84).
Hence, we should remember to try to minimize redundancy from information
sources. In some cases crowds make better decisions than individuals, espe-
cially when the crowds consist of independent opinions (Surowiecki, 2004).
This may be an important and unexamined way to shed light on what the
public finds useful. As the general public’s level of sophistication concern-
ing behavioral and mental health treatments rises, new patients increasingly
request certain types of treatment. This may be similar to the trend that
physicians have witnessed with the rise of direct-to-consumer advertising by

CLINICAL EXPERTISE AND DECISION MAKING 53

the pharmaceutical industry, which has resulted in more patients requesting
specific drugs. The industry’s heavy advertising, often promising a quick fix
to their distress, may have influenced them.

SUMMARY

In the absence of perfect information, compounded by the complexity

of human nature, which to a large degree is unpredictable, uncertainty is an
inherent element of clinical practice. Such uncertainty must be addressed
using a pragmatic approach to decision making. Clinical expertise requires
an understanding of decision analytics to guard against common decision-
making traps. Effectiveness in behavioral and mental health practice requires
not only an extensive knowledge base and experience but also the ability to
understand the ways in which our fast and slow approaches to processing
information influence our decision making. Decision making, which often
relies unduly on intuition, can be influenced by a host of documented cog-
nitive biases with which clinicians should be conversant. It is imperative
that we seek to minimize bias in clinical practice by increasing awareness of
decision analytics, providing training in decision making for all clinicians
regardless of their experience, and developing decision aids such as clinical
practice guidelines. We are duty-bound to ensure the best care by reducing
biases, which are inherent in human thinking.
We can distill several crucial pieces of advice from the literature on
clinical decision making. In aggregate, these principles can enhance clinical
outcomes. These include the following:
1. Familiarize yourself with the field of decision analytics and use
it to enhance your awareness of decision-making traps.
2. When making clinical decisions, be sure to “conceptualize
problems in multiple ways” (Ruscio, 2007, p. 44).
3. Always consider using existing algorithms when making clini-
cal decisions by referring to the extant literature. Moreover, as
clinical practice guidelines become the state of the science, refer
to them frequently to keep current.
4. “Recognize that personal experience is anecdotal evidence”
(Ruscio, 2007, p. 4) and, as substantial research has shown, that
anecdotal evidence is not sufficient to ensure optimal decision
making. As a wise person once said, the plural of anecdote is
not data. Anecdotes can be enormously helpful for generating
hypotheses in treatment, but they are rarely useful for testing
or corroborating them.

54 MAGNAVITA AND LILIENFELD

 5. Always rely on principles of probability for complex decision
analytics. Keep in mind that clinical judgment must be based
on a solid evidence base.
6. When there are cases that do not fit the statistical trends,
proceed with caution and keep in mind the cognitive traps to
which one may easily resort.
7. In your practice, refer to the extant literature on a regular basis.
This is becoming much easier with the development of infor-
mation technology, clinical practice guidelines, and systems
that make patient feedback much easier to incorporate.
8. Develop formats that provide feedback about one’s work, such
as videotape review of sessions, a consultation group, incorpo-
rating patient feedback systems, and using metrics to monitor
outcome.
9. Carefully examine and be aware of attitudes and beliefs that
influence your conceptualization of the mind, treatment, and
human change processes.
The remaining chapters in this volume explore many facets of decision
making relevant to clinical practice. We hope you find these illuminating and
useful to your daily work.

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60 MAGNAVITA AND LILIENFELD

 3
A DUAL PROCESS PERSPECTIVE
ON THE VALUE OF THEORY
IN PSYCHOTHERAPEUTIC
DECISION MAKING
JACK C. ANCHIN AND JEFFERSON A. SINGER

Over the entire course of a patient’s psychotherapy, within any given

session and across sessions, the practicing clinician is confronted with the
highly responsible task of making countless judgments and decisions. For
example, during initial assessment and evaluation, what kinds of information
about the patient are essential to acquire, in what sequence, and how should
this information be gathered? During initial case conceptualization, what
formulation best organizes and integrates these data from the standpoint of
maximizing understanding of the patient and his or her difficulties? And based
on this understanding, what treatment plan is indicated? In this respect, what
are appropriate and realistic treatment goals? In pursuing the latter, is brief
or longer term therapy most warranted? And what specific treatment strate-
gies, interventions, and techniques should be used to foster attainment of the
established goals?

http://dx.doi.org/10.1037/14711-003
Clinical Decision Making in Mental Health Practice, J. J. Magnavita (Editor)
Copyright © 2016 by the American Psychological Association. All rights reserved.

61
 The clinician is also confronted with decisions pertaining to the process
of psychotherapy. For example, as treatment unfolds, what ways of relation-
ally responding to and interacting with the patient will best establish, build,
and maintain the therapeutic alliance? At any given point when engaging in
inquiry, should an open-ended or a closed-ended question be used? How long
should silence be maintained before the therapist intercedes with a statement
or question? At a particular juncture in treatment, what degree of balance
between support and confrontation is most responsive to the patient’s cur-
rent treatment needs and clinical status? And what are the indicators that it
is appropriate to begin addressing treatment termination, and what is the best
way to implement termination with this specific patient?
Although these and innumerable other questions operate as decision
choice points for the psychotherapist, one facet of psychotherapy about
which the therapist does not need to make a decision is the overarching
purpose of the enterprise: Psychotherapy is an intrinsically goal-directed pro-
cess intended to help the patient move toward greater mental health and
self-understanding in his or her day-to-day functioning and subjective expe-
rience. This metagoal frames the entire endeavor, and therefore the practice
of psychotherapy presupposes that the therapist’s judgments and decisions
throughout the treatment process are motivated by this prevailing desire.
This motivation is of course crucial, but it is not sufficient. The therapist
must also have actual tools that, yoked to this essential motivation to help,
facilitate and guide his or her specific decisions in therapeutic directions.
In this chapter we discuss the centrality of theory as one such tool—as
vital to the psychotherapist as an architect’s blueprints are to builders or
a musical score is to musicians in a symphony orchestra. Just as blueprints
or a musical score stipulate the components of their ultimate product, they
also presuppose a particular endpoint—a skyscraper or a symphony. They are
created with a teleological purpose—to yield a particular “good outcome.”
Theory for psychotherapists works in the same way. It stipulates not only the
working parts of the process that will unfold but also the particular endpoint
of “good health” that is being pursued. Psychotherapy is always promoting a
particular vision of the good life, and theory is the medium through which
this message is constructed.
Theory contributes to psychotherapeutic decision making, and its utili-
zation can be maximized for the good. In the chapter’s first section we crystal-
lize key features of theory in psychotherapy, emphasizing that both explicit
and implicit theories inhabit the mind of the psychotherapist. In the second
section we elucidate the centrality of dual process conceptions of the human
mind by describing attributes of automatic and deliberative processing, their
differential approaches to decision making, and their interactivity. We then
integrate these two lines of discussion in the third section by presenting and

62 ANCHIN AND SINGER

analyzing a clinical vignette to illustrate how the judgments and decision
making of a psychotherapist are guided by both the automatic and deliberate
use of implicit and explicit theory. We conclude by translating our analy-
sis into specific recommendations for optimizing clinical applications of this
dual process perspective on theory’s value in therapeutic judgment and deci-
sion making.

THE NATURE OF THEORY IN PSYCHOTHERAPY

The psychotherapeutic endeavor abounds with astonishing complex-

ity, rendering theory essential—indeed, unavoidable. Over a half-century
ago, Shoben (1962) enduringly captured the indispensable organizing and
meaning-making functions served by theory in psychotherapy:
The world of the counselor confronted by a client is closely analogous
to the world of the baby as William James characterized it: a big, buzz-
ing, booming confusion. The counselee reports events from his own
history, considers his present and past experience, reacts directly to
the counselor and the counseling relationship, responds to tests, and
otherwise provides a welter of raw data about himself. The counselor,
if he is to understand the person to whom he is professionally respon-
sible, must discover (or create) some order in this chaos of impressions.
In short, he must make some fruitful sense out of what his client says
or does. . . . To say these things is to indulge in truisms, of course, but
reminding ourselves of them leads to the proposition that theory is
inevitable and inescapable in the counseling process and in the coun-
selor’s professional behavior. (p. 617)
In significantly facilitating a therapist’s navigation of psychotherapy’s
multiple concurrent, sequential, and nonlinear complexities, theory is akin
to a map (Hechter & Horne, 2003). A map provides an abstract visual rep-
resentation of a geographical territory and helps a traveler to physically tra-
verse this territory with accuracy and effectiveness. It does so in part through
labeling diverse features of the territory with different symbols, such as non-
linguistic representations (e.g., lines of different thickness denoting different-
sized roads; colors for indicating physical objects—blue for lakes, green for
forests), words (e.g., the names of towns and streets), and numbers (e.g., the
number 33 at various points on a particular line, denoting “Highway 33”).
These nonlinguistic, verbal, and numeric symbols not only signify different
aspects of the territory, but crucially, they also visually depict how these dif-
ferent aspects are organized in relation to one another. Yet maps of the same
geographical territory can be very different. For example, one may include
certain features but not others, but these excluded features may be depicted

A DUAL PROCESS PERSPECTIVE 63

on a second map of the same territory, and a third may contain elements from
the first two while adding still additional features absent in these but present
in the actual physical geography.
A psychotherapy theory, understood metaphorically as a map, is
similarly an abstract representation, but in this case the terrain of interest
encompasses human personality development and functioning; psycho-
logical health and disorder; and psychotherapeutic principles, procedures,
and processes (Anchin, 2006). As will be elaborated momentarily, different
theories provide different maps of these same clinical domains. Each deploys
its own specific set of concepts to designate what are viewed as these domains’
key features as well as propositions that specify how these concepts and the
features they signify are related to one another. However, this matter is not
as straightforward as it may seem, in that therapists characteristically—and
necessarily—navigate the complexities of psychotherapy’s regions of interest
with two types of maps: an explicit theory and an implicit theory (Jones-
Smith, 2012; Najavits, 1997; Sandler, 1983; Shoben, 1962). Each type of
theory is composed of different components, although in real time they are
highly interactive.

Explicit Theory

As concisely defined by Jones-Smith (2012), a therapist’s “explicit

theory of psychotherapy usually represents a theoretical orientation of some
school of thought” (p. 601). Principal contemporary schools of thought are
exemplified by the cognitive–behavioral, psychoanalytic–psychodynamic,
humanistic–experiential, family systems, and integrative paradigms. Each
such paradigm is characterized by “a set of assumptions [that are] founda-
tional, general belief statements” (Kim, 2010, p. 32) about personality, mal-
adjustment, and the aims of psychotherapy. These assumptions are “implicit
philosophies” (Elliott, 2008, p. 41), “first principles of thought” (Miller, 1992,
p. 6), that cannot be proven or disproven but are nevertheless taken to be
fundamental truths. And if these days they are not taken as truths with a
capital T, they are still held as essential working premises that give meaning
and narrative structure to what otherwise might often seem inchoate and
overwhelming (Spence, 1982). Each such explicit theory of psychotherapy
is a multicomponent knowledge structure composed of specific concepts that
delineate and define distinctively important elements in the realms of per-
sonality, psychopathology, psychological health, and psychotherapy; explan-
atory propositions that explain and predict operative relationships between
these elements; and specific intervention techniques for promoting change
that are intimately tied to the understanding of the patient and his or her
psychopathology enabled by these concepts and propositions.

64 ANCHIN AND SINGER

 It is essential to note that explicit theories of psychotherapy are nomo-
thetic in that they are formulated to apply to patients in general. Even in the
case of a theory of psychotherapy developed for a delimited class of disorders—
for example, interpersonal psychotherapy of depression (Klerman, Weissman,
Rousansville, & Chevron, 1984)—the concepts, propositions, and techniques
are abstractions that do not provide guidance for how to tailor treatment to
the particularities and vicissitudes of the individual case. As Shoben (1962)
astutely pointed out,
Thus, we are confronted with a paradox. Theories in counseling are
inevitable as necessary tools to bring orderliness into the chaotic world
of the counseling interchange and to promote the counselor’s under-
standing of his client. But theories are destined, by virtue of their abstract
nature, to leave out of the account the special and unique qualities of a
particular counselee’s behavior and history, and theories can contain the
danger of luring the counselor into conceiving the case before him as a
representation of abstract ideas and formal relationships rather than as a
highly distinctive and individual human being. (p. 618)
Shoben’s (1962) observations are a call for the necessity of bringing to
the therapeutic situation not only nomothetically based knowledge of person-
ality, psychopathology, and psychotherapy provided by explicit theory but also
the willingness and capacity to blend applications of this knowledge with an
evolving idiographic understanding of the patient. More than 50 years later,
Shoben’s caution is mirrored by the attentiveness to specificity strongly encour-
aged by today’s evidence-based practice movement in psychology. The APA
Presidential Task Force on Evidence-Based Practice (2006) suggested that
“psychological services are most likely to be effective when they are responsive
to the patient’s specific problems, strengths, personality, sociocultural context,
and preferences (Norcross, 2002)” and “that sensitivity and flexibility in the
administration of therapeutic interventions produces better outcomes than
rigid application of manuals or principles (Castonguay, Goldfried, Wiser, Raue,
& Hayes, 1996; Henry, Schacht, Strupp, Butler, & Binder, 1993; Huppert et al.,
2001)” (p. 278). Requisite to idiographic specificity, sensitivity, and flexibility
is attunement to and responsiveness within the relational matrix that unfolds
with the specific patient at hand—considerations that point to the important
role of a therapist’s implicit theory of psychotherapy.

Implicit Theory

Providing propositions that can guide a therapist’s handling of every

contingency or nuance that arises during the treatment process is beyond
the scope of any explicit theory of psychotherapy. A therapist’s implicit

A DUAL PROCESS PERSPECTIVE 65

theory is instrumental in filling this sizeable gap. Najavits (1997) defined
an implicit theory of psychotherapy “as therapists’ private assumptions or
‘working model’ about how to conduct psychotherapy that is distinct from,
but co-exists with, normal theoretical orientations” (p. 2). Moreover, as she
discerningly pointed out, these assumptions and beliefs “may be conscious,
preconscious, or unconscious to the therapist; ‘implicit’ simply refers to ad hoc,
tacit assumptions of therapists, as distinct from the formal propositions of
orientations” (p. 4). Indeed, similar to the therapist’s explicit theory, implicit
theory is a knowledge structure, but whereas the former can be conceived of
as a formal knowledge structure, the latter is more informal in its structure.
Drawing on clinical and empirical literature, Najavits provided an illumi-
natingly useful sampling of domains, presented in Table 3.1 (along with an
example that we provide for each), in which a therapist’s implicit assump-
tions and beliefs may operate.
The contents of specific tacit assumptions and beliefs composing a
therapist’s implicit theory develop in part through experience gained in prac-
ticing the craft—products of a learning process that to no small extent is itself
implicit. As Patterson, Pierce, Bell, and Klein (2010) explained, “‘Implicit
learning’ refers to the process of learning without intention and without being
able to verbalize easily what has been learned” (pp. 291–292). Less-than-
conscious acquisition of this clinically relevant knowledge is consistent with
empirical evidence that implicit learning occurs through associative learning
mechanisms that “pick up statistical dependencies encountered in the envi-
ronment and generate highly specific knowledge representations” (Frensch
& Rünger, 2003, p. 17). Patterson et al. characterized these statistical depen-
dencies as “dynamical statistical patterns and features in the environment”
(p. 290), and they presented evidence that among statistical patterns tacitly
learned are joint probabilities (the probability that an event A and an event B
will co-occur; e.g., “When I lose a sense of time passing in the session, it is
likely that the patient and I have become engaged in emotionally meaningful
work”) and conditional probabilities (the probability that if event A occurs,
then event B will follow; e.g., “If a patient with a substance disorder starts
therapy highly ambivalent about change, then it is likely that his initial treat-
ment motivation will be low”). Moreover, Patterson et al. pointed out that
this kind of learning “is a ubiquitous, robust phenomenon that likely occurs
in most, if not all, tasks in which individuals engage throughout their lives”
(p. 299). As such, implicit associative learning significantly contributes to
the development of expertise in a given content domain, and its product—
tacit knowledge (Patterson et al., 2010)—informs the expert’s judgments and
decisions in his or her domain of expertise.
Although derived in part from experientially based associative learn-
ing of regularities, a therapist’s implicit assumptions about how to conduct

66 ANCHIN AND SINGER

 TABLE 3.1
Sampling of Domains in Which Implicit Assumptions
and Beliefs May Operate
Domain Example
Personal strategies of what to do during Keep the patient focused on material that is
sessions emotionally charged, since the charged
nature of this content indicates that it
contains important meanings that will be
valuable to collaboratively cull out.
Views about what processes are actually Apart from the session-to-session content
occurring during therapy being dealt with, over time how the
patient experiences the therapist and
their interactions impacts the patient’s
view of and feelings about self in muta-
tive ways.
Views about what not to do in therapy Don’t try to convince the patient to see
things the way I do.
Assumptions that hinder treatment Do not stray from the agenda that I have
for the session, even if the patient
wishes to focus on a different topic.
Metaphors for the therapy process Psychotherapy is sometimes like arm
wrestling with the patient’s psycho-
pathology.
Personal axioms therapists tell them- Be in the here-and-now.
selves during sessions
Views on what to do when particular If the patient is an acute state of crisis
problem situations arise and despair, be willing to provide direct
advice.
Ideas of what makes therapy difficult to Despite assigning between-session
do well homework that has the potential to
advance therapeutic progress, patients
do not always follow through with imple-
menting assignments, and the amount
of control the therapist has for getting
them to do so is limited.
Subjective criteria by which therapists The patient is experiencing meaningful
measure their success changes in his or her life that on a day-
to-day basis are accompanied by more
frequent positive affectivity.
Note. Adapted from “Psychotherapists’ Implicit Theories of Therapy,” by L. M. Najavits, 1997, Journal of
Psychotherapy Integration, 7, pp. 1–16. Copyright 1997 by the American Psychological Association.

psychotherapy develop from still additional sources. Shoben (1962) suggested

that therapists, on the basis of their own life experiences, develop ideas about
how people “do and should behave” (p. 619) and that these “value-laden
attitudes about the nature of man [sic] may have something to do with the
ideas that we regard as ‘right’ and fruitful” (p. 619). These ideas may in turn
influence a therapist’s preferences in the direction of theories that validate

A DUAL PROCESS PERSPECTIVE 67

his or her tacit conceptions about personality and the relative importance of
different classes of human behavior. In truth, how could it be any other way,
given that cognitive consistency would demand that the theories we espouse
be congruent with our underlying values and beliefs about human nature?
Clinical supervision provides still another source of a therapist’s evolving
implicit beliefs about how to conduct psychotherapy. In the course of such
pedagogical exercises as case discussions, analysis of segments of videotaped
sessions, and providing feedback, clinical supervisors invariably not only
educate supervisees about formal theoretical concepts, principles, and tech-
niques but also communicate their own informal and tacit beliefs about the
practice and processes of psychotherapy, not to mention their conceptions of
what good health and a good life are.
Although the structure and content of explicit and implicit theories
in psychotherapy differ considerably, they share a significant commonality:
When all is said and done, both forms of theory fundamentally reside and
function in the mind of the psychotherapist. As such, explicating how a
psychotherapist draws on theory in making clinical judgments and deci-
sions must incorporate an understanding of how the human mind itself
operates. This knowledge is contained within a remarkably copious body of
theory and research centering on the view that the mind operates through
two types of “thinking, knowing, and information processing” (Slovic,
Finucane, Peters, & MacGregor, 2004, p. 313), a conception embodied by
dual process theories of mental functioning, to which we turn our attention
in the next section.

DUAL PROCESSING IN JUDGMENT AND DECISION MAKING

Over the past 3 decades, an array of dual process models of the human
mind have been developed in cognitive and social psychology. These models
and their associated cross-disciplinary research programs have extended their
reach to the study of judgment and decision making. Illustrating the value
of these concepts through their application to medical diagnostic reasoning
and decision making, Croskerry (2009b) suggested that “a variety of lines
of evidence from philosophy, psychology, neurology, neuroanatomy, neuro-
physiology, and genetics in recent years provides support for the view that
decision making might best be represented by dual process theory” (p. 29).
Lying at the heart of this body of formulations is the view that the human
mind is characterized by two “qualitatively distinct forms of processing”
(Evans & Stanovich, 2013, p. 226), one characterized by automatic and the

68 ANCHIN AND SINGER

other by deliberative processing.1 Comprehensive and incisive analyses by
Evans (2008), Evans and Stanovich (2013), and Gawronski and Creighton
(2013) make clear that dual process models are far from homogeneous, but
these scholars also agree that amid this diversity sufficient commonalities
exist to enable identification of generic properties and attributes character-
izing dual process formulations of the mind. Here, space limitations allow
only brief synopses highlighting frequently cited attributes of these two
types of processing; sources informing this discussion provide more extensive
detail (see Bargh, Schwader, Hailey, Dyer, & Boothby, 2012; Beevers, 2005;
Bodenhausen & Todd, 2010; Croskerry, 2009a, 2009b; Evans, 2008; Evans &
Stanovich, 2013; Gawronski & Creighton, 2013; Sinclair, Sadler-Smith, &
Hodgkinson, 2009; Slovic et al., 2004; Smith & DeCoster, 2000). Following
Evans and Stanovich (2013), we emphasize that for processing to be char-
acterized as automatic or deliberative, it is not necessary for the entire set of
attributes within each form of processing to occur together. Rather, within
each type of processing, “there is a clear basis for predicting a strongly correlated
set of features, [but] very few need be regarded as essential and defining
characteristics” (p. 228, italics added).

Automatic Processing and Decision Making

Automatic processing accounts for information processing, includ-

ing judgment and decision making, that is relatively effortless, rapid, and
efficient. It transpires without conscious awareness (and thus is variously
referred to as nonconscious and as unconscious), is triggered spontaneously
and unintentionally by features of the immediate context, is parallel (i.e.,
multiple processing tasks and operations are simultaneously engaged), and
occurs without necessitating working memory. Automatic processing also
tends to be associative; holistic, in the sense of “process[ing] separate fea-
tures as a single unified whole” (Richler, Wong, & Gauthier, 2011, p. 129);
and affect laden. Knowledge structures retrieved from memory and quickly
drawn on during automatic processing form slowly through experience-based

1Other theorists and researchers have characterized the distinction between these two forms of infor-
mation processing as, for example, automatic and controlled (Schneider & Chein, 2003), associative and
reflective (Beevers, 2005), experiential/intuitive and rational/analytic (Epstein, 2010), reflexive and reflec-
tive (Lieberman, 2007), System 1 and System 2 (Kahneman & Frederick, 2002), and Type 1 and Type 2
(Evans & Stanovich, 2013). Each such dualistic characterization captures major differentiating features
encompassed by dual process theories. For present purposes, the automatic–deliberative terminology has
been chosen to descriptively highlight a core distinguishing feature of each type of processing on which
other features of each system seem to conceptually load, as it were. It must also be noted that whatever
terminology is used, the dual process distinction is not without controversy (see, e.g., Keren & Schul,
2009; Newell & Shanks, 2014).

A DUAL PROCESS PERSPECTIVE 69

learning and skill acquisition. However, there is emerging evidence that in
certain realms (e.g., social–cognitive processes) automatic processing is not
exclusively dependent on the acquired products of experience but also draws
on innate motivational and emotional processes (see Bargh et al., 2012; for a
cognitive neuroscience perspective, see Singer & Conway, 2011).
In the realm of judgment and decision making, many of these features
of automaticity are akin to a form of intuition. Although in point of fact
“there are multiple kinds of intuition” (Glöckner & Witteman, 2010, p. 5),
Sinclair et al. (2009) provided an action-oriented definition that is pragmati-
cally valuable in the present context:
“Intuiting” [is] . . . a process leading to a recognition or judgment that
is arrived at rapidly, without deliberative rational thought, is difficult
to articulate verbally, is based on a broad constellation of prior learn-
ing and past experiences, is accompanied by a feeling of confidence or
certitude, and is affectively charged (Davis and Davis, 2003; Dane and
Pratt, 2007). (p. 393)

This definition concurs with the conceptualization of intuition adopted

in naturalistic decision making (NDM; see Schraagen, Militello, Ormerod,
& Lipshitz, 2008), a rich paradigm for understanding and improving decision
making that studies experts’ in situ decisional processes in dynamic, highly
taxing settings (e.g., firefighting, intensive care units, aviation, combat).
Characteristic of these naturalistic situations are “uncertainty, time pressure,
risk, and multiple and changing goals” (Schraagen, Militello, et al., 2008,
p. xxv). The applicability of these parameters—and NDM’s conceptions
more generally—to psychotherapy is striking, yet this paradigm has yet to be
deployed in the effort to study and understand psychotherapeutic decision
making. This is slightly ironic given how often therapists are confronted with
highly charged emotional interactions and on-the-spot decisions with regard
to suicidality, heightened family conflict, and recruitment of additional support
and/or legal authorities.
Klein’s (1998) model of recognition-primed decision making (RPD),
one of NDM’s flagship models (Keller, Cokely, Katsikopoulos, & Wegwarth,
2010), highlights intuition in explaining how experts in complex, exacting
situations rapidly identify and implement an effective course of action with
minimal deliberation. As Klein (1998) explained, “intuition depends on the
use of experience to recognize key patterns that indicate the dynamics of the
situation” (p. 31). In this pattern-recognition process, the expert decision
maker tunes in to certain situational cues and features and their configuration
on the basis of experientially based situational awareness. Through match-
ing this information to previously stored pattern exemplars or prototypes
the decision maker recognizes this to be a pattern of a certain kind (detects

70 ANCHIN AND SINGER

typicality; Klein, 1998, p. 149). On the basis of this similarity, the decision
maker draws automatic inferences about what to expect, what goal is plau-
sible, and what course of action is likely to successfully achieve that goal in
the context at hand. Crucial to this process’s rapidity is circumvention of
the time-consuming process of generating and comparing response options.
Rather, intuition in RPD derives from fast, unconscious pattern matching
and recognition; the decision maker consciously experiences only the output
of this process—that is, the decision as to what action to take, reflected in
cognitions and/or images characteristically interwoven with affect, for exam-
ple the feeling of rightness (Thompson, Prowse Turner, & Pennycook, 2011).
Empirical studies of experts’ decision making strongly support RPD’s success
in yielding effective decisions (e.g., Kahneman & Klein, 2009).
An alternative to the RPD perspective on intuition is the heuristics
and biases (HB) approach pioneered by Tversky and Kahneman (1974).
Whereas the RPD approach focuses on “Intuitive judgments that arise from
experience and manifest skill. . . . HB researchers have been mainly con-
cerned with intuitive judgments that arise from simplifying heuristics, not
from specific experience” (Kahneman & Klein, 2009, p. 519). Heuristics sim-
plify judgment and decision making in that they entail “mental shortcuts,
rules of thumb” (Croskerry, 2009b, p.1025) that enable a rapid decision to
be made in the midst of time constraints and uncertainty through apply-
ing what are essentially “simple decision algorithms” (Keller et al., 2010,
p. 256). Although heuristics necessarily ignore some of the information in the
decision situation, they “do not try to optimize (i.e., find the best solution),
but rather satisfice (i.e., find a good-enough solution)” (Gigerenzer, 2008,
p. 20), and in this respect they are highly practical and efficient. More than
40 heuristics have been identified (see Shah & Oppenheimer, 2008, Table 1);
representative exemplars include the representativeness heuristic (e.g., per
Garb, 1996, a clinician diagnoses a patient with a particular psychological
disorder because her presentation includes features that resemble—i.e., are
representative of—the clinician’s personal prototype of that disorder rather
than on the basis of attending to the specific Diagnostic and Statistical Manual
of Mental Disorders criteria for that disorder), the anchoring heuristic (e.g., per
Harding, 2004, a case worker makes a conclusive disability decision based on
initially reviewed case information and adheres—i.e., remains anchored to—
that decision rather than adjusting it in light of additionally gathered infor-
mation that points to a different, more reasonable decision), and the take-
the-best heuristic (Todd & Gigerenzer, 2007; e.g., a person in extreme crisis
with an urgent need to see a psychotherapist begins calling therapists and
makes an appointment with the first therapist who can see him that day).
As in RPD, the decision maker is consciously aware of the intuitive choice
that results from employing a heuristic, but application of the latter is itself

A DUAL PROCESS PERSPECTIVE 71

an unconscious process. Comparing these two perspectives does raise the
question of the degree or level of awareness engaged. For RPD, the pattern
matching may have a deeper level of automaticity—the match occurs and the
response ensues. With the heuristic perspective, the reasoning is below the
surface, but perhaps not fully out of awareness.
The accuracy and effectiveness of decisions based on the application of
heuristics has been and remains a controversial issue (Evans, 2010). On the
one hand, sizeable bodies of evidence, instrumental to the enduring influence
of the HB approach, leave no doubt that the use of heuristics can lead to
highly flawed and deficient decision making (Croskerry, 2002). On the other
hand, an alternative approach to the conception and investigation of heuris-
tics, the fast-and-frugal heuristics program developed by Gigerenzer and his
colleagues (see Gigerenzer, 2008), demonstrates that heuristics are capable
of rendering quite accurate, successful decisions. A key factor moderating
a heuristic’s effectiveness is its ecological rationality (Todd & Gigerenzer,
2007)—that is, the fit between the decision maker’s objective within the
environmental situation at hand and the decision heuristic deployed. A heu-
ristic is adaptive when it yields a decision sufficient for meeting the decision
maker’s situational objective and flawed when it is inadequate in doing so.
Croskerry’s (2002) perspective is noteworthy in this context; he pointed out
that the shortcuts heuristics provide for making decisions “for the majority
of cases, work well. When they succeed, we describe them as economical,
resourceful, and effective, and when they fail, we refer to them as cognitive
biases” (p. 1201).
The study of intuition specifically and of automatic decision making
more generally have also been marked by increasing interest in the role
played by affective reactions. This work provides mounting evidence that
not only is affect characteristically experienced as an essential output compo-
nent of automatic–intuitive processes (Glöckner & Witteman, 2010), but it
also operates as input to decision making (Han & Lerner, 2009), “enter[ing]
the decision stream earlier than do conscious considerations” (Lodge, Taber,
& Weber, 2006, p. 12). Highly pertinent in this regard is the distinction
between incidental and integral affect, both of which are characterized as
immediate emotions in that they “are experienced at the time of decision
making” (Lowenstein & Lerner, 2003, p. 620). As Mosier and Fischer (2010)
explained, incidental affect stems from sources extraneous to the decision at
hand (e.g., an emotion aroused by an experience just prior to but then carried
into the decision situation); it precedes the latter and is thus potentially task
irrelevant. In contrast to incidental affect, integral affect is task relevant in
that it is triggered by features integral to the decision making situation itself.
This affect-triggering process occurs within milliseconds of the activating
stimulus (Lodge et al., 2006); as Bodenhausen and Todd (2010) underscored,

72 ANCHIN AND SINGER

“Affective reactions typically carry many of the features of automaticity,
including rapidity, spontaneity, and efficiency” (p. 282).
An emerging consensus is that contrary to previous views that decision
making is a purely rational process and that therefore affect only disrupts an
optimal decision, “without emotional involvement, decision making might
not even be possible or might be far from optimal (Damasio, 1994)” (Pfister
& Bohm, 2008, p. 8; cf. Rosenbloom, Schmahmann, & Price, 2012). Slovic
et al. (2004) placed affect at the center of judgment and decision making,
postulating and providing supportive evidence for an affect heuristic—a
shortcut in which individuals use readily available affect (feelings of good-
ness or badness) as the basis for their judgments and decisions. As Slovic et al.
put it, “Although analysis is certainly important in some decision-making
circumstances, reliance on affect and emotion is a quicker, easier, and more
efficient way to navigate in a complex, uncertain, and sometimes dangerous
world” (p. 313).
Bearing in mind the importance of situational and contextual consid-
erations (Magnavita & Anchin, 2014), automatically evoked affect can help
or harm optimal decision making (see Exhibit 3.1). However, one impor-
tant constant remains: “The rapidity of automatic processes means that they
start to unfold well before any deliberation has occurred” (Bodenhausen &
Morales, 2013, p. 231). Whether reflective deliberation is brought into play
during the decision stream initiated by automatic processes depends on a
number of factors, a consideration to which we return after highlighting cen-
tral features of deliberative information processing.

Deliberative Processing and Decision Making

Deliberative processing entails information processing that is intention-

ally initiated, that is relatively slower and more effortful than automatic pro-
cessing, and that occurs largely within conscious awareness. It requires working
memory as well as more of other cognitive resources—such as attention and
declarative knowledge (e.g., knowledge of facts and concepts)—than are neces-
sitated by automatic processing, occurs serially in that it “follows a series of steps
rather than performing multiple actions at once” (Beevers, 2005, p. 978), and
is rule governed. Deliberative processing prizes analysis, rational reasoning, and
logic. Moreover, in contrast to the relatively slow, experience-based acquisition
of knowledge that supports automatic processing, information incorporated into
knowledge structures by deliberative processing can be learned rapidly, includ-
ing on the basis of a single experience. This feature facilitates adaptive flexibility
in both covert and overt responding to a given situation.
Within the realm of judgment and decision making, the framework of
subjective expected utility theory (SEUT) and its quantified methodology

A DUAL PROCESS PERSPECTIVE 73

 EXHIBIT 3.1
Ways in Which Automatically Evoked Affect Can Benefit
and Impede Optimal Judgment and Decision Making
Task-relevant (integral) affect can benefit judgment and decision making by
• rapidly directing or heightening attention to information (e.g., external cues, internal
knowledge structures) pertinent to the decision-making task at hand (Peters, Vastfjall,
Garling, & Slovic, 2006; Pfister & Bohm, 2008);
• facilitating the setting of a particular situational goal (Zeelenberg, Nelissen,
Breugelmans, & Pieters, 2008) and facilitating goal-directed behavior following choice
(Bagozzi, Dholakia, & Basuroy, 2003);
• speeding up choice making under time constraints (Pfister & Bohm, 2008);
• guiding estimation of risk associated with different choice options (Slovic et al., 2004);
• influencing moral judgments (Bargh et al., 2012) and enhancing commitment to moral
choices (Pfister & Bohm, 2008); and
• impacting whether in the course of making a decision deliberative processing is initi-
ated (Mosier & Fischer, 2010).
Task-relevant (integral) affect can impede judgment and decision-making by
• inducing the decision maker to search for or focus on only information consistent
with his or her particular affective state, thereby neglecting or distorting inconsistent
information (Mosier & Fischer, 2010);
• constraining appraisal of the situation as a function of the affect’s valence (i.e., posi-
tive or negative), distinct subjective–experiential quality (e.g., anger, fear, happiness),
or intensity—this potentially limited and therefore biased interpretation can in turn
reflexively result in an action choice that may actually be less than optimal for the
context (see, e.g., Lerner & Tiedens, 2006); and
• limiting the range of options that the decision maker considers (Schottenbauer, Glass,
& Arnkoff, 2007).a
Task-irrelevant (incidental) affect can impede judgment and decision-making by
• influencing judgments rendered and choices made without the individual knowing
that this incidental emotion is biasing his or her decisional processes (Bodenhausen
& Todd, 2010).
aAn important caveat is that these narrowing effects on generating options may be distinctly more associated
with negative as opposed to positive affective states. Fredrickson’s (2004) broaden-and-build theory of
positive affect holds that the latter is expansive and leads to more creative and open decision making. Thus,
it may be the case that if and when positive affect constrains decision making, moderating variables in the
specific context at hand are at play.

of decision analysis quintessentially represent deliberative processing. This

approach, promulgated as the optimal way in which decisions should be made
(Shaban, 2005), necessitates cognitive resources (e.g., working memory;
attention) and is carried out within conscious awareness. It also requires the
analytic process of identifying at the outset of the decision task all available
options and each option’s set of possible outcomes relative to achieving a
given goal (e.g., solving a particular problem, attaining a desired state); in
turn, each possible outcome is assigned a utility value (a number represent-
ing its relative desirability) and a probability value (indicating its relative
likelihood of occurrence). Drawing on one of several possible mathematical
algorithms, the decision maker calculates an expected utility value (EUV)

74 ANCHIN AND SINGER

for each option, and the option with the highest EUV score is considered the
best choice (Jain, Aggarwal, & Rana, 2010–2011, p. 276).
Decision analysis has been successfully applied in clinical (characteris-
tically medical) and nonclinical contexts (Chapman & Sonnenberg, 2000;
Edwards, Miles, & von Winterfeldt, 2007; Parnell, Bresnick, Tani, & Johnson,
2013), demonstrating how conscious, effortful deliberation that combines such
components as analysis, cognitive resources, and logic enables highly rational
decision making. Yet the highly rigorous and resource-intensive requirements
demanded by decision analysis (Croskerry, 2003) renders its practical fea-
sibility nearly untenable, especially given how significantly automatic pro-
cesses mediate everyday judgments and decisions (Bargh & Williams, 2006).
Moreover, the decision making approach represented by SEUT and decision
analysis
fail[s] to capture the reality of most decision situations in health-care . . .
that are characterized by incomplete knowledge of all available alterna-
tives, a lack of reliable probabilistic data of the consequences of these
alternatives, and few readily acceptable techniques for reliably gauging
patient utility. (Shaban, 2005, p. 4)
These circumstances certainly seem to apply to psychotherapy (cf.
Schottenbauer, Glass, & Arnkoff, 2007).
It is therefore not surprising that deliberative decision making focused
on choosing an option for achieving a particular goal is far more likely to be
implemented through the relatively less rigorous method of “option generation
and comparison” (Schraagen, Klein, & Hoffman, 2008, p. 4). In this familiar
method, the decision maker generates options for achieving the particular
goal at hand, systematically evaluates the reasons for and against each option
relative to attaining the desired goal (Hastie, 2001, p. 663), and chooses the
option offering the best ratio of pros to cons.2 Considerations about possible
outcomes may consciously enter the equation, but they do so in ways less pre-
cise than assigning specific numerical values as occurs in decision analysis. An
alternative approach to weighing options entails use of the previously alluded
to method of satisficing, wherein the decision maker evaluates one option at
a time and selects the first one judged as satisfying a subjectively set criterion
level—in essence, “looking for the first workable option rather than trying to
find the best possible option” (Klein, 2008, p. 458).
Whatever the degree of rigor and precision used, consciously evaluat-
ing options in order to choose one as the best course of action for pursuing

2Indeed, it is important to note that among major responsibilities of institutional review boards in evalu-
ating proposed research is identifying and weighing the possible risks and benefits posed to participants
in the proposed study (a risk–benefit analysis).

A DUAL PROCESS PERSPECTIVE 75

a goal epitomizes deliberative processing in judgment and decision making.
Other instantiations of conscious deliberation that can enter the decision
stream at different points include hypothesis generation and testing (Caspar,
1997), mental simulation (Evans & Stanovich, 2013; Klein, 1998), hypo-
thetical thinking (Evans, 2007; Stanovich & Toplak, 2012), and metacogni-
tion (Thompson et al., 2011).
As Evans (2010) has pointed out, there has been a tendency to view
deliberative processing as superior to automatic processing. In point of fact,
however, deliberative processing is not necessarily a royal road to producing
higher quality decisions. A decision arrived at through conscious delibera-
tion is not immune to bias and to that extent may be erroneous; illustra-
tive sources of bias and error in deliberative decision making are presented
in Exhibit 3.2. Despite these flaws and potential pitfalls, most therapies do
privilege the process of making the unconscious conscious and encouraging
deliberation and rational consideration before action.

Automatic and Deliberative Processing: Independent but Interactive

Clearly, automatic and deliberative processing are “qualitatively dis-

tinct” (Evans & Stanovich, 2013), with each type of processing bringing
advantages and limitations to the challenges of adapting to biopsycho-
social complexities and changes over the human life course (Epstein, 2010).
Lieberman and his colleagues (Lieberman, 2003; Satpute & Lieberman,
2006; Spunt & Lieberman, 2013) have strengthened the case for the dual
process distinction by linking it to findings in social cognitive neuroscience
(cf. Evans, 2008, p. 270). The evidence amassed by these scholars indicates
that automatic and deliberative processing systems are independent; each

EXHIBIT 3.2
Sources of Bias and Error in Deliberative Decision Making
• Selective attention to or overfocus on particular stimulus characteristics of the
decision situation (e.g., those that are most accessible or easily articulated) at
the expense of other information more relevant to the decision (Evans, 2007;
Bodenhausen & Todd, 2010)
• Gaps in the “mindware” (Stanovich, 2011) necessary to engage in rational thinking
(e.g., missing declarative knowledge in a particular domain pertinent to the deci-
sion situation)
• Incorrect information (Hammond, Hamm, Grassia, & Pearson, 1987)
• Premature closure on considering alternative causal hypotheses by virtue of
assuming an initial hypothesis is accurate (Croskerry, 2002)
• Reasoning that is quick and sloppy (Stanovich, 2011)
• Distraction (Croskerry, 2009b)
• Fatigue (Croskerry, 2002)

76 ANCHIN AND SINGER

recruits distinctly different neuroanatomical structures. Crucially, how-
ever, “the systems are independent in the sense that they rely on different
neural structures, but they are not independent in the sense that there is
no interaction between them” (Lieberman, 2007, p. 305).
Facets of this interaction are captured in the default-interventionism
model advanced by Evans and Stanovich (2013). In this view, intuitive
decisions yielded by rapid automatic processing provide the default response
in many decision situations and will not be modulated if accompanied by
a feeling of rightness and confidence. However, when the decision maker
experiences dissatisfaction or discomfort with an intuitive decision, delib-
erative processing may be brought to bear on this default intuition through
reflection on the judgments or decision at hand; this may or may not
lead to an override of the intuitive decision, a point to which we will
return in the last section of this chapter. Other factors that can prompt
consciously reflective intervention into a decision stream kick-started by
automatic processing include violations of the decision maker’s expecta-
tions (Lieberman, 2003); difficulty in pattern recognition (Klein, 1998);
novel, ambiguous, or unusual features in the problem to be decided about
(Croskerry, 2009b; Evans, 2010; Evans & Stanovich, 2013); availability
of time and/or cognitive resources (Bodenhausen & Todd, 2010; Evans,
2010); and motivation to engage in more systematic processing to ensure
accuracy in the service of decisional effectiveness (Beevers, 2005; Smith
& DeCoster, 2000).
The default-interventionism model suggests a sequential interaction in
which deliberation follows on the heels of automatic processing. However,
we hypothesize, following Hammond’s (2010) cognitive continuum theory,
that in the flow of real time there is a “continuous oscillation” (Croskerry,
2009a) between automatic and deliberative processing. As Hammond (2010)
explained,
The normal form of cognition [entails] human judgment that is neither
purely analytical [deliberative] nor purely intuitive [automatic] but
involves differing proportions of each, depending on which attributes [of
each type of processing] are present in our normal activities. The proper-
ties of the task move our judgments over this continuum back and forth
as task conditions change (as more and different information comes in)
as we try to cope with our various tasks, or various aspects of the same
task; different information will make different demands. Therefore the
specific attributes of intuition and analysis involved in any judgment—at
any one time—will depend on the momentary location of cognition on
this continuum. (p. 330, italics added)
Thus, automatic processing and its intuitive outputs are effective in
choosing a course of action in many situations and tasks (see, e.g., Epstein,

A DUAL PROCESS PERSPECTIVE 77

2010; Evans, 2010; Gigerenzer, 2008), and in others deliberative process-
ing is the most appropriate pathway (see, e.g., Stanovich, 2009). However,
judgment and decision making not infrequently entail a variegated interplay
between both types of processing and their distinct attributes (Bodenhausen
& Todd, 2010; Croskerry, 2009a, 2009b; Hastie, 2001; Slovic et al., 2004).
Different scholars provide different insights into features of this interac-
tion. For example, Bargh et al. (2012) pointed out that conscious (i.e., delib-
erative) and automatic processes each play a causal role vis-à-vis the other
and underscore their interdependent relationship: “These two fundamental
forms of human information processing work together, hand in glove, and
indeed one would not be able to function without the support and guidance
of the other” (p. 601). Epstein (2010) illuminated the circularity that can
characterize this interplay:
Any response (including a conscious thought) in the rational/analytic
[deliberative processing] system can evoke an association in the
experiential/intuitive [automatic processing] system, which can then
influence conscious thoughts and behavior in the rational/analytic
system, which can produce further associations in the experiential
system, and so on. Thus, rather than just an interaction between single
responses in the two systems, the two systems can interact in the man-
ner of a dance, in which a step in one of the systems elicits a step in the
other system. (p. 300)
Slovic et al. (2004) also used the instructive metaphor of dance, hom-
ing in on the respective identity of each of the partners: “We now recognize
that the experiential mode of thinking and the analytic mode of thinking
are continually active, interacting in what we have characterized as ‘the
dance of affect and reason’ (Finucane, Peters, & Slovic, in press)” (p. 314). On
the integration of the two modes of processing, Singer and Conway (2011)
wrote, “Receptive to both sense and sensibility, we achieve an affectionate
and clarifying unity. In this unity, we realize a kind of psychological wis-
dom that honors both unconscious and conscious, image and word, emotion
and reason” (p. 1203). And Bodenhausen and Todd (2010) specifically drew
attention to the critical issue of how diverse variations in the way these two
forms of processing interact to influence the caliber of the resulting decision:
“We need to work toward a conceptual synthesis that carefully delineates the
multiple ways that automatic processes interact with conscious thinking to
produce human decision making in all of its gradations of quality” (p. 290).
We now turn to how these two types of thought processes inform an analysis
of psychotherapists’ use of theory to guide their decision making.

78 ANCHIN AND SINGER

 A DUAL PROCESSING ACCOUNT OF THE ROLE OF EXPLICIT
AND IMPLICIT THEORY IN PSYCHOTHERAPEUTIC
DECISION MAKING

Considering their conceptual richness and empirical robustness, the

limited extent to which dual process theories have been explicitly applied to
psychotherapy is striking. The significant exception lies in dual process formu-
lations and investigations of selected forms of psychopathology, most notably
addictive behaviors (Wiers, Gladwin, Hofmann, Salemink, & Ridderinkhof,
2013), mood disorders (Beevers, 2005; Creemers, Scholte, Engels, Pieters, &
Wiers, 2013; Phillips, Ladouceur, & Drevets, 2008), and anxiety disorders
(de Jong, 2014; Etkin, Prater, Hoeft, Menon, & Schatzberg, 2010). However,
applications of dual process conceptions for understanding the in situ func-
tioning of psychotherapists per se have been minimal (see, e.g., Caspar, 1997;
Magnavita & Anchin, 2014, Chapter 10; Shilling, 2012). And yet, over the
course of even a single therapeutic hour, the volume and heterogeneity of
stimuli that the therapist must process in the service of engaging in multiple
therapeutic tasks—amid circumstances that are uncertain, constrained by
time, and infused with risks large and small—are enormous. Dual processing
grounded in psychotherapeutic theory provides a parsimonious and internally
consistent explanation for how a therapist meets these challenging demands
in a way that is efficient, organized, and therapeutic.
To illustrate, we draw on a clinical vignette presented in greater detail
elsewhere (Anchin & Pincus, 2010, pp. 129–135) and essentially slow down
the process, taking the reader inside the psychotherapist’s mind to demonstrate
how his judgments and decisions are intricately tied to ongoing oscillation
between automatic and deliberative applications of both explicit and implicit
theory. The vignette entails an extended prototypic therapist–patient dialogue
designed to illustrate assimilative integration (Messer, 2001) of interpersonal
psychotherapy with elements of cognitive, experiential, constructivist, and
solution-focused treatment approaches in therapeutically addressing a spe-
cific in-session event that occurs within the patient–therapist relationship.3
Though divided into segments for purposes of analysis and discussion, the

3This approach to interpersonal psychotherapy, also characterized as the interpersonal tradition, interpersonal
paradigm, interpersonal system, and interpersonal nexus (Pincus, 2010), is rooted in Sullivan’s (1953) seminal
interpersonal psychiatry and ensuing elaborations by such notables as Leary (1957), Carson (1969, 1982),
Wiggins (1979), Benjamin (1996), and Kiesler (1996). It is also important to note that Sullivanian inter-
personalism, synthesized with British object relations theory and self-psychologies rooted in Kohutian
theory, has been integral to the development of relational psychoanalysis (Aron, 1996; Mitchell, 1988;
Singer, 2005; Wachtel, 1997), and hence, not surprisingly, conceptual and technical–procedural parallels
between the interpersonal approach described in this section and relational psychoanalysis are consider-
able (see Anchin, 2002).

A DUAL PROCESS PERSPECTIVE 79

dialogue presented in the following is quoted verbatim from the material that
appears in Anchin and Pincus (2010).
The vignette begins at the point where the patient has seen the thera-
pist glancing at his desk clock and reacts by abruptly ceasing description of
an argument he had had with his wife earlier in the day and shifting into a
different affective state and mode of dialogue vis-à-vis the therapist. The
therapist responds in the following manner:
Therapist: [Pinpointing overt, observable behavior, focusing inward, and pin-
pointing affect] Bob, you just stopped talking about the argu-
ment you and your wife had this morning and stared at me;
then you looked away, shook your head, and gave this deep
sigh. What are you feeling?
This two-sentence response is underpinned by processes of both
automatic and deliberative judgment and decision making that funda-
mentally originate out of the interpersonal core of the therapist’s explicit
theory of psychotherapy. Whatever its specific content, a therapist’s
explicit theory automatically orients him or her toward certain stimulus
features of the situation and away from others. These shifts in orienta-
tion are vitally important from a decisional perspective because the data
selectively attended to serve as the determinative foundation for ensuing
therapist processing, including subsequent data attended to, inferences
drawn, and judgments rendered. Here, the therapist’s theoretical per-
spective heightens his attentiveness to the distinct shift in the patient’s
interactional behavior and its negative emotional tone and leads him to
automatically infer that a significant negative event has occurred in the
therapeutic relationship.
This intuitive clinical judgment sparks feelings of uneasiness and con-
cern, exemplifying integral affect in action. These emotions enter the thera-
pist’s decision stream and, integrated with his conscious attunement to their
immediate relational context and meanings, prompt his engaging in a rapid
deliberative process about how best to respond. He momentarily considers
remaining silent but then overrides this option, deciding instead to actively
intervene through initiating therapeutic metacommunication (literally, com-
munication about communication), a multicomponent intervention origi-
nally defined by Kiesler (1988) that centers on the therapist and patient
stepping back to examine and learn from the process that is taking place
between them (cf. Anchin, 2002; Anchin & Pincus, 2010, Muran, Eubanks-
Carter, & Safran, 2010). The decision to go in this direction reflects “the
dance of affect and reason” (Slovic et al., 2004) alluded to above: The thera-
pist chooses this option not only because it is logically consistent with formal
interpersonal principles, which stipulate the importance of collaboratively

80 ANCHIN AND SINGER

processing a negative in-session relational event both for reparative purposes
and for insights it may yield about the patient’s maladaptive interpersonal
behavior (Anchin & Pincus, 2010; Kiesler, 1996; Safran & Muran, 2000),
but also because—by virtue of this very consistency with his core theory—
this decision “feels right.” The affect heuristic has thus combined with the
rule-based logic of his theory to influence the therapist’s decision. Although
not the primary focus of our current analysis, we might also explore why the
therapist looked at the clock when he did and ask what was happening in the
“analytic third” or the intersubjective space shared by both participants that
might have influenced the therapist’s action (Ogden, 2004).
The patient provides an unambiguous response to the therapist’s ques-
tion as to what he is feeling, and the therapist’s response is automatic; no
deliberation is needed:
Client: To be honest, I’m pissed off!
Therapist: [Encouraging the client to elaborate] About?
Although overtly this is a simple one-word question by the therapist,
it is still theory driven. In this instance, it reflects the combination of the
therapist’s implicit theory of psychotherapy on the one hand, which holds
that depending on context it can be essential to unpack feelings expressed
by the patient, and the continued operation of his explicit theory on the
other hand, which, translated into technique, specifies that during metacom-
munication the therapist encourage the patient to express his feelings—and
as will be demonstrated in the following, subsequently engage him in collab-
orative processing of those feelings.
The overarching therapeutic strategy of metacommunication remains
in force as the dialogue continues, but as the exchange proceeds, the patient’s
material and the reactions it evokes in the therapist necessitate that the latter
make further automatic and deliberative judgments and decisions—based on
both additional facets of his explicit theory and a belief tied to his implicit
theory—about ways of responding that will keep the process moving for-
ward therapeutically. Thus, asked what he is “pissed off” about, the following
exchange occurs:
Client: You; what you just did. I’m telling you about something that
was very upsetting and you’re looking at your clock.
Therapist: [Not getting hooked by the client’s anger; instead validating his
observation] You’re right; I did. [Preparing the way for explain-
ing the link between meaning given to the other’s behavior and
consequent feeling] How are you interpreting that?
The therapist has thus learned what it is that has precipitated the
patient’s anger, but he is also aware of experiencing some anxiety in response

A DUAL PROCESS PERSPECTIVE 81

to the intensity of the patient’s anger. Nevertheless, two additional interper-
sonal principles of therapeutic metacommunication, in tandem, have virtu-
ally automatically guided the therapist’s reaction to his own anxiety and the
nature of his verbal response. One such principle (Kiesler, 1988) centers on
the inevitability of experiencing aversive feelings evoked by the patient but
not allowing oneself to remain “hooked” (caught up in and thereby con-
strained) by them, which could impede the therapist’s capacity to respond
therapeutically. The second principle specifies the importance of the thera-
pist providing the patient with appropriately focused validation in the course
of the metacommunicative process, which characteristically includes the
therapist explicitly owning his contribution to what has transpired (Muran
et al., 2010). Crucially, the therapist does not have to stop and take time
to access these two guiding principles; they are already deeply embedded in
his theoretical knowledge structures and are automatically activated by the
specific therapeutic context. Of course, the more experienced and the better
trained the therapist, the more likely that such principles are embedded. To
the extent that their guiding effects enter awareness, they do so in the form
of the therapist experiencing his anxiety as background and concurrently,
more at the foreground, the flash of an affectively tinged thought as to the
importance of validating the patient’s observation, reflected in his first state-
ment (“You’re right; I did.”).
The therapist’s immediately ensuing question (“How are you interpret-
ing that?”) demonstrates pattern recognition in action: In response to an
interpersonal trigger, the patient has experienced an intense negative emo-
tional reaction, and in the therapist’s experience, this sequence characteris-
tically signifies the activation of a mediating relational (self–other) schema
(Anchin & Pincus, 2010; Muran et al., 2010). A key concept in cognitive
theory of psychotherapy (e.g., Clark & Beck, 2010), a schema is a psychologi-
cal structure composed of an interconnected set of affect-laden core beliefs
about self and others that, when activated, automatically guides interpreta-
tion of and thereby meanings ascribed to another’s actions (Anchin, 2002).
Underpinned by this cognitive theory, the therapist automatically intuits
that the pattern of interpersonal trigger → relational schema → emotional
reaction is at play, and by virtue of this intuitive judgment he immediately
follows up his validation of the patient’s observation by asking him how he
interpreted his clock-glancing behavior.
Reflecting parallel-processing facets of automatic processing, this clini-
cal strategy is tied to multiple, overlapping, and simultaneously operating
goals: to move the therapeutic process forward in a constructive direction,
to elicit the specific contents of the patient’s interpretation, and to “set the
table” for bringing a cognitive perspective and associated interventions into
the metacommunicative process. Operating from this cognitive perspective,

82 ANCHIN AND SINGER

the therapist “hears” the patient’s response as an automatic thought4 and
checks to see if this cognition is indeed what went through the patient’s
mind; the patient confirms this while restating his automatic thought in
terms that hint at features of the underlying core belief:
Client: What interpretation?! It’s obvious that you can’t wait for me to
leave.
Therapist: [Probing for automatic thoughts] Is that what went through
your head when you just saw me look at the clock?
Client: Yeah, like, “He’s not really interested; he doesn’t really give
a shit about me.”
The therapist follows with an empathy-based response:
Therapist: [Empathy-based pinpointing of additional affects] It sounds like you
feel like I’m not taking you seriously—that you felt dismissed,
rejected.
This empathic response is underpinned by the confluence of the thera-
pist’s feeling for the immediate context, formal principles of metacommuni-
cation (explicit theory), and knowledge acquired from previous experience
(implicit theory). With lightning speed, these coalesce in his automatic
judgment that at this immediate juncture it is crucial that the patient feel
understood, supported, and accepted. Reflecting the extraordinary rapidity of
the continuous fluctuation between automatic and deliberative processing,
the therapist holds the patient’s words—“Yeah, like, ‘He’s not really inter-
ested; he doesn’t really give a shit about me’”—in working memory and seam-
lessly shifts from his automatic judgment about the immediate importance of
empathy into consciously “trying on” what the patient has said, sparking the
feelings he empathically experiences and verbally expresses. The velocity
of this oscillation is further evidenced by the fact that although the thera-
pist has intentionally—and thus consciously—engaged in and expressed
empathic understanding, he does not need to consciously figure out what
these feelings feel like or the words that capture them; on the basis of stored
experiential learning, the subjective experience of these feelings and their
verbal labeling kick in automatically. Just as crucial to consider is what the
therapist has not said. He implicitly senses that to deny his action would be
to invalidate the patient’s legitimate read of the situation and understand-
able emotional response to his action. Similarly, the therapist automatically
understands that precipitously apologizing for his behavior would interfere

4In cognitive therapy theory, automatic thoughts are immediate cognitions that consciously run through
a person’s mind in response to a situation and arise from the core belief activated in that situation
(Clark & Beck, 2010).

A DUAL PROCESS PERSPECTIVE 83

with the opportunity to allow the full emotional significance and meaning of
the event to be captured in their work together.
A critical sequence immediately follows and becomes the springboard
for intentionally moving the metacommunicative process an essential next
step, as explained momentarily:
Client: Absolutely! Hopefully, you can see why I’d feel that way!
Therapist: [Conveying acceptance of the client’s subjective affective state
while continuing to set the ground for explaining the relationship
between interpretations and feelings] Yes; I can—interpreting
what I did as meaning that I don’t care about you, it makes
sense that you’d feel dismissed, rejected, angry. I understand.
[Beginning to engage client in the metacommunicative process of
stepping back and collaboratively reflecting on the interaction in
order to turn this intrasession incident to therapeutic advantage]
But can we step back and look at this? Because maybe we can
both learn something from what just happened.
Client: It just really hit me wrong. But, yeah, go ahead, I’m listening.
In this exchange, the patient has confirmed the accuracy of the thera-
pist’s empathy, and the therapist, continuing in an empathic and supportive
mode, without hesitation reciprocally responds in a manner predicated on
his reflexive judgment that continued validation and acceptance is essen-
tial. However, the therapist’s response to the patient’s emphatic confirmatory
statements is grounded in further judgments and decisions that continue to
tap into explicit and implicit theory, automatically and deliberatively. Thus,
although the therapist provides validation, his customary strategy of integrat-
ing cognitive intervention into metacommunication is also operating con-
currently through parallel processing in that he simultaneously frames the
patient’s feelings as making sense within the context of the patient’s inter-
pretation. In addition, although up to this point the exchange encompasses
necessary components of metacommunication—for example, the therapist
owning his behavior, the patient openly expressing his feelings, and the ther-
apist validating the patient’s reactions—it is by no means sufficient for maxi-
mizing the therapeutic yield of this significant in-session relational event. Per
the therapist’s explicit theory, doing so requires that the therapist and patient
also join together to examine the how and why of what transpired in order to
attain insight into the patient’s interpersonal processes and in turn draw out
implications for change.
When to invite the patient to engage in this “collaborative inquiry”
(Muran et al., 2010, p. 174) involves a judgment about timing, strongly sug-
gesting that among the multiple simultaneous tasks enabled by automatic
parallel processing, the therapist must necessarily also be monitoring and

84 ANCHIN AND SINGER

integrating data (e.g., not only the patient’s verbal responses but also his
ongoing nonverbal behavior, the emotional tenor of the exchange, his own
comfort level) as bases for this judgment. Here, the therapist, on the basis of
the emerging data and his explicit judgment of what the patient can toler-
ate and how much good will has been generated, decides that the moment
is right to issue this invitation and does so in the question-and-statement
sequence “But can we step back and look at this? Because maybe we can both
learn something from what just happened.” Highly rapid deliberative thought
has also informed the therapist’s judgment as to phraseology, stemming from
his implicit theory-based belief that illocution and wording powerfully influ-
ence the effectiveness of verbal communication in achieving desired aims
during therapeutic discourse. Thus, through the way in which this invitation
has been issued, the therapist is attempting to achieve several aims—which,
parenthetically, again reflect the shifting nature of multiple immediate goals.
These objectives include (a) creating “a collaborative, egalitarian environ-
ment” (Muran et al., 2010, p. 175) both through intentionally requesting the
patient’s participation, as opposed to dominatingly imposing this agenda, and
choosing phrasing that highlights the conjoint nature of the endeavor (i.e.,
“But can we . . .”; “Because maybe we can both . . .”); (b) specifying the task
he and the patient need to engage in to move the process forward (“step back
and look at this”); and (c) explicitly indicating the purpose of this process
through suggesting that they can “learn something from what just happened.”
The effectiveness of the therapist’s automatic judgment about the tim-
ing of this invitation and its conscious verbal translation is suggested by the
nature of the patient’s response; his first sentence, in its past-tense wording
(“It just really hit me wrong”), connotes a subtle shift in his emotional tone,
and his second sentence (“But, yeah, go ahead, I’m listening”) suggests that at
this immediate moment, he is on board for the proposed collaborative inquiry.
From here, the therapist provides brief psychoeducation explaining
that how we interpret things people say and do strongly influences how
we emotionally react to these things and that “different interpretations of
the same situation can create very different feelings.” The patient conveys
understanding of this basic cognitive proposition, which prompts another
virtually automatic judgment that the moment is opportune to have the
patient begin the process of considering alternative interpretations of the
therapist’s clock-glancing behavior. Moreover, reflecting the simultaneity of
implicit theory, the initial wording he uses to initiate this process reflects his
tacit belief that the patient’s partnership can be facilitated through actively
tapping into the therapeutic relationship:
Therapist: [Fostering collaboration, encouraging the search for alternative
interpretations] So—go with me on this—could there be

A DUAL PROCESS PERSPECTIVE 85

 other ways to interpret my looking at my clock while you
were talking?
Client: I suppose; maybe you’re hungry and you can’t wait for the
session to end so you can get something to eat.
The therapist’s ensuing response is once again grounded in a fusion
between components of his formal, explicit theory and his more personal
implicit theory—in the case of the former, the therapeutic value experien-
tial psychotherapy places on immediate experiencing in enhancing insight
(Pascual-Leone & Greenberg, 2007), and in the case of the latter, the thera-
pist’s belief that tasting experiential consequences of an insight increases the
latter’s impact:
Therapist: [Fostering experiential understanding of the cognitive–affective
link] And if it was that, how do you think that would make
you feel?
Client: Maybe a little less pissed, but you’d still be thinking about
how hungry you are, like it’s more important than me.
The therapist consciously notes that in considering this alternative
interpretation, the patient experiences some lessening of anger; however, he
is more attuned to the fact that the patient continues to believe that he lacks
importance to the therapist and that this alternative interpretation, though
different from that initially rendered, is still inaccurate. Consequently, he
quickly decides to persist in this line of inquiry. The patient articulates an
accurate interpretation of the therapist’s behavior, activating within the lat-
ter a positive feeling (another instance of integral affect), which, in con-
junction with the cognitive tenets of his explicit theory, prompts automatic
validation and further elaboration:
Therapist: [Encouraging the search for additional alternative interpretations]
OK; but are there other possible reasons why I looked at the
clock, other possible interpretations?
Client: Hmm . . . I suppose; maybe you just wanted to see what time
it was so that you knew how much time we had left in the
session to deal with what I was talking about.
Therapist: [Confirming the client’s interpretation] Exactly; that’s exactly
why I looked at my clock. [Explaining the intent behind his
actions] I know that this was a very upsetting situation
between you and your wife, and I wanted to be sure we’d
have time to hone in on what was happening there.
Client: I suppose [nods head]; that makes sense.

86 ANCHIN AND SINGER

 With the patient appearing to accept this honest explanation for the
therapist’s clock-glancing behavior, the latter attempts to solidify the impact
of this more accurate understanding by intentionally following with the strat-
egy, used moments earlier, of having the patient get in touch with experien-
tial consequences:
Therapist: [Using immediacy to further enhance interpersonal–experiential
change] Understanding it that way, do you experience at this
moment a change in how you feel?
Client: I guess not really pissed off. I guess I appreciate that you
understand this was an extremely upsetting situation [this
morning] and that you wanted to make sure we had time to
figure it out.
Hearing this, the therapist experiences a mixture of positive affect and
heightened connectedness to the patient; consistent with the prescribed
importance of honest therapist self-disclosure during metacommunication
and his own sense of genuineness—and consciously mindful of the oppor-
tunity to provide corrective input vis-à-vis the patient’s maladaptive self-
other schema—the therapist deliberately chooses to share his thoughts and
feelings:
Therapist: [Reciprocating the expression of appreciation] Good; I appreci-
ate that you’re willing to rethink this. [Refuting the client’s
misconstrual of the therapist’s behavior with honest self-disclosure
of nurturing feelings] And can you see, too, that in wanting
to make sure we had enough time, that I do care, that I’m
genuinely interested in what’s happening in your life—that I
care about you, that you do matter?
Client: Yes, I can see where you’re also kind of saying that, too.
Therapist: [Further honest therapist self-disclosure to underscore his genuine
interest] Good—because the last thing I would want you to
feel is dismissed or rejected by me.
Client: [Listening, nodding head]
The therapist experiences the patient’s nonverbal response as indi-
cating that they are in synch and thus, automatically judging that it is
safe, consciously decides to push forward with educative intent anchored in
explicit cognitive theory. Accordingly, against the backdrop of the patient’s
more accurate understanding of the therapist’s behavior, the latter—
retrieving from short-term memory and inserting into working memory the
patient’s initial inaccurate interpretation—crystallizes for the patient both

A DUAL PROCESS PERSPECTIVE 87

the cognitive distortions he engaged in and how these led to his emotional
reaction:
Therapist: [Identifying cognitive distortions—selective abstraction, magnifi-
cation, and jumping to conclusions] So if we go back to what
just happened, it’s like you tuned in on that one piece of
behavior on my part, magnified it, and then jumped to a
conclusion—and a negative one, at that! And given that
conclusion, you got really angry with me.
The patient resonates to this interpretive feedback and offers a signifi-
cant self-observation:
Client: Yeah, I guess it’s true, I definitely do that . . . somebody says
or does something and I lose it; it’s like a switch goes off.
Automatically perceiving the patient’s engagement in the exploration
process and judging this resonant insight to be highly valuable by virtue of
the opportunity it offers to deepen and expand understanding, the therapist
experiences a sense of excited optimism and consciously chooses to seize on
the patient’s analogy—a decision also grounded in the dovetailing between
his own implicit belief and solution-focused components of his explicit the-
ory as to the value of analogy and metaphor as tools for promoting insight
(e.g., Anchin, 2003; de Shazer, 1985):
Therapist: [Applying this analogy to the immediate context to advance the cli-
ent’s social–cognitive learning] Bob, if we use what just happened
here between us, what do you think flipped that switch?
The therapist’s question bears fruit in advancing insight: Like a dart hitting
the bull’s eye of a target, the patient articulates fundamental beliefs about
himself and others that the therapist immediately hears as central ingredients
of a core maladaptive relational schema:
Client: I guess at some level I think that people don’t really care
about me, that I’m insignificant, I don’t matter . . . it’s like
this feeling is in the background; it nags at me!
Consciously perceiving this to be a critical point in the exploration,
and still guided by cognitive components of his explicit theory, the therapist,
in his response, intentionally chooses wording intended to crystallize the
beliefs embedded in the patient’s insight and to convey to the patient their
centrality; the therapist’s implicit beliefs about the importance of tending
to the therapeutic alliance and actively fostering collaboration also come
into play:
Therapist: So it sounds like there’s these two central beliefs—maybe
core beliefs—that you have. One is that “I’m insignificant”

88 ANCHIN AND SINGER

 and the other sounds like you believe “People don’t care
about me.” [With an eye on maintaining the alliance, promotes
collaborative exploration] Does that feel like it fits?
Client: Yeah, definitely . . . I’ve always felt . . . “haunted” is the best
word . . . by this terrifying feeling, deep down, that I’m
completely insignificant, that I really mean nothing . . .
nothing!—and that that’s also what I mean to people who
know me: nothing; that deep down they don’t care about me.

IMPLICATIONS AND RECOMMENDATIONS

In analyzing this vignette, our goal has been to demonstrate ways in

which a therapist’s moment-to-moment judgments and decisions derive
from continual oscillation between automatic and deliberative processing
drawing on both explicit and implicit theory. The content of our illustra-
tion has centered on addressing a specific event within the therapeutic rela-
tionship through the fluctuating coupling of an integrative interpersonal
approach with implicit beliefs activated by the unfolding situation at hand;
however, we believe that the types of automatic and deliberative therapist
mental processes illustrated in the preceding section continuously mediate
and moderate a therapist’s judgments and decisions irrespective of a thera-
pist’s theoretical orientation and the particular implicit beliefs at play. With
this consideration in mind, we seek here to facilitate the reader’s application
of this knowledge in order to enhance his or her psychotherapeutic judg-
ments and decision making. To do so, we extract key implications from this
example and the material preceding it and translate these lessons into specific
recommendations:
1. Within any given psychotherapy session, an essential meta-
goal is to keep the therapeutic process moving forward in a
constructive direction. In this light, be aware that you are
indeed continuously making rapid clinical judgments and
decisions and that these play a vital role in achieving this
supraordinate goal as therapeutic discourse unfolds. Aware-
ness of these ineluctable facets of your functioning as a ther-
apist can sharpen your attunement to thoughts and feelings
associated specifically with judgments and decisions being
made. Sensitivity to the ebb and flow of your dual process-
ing should also alert you more acutely to the products of
the intersubjective field and your own countertransference
responses.

A DUAL PROCESS PERSPECTIVE 89

 2. On the one hand, know that over the course of a given
session many of your clinical judgments and decisions are
being made automatically and that given the multiplicity of
stimuli that must be processed and tasks that must be car-
ried out under conditions of uncertainty and limited time, it
can be no other way. Moreover, not only are automatically
rendered judgments and decisions unavoidable, but as dis-
cussed in the preceding, they are also integral to effective
psychotherapy. On the other hand, remain ever mindful
of an equally critical fact concisely captured by Croskerry
and Norman (2008), who—drawing on Stanovich’s (2005)
depiction of automatic processes as “the autonomous set of
systems” (TASS)—remind us that “although TASS oper-
ates at an unconscious level, their output, once seen, can be
consciously modulated by adding a System 2 [i.e., delibera-
tive] approach” (p. S26).
3. The immediately preceding point made by Croskerry and
Norman (2008) speaks to the deliberative processing sys-
tem’s “monitoring capacity” (Croskerry, 2009b, p. 1025) over
automatic-processing system output. Consciously appraising a
given automatic initial judgment or decision does not in and
of itself signify that the latter needs to be overridden by a dif-
ferent decision or even slightly adjusted. For example, a gen-
eral statement made by the patient about “the problems in my
life” may prompt your automatic judgment that a moderately
confrontive question, the content of which instantaneously
appears in conscious awareness, needs to be posed. Rapid, delib-
erate consideration of the patient’s nonverbal behavior, the
context in which the statement was made, and the strength
of the alliance may result in an appraisal that posing this
question, at this moment, is minimally risky and can benefi-
cially advance the therapeutic process, and so the decision is
made to go forth with the question. However, if the patient’s
nonverbal behavior (e.g., tone of voice and facial expres-
sion) conveys that he is in a brittle state, the judgment may
instead be made that confronting the patient at this moment
is ill timed. Hence a deliberate override occurs: The decision
is made not to confront the patient and instead to ask him
gently what he was experiencing when he made that state-
ment. Time constraints preclude deliberatively evaluating
every automatically rendered judgment and decision whose
output appears in consciousness, but be aware that your

90 ANCHIN AND SINGER

 deliberative processing system provides this capacity. When
such monitoring and appraisal can and/or does occur and you
experience such cognitive–affective mixtures as hesitance,
discomfort, confusion, conflict, uneasiness, or dissatisfac-
tion vis-à-vis the judgment or decision that rapidly appears
in mind, consider that these negatively valenced subjective
states are signaling the need to modulate the judgment or
decision at hand.
4. Against the backdrop of the preceding recommendations, we
note Croskerry and Norman’s (2008) hypothesis that “per-
haps the mark of good decision makers is their ability to match
Systems 1 [automatic processing] and 2 [deliberative process-
ing] to their respective optimal contexts and to consciously
blend them into their overall decision making” (p. S26).
However, whatever the proportion of automatic and delibera-
tive processing underlying a given judgment or decision, the
shifting array of patient-generated cues and stimuli serves as
ongoing input to your dual processing systems. Consequently,
be keenly present in the here and now of the session, studi-
ously observe the patient’s nonverbal behavior, and listen very
closely to what the patient is saying lest you miss important
information that might otherwise significantly bear on the
judgments and decisions being made. At the same time (and
this is why what we do is extraordinarily complex), you must
be attuned to your own internal associative world of thoughts,
fantasies, wishes, emotions, and sensations because your paral-
lel inner world is also influencing both automatic and delib-
erative processing.
5. Building on this last point, be cognizant of the fact that your
affective states in particular can play a powerful role in influ-
encing your judgments and decisions. Indeed, by definition the
affect heuristic can operate as the chief determinant of certain
decisions that you make. However, a therapist’s subjective affect
can enter the decision stream at multiple points in the decision-
making process. For example, in the course of a specific line of
clinical inquiry intended to foster insight, in reaction to the
patient’s specific verbal responses during this inquiry, and/or in
the context of appraising the in-session impact of this interven-
tion, you may decide whether to continue with the explora-
tion or to shift gears. Moreover, these affective states can be
valenced positively to negatively and, depending on context,
can beneficially contribute to or disadvantageously hinder the

A DUAL PROCESS PERSPECTIVE 91

 accuracy and effectiveness of your decision making. Thus, to
the extent feasible, seek to be aware of your affective states as a
given session unfolds, be mindful of the fact that they can affect
your judgments and decisions for better or for worse and, in this
light, seek to harness and handle your emotional states in ways
that work to the patient’s good.
6. Given that affect unrelated to the decision task at hand can
influence and thereby bias your judgments and decisions (i.e.,
incidental or countertransferential affect), be keenly aware
of the mood state you are experiencing before beginning a
given session. It is essential, especially to the extent that you
are experiencing acutely positive or negative feelings stem-
ming from extraneous circumstances, that you consciously
down-regulate these feelings before the session starts. Engage
in “appropriate adjustment of . . . [your] mindset” (Dumont,
1993, p. 200) through self-regulatory processes to eliminate,
to the fullest extent possible, the risk of these feelings contam-
inating your clinical judgments and decisions in the ensuing
session. As Dumont (1993) pointed out,
As we all have our ups and downs, vigilance must be exer-
cised, whether we are veterans or “rookies,” in the mea-
sure that we sense ourselves under the influence of intense
moods. This is especially important when we share the
same mood as our client and thereby run the risk of poten-
tiating the biases to which each of us is inclined. (p. 200)
Put in current parlance, the practice of “mindfulness” with
regard to registering and letting go of potentially biasing emo-
tional states prior to beginning sessions is a critical prepara-
tion for our work.
7. As the previous example demonstrates, explicit theory’s impact
on clinical judgments and decisions is extensive and profound.
Automatically and deliberatively, it influences data selectively
attended to; specific kinds of data we seek to gather and learn
more about when working with the patient; meanings attrib-
uted to these data; interpretations of the patient’s immediate
in-session actions and verbalizations; our clinical hypotheses
and formulations; and, of course, the techniques and inter-
ventions we utilize (cf. Dumont, 1993). Arguably, explicit
theory thus functions as the very scaffolding of psychotherapy
as the therapist and patient collaboratively seek to develop and
build the latter’s mental health and self-understanding. Thus,
whether your explicit theory of psychotherapy is single school,

92 ANCHIN AND SINGER

 integrative, or unifying, learn, know, and understand it well;
the importance of being thoroughly and intimately conver-
sant with its evolving constructs, propositions, and techniques
cannot be overestimated. In this light, being willing to revisit
and open your theoretical assumptions to additional scrutiny,
modification, and growth is likely to enhance the flexibility
and acuity of your decision-making processes.
8. Following from the previous implication, the constructs, propo-
sitions, and techniques composing your preferred explicit the-
ory are likely to be “tagged” (Slovic et al., 2004) with positive
affect, predisposing formulations, inferences, and techniques
deriving from this theory to “feel right” and hence automati-
cally adhered to during the “doing” of psychotherapy. This
begs the question of whether there may be times when one’s
judgments and decisions are guided more by feelings stemming
from intrinsic positive valuation of one’s preferred theory than
by considerations about what may be best for the patient.
Particularly in bogged-down cases, it may be useful to delib-
eratively reflect on this question between sessions and to con-
sider the potential impact that complementing one’s preferred
theory with one or more alternative theoretical perspectives
may have on one’s clinical judgments and decisions in treating
the patient.
9. Seek to explicitly articulate the beliefs composing your implicit
theory of psychotherapy. Over the course of a given session these
tacit beliefs interact with the concepts and propositions of your
explicit theory in guiding clinical judgments and decisions and,
like the latter, are drawn on consciously and unconsciously,
deliberatively and automatically. Although at a given junc-
ture their role may be more or less prominent than explicit
theory, to the extent that they exert impact on judgments
and decisions, they affect the process and thereby the out-
come of a patient’s therapy. In this respect, Najavits (1997,
p. 12) astutely speculated that various kinds of inconsistency
between implicit and explicit theory may play a distinct role
in negative treatment outcomes. More generally, as she sug-
gested, explicitly knowing the content of your implicit beliefs
about how to do psychotherapy, compared with the level of
understanding that can be derived from focusing solely on your
explicit theory, can only enhance your understanding of how
you work—and it would seem that this “sophisticated, richer
understanding” (Najavits, 1997, p. 13) can benefit therapeutic

A DUAL PROCESS PERSPECTIVE 93

 process and outcome. To do so, you would be advised to avail
yourself of peer supervision and shared case conferences that
allow you to engage in supportive but reflexive examination
of particular session interactions. What you may not see with
regard to implicit processing, your peers may help you to track
and articulate.
10. As a pervasively goal-directed process that unfolds over
time, a patient’s treatment at any given moment is likely to
encompass multiple goals—that is, one or more immediate
goals are nested within short-term goals, which in turn are
nested within the therapy’s long-term goals. For example, at
the outset of the vignette shown earlier, the therapist’s imme-
diate goal of understanding how the patient interpreted his
clock-glancing behavior was nested within short-term goals
that included engaging the patient in metacommunication
and helping him understand how his interpretive processes
influenced his emotional reaction and how the contents of
his interpretation were driven by core beliefs about self and
others. In turn, these and other short-terms goals were nested
within long-term treatment goals that include fostering
development of a healthy sense of self and effective patterns
of interpersonal relating (see Magnavita & Anchin, 2014,
Chapter 3). With any given patient, maintaining mindful-
ness of the therapy’s long-term goals, being explicitly cogni-
zant of your short-term goals, and striving for clarity about
your immediate objectives at any given moment of the ther-
apy are essential to accurate, effective decision making; the
more aware you are of what you are aiming to accomplish,
the better the judgments and decisions you can make about
how to get there.

SUMMARY

To conclude this chapter, we might draw on a brief nautical analogy.

A good sailor begins with a charted course (the explicit psychological
theory of personality and change that guides the therapy). Influenced by
this metadestination, the navigator responds both intuitively and delibera-
tively to the vagaries of the current, the tides, and the wind (the particular
interactions of a given session). Drawing on previous knowledge of the par-
ticular waters, or ones that are similar, some adjustments come readily with

94 ANCHIN AND SINGER

a minimum of reflection. On the other hand, sudden unexpected changes in
the atmospheric conditions or the introduction of uncharted obstructions
can lead to heightened vigilance and arousal (moments of conflict, resis-
tance, and elevated emotion in the therapeutic interaction), calling much
more deliberative and explicit decision making into play. Good sailors and
good therapists are acutely attuned to the rhythm of this navigational interplay—
moments when one’s hand rests gently on the tiller and other moments when
an intentional tact must be implemented and more overt activity is required.
This decision-making dance—shifting continuously among flow, thought,
and action—is the work and art of therapy.

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 4
CLINICAL PRACTICE GUIDELINE
DEVELOPMENT AND
DECISION MAKING
LYNN F. BUFKA AND ERIN F. SWEDISH

Clinical practice guidelines (CPGs) are increasingly becoming a vital

component of clinical decision making. The complexity of decision mak-
ing requires both empirical evidence, which can be found in evidence-based
guidelines, and clinical expertise; neither alone is sufficient, as acknowledged
in both Institute of Medicine (IOM; 2005) and American Psychological
Association (APA; APA Presidential Task Force, 2006) policy. The devel-
opment of CPGs is being fueled by a number of forces that are shaping how
behavioral and mental health care will be delivered and reimbursed, not the
least of which is the focus on improving care and patient satisfaction while
containing costs. Most clinicians, when they understand the process of clini-
cal guideline development and the checks and balances that are built into the
system, will find that CPGs can be reliable resources to guide clinical decision
making. Behavioral and mental health clinicians need to become acquainted
with the process of developing CPGs. Familiarity with the processes of CPG

http://dx.doi.org/10.1037/14711-004
Clinical Decision Making in Mental Health Practice, J. J. Magnavita (Editor)
Copyright © 2016 by the American Psychological Association. All rights reserved.

105
development and the efforts undertaken to reduce potential forms of bias
(see Chapter 2, this volume, for an in-depth presentation of these forms)
is critical for their acceptance and uptake. In this chapter, we discuss how
CPGs enhance clinical decision making. We also provide an overview of the
development of CPGs and the efforts expended to reduce biases.

WHAT ARE CLINICAL PRACTICE GUIDELINES?

Over the past 2 decades there has been an increasing call for evidence-
based practice in all of health care, including treatment for behavioral
and mental health disorders. Both internal and external pressures, such as
demands for accountability, marketplace changes, technological advances,
and the explosion of research literature, have resulted in increased attention
to the quality and content of psychotherapy (Goodheart, 2010). Currently,
numerous empirically supported treatments (ESTs) for individuals with men-
tal health problems have been shown to be efficacious. More specifically,
sophisticated methodological designs have shown robust effects for various
ESTs for anxiety, depression, posttraumatic stress disorder, and bipolar dis-
order, to name a few (Barlow, Levitt, & Bufka, 1999; Barrett & Ollendick,
2003). Large-scale efforts to disseminate ESTs have occurred as the state of
science in psychology advances (Chorpita, 2002). However, other widely
practiced psychotherapy approaches have not yet accumulated corresponding
supportive bodies of research. Although lack of evidence does not indicate
lack of efficacy (APA Presidential Task Force, 2006), the lack of evidence
is problematic when payers and other third parties determine practices or
otherwise demand certain clinical treatment approaches.
CPGs are one tool to help link research and practice. CPGs as defined
by the IOM are “systematically developed statements to assist practitioner
and patient decisions about appropriate health care for specific clinical cir-
cumstances” (Field & Lohr, 1990, p. 38). The development of quality CPGs
for the treatment of behavioral and mental health disorders has the potential
to help patients, mental health practitioners, policymakers, and administra-
tors make better decisions about how to proceed with care.
Evidence-based CPGs are vital for effective clinical decision making
and efficient patient care. The three-circle model for evidence-based clini-
cal decisions (see Figure 4.1) was developed to promote a clear process for
decision making to inform clinicians’ treatment decisions (Haynes, Sackett,
Gray, Cook, & Guyatt, 1996). Separately, the three circles illustrate that
evidence-based clinical decisions use the best available research; clini-
cal expertise; and patient values, characteristics, and circumstances. The

106 BUFKA AND SWEDISH

 Best Available
Research

Pa!ent
Characteris!cs, Clinical
Culture, Exper!se
Preferences, &
Values

Figure 4.1. Three-circle model of evidence based practice in psychology. Data from
Haynes, Sackett, Gray, Cook, and Guyatt (1996).

convergence of the circles highlights the importance of integrating all three

sources of data in clinical decision making. By incorporating these three dis-
tinct yet overlapping circles, the model recognizes the need for the synthesis
of available information and knowledge, both from research and clinical
expertise, to provide the best treatment for each individual patient on a
case-by-case basis.
The three-circle model of decision making emerged as a part of the
evidence-based medicine (EBM) movement or the “conscientious, explicit,
and judicious use of current best evidence in making decisions about the care
of individual patients” (Sackett, Rosenberg, Gray, Haynes, & Richardson,
1996, p. 71). Sackett et al. (1996) also noted the importance of clinical
expertise and that both research evidence and clinical expertise must be
evaluated with an understanding of patients’ values and preferences. A defi-
nition of EBM was later adapted for policy by both the IOM (2001) and the
APA (APA Presidential Task Force, 2006). Evidence-based CPGs are critical
tools for assisting clinicians with the inherent complexity of decision making
in the clinical situation. The aim is to enhance the quality and efficiency of
health care and to identify gaps in knowledge by providing the pros and cons
of different interventions. Well-developed guidelines serve as an important
protection against the inherent biases that are common in clinical decision
making (see Chapter 5, this volume).

CLINICAL PRACTICE GUIDELINE DEVELOPMENT 107

 It is important to note that CPGs are explicit and actionable recom-
mendations that are based on a critical appraisal of scientific evidence where
attempts are made to avoid biasing the results so that they represent a valu-
able and reliable resource for clinicians. Research contains biases, and there-
fore CPGs can be vulnerable to those biases, but the process of guideline
development provides some mechanisms for evaluating the literature for key
sources of bias, although it does not eliminate all of it. For instance, the strin-
gent standards by which research for guidelines is reviewed results in only
very well-done studies being included in the analyses, and emerging areas
of research or informative but lesser quality research might not be included
in the final analyses leading to recommendations. Users of CPGs can gener-
ally feel confident in the quality of included evidence but should recognize
that other sources of research evidence may not have been considered in the
development of the guideline. CPGs are not a substitute for clinical judg-
ment, and in fact, IOM and APA both recognize the importance of clinical
expertise in the decision-making process. Guidelines should be viewed as
resources that offer basic rules, but rigid compliance with guidelines is not
in service of the patient; rather, the combination of high-quality evidence
and clinical expertise is the basis for professional accountability. At times,
depending on the clinical circumstances, such as patient preferences, cul-
tural and ethnic factors, comorbidities, and so forth, there may be reasons
for not complying with a guideline. Thus, guidelines offer one reliable source
of information among many essential to effective clinical decision making.
Furthermore, CPGs are not established standards of care that have legal
implications, although this may change as research advances and guidelines
become more sophisticated. Informed clinical decision making combines
the best available information with ethical standards. Practitioners may be
concerned that CPGs reduce autonomy or create “cookbook” treatment
(Arkowitz & Lilienfeld, 2008), but implementing the recommendations in
CPGs requires training and clinical expertise (see Chapter 5, this volume).
Additionally, CPGs do not determine what form of care ought to be covered
by both public and private health benefit plans, but it is likely that as their
credibility is established they will serve as resources that will be used as guide-
posts for policymakers, patients, and third-party payers. Guidelines are not
synonymous with reimbursement policies, but those policies may certainly
be informed by CPGs.
The National Guidelines Clearinghouse (http://www.guideline.gov) is
sponsored by the Agency for Healthcare Research and Quality (AHRQ). The
current criteria for guideline inclusion, effective June 2014, are that guide-
lines contain systematically developed recommendations; they are developed
by an organization; they are based on a systematic review (SR) of evidence;
they contain an assessment of the benefits and harms of recommended and

108 BUFKA AND SWEDISH

alternative care options; and the full text of the document, including the most
recent published version, is available. These criteria are consistent with emerg-
ing best practices in guideline development (IOM, 2011a, 2011b). Examples
of CPGs that meet current quality criteria include screening for cognitive
impairment in older adults (developed by the U.S. Preventive Services Task
Force) and the use of fluoride to prevent cavities (developed by the American
Dental Association). Furthermore, U.S. Department of Veterans Affairs (VA)
and the Department of Defense generate joint CPGs relevant to health care
providers in the Veterans Health Administration and Military Health systems.
In the United Kingdom, high-quality guidelines have been developed by the
National Institute for Health and Care Excellence. Currently, APA is gener-
ating CPGs for mental and behavior health problems in the United States to
help guide mental health clinicians in the decision-making process. The APA
process is consistent with the emerging best practices in guideline develop-
ment (Hollon et al., 2014).

HISTORY OF GUIDELINE DEVELOPMENT

In the United States, unlike some other countries, the federal govern-
ment has not assumed responsibility for creating CPGs. Typically, professional
associations or health care organizations either singly or collaboratively cre-
ate these guidelines in the United States. The U.S. Agency for Health Care
Policy and Research was established in 1989 with responsibilities that included
outcomes research and practice guideline development (Gray, Gusmano, &
Collins, 2003). In the mid 1990s, the agency faced criticism over its work.
Although the agency ultimately survived, it was renamed the Agency for
Healthcare Research and Quality, and its focus shifted to comparative effec-
tiveness research rather than guideline development. It is in this context
that guideline development by organizations and professional associations
increased, and standards for guideline development emerged in 2011.
Although the development of CPGs flourished in the 1990s and 2000s,
guidelines had strong opponents (Abrahamson & Saakvitne, 2000; Reed,
McLaughlin, & Newman, 2002). Criticism of existing guidelines included
lack of generality or objectivity, suggesting potential bias in their content and
therefore application or concerns regarding the presentation of the science
(Craske & Zucker, 2001). For instance, guidelines from government entities,
such as the VA, are focused on specific populations and therefore might not be
applicable to other populations. Additionally, guidelines developed by profes-
sional societies were seen as potentially slanting toward the interests of spe-
cific guilds, and guidelines funded by industry were potentially biased toward
industry interest, whether that funding and interest might be pharmaceutical,

CLINICAL PRACTICE GUIDELINE DEVELOPMENT 109

device, or managed care. The current evolution in the development of guide-
lines is heavily grounded in the advances in decision analytics presented in
this volume.
For many years, APA weighed the relative merits of developing CPGs
(also known in many settings as treatment guidelines or practice parameters).
APA chose not to develop such guidelines in the 1990s but instead developed
the “Criteria for Evaluating Treatment Guidelines,” a document that was
adopted as policy in 2002 (APA, 2002). This document offered criteria to
evaluate CPGs promulgated by health care organizations, government agen-
cies, professional associations, and other entities and proved useful for this
purpose, especially in light of APA’s decision not to develop CPGs at that
time. This document also provided an APA definition of treatment guide-
lines (CPGs), as distinct from professional practice guidelines, which “consist
of recommendations to professionals concerning their conduct and the issues
to be considered in particular areas of clinical practice rather than on patient
outcomes or recommendations for specific treatments or specific clinical pro-
cedures at the patient level” (APA, 2002, p. 1052).
However, since the 1990s, the environment for provision of psychologi-
cal services has changed, and many health disciplines are utilizing guidelines
for the purposes of synthesizing the research and conveying what is known
about best practices in treating various conditions and disorders. In 2005,
APA adopted a policy statement defining evidence-based practice in psy-
chology as “the integration of the best available research with clinical exper-
tise in the context of patient characteristics, culture, and preferences” (APA
Presidential Task Force, 2006, p. 273). An accompanying report elaborat-
ing on these principles was subsequently published (APA Presidential Task
Force, 2006). These documents were met with some controversy: Some crit-
ics thought research was undervalued, whereas others wanted greater empha-
sis on the value of clinical expertise. Nevertheless, these documents laid the
foundation for future APA policy developments, underscoring the research
foundation of psychological practice.
After this policy statement was adopted, leaders in psychology began
to reexamine the role of CPGs in health care and asked if now was the time
for APA to begin developing CPGs. Concerns about APA noninvolvement
in CPG development included the possibility that topical guidelines that
did not include psychosocial interventions would regulate treatment reim-
bursement and institutional quality controls and that existing guidelines
overemphasize medications to the relative neglect of often more preferred
and effective psychosocial interventions. Additionally, psychological science
undergirds clinical practice, and CPGs would be an opportunity to highlight
that connection and bring that evidence more broadly into health care deci-
sion making. Also, psychologists’ research training provides the knowledge

110 BUFKA AND SWEDISH

base and analytic skills necessary to understand, use, and oversee the devel-
opment of evidence-based guidelines. For these reasons, APA’s Council of
Representatives approved the undertaking of a strategic initiative to develop
CPGs and appointed an advisory steering committee in 2010. The commit-
tee has reviewed key issues in the arena of guideline development to create
a process for APA that could best meet the needs of the organization and
best utilize all potential resources (Hollon et al., 2014). These processes are
consistent with the standards described in two recent IOM reports, Clinical
Practice Guidelines We Can Trust and Finding What Works in Health Care:
Standards for Systematic Reviews (IOM, 2011a, 2011b).
Evidence-based guideline generation typically involves (a) the conduct
of a comprehensive SR of the empirical literature and (b) presentation of the
findings from the SR to a guideline development panel (GDP). The GDP, con-
sisting of practitioners, scientists, methodological experts, and patient rep-
resentatives, is then asked to generate recommendations that are informed
by the empirical literature but take clinical experience into account (Falck-
Ytter & Schünemann, 2009). This results in CPG recommendations derived
from the best available research evidence as filtered through expert clinical
judgment and reflective of patient values and preferences.
The recently published IOM standards promise to lead to major changes
in the way CPGs are developed (Kung, Miller, & Mackowiak, 2012). One
standard addresses the formation and functioning of GDPs tasked with gener-
ating the treatment recommendations (IOM, 2011a). Standards for the basis
of those recommendations, SRs of the literature, are addressed in the second
IOM publication (IOM, 2011b). Prior CPGs have been quite diverse with
respect to the methods followed and the way their recommendations were
made. To create uniformity in guideline quality, the IOM created standards
by which all CPGs should be developed. These standards are summarized in
Exhibit 4.1 and discussed in the following section.

EXHIBIT 4.1
Institute of Medicine Standards for Developing
Trustworthy Clinical Practice Guidelines
• Transparency in development and funding
• Disclose, manage and resolve conflicts of interest
• Panels multidisciplinary, balanced and include patient/community involvement
(adversarial collaboration)
• Systematic reviews of literature are basis for guideline recommendations
• Rate quality of evidence and recommendation strength
• Recommendations framed as actionable statements
• Submit draft guideline for public review and comments
• Update guideline periodically as necessary
Note. Data from Institute of Medicine (2011a).

CLINICAL PRACTICE GUIDELINE DEVELOPMENT 111

 INSTITUTE OF MEDICINE STANDARDS FOR
CLINICAL PRACTICE GUIDELINES

Transparency

To ensure that guideline development is perceived to be as free of bias

as possible, developers need to be transparent in reporting the processes of
guideline development and sources of funding. Although reporting alone
does not ensure lack of bias, the public is able to discern potential sources
of influence and weigh those contributions in the development process.
Additionally, transparency in the steps of guideline development ensures that
all those not directly involved are at least familiar with the processes for how
panel members were selected, how decisions were made, how recommenda-
tions were derived, and other key components of the development process.

Conflicts of Interest

Much attention has been focused on the potential impact of financial

conflicts of interest (COI), such as industry support or grant funding, finan-
cial remuneration for training, and royalties from related publication, but
increasingly the potential bias from nonfinancial, primarily intellectual, COI
has also been addressed (Akl, Karl, & Guyatt, 2012; Guyatt et al., 2010).
Guideline panel members with strong allegiance to particular clinical prac-
tices or orientations may not be able to review dispassionately the evidence
regarding particular methods or practices. Or, in discussions about the evi-
dence and potential recommendations, GDP members with a particular COI
may attempt to exert their point of view when it coincides with their areas
of expertise or areas of research funding. Hence it becomes important for
all involved to first disclose any potential or actual COI so that the panel is
informed. Then the panel can make determinations regarding how to man-
age any such conflicts. Management of such conflicts may range from basic
acknowledgement of potential allegiance to abstention from voting to non-
participation in deliberations to outright removal from the panel itself. And,
of course, documentation of such disclosure and management of COI ensures
transparency for those who will later read, evaluate and use the guidelines.

Guideline Development Panel Composition

Guideline panels composed of experts with a variety of perspectives

promote the possibility for “adversarial collaboration,” that is, for compet-
ing ideas to be evaluated and challenged in order to arrive at recommenda-
tions. Even when guidelines are developed by one professional organization,

112 BUFKA AND SWEDISH

formally including other professionals such that panels are multidisciplinary
can increase the likelihood that multiple perspectives are considered and
addressed in the guideline. Guidelines developed by researchers, clinicians,
and community members who represent a broad swath of potential contribu-
tors and users have a greater potential for reducing bias and incorporating key
considerations from multiple perspectives in the final product. Additionally,
strategies to incorporate public feedback during guideline development also
provide an opportunity to ensure that key ideas are addressed in guidelines
and content is framed in a manner applicable to a variety of users. The risk
of one perspective possibly dominating or biasing the guideline is reduced by
the adversarial collaboration, so such guidelines have the potential to serve
as useful tools for decision making because users may feel confident in the
final recommendations.

Interaction With the Systematic Review Team

CPGs based on high-quality SRs can serve as a foundation for clinical

decision making. Many practitioners are not familiar with the methodology
of SRs, but that process itself has several procedures to reduce the potential
for bias. These procedures ensure that only research that meets specific stan-
dards are included in the review, and many, if not all, guideline developers
are moving to adopt these procedures. One potential downside of the rigorous
decision making regarding inclusion and exclusion of research studies is that
some potentially informative research may not be included in the review.
However, when guideline panels work with the SR team (usually these are
distinct entities), panel members can provide input to the process and con-
vey important information. Keeping the review team distinct from the panel
supports the SR team’s standard approach to reviewing the literature with-
out undue influence from the panel, but some interaction between the two
ensures that the end review will be of use to the GDP. Users of finished guide-
lines can be assured that those based on SRs represent the strongest findings
in the professional literature.

Recommendation Evidence and Articulation

Recommendations are at the heart of any guideline document, and

those formulated with a clear rationale and with reference to the strength
of the research evidence will engender confidence in their use for decision
making. Recommendations that convey the strength (and gaps) of the rel-
evant evidence as well as discussion of the potential benefits and harms are
likely to be most useful. Although there are many areas where abundant
empirical findings can be culled, others may have a dearth of evidence and

CLINICAL PRACTICE GUIDELINE DEVELOPMENT 113

need further research. The quality ratings of recommendations indicate not
only confidence in the effect of an intervention but also that the evidence
supports a particular clinical decision by considering the benefit of the inter-
vention, potential risks, problems of not intervening, and potential patient
values (Balshem et al., 2011). Factors such as directness of evidence, pre-
cision, and publication bias are all important considerations in evaluating
the body of evidence in writing recommendations. Guideline developers are
also encouraged to explain how panel members’ values, opinions, theory, or
experiences may have informed the recommendations. This context, along
with clear information regarding ratings in the confidence of the evidence
underpinning the recommendations and the general strength of the recom-
mendation, can make it easier for users to determine the value of particular
recommendations to their specific decision making. Each of these elements
reduces the potential for bias in the guidelines statements.
Also, clearly articulated recommendations make it easy to determine
what the recommended action is and when it should be done, thus facilitat-
ing clinical decision making because the user can determine whether the
specific recommendation applies to the case at hand. Recommendations that
are actionable are preferred in CPGs. Although actionable recommendation
statements have more to do with implementing the end product, such state-
ments are also more readily measurable, and the impact of the CPG can be
evaluated. Such evaluations reflect the quality and usefulness of the guide-
lines for end users.

External Review

Subjecting guidelines to a rigorous external review process enhances

their usability for decision making. External review that encompasses feed-
back from relevant stakeholders, such as scientific and clinical experts, agen-
cies and organizations, patients, and the public, provides an opportunity for
a broad spectrum of perspectives to be considered. Potential biases may be
identified through this process, and revisions can be made to correct for these.
When guideline developers document comments received and responses to
such comments, users have a clearer understanding of the process as well as
the potential strengths and limitations of any such guideline when used in
decision making.

Updating

Users need to know that guidelines are current. Literature on particu-

lar topics and interventions is continually in development, and guideline
developers must stay attuned to the professional literature to be certain that

114 BUFKA AND SWEDISH

emerging evidence is either incorporated into guideline updates or deter-
mined to not alter the validity of the existing document. Guidelines deemed
to be too far afield from the extant research literature do not deserve signifi-
cant consideration by users. Out-of-date guidelines will not reflect current
knowledge, leading to possible errors in recommendations. Best practices sug-
gest that CPGs need to be reviewed and updated, minimally, every 5 years.
To the extent possible, the APA guideline development process follows
these standards. By so doing, APA’s guidelines will be perceived as trust-
worthy and useful tools that are essential and relevant for effective clinical
decision making.

SYSTEMATIC REVIEWS

Systematic reviews, which undergird the CPG development process, are

rigorous, planned reviews of the literature that focus on specific questions.
Those who conduct SRs are focused on the quality of the evidence for the
effect of the intervention, while other factors of evidence quality are relevant
in writing recommendations (Balshem et al., 2011). The IOM (2011b) has
published standards for SRs in order to provide guidance to those who con-
duct such reviews and to improve the overall quality of SRs. AHRQ has
provided guidance for managing COI as it relates to the development of SRs
and recommends balancing expertise, independence, and transparency in
the conduct of reviews (Viswanathan et al., 2013). These IOM and AHRQ
guidelines include creating a team to conduct the review that has the appro-
priate expertise and experience, managing the bias and COI of team members
and those providing input into the SR, soliciting user and stakeholder input
as the review is designed and conducted, developing an analytic framework to
define key clinical questions to be addressed and to link health interventions
to outcomes, and developing an SR protocol and submitting that protocol for
peer review. Developing the SR protocol is one of the more rigorous aspects
of the process and includes specifying the screening and selection criteria of
studies, describing precisely what will be addressed (outcomes, interventions,
comparison groups, and so on), defining the search strategy to identify rel-
evant evidence and the procedures for selecting studies, describing the data
extraction strategy, and determining the process for identifying and resolv-
ing disagreement between researchers conducting the SR. In addition, the
SR team must have specified practices for critically appraising identified
studies and evaluating the body of evidence.
These components, including specified search strategies, identification
of studies, and specified strategies for critically appraising and evaluating the
evidence, serve to safeguard the review from bias. Although eliminating all

CLINICAL PRACTICE GUIDELINE DEVELOPMENT 115

bias is not likely, careful attempts to reduce sources of bias, such as lack of
randomization, differences between comparison groups at baseline, and high
rates of attrition, and highlighting points of bias lead to higher quality SRs
and the potential to then have more confidence in final guideline products
based on high-quality reviews. When efforts are not made to control for
sources of bias, the potential for compounding these problems in the final
product increases.
A variety of methodological sources of bias can influence the SR pro-
cess and the quality of the recommendations derived from such reviews.
GRADE (Grading of Recommendations Assessment, Development, and
Evaluation) was developed to address many of these concerns (see http://
www.gradeworkinggroup.org/index.htm). Some of the methodological sources
of bias that are addressed include strategies for evaluating research studies
on a variety of components, such as how participants were allocated to con-
ditions, whether conditions were concealed, and how dropouts were man-
aged. Additionally, as the evidence across a body of research is evaluated,
inconsistencies and imprecision in findings as well as whether the evidence is
direct or indirect are noted and evaluated before recommendations are made.
Last, publication bias can also influence the results of SRs and the available
evidence from which conclusions can be made. GRADE, and adaptations
of GRADE, provide methods for addressing each of these areas during the
recommendation development process. The more confidence users have that
these sources of bias were addressed, the more confidence they can have in
the final guideline product.

ROLE OF CLINICAL PRACTICE GUIDELINES

IN REDUCING BIAS IN DECISION MAKING

Although CPGs have important external functions, such as providing

guidance to policymakers regarding appropriate services for various disorders,
CPGs are fundamental to practitioners’ clinical decision making. CPGs that
are built on high-quality SRs have the potential to reduce clinician bias
and support optimal clinical decision making. Although many factors can
influence decision making and introduce bias, such as the misuse of decision
heuristics and cognitive errors, one source of bias is an individual’s inability
to stay current with the exploding research literature. APA alone publishes
more than 80 journals in psychology, and many other relevant, peer-reviewed
journals exist. More than 10 years ago, Bazian Limited (http://www.bazian.
com/) estimated that 25,000 medical journals were in print and 8,000 articles
were published daily. Even in the circumscribed field of mental and behav-
ioral health, individual clinicians cannot keep up with the literature. Adding

116 BUFKA AND SWEDISH

to that, the vast majority of studies are not sufficient, on their own, to reliably
guide clinical decisions. An individual reader may not be familiar with the
breadth of research on a given topic, but his or her decision making could be
strongly influenced by the portion of literature with which he or she is famil-
iar. If that portion covers only a segment of the relevant topic, the reader’s
capacity to derive appropriate conclusions is limited as well. Even the most
dedicated scientist–practitioner can feel overwhelmed when attempting to
keep up with the complete breadth of the scientific literature.
CPGs serve as a synthesis of the research with a systematic strategy for
deriving recommendations. This reduces the tendency to base clinical deci-
sions on the most recent literature but ensures that such decisions are based
on a systematic, comprehensive, objective evaluation of the entire evidence
base. CPGs are not themselves without bias, but the conduct of the SR serves
to limit some of the bias in the research literature, and the transparent devel-
opment process allows users to evaluate where and whether bias may have
occurred in the panel’s decision making. Of course, clinical decision making
is not based simply on CPGs or even the empirical clinical research; other
sources of evidence also contribute to the process, such as professional knowl-
edge from related fields (e.g., developmental or cognitive psychology), clini-
cal interview and observation, theory, and patient response to the interaction
and intervention (Goodheart, 2006).
Increasingly, health care has focused on shared decision making, where
clinician and patient collaboratively arrive at and refine treatment decisions.
When treatment recommendations are relatively straightforward, decision
making can be as well, but this is rarely the case. When multiple options
exist, with differing balances of harms and benefits, understanding the indi-
vidual patient’s values and preferences becomes critical in making treatment
decisions. Effective CPGs can facilitate shared decision making with clear
recommendations and a clear explanation of the relative harms and benefits
of each recommendation. CPGs that do not provide that information are
less useful to the patient in decision making, but there may be times when
that information simply does not exist in the literature. The CPG still affords
some benefit, but the clinician must then interpret and utilize appropriately
the content of the CPG.
Shared decision making can be accomplished with the use of a variety
of decision support tools, generated for both clinicians and patients. Decision
support tools can range from simple printed disease fact sheets containing
symptom and treatment information to straightforward clinical algorithms to
sophisticated electronic algorithms embedded in electronic health records.
Even something as basic as a checklist has proven to be effective and life-
saving (Gawande, 2009). As CPGs are developed and refined, they are an
important source of information for developers using decision analytics to

CLINICAL PRACTICE GUIDELINE DEVELOPMENT 117

provide support tools, although they have not always been developed with
this in mind. Greater collaboration between developers of CPGs and deci-
sion support tools will likely result in products of greater use to patients and
their providers (van der Weijden, Boivin, Burgers, Schünemann, & Elwyn,
2012). Tools developed from the same evidence base will be able to both
highlight the same range of interventions and considerations and provide
consistent information to all those involved in evaluating options.

RELEVANCE OF CLINICAL PRACTICE GUIDELINES

FOR DECISION MAKING

Evidence-based CPGs can have numerous advantages in informing

clinical decisions in mental and behavioral health settings. For example, it
is nearly impossible for mental health clinicians to stay current on all of the
available literature on prevention and treatment of behavioral and mental
health problems; therefore, CPGs can provide clinicians with a clear and
concise reference to navigate the scientific research. By using CPGs, mental
health clinicians can ensure that their patients receive care that is informed
by the best up-to-date evidence.
Additionally, research suggests that recommendations provided by
CPGs can improve clinical decision making. For example, Grimshaw and
colleagues found that CPGs can produce positive changes in clinical prac-
tice and patient outcome (Grimshaw et al., 1995). Furthermore, the VA has
found a positive impact on clinical practice patterns and patient outcomes
in several studies examining clinician use of CPGs in treating a variety of
diseases (e.g., chronic obstructive pulmonary disease, asthma, sexually trans-
mitted diseases). For instance, the use of CPGs in the treatment of pressure
ulcers led to a 25% reduction in the development of additional pressure ulcers
(Berlowitz & Halpern, 1997).
Furthermore, the development of rigorous evidence-based guidelines
that consolidate results of numerous studies has the potential to improve
consistency in clinical decision making by avoiding the inherent biases to
which we are all subject. The consolidation of recent evidence from the lit-
erature about the relative effectiveness of various treatment options can also
help simplify the inherent complexity of decision making. Evidence-based
CPGs promote rational, informed clinical decision making that reflects the
best available scientific evidence. Often in psychotherapy practice, decisions
need to be made quickly (see Chapter 2, this volume), so guidelines can help
clinicians to more rapidly recognize options and choice points. Ultimately,
this helps to improve the quality of care and to reduce the inconsistency with
which it is delivered. CPGs can also reduce variations in service delivery by

118 BUFKA AND SWEDISH

informing public and scientific policy to ensure that interventions are appro-
priately covered and thus available to every patient.
An important benefit of CPGs is that they serve as decision-making
and educational aids not only for providers but for patients, as well. CPGs
allow for patient participation in clinical decision making, coordination of
care, and use of best practices. To counter the inconsistent recommendations
about best practices in health care settings promoted via the media, CPGs
can provide credible and consistent information that increases patient under-
standing about the best treatments for health conditions. As such, guidelines
can help inform patients’ decisions and clarify patient preferences.
Concerns have been raised that CPGs will replace clinical judgment,
although this should not be considered their purpose. Optimal treatment
requires clinical expertise to synthesize the most relevant high-quality infor-
mation to make clinical decisions. CPGs are recommendations based on
the best available research evidence at the time of their development. They
are not substitutes for clinical judgment, but they are used in conjunction
with clinical judgment to provide the best possible care. The responsibility
remains with the clinician to combine the evidence from CPGs with clinical
expertise and patient values in managing individual patients and achieving
the best possible outcomes. Evidence is used in practice to help reduce uncer-
tainty in decision making, not to eliminate it. Used properly, guidelines can
improve health care quality and be a support system in the decision-making
process not only for the clinician but also for the patient.

IMPLEMENTATION OF CLINICAL PRACTICE GUIDELINES

The development of quality CPGs is challenging; however, implemen-

tation is an even greater challenge. It is crucial that implementation strate-
gies take guidelines out of the developmental phase and into the professional
health care settings of decision making. Efforts to implement guidelines have
met with limited success (see Dopson & Fitzgerald, 2005). There are various
barriers to successful implementation, and these can be related to the practi-
tioner or the organization.
Guidelines need to be prepared and presented to practitioners so the
value and the benefits are readily apparent. If this information is in an eas-
ily accessible format and is useful, it is likely that more practitioners will
refer to guidelines and use them as an important foundation for practice.
Guideline recommendations that are clear and concise are more readily uti-
lized in decision making. Guidelines that are perceived as confusing or over-
generalized may have little impact on practice and may even be perceived as
unreliable, so guideline developers need to consider the end user throughout

CLINICAL PRACTICE GUIDELINE DEVELOPMENT 119

the development process to facilitate the eventual use of the guidelines.
Addressing potential barriers to use from the beginning may make it more
likely that CPGs are implemented in daily practice.
Addressing organizational factors such as structural characteristics,
management, philosophy, objectives, and operational capacities when intro-
ducing guidelines increases the likelihood of successful implementation.
Additionally, factors that may affect potential users of guidelines include
amount of insurance coverage and methods of institutional or practitioner
payment. Financial incentives and disincentives may also contribute to the
uptake and implementation of CPGs. Some systems are already piloting pay
for performance measures (providing incentives for specific clinical behaviors
or practice outcomes) that can be linked to CPGs, although additional data
are necessary to determine whether such strategies increase guideline use or
result in improved care.
Research has examined implementation strategies, and the results are
mixed on their effectiveness. For example, Grimshaw et al. (2004) found that
dissemination of educational materials, audit and feedback, and reminders of
CPGs had modest effects in changing clinicians’ behavior. Additionally, imple-
mentation is difficult to analyze, and studies often have methodological weak-
nesses (Grimshaw et al., 1995). It will be important to review the literature on
dissemination and implementation of evidence-based psychological treatments
(e.g., McHugh & Barlow, 2010, 2012) to identify strategies to adapt for use
with CPGs. Therefore, it is essential for future research to examine behavior
change in clinicians in order to develop effective implementation strategies.

SUMMARY

The implementation and use of high-quality CPGs has the potential to

reduce some of the biases inherent in decision making. However, behavioral
and mental health clinicians need to become acquainted with the process of
developing those high-quality CPGs in order to determine which CPGs are
worthwhile. The IOM has provided clear guidance on best practices in guide-
line development, and as more developers follow these practices, we will see
increased quality in guidelines, reduced bias in the production of them and the
underlying SRs, and uniformity in development procedures. Familiarity with
the processes of CPG development and the efforts undertaken to reduce all
forms of bias is critical for their acceptance and uptake. This should contrib-
ute to improved acceptance and uptake of guidelines, with the overall aim of
improving clinical care and reducing the biases in clinical decision making.
The development of quality CPGs for the treatment of behavioral and
mental health disorders has the potential to help patients, mental health

120 BUFKA AND SWEDISH

practitioners, policymakers, and administrators make better decisions about
how to proceed with care. High-quality CPGs can reduce bias in decision mak-
ing and ensure that such decisions are based on a systematic, comprehensive,
objective evaluation of the entire evidence base. CPGs can be trustworthy
and useful tools that are essential in enhancing clinical decision making.

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CLINICAL PRACTICE GUIDELINE DEVELOPMENT 123

 5
DEVELOPING CLINICAL PRACTICE
GUIDELINES TO ENHANCE CLINICAL
DECISION MAKING
STEVEN D. HOLLON

The clinical situation is complex, and no two clients are ever exactly
alike. At times only limited empirical evidence exists to guide the decision-
making process, and what evidence exists is often open to dispute. Clinical
practice guidelines (CPGs) are intended to help guide the decision-making
process. They are not a substitute for clinical judgment but when well crafted
can provide a basis for the decisions to be made. Clinicians need to under-
stand the basics underlying how these guidelines are developed in order to
get maximum benefit from their use.
The American Psychological Association (APA) has decided in recent
years to begin developing CPGs. That decision was not without some contro-
versy and represents an evolution of the position that the APA has taken over
the years (see Chapter 4, this volume, for a discussion of that evolution). It
formed an advisory steering committee (ASC) to guide the process, and I was
fortunate enough to be selected as its initial chair. The issues I describe in this

http://dx.doi.org/10.1037/14711-005
Clinical Decision Making in Mental Health Practice, J. J. Magnavita (Editor)
Copyright © 2016 by the American Psychological Association. All rights reserved.

125
chapter represent my own perspective on the questions that we confronted
and do not necessarily represent the views of the ASC or the larger APA.
In this chapter I describe the evolving science that underlies the devel-
opment of CPGs and its implications for the clinical decision-making process.
Guideline development has moved from a process based largely on unsystem-
atic clinical consensus to a more deliberative process in which a systematic
review (SR) of the scientific data is conducted and the resultant evidence
presented to a panel of individuals with diverse perspectives and expertise
(including service utilizers to provide input concerning patient preferences).
The goal is to ground the discussion in the best science currently available as
filtered through the differing perspectives and expertise of the panelists in a
manner that balances out whatever biases and blind spots each may possess.

INSTITUTE OF MEDICINE RECOMMENDATIONS

FOR GENERATING CPGs

Not long after the APA steering committee was formed, the Institute
of Medicine (IOM) published two sets of recommendations for generating
CPGs. These reports had been in process of development for several years and
did (in my opinion) a marvelous job of summarizing the current state of the
knowledge regarding how to generate guidelines that the public could trust.
The first report described the process of forming the guideline development
panels (GDPs) charged with generating the treatment recommendations
(IOM, 2011a), and the second dealt with the execution of the SRs on which
those recommendations would be based (IOM, 2011b). The reports them-
selves are available to the public and summarized in recent articles (Hollon
et al., 2014) and chapters (Chapter 4, this volume). Therefore, I highlight
only certain aspects of the reports (and the larger process of guideline devel-
opment) that I think are most relevant to their subsequent use.
It is important to note in that regard that both the IOM (2001) and the
APA Presidential Task Force on Evidence-Based Practice (2006) explicitly
adhere to a tripartite model of clinical decision making in which the best
available evidence (represented by the CPG) is filtered through the expertise
of the treating clinician to arrive at the best decisions consistent with the pref-
erences and values of the individual patient. In essence, the goal of guideline
development is to put the best available evidence before the patient and treat-
ing clinician, but the clinician trumps the guideline and the patient trumps
the clinician.
What this means to me is that I have an obligation to provide my
patients with the most complete and accurate information possible (drawing
when possible on the CPG in the process) and to make my recommendations

126 STEVEN D. HOLLON

regarding those potential options (even when they are not wholly consistent
with the guideline) but that the ultimate decision as to what is to be done
rests with the patient I am treating (so long as he or she is competent). When
I disagree with what the guideline recommends, I have an obligation to be
clear about the basis for that disagreement, and if I am unwilling to go along
with what the patient prefers, then I have an obligation to provide a referral
to someone else who will. I have in the past worked with patients diagnosed
with bipolar disorder who wanted to come off their lithium; both instances
resulted in clinical disasters that I do not recommend repeating. Prospective
patients also have asked me to treat them with an approach that I was not
competent to provide and that had not impressed me with its success. When
that happens I explain the reasons for my reticence and offer to make a refer-
ral. In other instances I have scrambled to add strategies to my basic cognitive
approach that had been found to have specific benefit for the kinds of prob-
lems that my clients faced (although I tend to specialize in the treatment of
depression, it is not unusual for clients to have comorbid problems with post-
traumatic stress disorder or obsessive–compulsive disorder or panic attacks).
The basic approach that I have taken throughout my career is to ground
whatever I do in the best available scientific evidence as filtered through my
own perceptions of what I think might work best for my particular client but
always guided by his or her individual preference.

Forming the Guideline Development Panels

Several key aspects of the guideline development process are particu-

larly relevant to the clinical decision-making process (and their inclusion
influences whether I am likely to be willing to adhere to the guideline). The first
is transparency. The IOM lays out a series of steps to ensure that the guideline
user can understand how the recommendations were developed. Each step in
the process is carefully documented, and a written record is made available
to the public for review at multiple steps along the way. What this means
is that the recommendations do not have to be taken on the basis of faith.
Anyone who questions a specific recommendation can see just how it was
generated and the evidential basis on which it rests. This allows the clinician
(myself included) to gauge the extent to which he or she agrees with the
recommendation.
Two recent guidelines on the treatment of depression highlight differ-
ences in how this issue was approached and the resultant impact that these dif-
ferences had on the confidence that I have in each guideline. The National
Institute for Health and Clinical Excellence (NICE) is charged by the
National Health Service in the United Kingdom with generating CPGs to
guide service provision within their single-payer system. The guidelines they

DEVELOPING CLINICAL PRACTICE GUIDELINES 127

develop are always based on an SR, and the organizations are meticulous in
documenting what they do and why they do it. Their guideline on the treat-
ment of depression was no exception (National Collaborating Centre for
Mental Health, 2010).
By way of contrast, the American Psychiatric Association generated
their guideline on the treatment of depression in the absence of any SR and
with no clear documentation of how they arrived at their decisions (American
Psychiatric Association, 2010). Neither course inspires much confidence in
their recommendations. I was particularly struck by two “oversights” on
their part that both worked to overstate the benefits of medications. Citing
a study by Turner, Matthews, Linardatos, Tell, and Rosenthal (2008) that
showed that withholding negative results in some instances and “spinning”
results in others to make them more favorable to medications inflated the
apparent efficacy of medications, the guideline’s only comment was that
“those factors do not appear specific to particular medications or medica-
tion classes” (American Psychiatric Association, 2010, p. 31). This com-
ment was disingenuous because the factors were true for all antidepressant
medications. An awareness of how confirmation bias can lead to favoring
results that support one’s thinking may have reduced the likelihood of these
cognitive traps.
The second “oversight” involved a thrice-replicated finding that anti-
depressant medications only separate from pill-placebo (show a specific phar-
macological effect) among patients with more severe depressions (Fournier
et al., 2010; Khan, Leventhal, Khan, & Brown, 2002; Kirsch et al., 2008). The
American Psychiatric Association guideline’s comment with respect to those
findings was that there was “some evidence suggesting greater efficacy rela-
tive to placebo in individuals with severe depressive symptoms as compared to
those with mild to moderate symptoms” (American Psychiatric Association,
2010, p. 31). The guideline neglected to say that the lesser efficacy relative
to placebo for those patients with mild to moderate depression dropped to zero
and that although those patients get better on medications, they get better for
psychological rather than pharmacological reasons. A less biased guideline
would do better.
The second key aspect is management of conflict of interest (COI).
Potential panelists often have secondary interests that might strongly bias
their judgments. Financial conflicts represent one obvious source of bias, but
intellectual passions can be a source of bias as well. Many of these have been
reviewed in Chapter 4 of this volume. The IOM recommends requiring a full
disclosure of potential COI at the time the GDP is formed (with periodic
updates as needed). In our experience, it was necessary to work with potential
panelists to educate them about just what might constitute a potential COI
in the eyes of others.

128 STEVEN D. HOLLON

 We chose not to exclude panelists with strongly held perspectives or
potential financial COI (as the IOM suggests) but elected instead to follow
a strategy of balancing such conflicts rather than excluding them altogether.
Our concern was that we not exclude participants with the necessary exper-
tise but instead provide an internal check on any undue influence through
a process that cognitive psychologists refer to as adversarial collaboration
(Mellers, Hertwig, & Kahneman, 2001). This led us to include panelists
with competing interests and expertise that spanned the major approaches
to treatment. For example, our depression guideline panel includes members
with recognized expertise in dynamic, behavioral, experiential, family, and
pharmacological approaches. It also is diverse with respect to members who
are primarily involved in clinical practice, treatment research, and health
care administration. What this means to the practicing clinician is that each
recommendation will have had to survive a fierce and lively debate among
advocates for the major schools of treatment and professional career paths.
NICE handles potential COI in a similar fashion, and one of their direc-
tors (Stephen Pilling, professor from the University College of London) met
with our steering committee early in our organizational process to discuss how
they handled this and other issues. Many research psychiatrists (including
most of the members of the guideline panel) receive money from the phar-
maceutical industry in the form of speaker’s fees and research grants (Angell,
2005). This was enough of a concern that the psychiatric association added
an advisory committee of senior psychiatrists who no longer accepted indus-
try funding to pass judgment on the final product. Once again, although
I know many of the psychiatrists involved and have often published with
them, I have more confidence in the way NICE handled the issue than the
American Psychiatric Association guideline.
A third recommendation from the IOM was that the GDPs be multi-
disciplinary in nature. This was something that we wholeheartedly embraced.
Most mental health disorders and problems in living can be treated with a
variety of interventions (including psychotherapy and medications), and we
wanted to be sure that we provided adequate coverage of all relevant treat-
ments. Our guiding principle was that we wanted to produce guidelines that
were in the public interest and not just in the interest of one profession or
another. (Our sense was that if the guidelines were good for the public then
they would be good for psychology as a discipline.) This principle extends to
our desire to make common cause with other relevant professional organiza-
tions to generate joint guidelines in the future.
NICE guideline panels are invariably multidisciplinary in nature.
Although a few psychologists were listed as commenting on the draft of the
psychiatric guideline, all of the participants on the GDP itself and the over-
sight advisory board were psychiatrists. Once again I have greater confidence

DEVELOPING CLINICAL PRACTICE GUIDELINES 129

in the process followed by NICE than the one used by the American
Psychiatric Association.
The IOM also recommends including current or former patients or
patient care advocates in the process, although no clear consensus exists as
to how this can best be done. My own sense is that inclusion of such mem-
bers helps to keep the professionals on the panel honest and focused on the
public welfare. After some deliberation and prodding from the first GDPs we
constituted, that is what we finally decided to do. What this means is that
users of the guidelines can expect that they will be broad in the interventions
that they cover and focused on what the public needs. NICE always includes
patients on their guideline panels; the American Psychiatric Association
does not.
A fourth set of IOM recommendations specifies the nature of interaction
between the GDP and the SR team. We opted to keep the two groups separate
(to minimize bias in the conduct of the reviews) but to have them interact
from the beginning in terms of formulating the questions to be asked and the
nature of the evidence to be covered. In essence, the GDP determines what it
wants to know (in consultation with the SR team regarding how best to for-
mulate those questions), and the SR team conducts the actual review (with
the ongoing feedback and subsequent requests for additional information
from the GDP). The analogy that we like to use is that the GDP functions
like a jury, determining what it wants to know, and the SR team functions
like both the prosecution and the defense, reporting back on the evidence.
What this means is that the guideline user can have some confidence that the
questions addressed are clinically relevant and that the evidence examined is
not constrained by preexistent bias.
I had the opportunity to sit in on a meeting of the NICE depression
guideline panel several years ago and was struck by how the members were
able to ask for clarifications in the data and have their queries answered
within a matter of minutes (the requests were made to Pilling who commu-
nicated them to the SR team). The psychiatric guideline conducted no SR,
so there was no one to whom to put a question regarding the data.
Once the SR has been conducted and the relevant evidence presented,
the GDP is charged with generating and rating the strength of the recommen-
dations. In some instances the evidence is quite clear, but in others, not so
much. Strong recommendations indicate that the benefits of a given approach
to treatment clearly outweigh its potential harms (or vice versa), but weak
recommendations indicate a less clear balance. Moreover, the quality and
amount of the evidence need to be taken into consideration. For example,
although quantitative reviews often suggest that different types of psycho-
therapies are comparably efficacious for nonpsychotic patients, some types of
treatments have been studied more extensively and stringently than others.

130 STEVEN D. HOLLON

A relative absence of evidence is not evidence of absence (of effect), but it does
limit certainty of recommendations. What this means is that clinicians using
the guidelines can tell from the rated strength just how strong is the evidence
base that underlies a given recommendation. NICE grades the strength of
their recommendations, whereas the psychiatric guideline did not.
The IOM also suggests articulating recommendations in a manner that
makes it clear what actions are being recommended. We plan to ask our
GDPs to generate recommendations in the form of clear action statements
that correspond to specific behaviors on the part of the clinician. That does
not mean that the clinician will have to follow any given recommendation
(clinical judgment still trumps any specific guideline), but it does mean that
the clinician will know exactly what is being recommended and how best to
follow that advice. NICE formulates its recommendations in terms of action
statements; the psychiatric guideline did not.
The IOM also recommends subjecting the recommendations to external
review and carefully documenting the changes that are made as a consequence.
Drafts will be made available for public scrutiny at various points throughout
the process. What this means is that there will be ample opportunity for indi-
viduals not directly involved in guideline generation to pass judgment on
the wisdom of the recommendations and their relevance to clinical practice.
NICE subjects its guidelines to intensive public scrutiny before publication;
the psychiatric association only invites comments from selected individuals
and does not publish their responses.
Finally, the IOM recommends updating the recommendations on a periodic
basis. Precisely when and how will be determined by the growth of informa-
tion in a given area, but the goal is to keep the guidelines current and up to
date. What this means is that the guideline user can have reasonable assurance
that the recommendations presented are current with the times. Both NICE
and the psychiatric association update their guidelines on a periodic basis.
On the whole, I am much more impressed with the fairness and the
balance provided by the procedures followed by NICE (most of which antici-
pated the IOM guidelines) than I am with those followed by the psychiatric
guideline. As a consequence, I am much more likely to take the NICE
recommendations seriously when it comes to areas that I do not know as well
as depression. I particularly like that fact that I can track the basis for the rec-
ommendations to see if I concur with the conclusions that are drawn. It was
clear to me that the IOM recommendations for guideline construction (most
of them anticipated by NICE) are more likely to produce guidelines that I (or
any other clinician) can trust than the procedures followed by the psychiatric
association. I have every expectation that future psychiatric guidelines will
follow those same IOM guidelines, and I hope our two associations will join
forces to produce subsequent guidelines.

DEVELOPING CLINICAL PRACTICE GUIDELINES 131

Conducting Systematic Reviews

The IOM also laid out a series of steps for conducting SRs. The details
of these steps are rather technical in nature and will not be reviewed in any
detail, but several aspects of the process deserve to be highlighted. First, con-
ducting an SR is broader and more inclusive than simply conducting a meta-analysis,
and in some instances (when studies are weak or few) conducting a meta-
analysis might not even be indicated. Meta-analyses provide a quantitative
summary of the empirical literature and can serve as a real guide to the recom-
mendation development process, but like all summaries they often obscure
relevant information. It is important for the GDPs to know just how many
and how strong the studies are that contribute to a given body of the litera-
ture and whether systematic limitations exist that ought to be reflected in the
nature and the strength of the resultant recommendations.
Second, publication bias is often a concern and tends to inflate the
apparent efficacy of the given interventions. This is true not only for medi-
cation treatment (as previously noted) but also with respect to psychother-
apy, although likely for noncommercial reasons (Cuijpers, Smit, Bohlmeijer,
Hollon, & Andersson, 2010). There is a tendency for small studies with weak
effects to not find their way into the literature, whereas small studies with large
effects (often a consequence of chance) are much more likely to be published.
Therefore, it can be important to search the “gray literature” for studies that were
never published. The IOM recommends working with a reference librarian or
other personnel experienced in the conduct of SRs to ensure adequate cover-
age. What this means is that the clinician and the public will not be misled by
inflated estimates of efficacy; it is important to know not only what works but
also how well it works. Paul Meehl (1987) once said that the basic attribute
that ought to distinguish psychologists from the other helping professions is
“the general scientific commitment not to be fooled or to fool anybody else”
(p. 9). Whether we devote the bulk of our time to research or (more often)
clinical practice, the one defining aspect of psychology as a profession is that
we were all trained as scientists and in its application.
Most current reviews start with the formulation of an analytic framework
that lays out the kinds of questions that the SR is intended to address. This
might involve questions such as, “Do the interventions produce the desired
changes in outcomes of interest (positive or negative)?” and if so, “Do they
do so through the mechanisms specified?” We have opted to ask the GDPs
to meet with the SR teams in the beginning of the process to generate the
analytic framework that they want the review to address. The reason that
this is important is because the GDP can focus the review on any aspect of
clinical change that seems important. It is not necessary to limit attention
to symptom change (although that will likely be one component), and most

132 STEVEN D. HOLLON

current reviews now address broader aspects of life satisfaction and adjust-
ment. There will be times when the existing literature has little to say about
these broader outcomes of interest, but one purpose of guideline development
is to call attention to important aspects of human existence that have not
received adequate empirical attention. The goal is not just to provide an aid
to clinical decision making but also to suggest additional issues for the science
to address.
The second key step involves generating structured questions based on the
analytic framework to guide the actual review process. We plan to adopt
the widely used PICOTS format in generating these questions. PICOTS
is a mnemonic that stands for populations (P), interventions (I), compari-
sons (C), outcomes (O), time (T), and settings (S). Thus a specific PICOTS
question might take the following form: For patients with major depressive
disorder (P), does cognitive therapy (I) compared with medications (C) have
an enduring effect that prevents subsequent relapse (O) following treatment
termination (T) in outpatient settings (S)?
Using PICOTS to organize the SRs facilitates asking questions of clini-
cal interest. The goal of personalized medicine is to find the best treatment
for the given individual. Looking for variation in response as a function of
differences in populations (P) can help to address that goal. For example,
in an earlier study we found that cognitive therapy and the antidepressant
medication paroxetine were comparably efficacious (on average) and both
superior to pill-placebo in the acute treatment of patients with moderate to
severe depression (DeRubeis et al., 2005). However, further exploration of the
data indicated that patients with personality disorders did better in medica-
tion treatment than in cognitive therapy whereas patients without personality
disorders did better in cognitive therapy than on medications (Fournier et al.,
2008). One common critique of the treatment outcome literature is that it
has tended to focus in the past on uncomplicated patients with single diag-
noses (Westen, Novotny, & Thompson-Brenner, 2004). This is no longer as
true as it once was, and to the extent that it remains a problem the CPG can
highlight the issue.
The technical term for this phenomenon is moderation, and it typically
is detected as an interaction between some patient characteristic and treat-
ment condition. It is not just patient characteristics that are relevant in this
regard; any aspect of the clinical situation that could influence treatment out-
come can be examined as a potential moderator. Factors such as time (T), the
length or frequency of treatment, and setting (S), exactly where and under
what conditions treatment takes place, can be explored as moderators. Among
recent examples, an intensive week of daily sessions of cognitive therapy for
posttraumatic stress disorders was just as efficacious and much more rapidly so
than the same number of weekly sessions spread out over a 2-month period

DEVELOPING CLINICAL PRACTICE GUIDELINES 133

(Ehlers et al., 2014), and 20 weekly sessions of cognitive behavior therapy for
bulimia was considerably more efficacious than 2 years of weekly dynamic psy-
chotherapy (Poulsen et al., 2014). Adopting the PICOTS format practically
guarantees that the SR will be broad in its focus with respect to the complexi-
ties involved in clinical practice and the inclusion of expert clinicians in the
GDP guarantees that it will relevant to the clinical situation.

SELECTING THE BEST TREATMENT FOR A GIVEN PATIENT

One of the most important clinical decisions to be made is how to iden-

tify the best treatment for a given patient. There is a critical distinction
between prognostic versus prescriptive information that has real implications
for the clinical decision making process. Prognostic indices are individual dif-
ference variables that predict how someone will do over time (possibly during
the course of treatment), whereas prescriptive indices are individual difference
variables that predict differential response to one treatment versus another
(Fournier et al., 2009). For example, in our work on depression, we have found
that chronicity predicts poorer response regardless of treatment (cognitive ther-
apy vs. medications). That means that it is worse to have a chronic depression
(an episode that has lasted 2 years or longer) than a nonchronic depression; you
will be less likely to get better no matter what treatment you receive than some-
one who does not have a chronic depression. On the other hand, employment
status is prescriptive in that patients who are unemployed do worse in medica-
tion treatment than they do in cognitive therapy (patients who are employed
do comparably well in either). What that means is that employment status can
be used to make a decision regarding what kind of treatment a given patient
should receive (if unemployed pick cognitive therapy), whereas chronicity
cannot.
Where clinicians (and scientists) get in trouble is when they confuse the
two kinds of information, and that is an especially easy thing to do. Prognostic
information can be gleaned by holding treatment constant and allowing
patient characteristics to vary. Prescriptive information, on the other hand,
requires holding individual differences constant and systematically vary-
ing the nature of the treatment (as is done in randomized controlled trials).
Because most clinicians do similar things with different patients (rather than
different things with similar patients), what we are most likely to learn in
the context of our clinical practice is what kind of patients best respond to
the things we typically do (prognostic) rather than what kinds of things are
best to do with a given patient (prescriptive). That means that typical clini-
cal practice is best suited to teach us how to select the best patients for our
preferred treatment rather than how to select the best treatment for a given

134 STEVEN D. HOLLON

patient. You do not have to try to fall prey to this logical fallacy when doing
clinical work; you have to try hard not to be fooled in this fashion. When we
ask ourselves who responds to what, we are most likely to recall prognostic
information. We are particularly likely to recall patients who did particularly
well or particularly poorly. That is what cognitive psychologists call the avail-
ability heuristic (Kahneman, Slovic, & Tversky, 1982). That is not an indict-
ment of the practicing clinician (I do the same thing myself when asked in
workshops who is most likely to respond to cognitive therapy); it is just a
reflection of how we are wired to think.
Most clinical lore is based on the wrong kind of information to draw
inferences about what treatment to select for a given patient. That is, most of
what we see in the course of our daily practice is purely prognostic in nature.
Prescriptive information can be ascertained, but it is a more difficult thing
to do and requires forethought. The clinician would have to systematically
vary the way he or she treated similar patients, and that is something that
most of us do not do. The best way to do so is on the basis of a randomized
controlled trial (RCT) in which similar patients are randomly assigned to dif-
ferent treatments. No matter how astute the clinician, recalling who did well
in a given treatment compared with other patients is no basis for treatment
selection; what is needed is what treatment did better than other treatments
for similar patients.
One problem with addressing anything as complex as clinical change
is that there are a lot of possible factors (patient or otherwise) that can influ-
ence treatment outcome, and it is not always easy to put them all together.
That is where clinical experience can come into play. It is well understood
that experience and expertise often confer special advantage in terms of
pattern recognition. Master chess players can anticipate what their opponent
is likely to do several moves in advance, and professional quarterbacks in
football describe the game “slowing down” with experience in a manner that
allows them to do a better job of anticipating the position of the pass defend-
ers. It is likely that experienced clinicians become more skilled in integrating
multiple patient and setting characteristics in a manner that allows them to
select the optimal treatment for a given patient. On the other hand, there
is ample evidence that statistical prediction is more accurate than clinical
prediction (Meehl, 1954). We all have the very human tendency to rely too
much on intuition; that is why casinos rarely go bankrupt.
DeRubeis and colleagues may be on the verge of developing a strategy
that allows them to integrate multiple patient characteristics in a manner that
facilitates identifying the optimal treatment for a given individual (DeRubeis
et al., 2014). Working with data from the placebo-controlled comparison
between cognitive therapy versus medication treatment previously described,
the authors developed a system for generating equations that predict how

DEVELOPING CLINICAL PRACTICE GUIDELINES 135

each patient would have been expected to do in either cognitive therapy
or medication treatment on the basis of presence of a personality disorder
and other predictive indices. About a third of the patients would have been
predicted to do better in cognitive therapy than on medications, whereas
another third of the patients would have been predicted to show the opposite
pattern (the remaining patients would have shown no advantage either way).
Assigning patients to treatment on the basis of this selection algorithm would
have improved outcomes by as much as the difference between either of the
active treatments versus pill-placebo.

HIERARCHY OF EVIDENCE

Treatments are intended to produce change (or to prevent bad things

from occurring in the case of preventive interventions). What this means is
that they are intended to have a causal effect. Even humanistic interventions
that presume that the locus of change is within the client specify certain nec-
essary and sufficient conditions that must be provided by the therapist for the
self-actualizing potential of the client to be realized (Rogers, 1957). There
are two major sources of outcome whenever someone enters treatment: how
they would have done in the absence of treatment (patients), and what gets
done to them in treatment (procedures). CPGs are intended to identify the
best treatment for the given patient, and that means that they are intended
to identify that treatment that produces the best balance of benefits to harm.
In essence, CPGs are all about personalizing causal inference and “guessing”
what procedures work best for a given patient.
A hierarchy of evidence exists with respect to what kinds of research
designs provide the best evidence with respect to the detection of causality
(APA Presidential Task Force, 2006). Uncontrolled case studies rank lowest
on this hierarchy. That is not because they are without value (most of the
greatest breakthroughs in clinical practice have come about as a consequence
of careful clinical observation) but because they do not provide a particularly
good basis for distinguishing between patients and procedures as the source
of that change. Philosophers of science distinguish between the context of
discovery and the context of verification (Popper, 1934; Reichenbach, 1938);
uncontrolled case studies are a rich source of the former but a poor basis for the
latter. Open trials that follow multiple patients treated with the same proce-
dures over time are somewhat more informative in that they provide prognos-
tic information but again confound patient with procedure. Nonrandomized
contrasts between two or more different treatments are more informative still
in that they allow some sense as to how different patients respond to different
treatments, but they still are susceptible to confounding patient prognostic

136 STEVEN D. HOLLON

with treatment effects. RCTs seek to control for patient characteristics by dis-
tributing them comparably across conditions. When patient characteristics
are comparably distributed (on average), then any observed differences in
outcomes can be attributed to differences in procedures and not to patients.
The controversy over hormone replacement therapy (HRT) illustrates
the risk of not controlling assignment to treatment. For more than 2 decades,
women going through menopause were encouraged to go on estrogen to mini-
mize aversive symptoms like hot flashes and to reduce risk for osteoporosis
and coronary heart disease. The common consensus (based on open trials and
clinical experience) was that women who were treated with HRT did better
than those who were not. However, these findings confounded patients with
procedures; it was women who took better care of themselves and had access
to better health care who typically sought out HRT. When the first RCTs were
finally done it turned out that HRT increased risk for heart disease (Manson
et al., 2003) and breast cancer (Chlebowski et al., 2003). In essence, differ-
ences in prognosis favoring women who received HRT (patients) masked
problems inherent in the treatment (procedures).
What we have just described goes under the rubric of internal validity
(Campbell & Stanley, 1963), which refers to the certainty with which we can
attribute the differences we observe at the end of treatment to the procedures
we manipulated experimentally. RCTs typically are privileged in SRs because
they provide the strongest basis for drawing a causal inference. However,
external validity also is relevant. External validity refers to the extent to which
the causal inference drawn generalizes to the context of interest. Early ana-
logue studies that treated less than fully clinical populations with poorly
implemented approximations of more traditional interventions (often for
unreasonably brief periods of time) lacked external validity and did not tell us
all that much about what worked best for the kinds of patients typically seen
in clinical practice. One of the reasons that we wanted to include practicing
clinicians on the GDPs was to ensure that the recommendations formulated
reflected a sophisticated understanding of the kinds of patients likely to be
treated and the nature of the interventions likely to be used.
The C in PICOTS stands for the comparison condition, and it is here that
studies differ most in the kinds of questions that they can address. Construct
validity refers to the extent that we actually understand how our treatments
work (Cook & Campbell, 1979). The first question that we want to address
about a given treatment is whether it actually works (efficacy), and this can be
addressed by simply comparing it with its absence. The second question that
we typically want to address is whether that treatment works for the reasons
specified by theory (specificity). That typically is best addressed by comparisons
with nonspecific control conditions like pill-placebos (in the case of medica-
tions) or supportive treatments that provide all the typical accouterments of

DEVELOPING CLINICAL PRACTICE GUIDELINES 137

going into treatment without whatever is presumed to make the treatment
unique. A third question is whether anything works better than its alterna-
tives (superiority). That is typically tested by direct comparisons between dif-
ferent presumably active treatments.
Although there is ample evidence that most of the major existing types
of treatments work (have efficacy), it is not so clear that they work for the
reasons specified by theory (specificity). There exists a major debate in the
psychotherapy literature as to whether different treatments work for differ-
ent reasons (as is typically promulgated by their advocates) or whether they
work for nonspecific reasons inherent in any helping relationship (Wampold,
2001). The answer to that question may differ as a function of disorder, and
it clearly differs as a function of severity with respect to depression. Just as
for medication treatment, psychotherapy for depression only separates from
nonspecific attention controls among patients with more severe depressions
(Driessen, Cuijpers, Hollon, Dekker, 2010). It may be the case that specific
effects only will be found (if they are found at all) for patients with more
severe (or chronic or comorbid) disorders. If so, then whether you provide
an active treatment (something that goes beyond the nonspecific effects of
simply going into treatment) may only matter for those latter patients.

DRAWING CONCLUSIONS REGARDING TREATMENT EFFICACY

There are at least two ways that the field has tried to determine what
works with respect to treatment, and they tend to result in somewhat differ-
ent answers. With respect to medications, the Food and Drug Administration
requires at least two well-conducted trials conducted by different research
groups that each produce positive findings (relative to pill-placebo) before it
will let a new medication go to market. That is, we require evidence of speci-
ficity (which presumes efficacy) before we will allow a novel medication to be
sold to the general public. (We also require evidence of safety as well but that
is another story.) A similar approach (albeit one that only requires that a treat-
ment is better than its absence to say that it is efficacious and that adds the mod-
ifier specific when it exceeds a nonspecific control condition) has been applied
to the psychotherapy literature (Chambless & Hollon, 1998). Application of
these criteria results in support for the efficacy of the cognitive and behav-
ior therapies, along with interpersonal psychotherapy, and has earned them
the appellation of “empirically supported treatments” (ESTs) with respect to
depression (DeRubeis & Crits-Christoph, 1998). This approach tends to be
favored by research scientists (who developed the ESTs) and viewed with
suspicion by the majority of practicing clinicians (who tend to practice more
traditional treatments).

138 STEVEN D. HOLLON

 The other approach is to conduct meta-analyses of the existing treatment
literature, often without regard to quality of study or treatment implementa-
tion. The results of this approach are also quite clear; everything works better
than nothing, and nothing works better than anything else (Smith, Glass,
& Miller, 1980). Meta-regressions sometimes are used to tease out important
moderating factors but can only be applied to information that can be coded
(Cuijpers, van Straten, van Oppen, & Andersson, 2008). Researchers who
conduct treatment trials (usually of their own preferred approach) tend to
revile this approach because it lumps strong and weak studies together in an
uncritical fashion.
It is likely that the truth lies somewhere between those two extremes.
Several of the more traditional and widely practiced types of interventions
that tend to be favored by practicing clinicians simply have not been ade-
quately tested against nonspecific controls in the kinds of trials with more
fully clinical patients that might allow specific treatment effects to emerge if
they did in fact exist. That is not to say that these more traditional approaches
would not produce such effects if given the opportunity (absence of evidence
is not evidence of absence), just that they have had no such opportunity to
succeed or fail. Studies of these interventions that do exist (and are available
for meta-analysis) typically are older trials in smaller samples of patients who
were not all that severely depressed. The typical finding is that something
beats nothing (comparisons with no treatment typically produce effect sizes
in the .6–.8 range) and that nothing beats anything else (effect sizes between
the “active” treatments are negligible). It is hard to imagine that such trials
could have produced any other outcome.
Those same studies also tend to produce modest advantages relative
to supportive psychotherapy comparable in magnitude with typical drug–
placebo differences (with effect sizes of about .3) but only when support-
ive psychotherapy is treated as a control condition for some other approach
that the investigator prefers. When supportive psychotherapy is the featured
intervention in the trial (i.e., when it is the intervention that the investigator
is actually interested in and not just a nonspecific control condition), it tends
to produce larger effects similar to those produced by “active” treatments
(Cuijpers et al., 2012). Cuijpers et al. (2012) estimated the proportion of the
variance in change in depression associated with the different components
of treatment in the set of studies that included supportive psychotherapy
as one condition; about a third of the change observed was associated with
the simple passage of time (spontaneous remission), about half was associ-
ated with the nonspecific aspects of simply going into treatment, and only
about a sixth was associated with the specific aspects of treatment. Given
that most of the studies on which these estimates were based were conducted
in less severely depressed samples (with whom it was ethical to conduct

DEVELOPING CLINICAL PRACTICE GUIDELINES 139

no-treatment controls), it is likely that the proportion of change associated
with specific aspects of treatment (a pharmacologically active agent or a psy-
chologically active causal mechanism) would account for a larger proportion
of change in more severely depressed patients. Nonetheless, the proportion of
change produced by nonspecific factors alone was striking and wholly consis-
tent with the notion that for patients with less severe depressions “anything
beats nothing and nothing beats anything else” (aka “all have won and all
must have prizes”; Luborsky, Singer, & Luborsky, 1975).
Tie scores in the empirical literature may reflect any of several different
possibilities: (a) limitations in the existing literature in terms of the quality of
the studies that are available for review; (b) different treatments work through
different mechanisms but just happen to produce comparable outcomes (possi-
ble but unlikely); (c) different treatments work through common mechanisms
to produce comparable change in different clients (nonspecifics); or (d) differ-
ent people respond to different treatments, but those differences get “washed
out” when results are averaged across a number of individuals (moderation).
I think that all of these potential explanations remain plausible, and I look
to the guideline panels to do the best they can to work things out. The EST
approach typically favors the cognitive and behavioral therapies, perhaps
because they have been the most often tested against stringent control con-
ditions and are the most likely approaches to have generated a sufficient
number of studies with successful outcomes to pass muster. The meta-analytic
approach typically suggests that everything works better than nothing and
that nothing works better than anything else. If that is true then it does not
matter what the therapist does so long as it is done with sufficient interper-
sonal skill.
How then is a guideline panel supposed to resolve these issues? My pre-
vious experience sitting in with the NICE depression guideline panel suggests
a possible path to resolution. What impressed me most was the way that the
diversity of professions and backgrounds represented in the group facilitated
the decision-making process. Some were practicing clinicians and some were
research scientists, some professionals with experience treating depression
and others were former patients with experience being treated for depression.
Some were pharmacotherapists and others were psychotherapists. All were
interested in depression and its treatment, and each provided a perspective
that enhanced the overall discussion. It was a classic example of adversarial
collaboration in operation. The panelists came from different backgrounds
and had different biases, but all were committed to generating the best pos-
sible recommendations given the existing information and all were commit-
ted to doing so in the public interest.
The discussions were informed by a review of the empirical data. Whenever
the panel considered the evidence supporting a particular approach to

140 STEVEN D. HOLLON

treatment, they had in front of them (projected on a screen) a forest plot with
findings from all the studies relevant to a particular PICOTS question. For
example, when considering the question of whether cognitive therapy had an
enduring effect that prevented the return of symptoms following successful
treatment (relapse), they had a display in front of them that showed all the
comparisons of prior cognitive therapy versus prior medication treatment.
Prior cognitive therapy does appear to have an enduring effect (as is evident
in six of the eight studies), but that effect is not evident in all trials (no dif-
ferences were evident in a seventh, and the findings went in the opposite
direction in the eighth). That means the finding is relatively robust (it holds
up across most studies) but it is not universal. Had they simply presented a
summary of the findings in a numerical fashion (an effect size or odds ratio)
as typically is done in a meta-analysis, the GDP would have had no idea how
little variance there was in this set of findings.
This process can be even more instructive when the findings are not
robust. Cognitive therapy generally has done well in the acute treatment of
clinical depression, but that has not always been the case. On the one hand,
two of the four relevant trials have found it to be as efficacious as medica-
tions and each superior to pill-placebo in fully clinical populations (DeRubeis
et al., 2005; Jarrett et al., 1999), whereas the other two relevant trials have
found it less efficacious than medications and no better than pill-placebo
among patients with more severe depressions (Dimidjian et al., 2006; Elkin
et al., 1989, 1995). The reasons for that variability in outcomes are open to
dispute, but it is important to know that such variability exists. For that you
need to see the actual forest plots. A moderate-sized effect could be the con-
sequence of a consistently mediocre intervention or an intervention with a
big effect that requires competence in its execution. It also could be a con-
sequence of heterogeneity in the treated populations. Either of the last two
explanations represents an instance of moderation; the first on the basis of
procedure and the second on the basis of patient characteristics.
Both represent instances of external validity. Studies can differ with
respect to the representativeness of the patients studied and the fidelity with
which the treatments are implemented. My sense is that you are unlikely
to get more than one or two strong showings just by chance (the odds of
doing that once might be one in 20, but the odds of doing that twice are one
in 400). What is more likely is that an otherwise efficacious treatment is
poorly implemented in a given trial. We did that in an early trial comparing
cognitive therapy with medications (we set our dosages too low and withdrew
the medications prematurely), and as a consequence found an advantage
for cognitive therapy over medications that has been hard to replicate sub-
sequently (Rush, Beck, Kovacs, & Hollon, 1977). Simply reporting the aver-
age effect size from a meta-analysis that includes this study underestimates the

DEVELOPING CLINICAL PRACTICE GUIDELINES 141

strength of medications relative to cognitive therapy (as does the Treatment
of Depression Collaborative Research Program in the opposite direction).
Graphing both studies in a forest plot allows the GDP to see just which studies
are contributing to the variability in outcomes in a given literature and forces
them to consider other factors that might account for this variation.

SUMMARY

I am a strong proponent of basing clinical decisions on the empirical

evidence, but I am an even stronger proponent of bringing human judgment
to bear on the way that evidence is evaluated. I recognize that we all have our
biases (myself included), and I like the notion of balancing those different
biases and perspectives in the context of reviewing the empirical evidence.
I have confidence that the GDPs will do a better job on the basis of a full
and fair evaluation of the empirical evidence than if I generated the recom-
mendations myself.
Whether I agree with the recommendations in any given situation
depends on my confidence in the quality of the evidence on which they are
based and the process that was followed in their formulation. When I disagree
I want to tell my clients why I disagree and make it clear to them what
the consensus recommendation happens to be. I always want to be guided
by the preferences and values of my clients. I will at times follow my clinical
intuition, but I am reluctant to do that in the face of good evidence to the
contrary. In most instances I rely on intuition to “fill in the blanks” only when
no good evidence exists to guide the process of shaping the strategies I adopt
to fit the needs of my particular patient.

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146 STEVEN D. HOLLON

 6
USING TECHNOLOGY TO ENHANCE
DECISION MAKING
FRANZ CASPAR, THOMAS BERGER, AND LUKAS FREI

Clinical decision making involves a number of issues we have dealt with

on other occasions in previous publications, such as decision under time pres-
sure, multiple constraint satisfaction, intuition, dealing with soft information,
prescriptive models for information processing and decision making, research
on expert performance, the use of technology in psychotherapy training and
in clinical psychology in general, and more (Berger, 2004; Berger, Hohl, &
Caspar, 2010; Caspar, 1997, 2004; Caspar, Benninghoven, & Berger, 2004;
Caspar, Berger, & Hautle, 2004). Although there are relations between these
topics and the use of technology for decision making, we concentrate on the
latter, profiting from our larger background, yet making links only when
necessary. Caspar (2004) stated,
We are getting used to receiving all kinds of services in life without assis-
tance by human beings: French fries are prepared by machines, autopilots
fly us over the ocean, phone numbers and timetables are searched on the

http://dx.doi.org/10.1037/14711-006
Clinical Decision Making in Mental Health Practice, J. J. Magnavita (Editor)
Copyright © 2016 by the American Psychological Association. All rights reserved.

147
 Internet, even English essays can be graded by computers without human
English teachers. Just a few years or decades ago, who would have expected
that all this could work, apart, maybe, from Jules Verne? The world has
changed, and in a dramatically changing world clinical psychology/
psychotherapy does not have the choice of standing still. (p. 222)
Some of the applications are really new, and some are extensions and
continuous developments of preexisting technological and nontechnological
approaches. Ten years after Caspar’s comment, as technology in general and
computers in particular increasingly permeate all domains of life, it would be
astonishing if they were not used for clinical decision making. The task of
decision making includes many subtasks with which technology can help. In
this chapter, we go through these tasks, depicting what technology can do
and which technology is actually available and in use or in development, and
we give a tentative evaluation of how each is utilized. As we all know, in the
domain of technology, predictions about what will turn out to be useful in the
long run can be terribly wrong, so the best we can do is provide perspectives
and arguments.
In line with our view of decisions we have presented on earlier occasions,
the term is not reserved for big, conscious, deliberate decisions. Decisions are
often made in an implicit process of accumulating premises, which ultimately
determine a decision, or rather, a course of action, even though a deliberate
decision is never made (see Chapter 2, this volume). It is plausible that tech-
nology could be used in support of more deliberate decisions, but this should
not make us forget the less deliberate processes that determine our actions
as clinicians and psychotherapists. These less deliberate processes dominate
all the more in adaptive treatment tuning processes (adaptive Indikation in
German), in which small adaptations are made to details in the process of
the actual procedure and in which selective treatment (selektive Indikation) is
fine tuned and set into action.
We focus here on decision making in the everyday clinical situation
and do not address decision making in politics and administration, although
obviously it affects clinical practice and vice versa. For example, decisions
against providing sufficient face-to-face psychotherapy is one factor that may
increase the demand for Internet therapy, and vice versa—that is, the use of
technology for therapy, as in Internet therapy, might influence to what extent
face-to-face therapy needs to be provided. It is obvious that the aggregation
of information for political and administrative decisions can take advantage
of technology. If technology is used professionally, this should contribute to
better informed decisions and less dependency on information provided by
lobbyists who might not work in the interest of high-quality service for those
who need it. An optimistic view is thus that technology works in favor of
patients on this level as well.

148 CASPAR, BERGER, AND FREI

 In the interest of keeping the focus of this chapter manageable, we also
do not address treatments fully delivered over the Internet or computers, as
for the example described in Comer and Barlow (2014), although such treat-
ments, as they unfold, of course also include decision making.

REASONS TO USE TECHNOLOGY FOR DECISION MAKING

To be attractive, technology needs to be superior in some way to humans

doing the task traditionally. It is possible that sellers of technology could make
a buyer or user believe in such superiority as well as the emphasizing new tasks
that a human is not able to do. The superiority may refer to various dimen-
sions, such as speed, efficiency, reliability, validity, information and concepts
or data that can be included, and costs. These dimensions are not independent
of each other. For example, speed may lower costs and enable the inclusion of
large databases; the greater speed and efficiency of computer-based testing may
lead to shorter testing, which in turn would be more valid because patients are
less tired toward the end of shorter testing; and so on. The following sections
provide an overview of tasks for which technology is potentially superior.

MAKING INFORMATION AVAILABLE

Theories and Findings

For how many disorders and problems do you currently have all available
information that can have an impact on decisions made for an actual patient? It
can be assumed that the honest answer from most clinicians (as well as clinical
scholars!) is at best three or four. How would the gaps be filled when one of the
other disorders or problems showed up? If the clinician has good professional
connections she or he may ask a knowledgeable colleague, most probably by
phone. The probability is high that information will be gathered through the
Internet, or, if the clinician is more thorough, by books selected and/or ordered
via Internet. Even a clinician who does not use technology-provided information
him- or herself has to deal with the fact that patients access these sources. Maggio
(2008) described how practitioners can expand their knowledge of evidence-
based practice by gathering background information, searching filtered resources,
and tracking down original studies through unfiltered databases. Some of the
reported resources and affiliated advances are especially worth mentioning:
! Online textbooks. In contrast to traditional paper textbooks, so
called e-texts, for instance Goodman and Gilman’s Pharmaco-
logical Basis of Therapeutics (Brunton, Chabner, & Knollman,

USING TECHNOLOGY TO ENHANCE DECISION MAKING 149

 2010), can be updated frequently, providing the most recent
information available.
! Knowledge databases. Professional resources such as the eMedicine
Clinical Knowledge Database (http://www.emedicine.com) pro-
vide instant access on constantly updated and reviewed articles.
According to Maggio (2008), approximately 10,000 health care
professionals contributed to this database, resulting in articles
on more than 6,500 conditions. Other websites contain com-
prehensive information on specific topics, such as a collection of
mental health and substance abuse interventions (http://www.
nrepp.samhsa.gov/find.asp), lists of available practice guidelines
(http://www.guideline.gov, http://www.nice.org.uk), and system-
atic reviews (e.g., the Cochrane Database). Often, direct links to
considered studies or further resources are provided. Internet sur-
veys with experts are a good means for extending and actualizing
databases, thus contributing to decision making based on the best
available knowledge (Gore & Leuwerke, 2008).
Together with large databases containing original research studies (e.g.,
MEDLINE, PsycINFO), these resources provide a powerful tool to assist the
decision-making process.

Information on Mental Problems and Treatments on the Internet

Beyond the specific information mentioned in the previous paragraphs,

therapists as well as patients and their relatives gather information of all kind
on the Internet—for example, on locally available treatment alternatives,
emergency services, legal information, self-help books providing psycho-
education and intervention programs complementing face-to-face therapy,
patient reports on experiences with different forms of therapy, and so on,
which may influence treatment decisions. In fact, seeking health information
is one of the most popular reasons for going online (Fox, 2011).
The use of web-derived health information may have several advantages
and disadvantages. For instance, web-based health information may make
patients better informed, leading to better health outcomes and more appropri-
ate use of health services. It may also improve the therapeutic alliance by shar-
ing the burden of responsibility for knowledge and enhancing communication
in general (Gerber & Eiser, 2001). The possibility of easily accessing all kinds
of health information may also empower patients and increase their sense of
control over their disease. Furthermore, because basic knowledge of a disease
can easily be gained over the Internet, the scheduled time during treatment
may be used more efficiently, for instance for more in-depth and higher level
discussions about treatment options and clinical decision making. Moreover,

150 CASPAR, BERGER, AND FREI

the fact that patients are well informed fosters participatory and informed deci-
sion making, which may increase compliance with treatment (Gerber & Eiser,
2001). On the other hand, the quality of many health websites is questionable.
Thus, web-based information may be misleading, compromising health behav-
iors and resulting in unnecessary anxiety or inappropriate requests for clinical
interventions.

Making Individualized Psychoeducative and Therapeutic Information

Available to a Patient

This is a special possibility, for which we have seen demonstrations (first

with Carlos Mirapeix in Spain). A therapist selects one- to two-page psycho-
educative documents with relevance for the patient during a session. At the
end of the session, an individualized stack of information is printed out and
given to the patient. This information, read between the sessions, can be a basis
for shared decision making about the further course of therapy. More gener-
ally, one of the growing developments in the field of Internet- and computer-
based treatments is their blending with traditional treatments. For instance, in
a recent study, Månsson, Skagius Ruiz, Gervind, Dahlin, and Andersson (2013)
evaluated an Internet-based support system for face-to-face cognitive behav-
ior therapy (CBT). The web-based platform used within and between sessions
included a library with both text and media resources used in psychoeducation
and as homework assignments. The platform was built to give support to both
therapists and patients in the delivery of face-to-face CBT. In this proof of
concept study, therapists found several major benefits to delivering treatment
in this format, such as the possibility of focusing more on the relational aspects
of treatment during sessions because basic therapeutic tasks such as the delivery
of psychoeducational information were supported by the platform. Moreover,
most of the patients expressed largely positive opinions about sharing informa-
tion and homework over the Internet.

Data Related to a Specific Patient

Computer-assisted questionnaires and tests (Coyle, Doherty, Matthews,

& Sharry, 2007) can be administered in a clinical setting, sometimes with
a clinician standing by (usually referred to as computer-assisted testing), or
they can be run over the Internet, providing the client with the possibility
for answering it from any place preferred (usually referred to by such terms
as web assessment, Internet-based testing, and online testing). Although impor-
tant, this distinction is not always very clear, because web assessment can
be seen as a subcategory of computer-assisted testing, and even in a clinical
setting, a test can be run over the Internet. However, web assessments raise

USING TECHNOLOGY TO ENHANCE DECISION MAKING 151

several additional questions when it comes to psychometric properties and
the validity of such tests. The validity of frequently used questionnaires has
been examined in several studies (Butcher, Perry, & Hahn, 2004), and it is
generally good and comparable to the validity of paper-and-pencil versions
(Carlbring et al., 2007; Coles, Cook, & Blake, 2007; Herrero & Meneses,
2006; Holländare, Andersson, & Engström, 2010). On the other hand,
Buchanan et al. (2005) reported several studies finding differences between
web-based and paper-and-pencil assessments. Differences are found not only
in score distribution, impairing the use of earlier norms, but also in the fac-
tor structure of the measured constructs, raising questions about the valid-
ity of web-based assessment. In a recent publication, Weigold, Weigold, and
Russell (2013) identified several factors that may account for at least some of
the differences, such as unequal recruitment procedures and self-selection on
behalf of participants.
Generally, utilizing validated web-assessment instruments is recom-
mended. Differences do not necessarily speak against the Internet version.
A meta-analysis showed advantages of a web version over a paper version
in precision (Butcher et al., 2004). Further advantages include less embar-
rassment, more control, time saved, possibility of repeating, no interpersonal
interferences with the presence of other persons, possibility of giving imme-
diate reports or recommendations; these, as well as disadvantages, were dis-
cussed by Coyle et al. (2007). Computerized tests can also be adaptive; that
is, during the testing and depending on given answers, decisions are made
on what further items are presented, so noninformative items can be left out
(Butcher et al., 2004; Coyle et al., 2007). This saves time, makes the proce-
dure less annoying, and contributes to patient motivation and validity.
The assessment of biological states is another goal typically requir-
ing technical equipment. Biofeedback is mainly used as an intervention in
which the effective factor is information a patient receives about physiologi-
cal states that can otherwise not be validly monitored by the patient him- or
herself. For this, technology is needed. On the basis of biofeedback informa-
tion, patients can learn to influence body functions that are otherwise out of
their control. Biofeedback is commonly used as an intervention method, not
a tool in decision making, yet it can also be used to monitor change, compli-
ance, and emotional processing (Clough & Casey, 2011).
More sophisticated and expensive tools would be needed to provide
information on brain functioning as a basis of clinical decisions. For example,
DeRubeis, Siegle, and Hollon (2008) proposed that the decision about psycho-
therapy versus antidepressants should depend on whether depression seems
mainly related to amygdala hyperfunction or prefrontal cortex hypofunction.
The determination of these conditions for each patient individually, for exam-
ple via functional magnetic resonance imaging, is currently very expensive and

152 CASPAR, BERGER, AND FREI

cannot be considered a standard procedure. On the basis of the assumption that
equipment for the assessment of brain states will become cheaper and more
mobile, Grawe (2007), in his visionary work Neuropsychotherapy, proposed
assessing temporary brain states of a patient to give a therapist information as a
basis for deciding whether the conditions for a particular intervention are favor-
able or not. A recent development in this direction is neurofeedback, which is a
type of biofeedback that uses real-time displays of electroencephalography to
illustrate brain activity and to teach self-regulation.

Feedback Systems

Computers can be used not only for single assessments but also to keep
track of the process and progress of an ongoing therapy, providing feedback to
clinicians. Bickman, Kelley, and Athay (2012) designated such applications
measurement feedback systems (MFSs), and according to them, “the primary pur-
pose of an MFS is to provide feedback that is used to inform clinical practice”
(p. 277), which, of course, means a use for decision making (See Chapter 9,
this volume). What are the benefits of MFSs? One argument mentioned by
Duncan (2012) is their potential to reduce the high dropout rates usually
found in routine practice through the identification of at-risk patients.
They are also being discussed as tools for quality assurance and for opti-
mizing cost effectiveness of therapies (Strauss et al., 2015). Additionally,
MFSs may enhance patients’ active participation in an ongoing therapy
(Sexton, Patterson, & Datchi, 2012).
Feedback systems can be used to predict the course of an individual
treatment by using data from patients who are similar to the current patient
to make assumptions about how this patient can be expected to develop
(Lambert, 2007; Lutz, Tholen, Kosfelder, Grawe, & Schulte, 2005; Percevic,
Lambert, & Kordy, 2004). Some trials have demonstrated several benefits,
including a reduction in the duration of treatments, reduced failure rates for
at-risk patients, greater success rates of clinically significant improvement,
and reduced operating costs (Coyle et al., 2007); other studies did not find
superiority (Strauss et al., 2015).
In sum, feedback systems show a considerable capacity to improve out-
come, especially for problematic therapies, if the therapist is supported in
interpreting and utilizing the feedback (see the section Support of a Decision-
Making Process in Therapy later in this chapter) and if the patient is also
informed (De Jong et al., 2014). It is important to note that technology does
not do the job of improving the procedure but that it helps provide extrinsic
feedback (feedback that is not naturally and without particular efforts pro-
vided by the therapeutic procedure), which can be an essential input for a
therapist trying to understand a patient and an ongoing procedure.

USING TECHNOLOGY TO ENHANCE DECISION MAKING 153

Ambulatory Monitoring

Ambulatory monitoring or ecological momentary assessment (EMA;

Axelson et al., 2003; Coyle et al., 2007; Marks, Cavanagh, & Gega, 2007;
Matthews, Doherty, Coyle, & Sharry, 2008) is a special form of data collec-
tion that leads to more valid assessment than retrospective recall. EMA is a
“noninvasive method of gathering real-time data from subjects” (Axelson
et al., 2003, p. 255). Mobile phones and personal digital assistants can help
a patient collect data in everyday life—for example, about mood, behavior,
motivation, or social activities (Clough & Casey, 2011).
A recent development is to include sensors such as GPS, motion
detectors, and sound recordings. These measures may enrich and enhance
the validity of traditional EMA self-report measures. The monitoring of
the activity or self-report data in real life and time offers the opportunity to
obtain a wealth of information for decision making, to follow the treatment
progress over time, and to adapt the intervention.

Video Recordings, Data From a Patient, and Their Use in Supervision

and Peer Consulting

It has long been shown that therapist written records of therapy ses-
sions are highly unreliable (Levenson & Strupp, 1999). Although there are
still big differences between private practice and training or research set-
tings, it has become common to video-record single psychotherapy sessions
or even entire therapies. Not only research protocols but also some training
programs require recording on a regular basis, and more and more therapists
are finding that video is a useful source of information for regular practice
as well. Video records can be used to complete the information a thera-
pist has about a session in which his or her capacity for watching, listen-
ing, and interpreting was limited, or they can be used to give others insight
into a therapy (for supervision or peer consulting; see the section Online
Supervision later in this chapter). For patients, it has become common to
be video-recorded, and hardly any of them ask anymore whether this will be
on the TV news.
Manring, Greenberg, Gregory, and Gallinger (2011) described how
to set up a video-recording system and which issues should be considered.
In principle, only a computer with a webcam and a microphone (usually
built in on a laptop) are needed for reasonably good records. Video-recording
has become so inexpensive that the cost of a reasonably good picture and
sound recording system is no longer an argument against installing and using
video-recording systems. In advanced video systems using a server, as we have
installed in our training clinic, video recordings are stored on a secured server

154 CASPAR, BERGER, AND FREI

and can be accessed during supervision sessions with external supervisors
from their offices. The system has passed rigorous security checks, and risks
of unauthorized access are smaller than losing video recordings through, for
example, burglary of a supervisee’s car. In any case, security and protecting
video files at least with a password are important issues.

Support of a Decision-Making Process in Therapy

As Comer and Barlow (2014) argued, for problems that do not occur
frequently it would be inefficient to train a large number of clinicians so that
they would have all necessary information available at all times. Technology
can help to quickly provide the information needed to make a clinical deci-
sion, and it also enables well-informed decisions for rare disorders. Providing
conceptual and empirical information has been an issue, as described earlier.
Here we discuss more direct support of decision making.
A branch of decision-making research has proposed basing clinical deci-
sions on explicit probability calculations, even by a general practitioner on a
home visit. An “actuarial” or “statistical” way of making decisions is claimed
to be superior to “clinical” decision making, which includes soft information,
qualitative decisions, and intuitive information processing. There is no doubt
that statistical decision making would be a field for the use of technology. We
are convinced, though, that although the inclusion of probability informa-
tion in clinical decision making is highly recommended, primary reliance on
it in mental health and psychotherapy-related clinical decision making is
not a viable approach. We therefore do not detail here how technology and
computers could be used in such an approach.
Beutler and Harwood (2004; Beutler, Williams, & Norcross, 2011;
Harwood et al., 2011) described a web-based systematic treatment selection
system approach that is based on an Aptitude × Treatment Interaction design,
providing information about adequate interventions or therapeutic styles.
Before intake, certain patient characteristics (e.g., the patient’s therapist
preferences, most dominant symptoms, demographic data) are assessed via
a web-delivered self-report measure, resulting in a tailored self-help tool for
the patient and a more detailed report for the clinician. During the treatment
process, a patient’s symptoms are continuously being assessed, and the result-
ing change trajectory is compared with a projected change trajectory, showing
the expected development according to initial information. This corresponds
largely to the feedback systems described earlier. Harwood et al. (2011) fur-
ther described how certain patient characteristics, such as functional impair-
ment, coping style, subjective distress, social support, reactance–resistance
level, problem complexity–chronicity, and stages of change–readiness are
being used by systematic treatment selection to assist treatment planning.

USING TECHNOLOGY TO ENHANCE DECISION MAKING 155

Although the concepts on which the system is based are empirically derived,
so far no empirical evaluation of the program itself exists.
Beyond descriptive feedbacks, some MFSs provide further assistance
by providing decision trees and suggesting interventions. Clinical support
tools (CSTs), for instance, attempt to assess therapeutic alliance, patient
motivation, social support, and errors in diagnostic and treatment planning.
If one of those variables is identified as problematic, suggestions for possible
interventions are made. In a summary of two studies (Lambert, 2010), the
percentage of at-risk patients deteriorating during the continuing therapy
process dropped from 20% in the control group to 8% in the “feedback +
CST” group. At the same time, the percentage of at-risk patients showing
significant improvement doubled from 22% in the control group to 45%
in the “feedback + CST” group. However, these promising results should
be considered with caution: One of the included studies used data from
prior feedback studies as a control group (Harmon et al., 2007), and in the
second study, therapists could decide whether to use CSTs for a particular
at-risk patient or not (Whipple et al., 2003), resulting in selective compari-
son groups. Although this particular MFS used nonelectronic tools, it gives
an idea of how electronic feedback systems might be further enhanced for
decision making.
This nonexhaustive list of more recent MFSs shows a wide applica-
tion spectrum: Computerized and sometimes web-based feedback systems
can be used for initial treatment planning, for session planning during an
ongoing therapy, for tracking therapy progress, and for identifying at-risk
patients. Assessments can occur between, directly before, or directly after
sessions, providing information on outcomes, alliance, and motivation.
Feedback is not limited to mere descriptions but may also provide more
or less specific suggestions. Aside from these promising possibilities, the
number of sometimes very similar systems and their general lack of evalu-
ation raise the assumption that the search for a more widely applicable
MFS is not over yet.
A special topic is decision making in a stepped-care approach involv-
ing the use of Internet-based self-help. Although stepped care as such
does not require technology-based decision making, Internet therapy—if
involved—may render relevant data. In a study by Berger et al. (2011),
the number of mouse clicks during the first week of Internet-based treat-
ment turned out to be an extremely simple and predictive criterion, readily
delivered by technology. Activity and time spent in the self-help program
during the first week of treatment was significantly associated with treat-
ment outcome. Such early process predictors can be used to step up clients
to more intensive interventions such as face-to-face psychotherapy early in
the treatment process.

156 CASPAR, BERGER, AND FREI

 CONTACT AND COMMUNICATION

Videoconferencing

Some uses of technology in the process of clinical decision making are

very obvious: Regular phone and Skype contacts among clinicians need no
further mention, and just like we can use videoconferencing for all kinds of
other shared decision making, we can, of course, also use it for clinical deci-
sion making. Although meetings in person may be favorable to initially build
a personal relationship and trust, once those are established, videoconferenc-
ing is a very efficient way of bringing clinicians together among each other or
with experts. When distances forbid a personal contact, videoconferencing
is an excellent alternative.

Webinars

Similarly, webinars (web-based seminars) have become a common tool to

make the wisdom of international experts available for trainees and colleagues
who cannot easily travel to conferences, or to complement these. For example,
the Society for Psychotherapy Research offers webinars on a regular basis.

Blended Treatment

As we mentioned before, we are not covering in this chapter the exten-

sive literature on Internet-based treatments that are fully delivered online.
With regard to decision making in traditional psychotherapy, it may be rel-
evant that therapists are becoming more accustomed to offering some elements
of the treatment online (e.g., psychoeducational information; Månsson et al.,
2013; see earlier discussion) and to communicating online in between sessions.
There are several indications from the literature that blending of traditional
with Internet-based treatment may be a promising venue. In a recent review,
it was concluded that patients’ treatment adherence may be improved through
new technologies (Clough & Casey, 2011). For instance, e-mails between ses-
sions may be useful in prompting patients to do homework reports, providing
more frequent feedback on homework, adapting the homework according to
patients’ feedback, and encouraging reflection (Murdoch & Connor-Greene,
2000). As with ambulatory assessments (see earlier discussion), therapists
also receive more real-time and real-life data as a basis for their decisions
when they communicate with their clients between sessions. In addition, it
has been shown that aftercare also may be improved by the use of technologi-
cal adjuncts such as online chat or SMS interventions (e.g., Bauer, Percevic,
Okon, Meermann, & Kordy, 2003).

USING TECHNOLOGY TO ENHANCE DECISION MAKING 157

Collaborative Problem Solving

Complementary profiles in knowledge and skills may make it desirable

that professionals with, for example, psychological and medical backgrounds
cooperate. Although the telephone may be good enough when the informa-
tion on which the collaboration is based is sufficiently simple, the situation
changes when the needed information is more complex. Then more sophisti-
cated technical support may lead to better outcomes. Because the competent
handling of such collaboration is not trivial, several forms of training have
been developed and evaluated.

TRAINING

Applications Concentrating on Video Recordings

Some information has already been provided in the previous section

on video and its use for supervision. However, there are many more uses of
video recordings.
Video is prominent in several applications serving the training of thera-
pists. Beyond the use of raw video recordings for supervision, several applica-
tions provide rating systems, further structuring the supervision process. One
of them is the Internet-based training system (ITS) developed to observe,
rate, and comment on videotaped mock sessions through the use of structured
feedback items (Worrall & Fruzzetti, 2009). These ratings and comments can
then be compared with those from other therapists.
One very similar tool is e-SOFTA (which stands for System for Observing
Family Therapy Alliances, an electronic system for observing family therapy
alliances; Escudero, Friedlander, & Heatherington, 2011). Although e-SOFTA
is useful only for specific therapy settings and only for certain aspects related
to the alliance, it is an example of a well-documented, frequently used, and
freely available instrument. Both the documentation and the program can
be accessed through the SOFTA website (http://www.softa-soatif.com). A
therapist can use the software to rate videos of therapy sessions on engage-
ment in the therapeutic process, emotional connection with the therapist,
safety within the therapeutic system, shared sense of purpose within the fam-
ily, and the therapist’s contribution to the alliance. Ratings are linked to
the respective time during a therapy session and can be supplemented with
a comment. The same video can be rated by several persons (e.g., a therapist
and a supervisor), and ratings as well as comments can be compared easily.
The rating scales of e-SOFTA have been validated (Friedlander et al., 2006),
and the tool has been successfully used in a training intervention for students

158 CASPAR, BERGER, AND FREI

(Carpenter, Escudero, & Rivett, 2008), significantly improving their knowl-
edge related to the therapeutic alliance (from 43% to 74%, p < .001) as well as
their observation skills (from 43% to 65%, although without reaching statisti-
cal significance; p = .08). A related tool is Counselor Assisted Supervision, a
program that trainees can use to watch and critique tapes of their counseling
sessions (Gore & Leuwerke, 2008). All this is not directly related to decision
making in a narrow sense, but abilities are trained that are plausibly relevant
for decision making.

Computer-Based and Web-Based Training

The number of studies investigating the use of computer- and web-based

training in schools of medicine, nursing, and allied sciences has increased
substantially in the past few years. Obvious and documented advantages of
computer- or web-based training in comparison with traditional classroom
teaching are (a) self-paced learning—students can progress at their own pace
and repeat as they please; (b) increased accessibility—as technical devices
become more easily accessible, courses can be accessed when and where they
create minimal intrusion into students’ lives and when they are in the best
possible learning state; (c) decreased costs—costs decrease in proportion to
the number of learners using a specific program; and (d) constant quality—
many students can use the same qualified training module (Berger, 2004). An
example of such a web-based training program in the field of psychotherapy is
Psychotherapy Training e-Resources (PTeR; Weerasekera, 2013). PTeR con-
sists of 11 web-based modules with content information being presented in
multiple forms, including clinical vignettes to demonstrate expert modeling
of clinical skills. The program houses more than 70 video clips demonstrat-
ing several types of psychotherapy. The program also includes pre–post tests
in each module so that performance can be monitored throughout training.
Another example is an interactive multimedia online training (OLT) in
dialectical behavior therapy skills. In a controlled study, Dimeff et al. (2009)
compared the OLT with a written treatment manual and a 2-day instructor-
led training workshop (ILT). Participants in the OLT group outperformed
participants in both other conditions in terms of knowledge. OLT and ILT
further resulted in larger gains in self-efficacy than the manual-only condition.
However, comparing the use of the training content in their clinical prac-
tice, self-reports of participants did not differ across conditions, nor did the
observer-rated adherence or competence in a simulated clinical interaction.
In medicine and allied sciences, hundreds of studies comparing
computer- and web-based trainings with conventional modes have found
computer-based trainings to be either equivalent or superior to conventional
instruction with regard to students’ learning (Kulik, 1994). However, critics

USING TECHNOLOGY TO ENHANCE DECISION MAKING 159

of these findings who cited various biases in the studies, such as different
degrees of effort used in designing computer-based trainings and control con-
ditions, should be taken seriously (Clark, 1994). In well-controlled studies
in which the same material was used and the same teacher provided the
instructions for the experimental and control groups, equivalent results were
reported (Fletcher-Flinn & Gravatt, 1995). It seems plausible that learning
outcomes are a function not of the delivery medium but of the instruction
itself (Clark, 1994).

Computer-Based Training of Skills Related to Case Conceptualization

Our own group has developed computer-assisted trainings based on the

concept that only limited skills can be taught in computer-supported training
modules. In line with the deliberate practice model for the development of
professional expertise in general (Ericsson, Krampe, & Tesch-Römer, 1993),
it is assumed that the goals of learning need to be concrete, that success should
be achievable within a reasonably short time to provide success experiences
motivating further efforts, that the provision of feedback is crucial and that
it needs to be fast and informative, and that trainees should have the pos-
sibility to improve their behavior in further rounds and get feedback again.
It is further assumed that computer support should be used because there
are not enough human masters from whom to learn, and if they were avail-
able, they would be too expensive. Because there are plenty of more complex
tasks that can hardly be squeezed into computer-supported limited modules,
there is no threat to the demand for human experts–trainers. There is also no
concurrence between the training of relatively simple, limited skills and the
training of more complex skills; instead, by using computer-supported learn-
ing for the structured, efficient training of basic skills, resources are freed for
training in more complex skills in psychotherapy. In supervision, for example,
supervisors would be confronted as little as possible with a lack of basic skills
in their supervisees and therefore would not need to address such a lack in
their supervision.
More concretely, as a first step, a training has been developed in opti-
mizing coherence. This is based on the idea that coherence is a crucial crite-
rion for the strength and plausibility of models in general (Thagard, 1989).
In a computer-supported training, trainees were instructed to use a graphi-
cal tool to express their view of important aspects of the structure of their
patient’s functioning. The general goal is the development of abilities to see
and explicitly express the structure with multiple links between its elements.
Conflicts and contradictions residing within the patient can also be fed into
the program and, if appropriately expressed, do not hamper the coherence
fed back to the user. The user can get feedback on the achieved level of

160 CASPAR, BERGER, AND FREI

coherence any time while working on the network. Therapists can use their
own patients because the program does not need to “understand” content.
Thirty-four users participated in a study on the effects of such a training
module, 19 in the training, 15 in a control condition with a training of differ-
ent content. Acceptance was good, and the networks representing the view
these therapists had of their individual patients became richer and more com-
plete, more complex in a positive sense, and more coherent, although the latter
criterion did not reach significance. It is concluded that computer-supported
training can be used to acquire specific skills that are relevant for case concep-
tualization and decision making (Caspar, Benninghoven, & Berger, 2004).
A second approach includes content as opposed to formal aspects of
the structure in the coherence training. One would think that computer-
supported training including content would require more standardization in
the sense of using multiple choice answers and/or expert systems in which it is
clearly defined which view of a patient is wrong or right. In our view, though,
in clinical–psychotherapeutic reality the view of experts may differ, and out
of different perspectives several may be of value. To pretend that the clinical
world is simple would convey an incorrect view, and a program based on such
a view would get little acceptance by those who know. Although we felt that
content should be included, we renounced doing this in a simplistic way. The
situation changed when we became acquainted with latent semantic analy-
sis (LSA) through Kintsch and Landauer (Landauer, Foltz, & Laham, 1998).
The second author of this chapter adapted this concept and the underlying
programs so that the program could project users’ typed-in formulations into
a semantic space in which their views of videotaped cases could be compared
with the views of a number of experts. How this works is based on mathematics,
and an explanation is beyond the scope of this chapter (Landauer et al., 1998),
although Figure 6.1 illustrates the principle.

textbooks

case examples feedback

video tape
trainee’s
view
possibilities of
experts’ view in
exploration
free language
Figure 6.1. Feedback based on latent semantic analysis; see explanation in the text.

USING TECHNOLOGY TO ENHANCE DECISION MAKING 161

 A semantic space is built up by feeding thousands of clinical texts (e.g.,
articles, case reports) into a computer program. This program analyzes how
close together words are used and builds up a semantic space based on this
information. This is very different from a classical expert system, which has
to be constructed by experts deciding what is right or wrong. In a second step,
experts watch a videotape of an intake interview and type in their view of the
case. This information is then projected into the semantic space. Now the sys-
tem is ready to be used by trainees. They also watch the videotape and type in
their view of the case just like the experts did. They then get several forms of
feedback. The first simply tells them which aspects of the observed case that
were covered by the experts have also been addressed by the user and what
percentage of what the experts have stated they have succeeded in covering
as well. The goal is not to bring the histograms in the graphical feedback up
to 100% because not all experts would agree with all that has been said by
other experts. But if the percentage covered by the user is very low, this is a
challenge to think about what could have been overlooked and to amend the
originally typed-in view to drive up the percentage. Other forms of feedback
follow, and ultimately the program, in exploring the views of the experts, sup-
ports the user. He or she also gets a realistic impression of potential variations
in the experts’ view.
The procedure and positive results of a first study were described in
Caspar, Berger, and Hautle (2004). The breadth of those users who had a
chance to practice repeatedly with the program was significantly superior to
trainees who received another form of training. Acceptance was very good.
In a second study, LSA-based feedback was compared with traditional writ-
ten feedback received 2 weeks after sending in a text on the patient. In a
third study, users typed in their verbal answer to a video scene and were then
confronted with the answer of the patient, which was chosen by the pro-
gram out of several alternatives depending on the quality of the user’s written
intervention. Then, the user typed in his or her next intervention and got
feedback on this. Subsequently, users could also read what the experts would
have said. This form of learning requires the user to act (albeit only in the
form of typing), and the task is more dynamic because the dialogue develops
over a short time. The acceptance for this program is also good; the effects
are still in evaluation.

Online Supervision

Great possibilities lie in online supervision. About 10 years ago, Miller,

Miller, and Evans (2002) stated that the counseling literature was full of
studies examining the effectiveness of live supervision, and they provided
a short overview of the different forms being used. Early live supervision

162 CASPAR, BERGER, AND FREI

was provided in person, through the “knock-on-the-door” method, where
the supervisor interrupted a session to consult with the supervisee or to give
additional input. Similarly, using the “telephone call-in” approach, a supervi-
sor disrupted the session by calling in via telephone. Technological advances
allowed less intrusive feedback, through the use of a microphone and an ear-
piece unit (“bug-in-the-ear”), or by providing visual feedback (“bug-in-the-
eye”). The latter has the advantage of being less intrusive than a bug in the
ear: Whereas a therapist unavoidably hears what a supervisor says, he or she
has the freedom to look or not to look at a screen behind the patient display-
ing hints from a supervisor. There is limited empirical evidence for the effec-
tiveness of the bug-in-the-eye method (Miller et al., 2002). Surprisingly, the
past decade yielded little additional research on live supervision methods, and
what there was has had mixed findings (Bartle-Haring, Silverthorn, Meyer, &
Toviessi, 2009), which should not surprise us given that the balance between
disturbing–intruding versus helping is not equal for all therapists, patients,
supervisors, and situations. Nevertheless, live supervision seems to be quite
common (Denton, Nakonezny, & Burwell, 2011), and both bug-in-the-ear
and bug-in-the-eye have been further developed to be used in remote super-
vision (Jakob, Weck, & Bohus, 2013; Rousmaniere & Frederickson, 2013;
Smith et al., 2007, 2012). Through videoconference software, the therapy
session is streamed onto the supervisor’s computer, and the supervisor, in turn,
can give instructions to the supervisee, either via microphone and earpiece
(bug-in-the-ear) or through text messages, which are then displayed on a lap-
top computer sitting next to the patient (bug-in-the-eye). Aside from some
anecdotal evidence from the parties involved on “more intense” and “closer”
experiences, no evaluation of this approach seems to exist so far.
Another branch of research is related to the use of videoconferencing
for supervision. Abbass et al. (2011) provided a short survey on the respec-
tive literature and concluded that there has been limited research in this
area. Existing studies mainly focused on the experiences of supervisors and
trainees, whereas the impact on efficacy and client-based outcomes has
been neglected (Reese et al., 2009; Sørlie, Gammon, Bergvik, & Sexton,
1999; Xavier, Shepherd, & Goldstein, 2007). Although videoconferencing
offers promising possibilities for supervision, most researchers point out legal
and ethical issues that need to be addressed (Worrall & Fruzzetti, 2009).
According to Rousmaniere and Frederickson (2013), most guidelines con-
cerning technology-assisted supervision and training are rather vague and do
not provide specific instructions. As more specific guidelines, they cite Best
Practices in Clinical Supervision by the Association for Counselor Education
and Supervision (ACES Task Force, 2011), which mentions that “in using
technology for distance supervision, the supervisor clearly approximates
face-to-face synchronous contact” (p. 6); that the adopted technology has

USING TECHNOLOGY TO ENHANCE DECISION MAKING 163

to be “in compliance with ethical guidelines and regulations promulgated by
accreditation, certification, and licensure bodies” (p. 7); and that the super-
visor “is competent in the use of the technology employed in supervision”
(p. 7). As a fourth premise, password protection and encryption must be
compliant with the Health Insurance Portability and Accountability Act to
ensure confidentiality. Several videoconference tools seem to exist, where
such compliance is given (e.g., https://liveconferencepro.com; http://www.
talktoanexpertinc.com).

Collaborative Problem Solving

Collaborative problem solving with videoconferencing is not a trivial

task. Extensive research has shown that the success of collaborative efforts
does not occur on its own. Therefore, trainings for such collaboration have
been developed and evaluated (Rummel & Spada, 2005). Rummel and Spada
(2005) developed a program to train users for a collaboration between pro-
fessionals with medical versus psychological backgrounds whose joint task is
to formulate a report that includes a detailed diagnosis for the patient and a
proposal of a suitable therapy. In this scenario, the two experts work at distant
locations and cannot afford the time to meet in person. Instead, they decide to
take advantage of a desktop videoconferencing system that has recently been
implemented at both of their institutions. There are three constituent elements
to such a collaboration: There is symmetry between the two; nobody is superior,
but they have complementary competencies. Each of the partners is a “novice”
in the other’s domain and an “expert” in his own. They have common goals,
namely, to solve the problem, and there is a division of labor. The presented task
is both realistic and of high practical relevance. The findings show that obser-
vational learning from worked-out collaboration examples is a successful way to
promote collaborative skills. If such an example is well conceived, it functions
as a model for the people observing the collaboration, especially if they have
the possibility to reflect on what they see and hear. Partners who work jointly
on a problem-solving task following a cooperation script acquire collaborative
skills that also improve collaboration in subsequent tasks.

Virtual Reality

Virtual reality has been used for the assessment of medication manage-
ment skills (Kurtz, Baker, Pearlson, & Astur, 2007). Beutler and Harwood
(2004) proposed a virtual reality–based training in their empirically sup-
ported and multifaceted systematic treatment selection model (see also the
section Support for Decision Making earlier in this chapter). As far as we
know, only a pilot model has been developed.

164 CASPAR, BERGER, AND FREI

 ACCEPTANCE AND SKILLFUL USE

Comer and Barlow (2014; Rogers, 2003) pointed out the importance
of four factors for the acceptance of new approaches: (a) limited complex-
ity; (b) trialability, which means the possibility of trying out something new
before a decision for or against its permanent use is made; (c) compatibility
with existing approaches; and (d) the testability of results. Acceptance will
also depend on financial compensation; for example in telemedicine, face-
to-face contact is replaced by virtual contact, but where technology comple-
ments human activity, the tools and procedures must also be financed.
Beyond acceptance, the skillful use of technology is an issue. Depending
on how close the use of the technology is to the everyday use, it may be very
demanding in terms of resources and motivation to introduce and effectively
use technology. Dedication as well as communicative and didactic skills of
personnel may become crucial, along with employee retention in the interest
of not losing knowledge and experience with turnover on the job (Comer &
Barlow, 2014). As a basis for appropriate training, requirements for competent
use must be defined by the developers of applications (Comer & Barlow, 2014).

RISKS

There are some risks related to the use of technology:

! Fascination with technology could lead to an application in
which costs and disadvantages outweigh the advantages, or
technical aspects could blind users as well as developers to
clinical aspects.
! The use of traditional expert systems as an aid in decision mak-
ing may mislead users to believe that there are simple truths and
solutions in this field.
! Responsibility for the quality of decisions and for errors could
be diffuse or delegated to technology; this is a hot debate also
in medicine, for example, in robotic surgery.
! Reduced practice in the own processing of information, such
as recognizing patterns, may lead to a loss of abilities and to
dependency on technology, just like abilities to read maps effi-
ciently may deteriorate when people use a GPS on a regular
basis (see also Chapters 4 and 11, this volume).
! Letting technology do jobs without really knowing what is
done and how may lead to bad solutions, which translates into
deterioration or failed improvement and its consequences for the
patient’s quality of life and, in the worst case, even loss of life.

USING TECHNOLOGY TO ENHANCE DECISION MAKING 165

 ! Technology supporting the dissemination of relevant informa-
tion to practitioners not fully trained for their task may lead to
superficial use of information. To have information available
does not imply its competent use, so the availability of tech-
nology may contribute to an overestimation of the quality of
service and may thus mask a need for better training.
! Risks from not seeing a patient in person exist, although Inter-
net therapy applications show that even without a personal
contact, individual emergency plans can be developed.
! Privacy–confidentiality is always an issue in applications involv-
ing exchanges over the Internet.
Overall, there are undeniably a number of risks, but if they are recog-
nized and dealt with, the risks do not forbid a use of technology.

SUMMARY AND FUTURE DEVELOPMENTS

There are many aspects or parts of clinical decision making where

technology contributes to or is even essential for the quality and efficiency
of decisions. Applications utilizing technology for decision making in a nar-
row sense are rare, but technology contributes to gathering and passing on
information and communication with patients, colleagues, supervisors, and
experts. Some applications, like the use of telephones, have become so obvi-
ous that we are mostly not even aware of using technology. When we use
highly sophisticated computer programs, we are aware of this, even if it is
part of the quality of such programs that the user recognizes only the tip of
the iceberg of the underlying technology. And then there are applications
that are highly technological on the user side as well as on the provider
side—such as Internet search—but that are becoming so much a part of
everyday life that we soon may experience it as a use of technology on par
with the telephone.
If seen as a complex process of accumulating premises—as opposed to
making big decisions between clear alternatives at limited points of time—a
large part of clinical decision making already is determined by technology.
A big question is, of course, what further developments we have to expect
or to strive for. When looking into models of the development of human
professional expertise, there is a progression from the conscious, relatively
crude, rule-based information processing of the novice to the more com-
plex information of the expert. This takes into account more complex and
subtle factors and circumstances to come up with a professional behavior that
is much more flexible and adapted to the patient’s individual, momentary

166 CASPAR, BERGER, AND FREI

situation. In principle, technology, and in particular computers with access to
the Internet, can provide much of the information needed. Schäfer (Schäfer
& Niederer, 2014), a German “Dr. House” in his Marburg clinic for unrec-
ognized diseases, has said that even extremely rare cases can be diagnosed
by doing a simple Google search with the right combination of symptoms.
To what extent this applies also to the field of mental disorders, and what
it takes to assess the symptoms correctly, is another question. Clinical deci-
sions, at least in the field of psychotherapy, are not only a question of the
right diagnosis. A good qualitative understanding of the functioning of a
patient, as it is typically elaborated in case conceptualizations, is essential.
Such a conceptualization is probably more than medical diagnosis based on
subtle, soft information, on inferences requiring information processing such
as pattern recognition, and the like. No clinician would survive a day with-
out implicit and intuitive information processing. The question is whether
this should and could be replaced by technology-supported rational decision
making. Dreyfus and Dreyfus (1986) formulated concerns that the quest for
rational, justifiable decisions might suppress the development of true exper-
tise so that professionals would get stuck at a suboptimal, subexpert stage of
development. We believe that this danger exists, but whether technology
contributes to such a suboptimal development depends on ingenuity and the
smart use of technology. For example, the speed and efficiency with which
knowledge relevant for a case can be gathered today could set free resources
that we can use to lean back and let our imagination and intuition do some
work on our view of the patient’s problems before we switch back to a more
rational mode of thinking about the patient. Effective telecommunication or
webinars enable us to tap into intuitive decision making of experts. The tech-
nology behind our LSA-based training program (Caspar, Berger, & Hautle,
2004) is so smart that we do not have to pretend that there is one correct
view of a case or problem and that one arrives at it with answers to multiple
choice questions. Rather, as described earlier, users can formulate their views
freely, the program compares it with the views of several experts, and the user
can see that there is not only one correct view and is supported in exploring
the views of several experts.
If we use technology in such a way, without forcing our minds into
a procrustean bed of one-sidedly rational thinking, we see a great poten-
tial in the future. Which concrete development we can expect is hard to
predict.
The task for clinical researchers and practitioners will be to make intelli-
gent use of technology; “empty” technology is of little use. . . . One thing
is clear: Many products developed will appear as “dinosaurs” in just a few
years, but they are necessary stepping stones for further development.
(Caspar, 2004, pp. 348–349)

USING TECHNOLOGY TO ENHANCE DECISION MAKING 167

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 7
CLINICAL DECISION MAKING
WHEN THE STAKES ARE HIGH
JEFFREY J. MAGNAVITA

Many decisions made in clinical practice are relatively routine and

automatic, whereas others are much more complex and more prone to the
influence of biases. There are a number of disorders with high base rates asso-
ciated with abundant information, along with a continuum of evidence-based
treatment approaches, to guide clinical decision making (National Institute
of Mental Health, 1999). Patients with uncomplicated clinical presenta-
tions generally do not demand multiple resources; clinical decision making
is relatively straightforward in these cases. Internet searches can supplement
knowledge and experience by supplying abundant information concerning
uncomplicated presentations (see Chapter 6 in this volume).
However, clinical practice is often not routine. There are situations
where the stakes are high because the clinical decision making involves com-
plex and potentially risky outcomes, such as medical and legal risks. High-risk

This model of collaborative treatment for high stakes cases was developed and practiced with John
Santopietro, MD.
http://dx.doi.org/10.1037/14711-007
Clinical Decision Making in Mental Health Practice, J. J. Magnavita (Editor)
Copyright © 2016 by the American Psychological Association. All rights reserved.

175
situations may be life threatening and the outcome possibly catastrophic in
terms of harm to self or violence toward others. There are far too many exam-
ples of these high-stakes situations; for example, in recent years our nation
has struggled to understand and prevent school shootings and other cases of
mass murderers who have slipped through the treatment net. Most clinicians
who have been in practice for some time have run into similar cases.
In this chapter, some of the important issues that are inimical to mak-
ing decisions when the stakes are high are presented. A model is presented
of collaborative–shared decision making, developed in collaboration with a
psychiatrist colleague, that has been found to be effective. This model is dif-
ferent from most decision-making models in that it expands the traditional
dyadic configuration (i.e., between patient and clinician) by utilizing a tri-
adic configuration (i.e., among patient; two clinicians; treatment team; and
other significant parties such as families, community representatives, etc.).
This model is anchored in system theory, which we used as a framework for
unifying and orienting our clinical work (Magnavita, 2012; Magnavita &
Anchin, 2014). Human behavior and mental and relational processes can
be understood by incorporating complexity or chaos theory, which are recent
iterations of system theory. Using chaos and complexity theory allows one to
see patterns in systems as they emerge and/or are repeated. These patterns rep-
resent attractor states, which are essentially convergent processes such as we
might see in a severely eating-disordered family member who organizes the
family system around the management of his or her illness (Magnavita, 2005a).
Recurrent processes have been explained as follows:
The strength of an attractor is measured by the depth of its basin. A deep
attractor is well-developed and behavioral repertoires are frequently
drawn to this attractor. As behavioral patterns are repeated, the attrac-
tor is strengthened. In any given interaction, there are likely to be several
available attractors in the state space, with some presenting a stronger
pull than others. (Stanton & Welsh, 2012, p. 21)
Complex systems operate in a nonlinear holistic fashion, viewed through
the lenses of the various levels and domains of the biopsychosocial model
(Magnavita & Anchin, 2014). The use of theory in decision analytics is cov-
ered in Chapter 3 in this volume.

HIGH-RISK CASES—WHEN THE STAKES ARE HIGH

Some cases give rise to fear in behavioral and mental health clinicians;
most often these are cases where the stakes are high and the outcome uncertain.
Most clinicians can easily recall those experiences in which decision making
was risky and the potential for disaster loomed large. Such cases are generally

176 JEFFREY J. MAGNAVITA

emotionally laden not only for patients, families, and communities but also
for the clinician. Examples of high-risk cases may include patients referred
for follow-up care after a near lethal suicide attempt, severe psychotic decom-
pensation, or patients with comorbid disorders such as traumatic brain injury
and posttraumatic stress disorder that severely compromise executive func-
tioning and make standard treatments difficult to administer.
We begin with a discussion of the central features of high-risk cases.
High-risk cases tend to challenge our decision making because they generally
do not follow the algorithms that we rely on for less complex cases. Often
these cases are characterized by multiple pathologies, family dysfunction,
trauma, and/or generational transmission processes that are quite powerful
and are often carried forth by subsequent generations. There are often limited
data available with which to make predictive decisions, so clinical decision-
making processes must be employed along with clinical expertise to bring
about a positive outcome. An overview of some of the common high-risk
categories that are seen in clinical practice includes the following:
! severe eating disorders,
! severe personality disorders,
! complex trauma,
! severe treatment refractory affective disorders,
! nontreatment-compliant severe mental illness,
! severe treatment refractory addictive disorders,
! fibromyalgia and chronic fatigue syndrome, and
! chronic and some acute medical disorders.
This list is not meant to be comprehensive but represents a heuristic sampling
to bear in mind when treating patients with these presentations. Other com-
plicating factors for decision making include a high degree of co-occurring or
comorbid disorders that may be interacting in complicated ways that make
first-line treatments ineffective.

A HIGH INCIDENCE OF COMORBID DISORDERS

Generally speaking, patients with multiple comorbidities and a his-

tory of multiple treatment failures are likely to be categorized as high-stakes
patients. Many high-risk patients suffer from a personality disorder as one of
their primary conditions (Magnavita, 2004, 2010a). They also tend to have
other comorbid presentations such as addictions; eating disorders; mood dis-
orders; traumatic brain injury; chronic or acute medical disorders; complex
trauma; and a spectrum of somatic conditions such as fibromyalgia, chronic
fatigue syndrome, and severe sleep disorders.

WHEN THE STAKES ARE HIGH 177

 When the stakes are high in clinical situations and the outcome is not
certain, our decision-making capacity is tested. For some patients it may
be that they have a behavioral or mental health condition, as previously
discussed, which if not treated appropriately will likely result in an unfa-
vorable outcome. For example, in one case a 50-year-old male who suffered
from a severe alcohol addiction, which for a period of time was in remission,
resumed drinking with a vengeance and was highly refractory to treatment.
In this particular case, it was apparent to the clinician that this patient would
eventually destroy himself as a result of his drinking. There had been many
treatment interventions, hospitalizations, and rehabilitation efforts. It was
clear that this was a high-stakes case. Unfortunately, the patient did end up
drinking himself to death. Sometimes, a high-stakes patient is one who has
had multiple treatments without any improvement, so they will not com-
mit to a treatment even though we predict a positive outcome. In many
similar cases, the complex disorders can have many negative consequences
that impact employment and children’s mental health and well-being and
also tax community resources. There are common features present in high-
risk cases. Patients with the disorders described in the previous section often
share a high degree of self-destructive potential. This is another useful heu-
ristic: When a pattern of chronic self-defeating or self-destructive behavior
is apparent, one might consider this to be a high-stakes case. Occasionally,
cases with a history of violence can become high-stakes cases. Another com-
mon indicator of a high-risk case is found with patients who engender intense
countertransference reactions in their health care professionals.

A COLLABORATIVE SHARED DECISION-MAKING MODEL

Shared decision making is considered an important element of enhanc-

ing quality of care (Institute of Medicine, 2001). Typically, shared decision
making is considered to be primarily dyadic—between patient and provider.
The basic framework presented in this chapter is systemic—the patient as
part of a larger system of nested, interactive structures. The original pur-
pose of this model was to expand the dyadic framework to include as many
appropriate stakeholders as reasonable and ethical in the patient’s treatment,
assuming the multiple benefits of enhanced “wisdom” in the participating
group. In this model, the group is defined by the parameters of each case
on an individual basis. Sometimes there are a number of other profession-
als who manage or treat a particular aspect of the patient’s care, such as the
family physician or community social worker. Often patients with complex
issues become frustrated with their therapist, which is not an uncommon
transference reaction. The advantage to this collaborative model is that it

178 JEFFREY J. MAGNAVITA

affords us the opportunity to “hold” the negative affect in the triad, enabling
metabolization of these destructive impulses and negative emotions, which
often would have resulted in a premature termination, acting out, or sabo-
taging treatment. Another central aspect of this model is the emphasis on
active decision making based on shared data and open communication. This
open feedback loop is essential for monitoring the system and was used as
a barometer to track the cases, allowing interventions before the situation
reached a dangerous tipping point. “The decision-making process refers to
how information and values are combined to form preferences and to arrive
at decisions” (Wills & Holmes-Rovner, 2006, p. 13). There is a range of treat-
ments and modalities to offer patients, but in each case an attempt should be
made to calculate the benefits and harms and to encourage a buy-in from the
patient and system. Patients are key partners in shared decision making with
health care providers, an assumption that is central to this model (Wills &
Holmes-Rovner, 2006). Furthermore, patients are reinforced and welcomed
when they seek out services independently.
The model presented in this chapter emerged from a 3-year collabora-
tion between the author and a psychiatric collaborator. We sought to develop
and pilot a model of collaborative and shared decision making that would
allow us to offer patients whom we considered to be high risk an intensive
treatment experience that would maximize their adaptive capacity and pre-
vent overutilization of costly and often retraumatizing higher levels of care.
“Patients’ decisions impact behavior, such as treatment initiation and contin-
uance, which in turn can influence individual and aggregate clinical health
status and health systems outcomes” (Wills & Holmes-Rovner, 2006, p. 9).
We strove to keep patient preferences at the center of our collaborative rela-
tionship. It is important for the clinician to maintain the dialectic between
“expert with specialized knowledge” and “not knowing” by remaining curious
and open to new perspectives.
True experts, it is said, know when they don’t know. However, nonexperts
(whether or not they think they are) certainly do not know when they
don’t know. Subjective confidence is therefore an unreliable indication
of the validity of intuitive judgments and decisions. (Kahneman & Klein,
2009, p. 524)
One of the findings that has emerged from converging sources is that
we clinicians are prone to overestimating our expertise (see Chapter 2, this
volume). We believe that working in a team with open and honest feedback
is an important way to guard against this and the other biases we are prone
to, which are presented in Chapter 2 and elsewhere in this volume. It is
important to recognize that clinicians should present themselves as experts
and try to be confident about their work, yet it is also important to critically

WHEN THE STAKES ARE HIGH 179

analyze the quality of information that we use to make decisions. Falling
back on unexamined beliefs about our expertise is potential source of bias for
experienced and novice clinicians.

EXPECTED UTILITY THEORY

The “best” decisions maximize utility that we expect for an outcome.

Expected utility (EU) theory, developed in the 1980s, provides a formula for
considering and weighing competing and multiple goals, which may be in con-
tradiction with one another, to achieve the optimal outcome (Schoemaker,
1982). EU can be represented as the following equation: multiplying the
probability (p) of an outcome by its value/utility (u) and then summing the
products of each outcome. EU offers a systematic approach for determining
the optimal tradeoffs that should be made to attain the desired goal. Often the
probabilities used in calculating outcome are unknown, but there is still util-
ity in using the best evidence to make probabilistic statements. For example,
a patient suffering from an anxiety disorder might consider a psychoanalytic
treatment versus a cognitive behavior therapy (CBT) approach. We can
compare treatments and ascertain various factors that assist us in making an
appropriate determination as to what course to take. The analytic approach
is likely to be of longer duration and costlier, and the evidence is weaker for
a reduction of anxiety symptoms; on the basis of these factors it appears that
CBT would optimize outcome. Other factors, however, may complicate the
picture and must be considered. The prospective patient might be interested
in developing a deeper appreciation of the inner workings of his or her mind
or they might be contemplating pursuing psychoanalytic training and want to
experience this form of treatment. These and other factors may overshadow
the need for the quickest path to reduction of anxiety symptoms.

A SIMPLIFIED DECISION-MAKING MODEL

Rothert et al. (1997) developed a simplified decision model, which has

been applied by Wills and Holmes-Rovner (2003) to depressed patients seen
in primary care practice. The main elements are briefly summarized in the
following paragraphs.

Information

The data relevant to decision making is the information used in deter-

mining a course of action. This includes the probability of risks and benefits

180 JEFFREY J. MAGNAVITA

and the evidence of effectiveness of a particular treatment approach. It is
essential to stay informed about current treatment approaches and refer to
trusted sources of information when making decisions. It is important to be
able to share the most accurate and current information with patients and
also to provide resources for patients that inform their choices.

Values

Values refers to the importance that a person places on aspects of his or

her experience and other factors in the spectrum of decision making. Values
are inherent to any decision-making process, and it is imperative that clini-
cians spend time determining the values that are important to each patient.
For example, some patients hold the core value that medications are bad;
others believe in their benefits. Extreme values and their underlying beliefs
have important implications for treatment. For example, many patients hold
the belief that therapeutic healing occurs and may be influenced by power-
ful placebo effects, whereas others may be described as being influenced by
negative beliefs that nothing will help and they won’t get better, a “nocebo”
response. Clarifying and honoring each patient’s value system is a fundamen-
tal part of the decision-making process.

Preferences

Preferences refers to the likelihood of preferring one alternative or treat-

ment to another. We have found that although there are a number of effec-
tive treatments that we can offer, some patients have strong preferences for or
against a certain course of action. For example, in the collaborative relation-
ship developed when using this model, one of us provided psychotherapy and
the other primarily pharmacotherapy. There tended to be a self-selection pro-
cess whereby patients with preference for psychotherapy would often find their
way to me, and those with preferences for pharmacotherapy found their way to
my colleague. One of the benefits of a collaborative process was that we could
introduce the potential benefits of each approach, providing relevant infor-
mation valuable in decision making. We found that offering the alternatives
for discussion was a very powerful educative and decision-making experience.

QUADRATIC DECISION-MAKING

To maximize our decision analytics, we have often used a quadratic

decision-making model (see Table 7.1). This model is easy to use and helps to
systematically weigh benefits and risk based on two ways of asking a question.

WHEN THE STAKES ARE HIGH 181

 TABLE 7.1
Quadratic Decision Making
Benefit Risk
Benefit associated with continuing Treat- Risk associated with continuing Treat-
ment A (e.g., patient on mood stabilizer ment A
with uncertain diagnosis) Unnecessary burden of continued
Continued stable mood treatment; effects on fetus when
pregnant; long-term effects of
medication
Benefit associated with discontinuing Risk associated with discontinuing
Treatment A Treatment A
Reduce side effects and potential long- Potential relapse; possible loss of
term damage; diagnostic confirmation; time from work; disruption in per-
less risk for fetus sonal life; possible need for higher
level of care

As has been discussed earlier in this volume, the way a question is framed
influences the answer. Quadratic modeling can guard against some of these
framing risks.
An example is a case of a married woman in her early 30s who, prior to
being seen by one of us, was hospitalized and diagnosed with bipolar disorder
for which she was placed on a mood stabilizer. She was referred for pharma-
cological treatment and medication management. My colleague wondered
if the diagnosis was accurate. The patient wanted to come off her medica-
tion because she was considering having a child. Quadratic decision making
helped to assess the risks involved in weaning her off medication. The first
question we sought to assess was the veracity of the diagnosis, and the ques-
tion was, “Is the patient suffering from bipolar disorder?” Second, we wanted
to decide if she should continue to be treated for bipolar disorder. The ques-
tion we posed was, “Should she be supported in coming off her medication
when she is trying to conceive a child?”
We addressed our questions in as systematic a fashion as possible.
We wanted to know what evidence showed that the patient suffered from
a bipolar disorder. The evidence we had on intake was that she was diag-
nosed with bipolar during a brief hospitalization. More information was
gathered through a history and clinical interview and then a recommen-
dation that she be further evaluated with psychometric testing for more
data. A Millon Multiaxial Clinical Inventory–III (Millon, Millon, Davis,
& Grossman, 2009) was administered and did not endorse bipolar dis-
order. Instead, from history and interview, it appeared that the patient
suffered, at least in part, from an undiagnosed posttraumatic stress disorder
(Magnavita, 2005b).

182 JEFFREY J. MAGNAVITA

 The quadratic questioning was then formulated as follows:
What is the risk of weaning the patient off her mood stabilizer? And con-
versely, What is the benefit of weaning the patient off her mood stabilizer?
These questions represent two sections of the quadrant.
The subsequent question was formulated as follows:
What is the risk of maintaining the patient on a mood stabilizer if she does not
have a bipolar disorder? And conversely, What is the benefit of maintaining
the patient on a mood stabilizer if she does not have a bipolar disorder?
After jointly collaborating with the patient, it was agreed that she
would be weaned off her medication and during this time undertake a more
intensive course of trauma-focused psychotherapy. She was monitored closely
by us both, and although she had some difficult times was able to successfully
come off the mood stabilizer.

DECISION-MAKING AIDS

We sought to incorporate as many decision-making aids (DAs) as we

thought useful to educate patients and inform their decisions. “DAs are inter-
ventions to help people make deliberative, effective choices about health
treatment options (including maintaining a status quo position) for complex
decisions” (O’Connor et al., 1999, p. 731).
The current criteria for key DA elements include information about
options, presentation of probabilities of outcomes, values clarification, use
of patient stories/testimonials, guidance/coaching, disclosure of conflicts of
interest, balanced information, use of plain language, use of current scientific
information, and assessment of decision quality and effectiveness (IPDAS,
2005). (Wills & Holmes-Rovner, 2006, p. 14)
Where possible, we reviewed and offered information from the most current
practice guidelines (see Chapters 4 and 5, this volume).

ELEMENTS OF A COLLABORATIVE JOINT

DECISION-MAKING CARE TEAM

Establishing a collaborative joint decision-making care team is a nec-

essary component for treating high-risk patients. In developing this collab-
orative model we were able to work in close physical proximity, with offices
next to one another. While working with a patient, and if the timing seemed
appropriate, we would often introduce the value of considering psychotherapy

WHEN THE STAKES ARE HIGH 183

or pharmacology in addition to what we were each offering. By expanding the
frame we opened up the possibility of exploring another treatment venue. If
the timing seemed right we might ask if the patient was willing to meet our
associate. At this point, if they were open to the possibility, we would often
check to see if the other’s consulting room door was open or closed. If open
we would ask if the other could stop in and we would introduce, join, sum-
marize, and model a collaborative relationship. Often the patient would agree
to schedule an appointment, and at other times they would ask us questions
and take our contact information. This physical proximity also afforded us tre-
mendous opportunity to have a continuous feedback system where we could
chat between sessions and meet patients when appropriate. There are some
important elements that we think are crucial to this approach.

Team Approach

A team approach can sound like an overused cliché. Respect and trust
are essential to a functional team. Part of the benefit of a multispecialty team
approach is that the perspectives offered by various members can be a strong
corrective to the bias of one’s model and the underlying beliefs that inform
one’s clinical work. Our goal was to establish open and regular lines of com-
munication with other health care providers who were involved in the cases
we were treating.

Utilization of Experts to Enhance a Team’s Breadth

One of the important aspects of this model is the inclusion of as many

health care providers as necessary to manage the multifaceted physical and psy-
chological needs of patients who are deemed to be high risk. This requires careful
attention to competitive feelings that are often common between health care
and related professionals. Often there are understandable turf issues about who
controls the patients’ care. Financial and ego issues often drive these dynamics
and must be sensitively handled to assure that splitting does not occur among
team members. Splitting refers to some patients’ tendencies to divide therapists
into dichotomous categories such as “bad” or “good,” “rigid” or “flexible,” “com-
passionate” or “uncaring,” and so forth, which unsuspecting clinicians can fall
prey to believing. These patient “projections” can intensify rivalrous feelings
about compensation, status, and other dynamics among team members, which
may result in them working at cross-purposes. When there is splitting, which is
inevitable, there is a process for handling these feelings. We strove to be quick
to acknowledge when we didn’t have the required expertise and often referred
to different prescribers or other therapists when there seemed to be a better
fit. For example, we sought out consultation and management with addiction

184 JEFFREY J. MAGNAVITA

specialists when we were dealing with patients with opioid dependence or who
required very complex pharmacological treatment. We attempted to keep all
the treatment options open. We frequently referred to the literature to see what
the empirical evidence suggested and when there were new approaches that we
could incorporate such as heart rate variability biofeedback, neurofeedback,
transcranial magnetic stimulation, and electrical cranial stimulation. We also
made use of alternative approaches such as yoga and physical exercise train-
ing with practitioners we knew and trusted. One problem that we faced was
determining which treatment element was beneficial while administering a
comprehensive treatment package with multiple components. Some options
such as exercise and structured activities such as yoga seem to have benefit.
However, there are times when even these might be detrimental, and their use
should be considered with decision-making processes. For example, patients
with chronic fatigue and fibromyalgia often report that exercise makes them
worse and forces them to spend days in bed.

Establishing a Supportive Core Care Team

Our core team included a board-certified psychiatrist who specialized in

case consultation and pharmacological treatment and a board-certified clini-
cal psychologist who specialized in the psychosocial treatment of high-risk and
refractory cases. We also developed strong working relationships with an array
of health care providers including nutritionists, family practitioners, neuro-
psychologists, physical trainers, educational specialists, vocational rehabilita-
tion specialists, social workers, and other disciplines whom we trusted and felt
would add a valuable component of care to the treatment team.

“Handing Off” Patient Systems

One important feature of our shared collaborative care model is what

we describe as the patient “hand-off.” We believe that this is a critical to
expanding the scope of treatment. As we have observed in our practice and
in those of our peers, there is often a tendency for patients who are seek-
ing or referred for behavioral and mental health treatment to have prefer-
ences about the kind of treatment they expect will be efficacious. Some seek
psychopharmacological treatment. This trend seems to be increasing and in
our view is related to the increased advertising of medications in the media.
Other patients have strong beliefs about medication and may believe they are
toxic and or mind-controlling agents that should be avoided. There is some
illuminating research on this issue. When clinicians believe that a behavioral
or mental disorder is biologically based we are likely to refer them for pharma-
cological treatment, and when we believe that there is a psychological basis

WHEN THE STAKES ARE HIGH 185

the referral tends to be for psychosocial treatment. It is also interesting that
for those who are viewed as having a primarily biological basis to their dis-
order less stigma is attributed to the person compared with when one believes
there is a psychological basis (Ahn, Proctor, & Flanagan, 2009).
Important components in the way this model of collaborative treatment
evolved were friendship, mutual respect, and shared values. We attempted
where possible to make our work flexible and consumer oriented in that we
tried to offer the kind of treatment that we would expect for families, friends,
and ourselves. Patients with complex presentations may often miss sessions or
disappear from treatment. We always strove to nonjudgmentally accept patients
when they returned after an absence. Patients were reinforced for appropriately
contacting team members when they felt a need and were not made to feel
that access to clinical care or our attention were misused. We strove to make
patients feel they were most welcome to contact us. Much of what we did was
psychoeducational. We both spent a great deal of time educating our patients
about other modalities of treatment and the benefit of a pharmacological or
psychotherapeutic approach if we thought that might be beneficial. We would
often be a consultant to the patient about the other’s role and work. For exam-
ple, if a patient was opposed to medication, time might be spent educating the
patient about the possible benefits as well as some of the risks and side effects.

The Consultation Model—Joint Collaborative Care Meetings

One of the most helpful experiences for many families was the oppor-
tunity to have both of us present at collaborative care meetings. These were
often necessary in situations where there was deterioration in a patient,
couple, or family’s condition. These downward spirals are the situations that
in the past would have resulted in a hospitalization. Instead, with a review
of treatment and modification of the treatment plan we were often success-
ful in averting hospitalizations or in keeping them limited except in cases
of extreme necessity where stabilization required a longer episode of care.

COLLABORATIVE CARE MODEL GOALS

A collaborative care model for treating high-risk patients, although

complex, includes a number of clear goals. Overall, the goals of collaborative
care are to maximize communication, enhance access to vital information,
and be aware of biases that might interfere with decision making. The goals
include the following:
1. Manage risk in the least restrictive and most cost efficient manner.
2. Provide ongoing treatment planning and case formulation.

186 JEFFREY J. MAGNAVITA

 3. Encourage a feedback system among patient, families, team
members, and other providers and institutions.
4. Create an optimal care environment that encourages use of our
services.
5. Encourage use of appropriate decision aids.
6. Provide ongoing consultation for complex cases to team,
agencies, and families.
7. Empower patient systems that utilize all available resources for
maintaining high quality of life.

RISK MANAGEMENT

The management and tolerance for risk is a necessary function of treating

high-risk patients. Clinicians who work with high-risk, treatment-refractory,
or complex cases should have the necessary training and experience. A level
of expertise can be attained through advanced training (Magnavita, Levy,
Critchfield, & Lebow, 2010). An understanding of the challenges that other
clinicians have faced is useful (see Chapter 10 in this volume).

TOLERANCE FOR UNCERTAINTY

Treating high-risk patients can cause high levels of anxiety for clini-
cians because of the chaos and uncertainty involved. Continual monitoring
of the therapeutic alliance is critical for risk management. Shared collabora-
tive decision making is one way to tolerate the uncertainty and risk. Anxiety
in the care team can at times run rather high, and on occasion vicarious trau-
matization of the team or a team member is not uncommon. Many high-risk
patients have suffered from a variety of traumatic experiences and develop-
mental traumata. The clinicians who treat high-risk cases should be trained
extensively in trauma and be alert to the possibility of suffering from compas-
sion fatigue and vicarious traumatization.

CASE MANAGEMENT VERSUS PROVIDING A VEHICLE

FOR UNDERSTANDING

Often the approach utilized for treating high-risk cases is based on a

case management model. Our model sought to expand the case manage-
ment aspect by providing a shared decision-making model offered in a con-
taining framework of the team collaborative care context. One goal for this

WHEN THE STAKES ARE HIGH 187

framework was to provide understanding and to tolerate the messiness of
decision making when sufficient data were not available to fully inform the
family and our efforts.

USING PATTERN RECOGNITION IN HIGH-RISK CASES

The use of pattern recognition heuristics in high-risk cases can be central

to reducing the uncertainty and finding the leverage necessary to positively
influence a patient system.

Essential Theoretical Constructs

The most fundamental pattern recognition tool in our minds is the

biopsychosocial model used in a unifying framework (Magnavita & Anchin,
2014). This is a multiperspective and multipragamatic framework that
emphasizes interdisciplinarity (Magnavita, 2005a). Important pattern recog-
nition tools are essential to clinical decision making in high-risk cases. We
rely on the four domain levels that included in a unifying framework. All
theoretical frameworks are in part pattern recognition tools. The unifying
framework that has been elaborated in a number of previous publications has
been extremely helpful especially in complex cases.

Personality Systematics

Personality systematics is the study of the interrelationships among the

domains of the personality system from the micro- to the macro-level (Magnavita,
2005a). The personality system can be conceptualized as four embedded
subsystems that, at the microscopic level, involve biological–intrapsychic
structure and processes integrally intertwined at increasingly macroscopic
levels with dyadic, triadic, and sociocultural structures and processes.

MANAGING COUNTERTRANSFERENCE–
TRANSFERENCE REACTIONS

Countertransference–transference phenomena are commonly acti-

vated in the treatment of high-risk cases (Magnavita, 2010b, 2013).
“Countertransference–transference may be conceptualized using a systemic
model that views the entire personality system embedded in various matri-
ces” (Magnavita, 2013, p. 228). Countertransference reactions are evident
in response to individuals (Muran & Hungr, 2013), couples dyads (Gottman

188 JEFFREY J. MAGNAVITA

& Gottman, 2013), and family systems (Heatherington, Friedlander, &
Escudero, 2013). We often noted that strong countertransference responses
from referring clinicians were suggestive of high-risk and refractory cases. We
also noted among our treatment team that when countertransference or trans-
ference reactions were high this was a sign of high-risk cases. Betan, Heim,
Zittel Conklin, and Westen (2005) summarized, “Although every clinician
and every therapeutic dyad is distinct, the significant correlations between
countertransference factors and personality disorder symptoms suggest that
countertransference responses occur in coherent and predictable patterns”
(p. 234). Accordingly, it is not only clinicians who react in predictable ways;
it is also likely that significant others respond in this manner as well.

SAFEGUARDS AGAINST COGNITIVE BIASES

It is of the utmost importance when treating high-risk cases to examine

your personal biases (see Chapter 2, this volume) and to be continually mind-
ful of the ways in which your biases can influence decision making. High-risk
patients often have had multiple previous treatment episodes of various lev-
els of intensity and may have had experiences with a number of health care
professionals. These trajectories can be convergence points for a variety of
biases discussed in Chapter 2. For example, a patient may have been diag-
nosed early in their mental health history, and this diagnosis then becomes an
anchor, risky for later providers to challenge. For example, a patient who was
diagnosed with an eating disorder and was refractory to treatment on further
consideration showed signs of borderline personality disorder. The eating dis-
order, which was the focus of treatment for many years by many clinicians,
took on a different set of considerations when the patient was viewed through
the lens of a personality disorder.

SUMMARY

In this chapter we described a pilot model of collaborative treatment

for high-risk cases and discussed various components. The stakes are high
for clinicians and families when there are potentially negative outcomes,
which are particularly common in certain clinical conditions. This model
emerged during a collaboration that lasted over a period of 3 years between a
board-certified psychiatrist and board-certified clinical psychologist offering
a holistic model of treatment that integrated pharmacotherapy and psycho-
therapy. Also, this model incorporated many other behavioral and mental
health specialists as well as medical practitioners to form a flexible team of

WHEN THE STAKES ARE HIGH 189

behavioral and health care providers, so that a comprehensive treatment
approach could be offered. A shared decision-making model with close col-
laboration allowed risk to be analyzed and options explored and agreed on by
all the relevant members of the patient system and clinical team.

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WHEN THE STAKES ARE HIGH 191

 8
USE OF EMPIRICALLY GROUNDED
RELATIONAL PRINCIPLES
TO ENHANCE CLINICAL
DECISION MAKING
KEN L. CRITCHFIELD AND JULIA E. MACKARONIS

Recent clinical science has demonstrated the importance of taking into

account underlying principles of change when implementing interventions
in clinical practice (e.g., Castonguay & Beutler, 2006). Our focus here is the
contextual use of relationally based treatment principles to enhance treat-
ment efficacy for specific individuals. In addition to being evidence based,
relational principles apply across the spectrum of clinical work, from collab-
orative setting of treatment goals to moment-by-moment word choice. Our
conceptualization of interventions emphasizes the use of underlying prin-
ciples and mechanisms of change, in contrast to emphasizing specific tech-
niques or treatment packages for specific symptoms or disorders. From our
principles-based viewpoint, the same underlying change mechanisms may be
activated by techniques and procedures used across schools. An advantage to
the use of principles is that treatment response can be measured, articulated,
and applied in ways that are responsive to context. Magnavita (Magnavita,

http://dx.doi.org/10.1037/14711-008
Clinical Decision Making in Mental Health Practice, J. J. Magnavita (Editor)
Copyright © 2016 by the American Psychological Association. All rights reserved.

193
Levy, Critchfield, & Lebow, 2010) has emphasized that use of principles is
essential for ethical intervention in areas where there is little empirical evi-
dence, such as decision making for patients with comorbid disorders; patients
with understudied disorders; patients with unusually severe or chronic dis-
orders or unusual cultural experience; or patients who have shown little benefit
from previous treatment trials.
A focus on principles represents a return to the conceptual origins of
most manualized approaches, which are premised on guiding principles about
the etiology, maintenance, and change processes governing psychopathology.
For example, the psychodynamic “blank screen” of neutrality—a technique—
is intended to make transference patterns more available for interpretation,
insight, and change. Similarly, in cognitive behavior therapy (CBT) for anxi-
ety disorders, graduated exposure protocols are intended to inhibit avoidance
responses and stimulate new learning. In each approach, specific techniques
serve as tools for engaging a deeper change principle. Presumably, if a given
principle is validly linked to problems and change processes, any technique
that activates it in a specific context will be effective.
Psychotherapy research has shown that many therapy approaches have
efficacy for a wide variety of disorders. Generally equivalent results, however,
have been found across protocols for the same disorders (Wampold, 2001).
One possible explanation for equivalent results is that these protocols may
use techniques that activate the same or similar underlying mechanisms. For
example, cognitive restructuring, eye movement desensitization and repro-
cessing, and psychodynamic–interpersonal approaches all impact trauma
symptoms to some degree (Chard, Schuster, & Resick, 2012; Gallagher &
Resick, 2012; Nayak, Powers, & Foa, 2012; Schottenbauer, Glass, Arnkoff,
& Gray, 2008). This may be because they all require some degree of “being
with” traumatic material in the context of a safe, therapeutic “secure base”
(Cloitre, Stovall-McClough, Miranda, & Chemtob, 2004; Keller, Zoellner,
& Feeny, 2010; Kinsler, 2014).
Research to establish treatment efficacy has primarily emphasized the
randomized controlled trial (RCT). RCTs frame the primary research ques-
tion as, “Do a set of specific techniques applied in a systematic way produce
an average benefit for a specified population?” Internal controls are strong,
largely owing to random assignment to groups and clear operationalization of
techniques. Evidence produced from RCTs is powerful for answering whether
average effects can be attributed directly to the impact of the treatment
package. However, RCTs tell us relatively little about how individuals might
respond to the treatment, especially those differing significantly from RCT
samples, such as those with comorbid diagnoses or any number of cultural
differences (Holt et al., 2013). RCTs also do not aid clinicians in select-
ing or tailoring treatments to best match individual strengths, weaknesses,

194 CRITCHFIELD AND MACKARONIS

or preferences. The same standardization procedures that are essential for
establishing scientific certainty about a given effect also produce treatment
approaches that are not easily adapted to new contexts.
Since the advent of RCTs, the idea that a treatment is based on under-
lying principles seems to have been supplanted with the idea that treatment
consists only of techniques. If this notion is pursued too strictly, we become
unable to address the question usually faced in the clinical encounter: “What
does my particular patient need in order to feel and function better in life?”
Here, the American Psychological Association has provided important per-
spective in the form of evidence-based practice of psychology (EBPP; APA
Presidential Task Force, 2006):
It is important to clarify the relation between EBPP and empirically sup-
ported treatments (ESTs). EBPP is the more comprehensive concept.
ESTs start with a treatment and ask whether it works for a certain disorder
or problem under specified circumstances. EBPP starts with the patient
and asks what research evidence (including relevant results from RCTs)
will assist the psychologist in achieving the best outcome. (p. 273)
In keeping with EBPP, a focus on principles allows clinicians to keep the
primary focus on individual clients in their particular contexts. Some work has
been done already to identify principles supported by the existing evidence base.

EMPIRICALLY DERIVED PRINCIPLES SPANNING

TREATMENT APPROACHES

In 2006, Castonguay and Beutler convened a task force of APA

Division 12 (Society of Clinical Psychology) and the North American
Society for Psychotherapy Research (hereafter referred to as the Task Force)
to distill principles from the empirical literature on psychosocial treatments
for mood, anxiety, personality, and substance use disorders. Principles were
identified on the basis of the presence of empirical data and/or their inclusion
in treatments with empirical support and were organized as relating to partici-
pant characteristics, aspects of the therapeutic relationship, or elements of
treatment technique associated with improved outcomes. As Castonguay and
Beutler noted, there is an inherent connection between therapeutic relation-
ships and techniques:
One of the most salient controversies in the field of psychotherapy is
whether client change is primarily due to the therapist’s techniques or
the quality of the therapeutic relationship. . . . this controversy reflects,
more or less implicitly, an “either/or” assumption that is conceptually
flawed and empirically untenable. (p. 353)

USE OF EMPIRICALLY GROUNDED RELATIONAL PRINCIPLES 195

 Connections between relational processes and techniques have been
observed for many forms of treatment. For example, Critchfield, Henry,
Castonguay, and Borkovec (2007) demonstrated the strong relational impact
made by including a reflective–listening component in a treatment study of
generalized anxiety disorder. Others have established connections in treat-
ments such as psychodynamic (e.g., Ulberg, Amlo, Critchfield, Marble, &
Høglend, 2014), process–experiential (Wong & Pos, 2014), CBT (Ahmed,
Westra, & Constantino, 2012), and group work (Tasca et al., 2011).
The relevance of an interface between relationship and technique ele-
ments is most striking for those whose personality patterns are rigid, problematic,
or qualify for a personality disorder (PD) diagnosis. The Task Force concluded
that comorbid PD predicted poorer treatment response and longer treatments
for other disorders. This is significant given that roughly half of community out-
patients meet criteria for PD (Keown, Holloway, & Kuipers, 2002).
An integrative summary of factors associated with outcome for treat-
ment of PD was distilled by Critchfield and Benjamin (2006). To be included,
each principle had to be (a) linked to outcomes, (b) included as an element
in empirically supported treatments, or (c) widely assumed to be relevant to
this understudied area. Critchfield (2012) reorganized key relationship and
treatment principles to aid mindful treatment with patients who show unique
patterns of comorbidity (summary shown in Exhibit 8.1). A number of these
principles were found to be shared across disorders and are relevant to this
chapter. These include presence of a strong positive alliance, a clear case
formulation that is transparent and addresses current concerns, and interven-
tions that focus on increasing adaptive and decreasing maladaptive patterns
(behaviors, affects, cognitions).

PRINCIPLES OF INTERPERSONAL RELATING RELEVANT

TO CLINICAL DECISION MAKING

Relational elements clearly have powerful links to outcomes across dis-

orders and treatments (Castonguay & Beutler, 2006; Norcross, 2002). The stan-
dard recommendation from the literature is thus that therapists should establish
a strong alliance. This good advice is not accompanied by much detail as to how
this blessed state should be achieved and maintained, however, and many dis-
orders involve disruptions of interpersonal relationships (Kiesler, 1996). A hall-
mark of PDs in particular is difficulty in maintaining collaborative relationships.
One of the themes of Linehan’s (1993) dialectical behavior therapy,
initially developed for borderline PD, is that balance must be struck between
validation and support for change. The particular balance may need to be dif-
ferent between patients or at various points in therapy. For example, provision

196 CRITCHFIELD AND MACKARONIS

 EXHIBIT 8.1
Questions to Aid Mindful Practice of PD Treatment Based on
Principles Summarized in Castonguay and Beutler (2006)
Principles of Therapeutic Change That Work
Features of the Therapeutic Relationship
• Is there evidence of a good therapeutic relationship: (a) a strong bond?
(b) collaboration to reach shared goals?
• Am I able to be supportive?
• Do I communicate empathy and positive regard?
• Am I able to be open-minded, flexible, and creative?
• Am I able to have patience, tolerance, and remain congruent despite personal
reactions to the patient and/or session content?
• Can I discuss the therapy relationship (including my own limits) in ways that will be
helpful to the patient if needed?
Intervention Focus
• Are the goals of therapy clear, grounded in a clear rationale, and pursued in well-
structured and sensible ways? Does my patient agree?
• Are interventions consistent with the case formulation and goals for treatment?
• Do interventions address current problems and concerns? Does my patient agree?
• Is there a shared understanding of what to do in crisis?
• Am I available and flexible enough to implement my part of the crisis plan if needed?
Intervention Quality
• Am I relatively active in sessions?
• Is treatment intensity (frequency, depth) appropriate for the level of patient
impairment?
• Is there a focus on change, balanced with support and validation for the present?
Intervention Impacts
• Is motivation for change enhanced?
• Is there increased understanding of problems relative to environmental inputs,
affect, cognition, and behavior?
• Are maladaptive ways of thinking and behaving decreased?
• Are adaptive ways of thinking and behaving increased?
Therapist Supports
• Do I have adequate access to support and consultation?
• Would specialized training enhance aspects of the treatment?
Note. From “Tailoring Common Treatment Principles to Fit Individual Personalities,” by K. L. Critchfield, 2012,
Journal of Personality Disorders, 26, p. 122. Copyright 2012 by Guilford Press. Reprinted with permission.

of warmly consistent structure may be an effective antidote to abandonment

fears, affective dysregulation, and internal chaos for a particular patient with
borderline PD. The same approach may discourage initiative in a depen-
dent patient or lead to reactivity (to perceived control) from individuals with
more antisocial, paranoid, or passive–aggressive personalities. Similarly, an
open-ended, validating stance may do little to promote change among those
with antisocial, narcissistic, or other PDs who tend to see “the problem” as
external to them. Evidence addressing how alliance is best optimized and
maintained in the face of such diverse patterns is still needed. A literature

USE OF EMPIRICALLY GROUNDED RELATIONAL PRINCIPLES 197

on alliance rupture and repair has explored part of the necessary territory,
noting that markers of alliance rupture include patients “tuning out” or show-
ing signs of hostility, distress, or resistance. They also include therapist and
patient appearing not to understand each other (Eubanks-Carter, Muran,
Safran, & Hayes, 2011; Safran, Muran, & Eubanks-Carter, 2011). This lit-
erature also suggests that alliance repairs may offset ruptures and sometimes
strengthen subsequent outcomes.
Research supports the proposition that the interpersonal contributions of
both therapist and patient impact outcomes (Benjamin & Critchfield, 2010)
and demonstrate links with outcome not just for global views of the alliance
but also for patterns of moment-by-moment interpersonal processes (Ahmed,
Westra, & Constantino, 2012; Coady, 1991; Henry, Schacht, & Strupp, 1986,
1990; Karpiak & Benjamin, 2004; Tasca et al., 2011; Ulberg et al., 2014; Wong
& Pos, 2014). The relational qualities of the therapist come into play especially
in difficult therapeutic encounters and for patients with complex presentations.
For example, treatments for PD and complex trauma are often long and can
involve a quite difficult process. Intense feelings about the therapist or therapy
may occur in the form of anger, fear, love, contempt, envy, or dependency.
A therapist may easily become anxious, frustrated, critical, or overwhelmed.
To prevent adverse outcomes, therapists need to be empathic, engaged, and
willing to talk about the therapeutic relationship while still retaining a sense
of boundedness and separation from the patient’s patterns. The opposite also
holds true. Henry et al. (1986, 1990) found that even small amounts of hostility
expressed in therapeutic interactions can predict poorer outcomes. A thera-
pist’s use of interpersonal control can also produce poor outcome expectations
when following patient resistance (Ahmed, Westra, & Constantino, 2012).
Task Force principles emphasizing therapist empathy, tolerance, patience, and
ability to acknowledge limits all relate to these challenges.
With these observations in mind, we turn next to a model for describing
interpersonal behavior to anchor our discussion of how relational principles
can be translated directly to moment-by-moment intervention and even
word choices. We apply the model to specific case examples to illustrate use
of relational principles designed to enhance adaptive responses.

STRUCTURAL ANALYSIS OF SOCIAL BEHAVIOR:

A MODEL FOR PRACTICAL ANALYSIS
OF RELATIONAL PROCESSES

According to Benjamin (1979, 1996), any interpersonal behavior (e.g.,

a sentence, a gesture) may be described using three dimensions: focus of the
behavior (transitive focus on other vs. intransitive focus on self), degree of

198 CRITCHFIELD AND MACKARONIS

affiliation (friendliness to hostility), and degree of interdependence (enmesh-
ment to differentiation). These dimensions are organized in the structural
analysis of social behavior (SASB) model shown in Figure 8.1. Behaviors
focused on others are boldface, and behaviors focused on the self are under-
lined. SASB’s structure and internal and predictive validity have been well
established (Benjamin, Rothweiler, & Critchfield, 2006). The version shown
here is the simplified cluster model, which defines eight positions for each
focus. The model can represent behavior that is loving, aggressive, control-
ling, and freeing (when focused on others) or delighted, submissive, recoiling,
and separate (when focused on the self). There is “space” for forms of enmesh-
ment (bottom of the model) as well as forms of differentiation and autonomy
(top of the model). The model also accommodates “complex” behavior such
as simultaneous hostility and friendliness or simultaneous focus on the self
and another person. It can thus characterize double-bind and mixed-message
behaviors as well as commonly encountered clinical dynamics such as demand-
ing dependency (“You have to help . . . I can’t do this without you,” Control
plus Trust), blaming interpretations (“It sounds to me like you went back to
your old ways again by saying . . .”; Protect plus Blame), and defensive disclo-
sure (“So I lost my cool again . . . what else do you expect from me?” Disclose
plus Sulk).
In addition to characterizing one person’s behavior in a moment, the
model can be used to track or even predict interactive patterns. Perhaps the
most important of these predictive principles is complementarity. According
to complementarity theory (Benjamin et al, 2006; Carson, 1969; Kiesler,
1996), any interpersonal behavior “pulls for” a limited set of responses while
constraining the likelihood of others. In the SASB model, complemen-
tary behaviors occupy the same position, differing only in their focus. For
example, Control and Submit form behavioral complements (bottom center
of Figure 8.1), as do Ignore and Wall-Off (top left of Figure 8.1). Certain
pairings are common in therapeutic practice; for example, therapists often
focus on patients with moderately friendly and autonomy-granting behaviors
(Critchfield et al., 2007). Expressions by a therapist of affirmation, empathic
reflection, or desire to understand a patient are all examples of these behav-
iors, seen in the upper right quadrant of Figure 8.1. Patients often adopt the
complementary position of comfortable, open disclosure that is focused on
the self. Another common pairing occurs in the lower right quadrant of the
SASB model: A therapist provides friendly structure, advice, instruction,
or didactic input while a patient adopts a stance of trusting or following the
input. Complementary interactions are often stable over time.
Other configurations are also important. Similarity is defined as two
individuals showing the same behavior (e.g., Blame is met with counter-
Blame), whereas positions that are 180 degrees apart on the same surface

USE OF EMPIRICALLY GROUNDED RELATIONAL PRINCIPLES 199

 Surface 1: Surface 2:
Focus on Other complements Focus on Self

Emancipate Separate

Ignore Affirm Wall-Off Disclose

Active Reactive
Attack Recoil Love
Love

Blame Protect Sulk Trust

Control Submit

complements

Figure 8.1. Structural analysis of social behavior simplified cluster model illustrating complementary behaviors. Behaviors focused on others are boldface,
and behaviors focused on the self are underlined. In this adapted version, the focus on Other and Self are shown in separate “surfaces,” and lines and
arrow are added to illustrate complementary conceptual pairings. From Interpersonal Diagnosis and Treatment of Personality Disorders (2nd ed., p. 55),
by L. S. Benjamin, 1996/2003, New York, NY: Guilford Press. Copyright 1996/2003 by Guilford Press. Adapted with permission.
are opposites (e.g., Blame and Affirm; Protect and Ignore). Similarity and
opposition are predicted to be unstable. The antithesis or antidote refers to a
position that is maximally different from another behavior on all three SASB
dimensions.

DEFINING “NORMAL” THERAPY RELATING

The optimal therapy relationship can be thought of as a kind of attach-

ment relationship in which the therapist provides a secure base characterized by
friendliness, moderate enmeshment, and moderate differentiation (Benjamin
et al., 2006; Florsheim, Henry, & Benjamin, 1996). The relationship is asym-
metric in focus (both stay focused on the patient), and expressions of love occur
only in limited, contextualized ways. Interventions are usually characterized by
Affirm and Protect. Patients are in complementary positions of Disclose and
Trust. Across studies, these positions characterize about 88% of all therapist
and patient statements (Critchfield et al., 2007).
SASB-based studies of therapeutic process have repeatedly found that
deviations from the optimal baseline are associated with poorer outcomes.
Henry et al. (1986, 1990) found that even small amounts of therapist Blame
and Ignore, or complementary patient behaviors of Sulk and Wall-Off,
predict poorer symptomatic outcomes and more hostile self-treatment. These
findings have been replicated in additional studies (Samstag et al., 2008; Schut
et al., 2005; Von der Lippe, Monsen, Rønnestad, & Eilertsen, 2008). Poorer
outcomes are also associated with extremes along the vertical dimension of
SASB, especially therapist Control, and patient Separate (Ahmed, Westra, &
Constantino, 2012; Macdonald, Cartwright, & Brown, 2007).

USING INTERPERSONAL PRINCIPLES TO INTERVENE WITH

THE MOMENT-BY-MOMENT THERAPY PROCESS

The following example demonstrates use of the therapy relation-

ship conforming to the optimal interpersonal patterning just described,
with emphasis on the upper right of the SASB model (friendly differen-
tiation). The interaction occurred at the beginning of a second session
during an inpatient hospitalization for a patient with multiple diagnoses,
including PD:
Therapist: I’d really like to just follow up on our meeting yesterday, sort of
what thoughts and feelings you’ve had about that discussion,
and maybe figure out where to go from here, or whether to
go from here.

USE OF EMPIRICALLY GROUNDED RELATIONAL PRINCIPLES 201

 Patient: OK, I know it brought out a lot of emotions and a lot of feel-
ings, some good, some bad, especially when we talked about
how I needed to learn to cope on my own because I’m so
dependent on people. That kinda freaked me out.
Therapist: Really, in what way?
Patient: Because I just, I don’t think I can do it. I’m terrible at talking
with people, so I don’t know.
Therapist: So you feel freaked out by the idea.
Patient: Yeah, that I could help do it on my own and learn how to not
depend on people and I just don’t know how I—I’ve always
had someone to help me.
Therapist: What would that look like? I mean, what would it be like
to try and cope with things and build a life? Do you have
any . . . ?
Patient: Well eventually I felt more suicidal. I hate to say that. But
the thought of just doing it made me even more unsure.
Because right now I’m dealing with the pain and trying to
manage on my own, and trying to manage without pain pills,
and it’s just like . . . I lost my train of thought.
Therapist: That’s all right, um, you were telling me about how thinking
about this sounds like it’s just overwhelming to add on
top of . . .
The conversation returns to the patient’s sense of hopelessness about
being helped several times and develops as a theme for the session. She dis-
cusses how her mother had always been there in the past to “advocate” for her
with doctors and others and that she now feels she doesn’t have the strength
to fill this role for herself. Later, she remembers her mother:
Patient: We all just laughed and that made her even madder. [laugh]
We lived with her drama queen scene so much that it was
just like every time she did something we ended up laughing,
so . . . [pause]
Therapist: Do you miss her?
Patient: A lot.
Therapist: I imagine. I imagine it would be hard not to.
Patient: Mm-hmm.
Therapist: You said that even if she couldn’t figure out a way to advocate
or take the pain away, she’d be up here helping in whatever
way she could think of.

202 CRITCHFIELD AND MACKARONIS

 Patient: Mm-hmm. She was really knowledgeable and she didn’t
believe in medicine and drugs. But she advocated for me
because she saw I couldn’t function and when it became
that I was in too much pain she said, “OK, this needs to
be done.” But other than that like with her cancer just got
into all these different things and so she’d probably get, if
she couldn’t find a doctor to prescribe or help with my pain
she would try to find a way to bring me out of it, instead of
feeling like giving up. . . .
Therapist: So it sounds like it just makes everything that much more
intense that she isn’t here, not just as your advocate, but as
your mother.
Patient: Mm-hmm.
Therapist: And the idea of trying to take over some of that role for yourself.
Patient: I’ve lost all hope. I just don’t care. There is a tiny piece in
there that cares because I would have left here already and
ended it. But, the majority of me has said, “I’m sick of this. I
hate the way doctors treat me. I hate going in and out. I have
to live like this the rest of my life.” It makes it hard to have a
relationship or friends or anything so I feel like, there is that
little bit that would like to try, but the majority of it is still
thinking to end it.
Therapist: Well, I hear you. And there’s no one who could stop you if you
make that choice in the long run, and you know that as well
as anyone does. I do appreciate your honesty in just saying it
how it is. And I hope you feel like I’m hearing you.
Patient: I do.
Therapist: And I also hear the tension in you between that part of you and
the little part that has made it this far.
Patient: Mm-hmm.
Overall, the session sustains a clear process of collaboration around the
central topic of developing a healthy capacity for self-care. The therapist
carefully listens and tracks, softly but persistently returning to a key part of
the patient’s struggle (dependence vs. autonomy and self-care), exploring
how the struggle developed and why it remains important given her his-
tory with her mother. The therapist makes optimal use of Affirm to under-
stand and track the patient accurately. In this case, a dramatic positive shift
occurred over the next few sessions of daily inpatient work that drew sur-
prised comments from staff. Her focus between sessions appeared to parallel
in-session conversations, shifting from hopelessness, suicidality, and craving

USE OF EMPIRICALLY GROUNDED RELATIONAL PRINCIPLES 203

for a return of her mother’s advocacy and protection to the process of building
a new, self-chosen life.
There are many ways to deviate from the optimal interpersonal base-
line. Some deviations, such as hostility, distancing, or walling-off, can be
cues that the alliance is troubled. Often, if caught quickly, these problems
can corrected and discussed. Other deviations are more subtle. For example,
in the following excerpt, a therapist briefly reverses focus from the patient to
herself. The choice does not express hostility or obvious neglect of what the
patient is saying, but the session does not deepen as opportunities are missed
to focus on the patient’s central theme (sense of being exploited and treated
unfairly by those on whom he depends):
Therapist: How are things going?
Patient: OK. Looking forward to moving out. I have gone out and
looked at some apartments.
Therapist: How did that go? How did you feel doing that?
Patient: Just a little overwhelming kind of, kind of reminds me of
looking for a job. A lot of them are already filled, or you
know, fill out this application and leave it with us and we
will call you if, you know, we’re interested. So I have an
appointment to go look at a couple more tonight.
Therapist: OK. That sounds good. So as you were doing it you were feeling
like it was kind of overwhelming?
Patient: I just, it just reminds me of looking for a job, and I hate that.
I really hate that.
Therapist: Mhm. What’s the worst part about it?
Patient: [pause] I guess it’s just hard. To think that you know the
money I’ll be spending, I guess it’s not my money, that it’s
my father’s money, is just going in somebody’s pocket.
Therapist: Mmm.
Patient: . . . and it doesn’t bother me to buy a home, because the
money is going to buy my home. But it just kinda bothers
me that my money’s just going into somebody else’s pocket.
Therapist: Mmm. You like thinking of it as investing in something.
Patient: Yeah, I thought even if I got you know a lump sum, depend-
ing on how far back on my disability they go . . . I’ve got you
know, heck I’d rather buy a fourplex or a duplex and rent out
the other three units, or two units, and you know. I’d prob-
ably make enough to make the payment and you know just
live there for free.

204 CRITCHFIELD AND MACKARONIS

 Therapist: Yeah, I mean I have an apartment too, and it’s something to
think about is buying duplexes. I’ve had people tell me it’s a
great investment especially if you are willing to live in half
of it and have the other half almost pay for your mortgage
usually.
Patient: Yeah.
Therapist: Well, it sounds like some good plans. I mean, I like the way you
are thinking because even though you’re feeling like it might
not be the best and wisest use of the money that you’re kind
of still looking down the road to maybe what you might do
differently in the future, which is good.
This session touches on several domains and relationships. In each
one, the patient complains about unfair treatment by those on whom he is
dependent. However, thoughts about how to understand and change this
pattern, which is linked to his suicidality and depression, are never brought
into clear focus. Even though there are some occasional departures from the
optimal interpersonal baseline, this therapist’s process is generally friendly,
nonhostile, and patient focused. What is missing is a connection between the
relational process and decision making about use of techniques to track the
patient’s interpersonal themes. These missing elements are, in fact, empiri-
cally based principles related to the need to follow a clear case formulation.

CROSS-CUTTING PRINCIPLES OF CHANGE: USE OF A CLEAR

CASE CONCEPTUALIZATION AND INTERVENTIONS
THAT WILL INCREASE ADAPTIVE BEHAVIOR AND
DECREASE MALADAPTIVE BEHAVIOR

In addition to the centrality of the therapeutic relationship, several key

treatment principles were also identified by the Task Force as shared across
treatments and disorders. Several are highlighted here, especially (a) using
a case formulation that links patterns of cognition, affect, and behavior to
problem maintenance; (b) using a focused, consistent, and theoretically
coherent method; and (c) seeking (with sensitivity to pacing and support) to
increase adaptive patterns while decreasing maladaptive ones.
The Task Force principles do not specify a theory of pathology or of
the change process, instead emphasizing that problems must be addressed
in a coherent way that makes sense to the patient. Data suggest that out-
comes are improved when therapists make accurate relational interpreta-
tions focused on a patient’s central interpersonal issues (Crits-Christoph,
Cooper, Luborsky, 1988; Crits-Christoph, Gibbons, Temes, Elkin, & Gallop,
2010; Norville, Sampson, & Weiss, 1996). Given a clear formulation, the

USE OF EMPIRICALLY GROUNDED RELATIONAL PRINCIPLES 205

therapeutic relationship can also be used to steer toward healthy goals.
Karpiak and Benjamin (2004) provided sequential data from therapy tran-
scripts showing that when therapists follow either adaptive or maladaptive
patient comments with Affirm, those behaviors tend to persist and to shape
outcomes.
Interpersonal principles are useful for complex interchanges and
unusual contexts. The next two case examples show how an interpersonal
case formulation, plus a clear sense of the interpersonally defined goal, can
be used in concert with principles of complementarity to make specific
intervention choices. The first example is interesting in part because the
therapeutic goal is the unusual one of needing to cease collaboration and
end the relationship. What initially appears to be a friendly announcement
and invitation is soon revealed to have another agenda. The goal in this
example is not to establish and maintain a therapeutic relationship but to
assert a firm boundary and use principles of complementarity to steer the
client toward appropriate help without provoking potentially dangerous
reactance.

Case Example 1: When the Goal Is Not to Collaborate

Ted entered individual and group treatment with a female trainee super-
vised by clinic psychology staff as his therapist for a convicted sexual offense.
He was a youthful-looking 40-year-old, and his offense involved having sex
with a teenage girl he had pursued after seeing her be turned away from a
bar. He was of average intelligence with a stable job in finance. He demon-
strated strong tendencies toward grandiosity, exertion of control over others,
and use of seeming compliance and indirect resistance to demands placed
on him, combining features of both narcissistic and passive–aggressive PDs.
Ted’s interactions with others, particularly women, were often marked by
contempt or objectification. During treatment, he began dating a reportedly
“young-looking” 18-year-old woman (Heidi), which greatly concerned his
probation officer. When confronted in therapy, Ted insisted that his therapist
was “making a big deal out of nothing.” He received feedback from group
therapy members that his choice seemed reckless at best and a return to his
major problem pattern at worst. A week later Ted reported to the group that
he had told the young woman that he could not see her again. He said he
made this decision to make his treatment as smooth as possible, and she was
not mentioned again. On his last night in group, Ted told each member what
he perceived to be their greatest flaws, and he said to his therapist, “If you
weren’t my therapist, I would have asked you out a long time ago.” He then
failed to schedule any of his planned individual follow-up sessions with the
clinic director.

206 CRITCHFIELD AND MACKARONIS

 Roughly 2 years later, his therapist, who had since left the clinic,
received the following text: “Hey, is this still [therapist’s] number? This is
Ted. You used to be my shrink.” Within an hour, a voicemail followed: “Hi,
[therapist]. This is Ted. I am married now, and my wife and I wanted to invite
you out for coffee or lunch.” The former therapist consulted with peers and
responded, beginning the sequence of texts shown in Figure 8.2, along with
the location of each interpersonal behavior on the SASB model. Ted’s initial
text and voicemail appear open, inviting, and friendly, although use of the
word shrink may have been subtly derogatory. The therapist’s response was not
simply to follow the pull of complementarity (i.e., to happily accept the invi-
tation). Instead, friendliness was returned, but with focus now placed back
on the patient (congratulations), coupled with an assertion of interpersonal
distance (i.e., refusal of the invitation accompanied by brief explanation of
the reason). The hoped-for, complementary response would be for Ted to
feel understood and affirmed and no longer to pursue focus on the therapist.
The goal was neutral and differentiated interpersonal territory at the top
of the SASB model—in other words, a friendly end to the briefly engaged
relationship.
The strategy did not work. The next morning, Ted sent a series of text
messages, also shown in Figure 8.2. He was blaming and sulking, revealing
that he held a strong grudge. What he really wanted from his former therapist
was an in-person apology. In other words, the invitation for friendly connec-
tion didn’t achieve his ends, so Ted next tried to pull his therapist in with a
bid toward hostile enmeshment. Given Ted’s patterns, concerns grew that he
might persist in demands for submission and apology, perhaps escalating to
stalking or public confrontation. The trainee consulted her former supervisor,
who encouraged her to set firm boundaries, and stated that Ted should direct
all further contact to the supervisor.
The trainee used SASB to conceptualize the goal for subsequent relat-
ing, complementary pulls involved, and consideration of Ted’s likely responses
in crafting a response. The chosen medium was by text, in part to empha-
size and enforce distance. In SASB terms, the goal was not just to assert a
boundary; it was to encourage him to end pursuit of the therapist altogether
(i.e., receive from Ted any responses at the top of the model, preferably to
simply cease contact and let her go: Emancipate). In order to receive this
response, a complementary pull was needed from the therapist that involved
separation (self-focused, located at the top of the model) and avoided any
impression of openness to friendly engagement or enmeshment (i.e., avoiding
right and bottom regions of the SASB model). Ted’s case formulation pre-
dicted that language to avoid included anything paralleling his maladaptive
patterns—any form of enmeshed, self-focused language, such as reference to
being “supervised,” of “trainee status,” or “no longer with the clinic”—was

USE OF EMPIRICALLY GROUNDED RELATIONAL PRINCIPLES 207

1. Ted: Text: “Hey, is this still [therapist’s]
number? This is Ted. You used to be
my shrink.”
Voicemail: “Hi, [therapist]. This is Ted. I
am married now, and my wife and I
Ac!ve Love wanted to invite you out for coffee or
[friendly invita!on] lunch.”
Blame?
[“shrink”]

2. Former therapist:
Text: “Hi Ted—I am very glad to hear
Separate you are doing well. Congratula!ons on
your marriage! Thank you for the
invita!on to coffee with you and your
Affirm wife, as well. I will have to decline the
invita!on, though. There are strict
guidelines for therapist client contact,
even when therapy has ended. S!ll,
thank you for the thought, and please
know I wish you both the best.”

3. Ted: Mul!ple texts (excerpts): “We invited you out

so we could accept your apology … you were
very against me da!ng a younger woman … it
was inhuman to try to keep us from one
another … if you really respect client/therapist
rules, then you wouldn’t have done what you
did … You should just know that I felt hurt and
Blame stomped on when you all a#acked me about
Sulk da!ng her.”

4. Former therapist: Text: “Hi Ted. I was sorry to see that you seem
upset and may be in need of support … I am no
Separate longer employed at the clinic … Dr. Smith
[supervisor] is now your point of contact … I
Ignore Disclose
shared your texts and voicemail message with
him, and we agreed that it might be helpful for
you to talk with him … I will no longer be
communica!ng with you about these issues,
and if you try to contact me, I am sorry to say
that I will need to block your number. Again,
Dr. Smith would be happy to discuss your
concerns with you, and can be reached at … ”
Control

Figure 8.2. Text-based interaction with Ted.

208 CRITCHFIELD AND MACKARONIS

5. Ted: Text: “Oh, haha, no I’m not upset at all I was just
[Emancipate] looking for an apology.” [No further contact]
Separate

Sulk

potentially hazardous. As seen in Figure 8.2, the therapist’s final text empha-
sized interpersonal distance in several forms but also included interpersonal
control worded to further enforce the distance (contact the clinic, not me;
if you contact me, I will block your number). Ted’s final communication
retained a hint of hostile enmeshment but appeared to largely follow the pull
of complementarity, and he distanced himself from the entire conversation.
Ted has not contacted the therapist again over an interval of several years.
The next example further demonstrates how interpersonal principles of
complementarity can be used with a case formulation to enhance adaptive
and discourage maladaptive patterns.

Case Example 2: Pursuing Collaboration With

the Right “Part” of a Patient

Annie was a 22-year-old woman who worked as an assistant man-

ager at a group home for autistic children, with aspirations to be a singer-
songwriter. She was a middle child, with an older brother and two younger
sisters. She had a series of treatments, including inpatient hospitalizations
for suicide attempts (usually by overdose of prescribed medications), residen-
tial treatments, and outpatient treatments, beginning in early adolescence.
The major presenting concern was that she was chronically suicidal. Referral
to her current therapist was made after two inpatient readmissions within
6 months. Her former therapist of nearly 7 years decided her work was no
longer to Annie’s benefit and terminated during the last hospitalization,
attempting to safely convey her hopes that a different treatment relationship
would be more helpful. In formal assessment, Annie qualified for several dis-
orders: major depression; posttraumatic stress disorder; generalized anxiety;
anorexia; and a history of polysubstance abuse involving alcohol, marijuana,

USE OF EMPIRICALLY GROUNDED RELATIONAL PRINCIPLES 209

and amphetamines. She also qualified for avoidant and borderline PDs on
formal Structural Clinical Interview for DSM Disorders assessment. In inter-
views, she conveyed a pervasive pattern of resentful compliance and secret
defiance of perceived demands by others, leading to additional diagnosis of
passive–aggressive PD.
Annie’s case formulation was based on an understanding of her concerns
in light of patterns learned in her attachment history. The approach used
was interpersonal reconstructive therapy (IRT; Benjamin, 2006), a treatment
approach developed in many respects from observations using the SASB model
to track patterns from early to adult relationships. Annie’s parents were, for
most of her childhood, strictly religious and quite authoritarian. Her family
appeared as a close, cohesive, and happy unit in their many evangelical church-
related functions; her father often held leadership positions in their local par-
ish. However, there were harsh punishments for disobedience. One of her
strongest childhood memories was of the “twice-teller,” a stick that her father
would use to hit her and her siblings, because children “shouldn’t have to be
told twice.” At age 12, Annie returned home to find her father being led away
by the police. He was indicted for white-collar felonies and served a several-
year prison sentence, and it also emerged that he had had several extramari-
tal affairs. Annie’s family’s dissolution was sudden and tremendously chaotic;
during the process of her parents’ divorce, her mother engaged in several new
relationships that were supposed to be “kept secret.” Both parents began visibly
using drugs—cocaine (father) and amphetamines (mother)—after the father
was released from prison. The children struggled greatly. Annie and her older
brother lived with a family friend for a period of time. Annie was aware that
her brother, with whom she was very close, began to slip into a deep depression,
but was still surprised when he hanged himself when Annie was 15.
Annie was able to speak at times quite frankly about her own case con-
ceptualization. She identified with both her suicidal brother and her substance-
abusing and grief-stricken parents, treating herself as she saw them behave.
She also recapitulated the early family experience, expecting and experiencing
more instances of betrayal and loss. The suicide attempt that most immediately
preceded therapy work was near her brother’s birthday, and she stated it was
because she felt incredible guilt at becoming older than he lived to be. Annie
also carried a great deal of both anger and self-hatred over her process with
treatment providers; she felt abandoned by her previous therapist but con-
cluded that she “drives people away” by getting too close and then failing to
“get better” when they try to help. This had happened multiple times with
family friends, including once immediately prior to her last hospitalization.
As she understood it, support from others was wholly contingent on her being
different than she was—“pulling herself up by her bootstraps,” in her mother’s
words, and out of the depression.

210 CRITCHFIELD AND MACKARONIS

 Given her history of felt betrayal, loss, and the perceived “burnout” of
her previous therapist, initial sessions were almost entirely focused around
building a stable therapeutic contract and rapport. Annie and her thera-
pist worked explicitly to articulate shared goals, which involved helping
her grieve losses and ultimately give herself permission to have a positively
defined self. Goals involved positions on the SASB model that, in relation
to the self, were the friendly antitheses to her longstanding patterns of self-
criticism, self-neglect, and self-destruction. Pacing and accurate empathy
were very important: Moving too far or often into her past left her seriously
suicidal, but failures to acknowledge the past led her to feel misunderstood,
betrayed, and again suicidal.
The course of therapy was tremendously challenging. Annie was often
willfully self-harming (including cutting, anorexic behaviors, substance
use, reckless sexual encounters, even skydiving with the expressed hope
that her parachute would fail to open) and acknowledged these behaviors
as partially suicidal and partially to test if her therapist would react as her
family did: get mad and attempt to control her or abandon her. Her fear of
opening up to her therapist also meant that she was frequently silent and
walled-off in session.
A safety contract was in place that involved contact with the therapist
to try and forestall crisis and prevent hospitalizations (or to allow collabora-
tion around deciding to hospitalize, when needed). This approach followed
another principle identified by the Task Force, unique to PD, recommending
increased therapist availability during crisis (Linehan, Davison, Lynch, &
Sanderson, 2006). In this spirit, therapist phone numbers were made avail-
able to clinic patients. It was made clear that texting was not an acceptable
way to communicate suicidality. However, it clearly could still happen at
times and needed to be responded to appropriately. The therapist occasion-
ally learned about alliance ruptures in the form of suicidal texts sent after
sessions. A series of these texts is shown in Figure 8.3. To fully understand the
sequence, a few additional orienting comments about IRT case formulations
are needed.
In IRT, the patient is conceptualized as having two basic “parts.” One,
the Growth Collaborator (GC) is pursuing healthy adaptation. The therapist
attempts to engage this part of the patient by supporting and drawing her in
while also reinforcing and encouraging her to nurture, care for, and affirm
herself. The other, Regressive Loyalist (RL), persists in maladaptive repeti-
tion of patterns learned and internalized from close attachment figures. These
patterns are articulated by the case formulation that guides treatment. The
therapist seeks not to support or reinforce the patient’s RL but instead to help
the GC recognize where the patterns come from and what they represent
(often a persistent loyalty to the perceived rules and values of loved ones)

USE OF EMPIRICALLY GROUNDED RELATIONAL PRINCIPLES 211

1. Annie: Text: “I’m sorry. I just want to take the
easy way out. If someone could just
(Ignore) tell me my family would be OK. I don’t
(Wall Off) want to live this life anymore. I don’t
know why I’m telling you this instead
of just going through with it. I guess I
just don’t want to hurt my sisters,
mostly. Why can’t I just be grateful
Trust with my life? Why can’t I just be
(Trust) posi!ve? I hate myself. I truly do. And
no, I don’t feel like talking, so don’t try
2. Therapist: calling me. I’m sick of people leaving
me, I’m sick of people not caring. I’m
just fed up. Do you think they’ll be
OK?”

(Ignore) Text: “Message received. I am very

concerned—I care, and want to help
you through this. Would you call me?
Or can I call you? Even if it is just a five
minute phone call—if not tonight,
Protect then tomorrow morning?”

3. Annie: Texts: “Do you think it [suicide] will

hurt my sisters really bad? Please say
no...I don’t want to be here anymore,
(Ignore) I’m so !red,” followed by “Sorry, I
shouldn’t have texted you, I’m just
scared of what I’ll do and what it will
do to my sisters.”

(Sulk) Trust
(Trust)

4. Therapist:
Phone conversa!on: Collabora!vely
discussed that part of her feels that
suicide is inevitable, and it can be hard
to see why not to just “get it over
(Ignore) Affirm with.” Pa!ent agreed that the part of
her that is !red is the part of her that
has been figh!ng to live, and cares
deeply about her sisters.
Protect

Figure 8.3. Interactions with Annie. Behaviors in parentheses show interactions with
the Regressive Loyalist (RL) in contrast to interactions with the Growth Collaborator
(GC) parts of Annie.
5. Annie: Text: “About ready to give up....I can’t
do this. I might text but I don’t want to
talk.”
(Wall Off)

Trust

6. Therapist:

Text: “I am very sorry to hear how

(Ignore) Affirm much you have been struggling but I
am very glad you texted. I would really
like to talk with you as soon as you are
ready—either by phone or when we
Protect meet tomorrow. Would that be okay?”

7. Annie: Text: “I don’t want to talk. Like anyone

cares anyway....Don’t plan on me
tomorrow either.”
(Wall Off)

(Blame)
(Sulk)

8. Therapist:

Phone conversa!on: Message to

pa!ent was that she sent two
messages, the first being that she
wanted to push help away, but the
(Ignore) second that she wanted help; therapist
expressed desire to respond
specifically to the second.

Protect
and make the decision to let them go in favor of healthier ways. The many
implications of an IRT approach to treatment is beyond our present scope;
primary emphasis here is how relational principles can optimally be used
in concert with a clearly articulated case formulation to address severe
clinical problems. In IRT, relating with the patient can often be thought
of as a relationship not with one unitary patient but two separate persons:
one showing RL patterns, another showing GC patterns. Thinking of the
patient as having separate parts allows for more targeted use of relational
interventions.
Figure 8.3 shows a sample of postsession text exchanges initiated by
Annie to her therapist, with the relationship process with the GC in standard
text and the relationship with the RL in parentheses. The sequence illus-
trates how Annie’s therapist responded to differentially reinforce adaptive
versus maladaptive patterns as defined in Annie’s case formulation. Given
Annie’s strong withdrawal and sense of abandoned alienation, her therapist’s
struggle is often to simply create and maintain a collaborative alliance in pur-
suit of a healthy goal; interpersonally, this means to increase friendly forms
of enmeshment in the therapeutic relationship (so that the same themes can
also be inspected in her self-concept and relationships with others). Annie’s
old RL pattern, however, is to pull for her therapist to recapitulate her history
of abandonment by withdrawing and attempting to frustrate her therapist’s
attempts to connect and provide help.
In the first text, Annie places her therapist in a bind, expressing sui-
cidality and hopelessness while also requesting that her therapist give per-
mission for suicide and confirm that her family will not be affected by her
loss. This is clearly a message from Annie’s RL and contains elements of
trust in the therapist (albeit maladaptively directed), coupled with neglect
of her therapist’s feelings and role and clear walling off (“don’t try calling
me”). Annie’s pattern in the past had been simply to implement a suicide
attempt, so there is a hint that the GC was also present by the fact of her
reaching out to her therapist in any form (“I don’t know why I’m telling you
this . . .”). Although small, it suggests trust and the potential for greater
collaboration in the future.
One relatively common option in crafting a response to the first text
in health care settings might be along the lines of: “I’m sorry to hear you are
upset. But, it is after hours. If you’re suicidal I need you to call the crisis center
per our safety contract.” Annie had received this sort of response before. It is
kind, professional, and appropriate in many respects but would very likely be
taken by her as further evidence that she is burdening her therapist and will
be abandoned by her sooner or later. The therapist could have responded in
an attempt to block suicidality by directly engaging the RL. But any attempt

214 CRITCHFIELD AND MACKARONIS

to argue about whether others care for her could be unproductive and even
lead to escalation if the healthy GC part perceives it as being told she is
“wrong” after reaching out for help. Such “confrontations” are difficult to
implement effectively even in the face-to-face setting. Another possibility,
simply giving no response (submitting to Annie’s stated desire not to inter-
act) would be unacceptably risky and could easily be taken by Annie as fur-
ther evidence that no one cares, further fueling suicidality.
In this case, the therapist responded by expressing caring and a desire
to help, ignoring the request for no further contact to a substantial degree by
requesting a follow-up call. On the surface, one could argue that the therapist
here has delivered a “mixed message” that involves interpersonal hostility; the
patient’s clear boundary (“don’t try calling me”) was ignored. A simple read
of the therapy process literature would predict a poor outcome on the basis of
this “complex communication.” However, looking deeper, the Ignore com-
ponent (moderated by the strategy of asking for permission to talk, rather
than immediately calling in response) is directed at the maladaptive pattern
of withdrawal and distancing, whereas the friendly and protective part of
the message is directed specifically toward the healthier part of Annie in an
attempt to engage her in collaboration and sufficient self-protection until
their next meeting.
The remaining exchanges are variations of the same pattern. The thera-
pist’s intervention is to engage and “draw in” Annie’s GC, inviting her away
from hostile withdrawal and toward friendly enmeshment using explicit
statements and implicitly invoking the principle of complementarity. At the
same time, the maladaptive RL component is systematically neglected and
set aside. Benjamin (2006) has described other contexts in which forms of
interpersonal hostility, carefully directed and contextualized, might also be
useful to weaken or confront the RL. Alternatively, there are times when a
friendly “cozying up” to the RL may be required to build initial collaboration.
In each example with Annie, collaboration was subsequently regained, safety
was reestablished, and rehospitalization was avoided.
Annie’s therapy ended after 40 sessions, when she decided to move out
of state to pursue a better job opportunity. She acknowledged that the deci-
sion was partially because the treatment was helpful. She felt that she and her
therapist were getting too close, and she feared letting anyone become close
enough to care about her if she ultimately killed herself. However, Annie
also discussed how improvements in her career options, plus choosing a life
separate from close proximity to family, offered increased hope in pursuing
her own life and her ability to move on from grief and loss. Annie summarized
the therapy by saying that her therapist helped her see that being healthy
is both her right and her choice. We believe her conclusion was a result of

USE OF EMPIRICALLY GROUNDED RELATIONAL PRINCIPLES 215

the therapist’s consistent emphasis not just on friendly control (which was
especially necessary in crisis and when the RL was poised to take her over)
but also on friendly autonomy and the goal of having a self that would be
affirmed and nurtured by Annie and no longer defined by internalization of
losses, or by loyalty to her family’s self-destructive and punitive patterns.
For patients like Annie, where the self is a fragile and fragmented thing,
the importance of this kind of focus on developing a self (through whatever
specific methods may be handy) cannot be underestimated and is largely
conveyed through a relationship with a therapist, especially early in the
process. To successfully navigate these issues, a case formulation and sense
of therapeutic goals need to be clearly articulated at a level of specificity
that facilitates decision making about the specific relational approach used
at any given moment.

RELATIONALLY BASED PRINCIPLES FOR CASE FORMULATION

CAN BE APPLIED COMFORTABLY WITHIN MULTIPLE
THEORETICAL FRAMEWORKS

In the interpersonally based approach to case formulation used in IRT,

therapists assume that a patient’s developmental history includes learning
“rules” for interpersonal relatedness and that some of these will be adap-
tive, whereas others will be maladaptive in the present. As therapists and
patients work to uncover and name these rules, the conceptualization comes
to include two parts of the patient: the GC, who pursues healthy adaptation,
and the RL, who remains loyal to the caregivers with whom the patterns
were first learned. These terms have clear corollaries for providers skilled
in conceptualizing in different modalities. In CBT, for example, a patient’s
RL would likely be present in core negative schemas as well as the thoughts,
feelings, and behaviors typically engendered by negative schema activation.
In dialectical behavior therapy, the maladaptive patterns would likely be
captured through behavioral analysis whenever their affect is high and their
emotional regulation is taxed to the point of impairment. In psychodynamic
treatments, the RL would be captured by defenses and manifestations of old
wishes and fears in relation to the self and others. In motivational interview-
ing (Miller & Rollnick, 2013), the conflict between a patient’s GC and RL
will appear as ambivalence toward change that tips toward inertia and main-
taining the status quo. As we described earlier, SASB principles and IRT make
something of a natural pair, but we strongly believe that skilled therapists can
operate from their “home orientation” while integrating SASB interpersonal
principles to differentially intervene with both adaptive and maladaptive
patient patterns.

216 CRITCHFIELD AND MACKARONIS

 CONCLUSION

An advanced graduate student therapy trainee recently expressed the

following to one of us:

A patient I’m seeing now doesn’t like [the manualized approach I’m
using] for specific reasons, and it also hasn’t worked for her in the past.
But, how can I respond to my patient’s needs and still be evidence
based? Isn’t it unethical to deviate from the manual if it is empirically
supported?

Clinicians are often trained to have multiple technical means available to

them. Deciding among techniques should not be a matter of fidelity to one
school of thought, or even an RCT, nor should it be given over to unbridled
eclecticism. Clinical decision making should instead flow from accurate
principles related to symptoms, relationships, and change processes. The
approach envisioned here emphasizes use of an interpersonal lens on each
of these domains.
We believe a principle-based approach will best be served by thera-
peutic skills and values founded on a commitment to scientific minded-
ness, critical thinking, integrative capacity, and sensitivity to relational
context (Critchfield & Knox, 2010). We also believe the field would be
best served by an increased research focus on principles underlying dis-
orders and change processes rather than continuing with our current focus
on packages of techniques. In the IRT clinic, recent research has focused
directly on measurement of underlying principles of change (Critchfield,
2013). Preliminary results have been promising, showing substantial
reductions in rehospitalization rates, symptomatology, and personality
dysfunction among patients with severe and comorbid problems that pre-
viously had not responded to standard treatment attempts. In particular,
and broadly consistent with Task Force findings, there have been observed
linkages between outcome and (a) the use of the interpersonal case formu-
lation and (b) interventions that enhance patient will to change. These
principles retain potency even after controlling for the more traditional
“common factors” principle of therapist empathy. The primary “rule” for
clinical decisions in IRT is that any intervention is acceptable so long as
it matches the case conceptualization. This rule becomes an easy means
of reflection for IRT clinicians: “Does what I am doing make sense for this
patient in terms of the case conceptualization?” As illustrated in the exam-
ples presented, interpersonal principles can refine options for in-session
tailoring of interventions to provide discriminative feedback and differen-
tial reinforcement for adaptive versus maladaptive patterns.

USE OF EMPIRICALLY GROUNDED RELATIONAL PRINCIPLES 217

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USE OF EMPIRICALLY GROUNDED RELATIONAL PRINCIPLES 221

 9
INTEGRATING ONGOING
MEASUREMENT INTO THE CLINICAL
DECISION-MAKING PROCESS WITH
MEASUREMENT FEEDBACK SYSTEMS
THOMAS L. SEXTON AND ADAM R. FISHER

In the search for the best psychological methods, models, and services
for helping clients, it has become clear that effective psychological services
are those that include the strongest available research evidence delivered with
clinical expertise and that are in line with patient values (APA Presidential
Task Force, 2006; Hollon et al., 2014; Sackett, Straus, Richardson, Rosenberg,
& Haynes, 2000). Yet, debates have continued about the role of research and
the mechanisms needed to integrate it into the practice of psychotherapy.
These debates are represented in the vibrant series of publications examin-
ing the strengths and weaknesses of the research and its potential impact on
practice (Hollon et al., 2014; Sexton, Alexander, & Mease, 2003; Sexton
& Coop Gordon, 2009; Westen, Novotny, & Thompson-Brenner, 2004).
There is considerable outcome and process research that can guide practice in
individual, couple, and family treatment (Sexton, Datchi, Evans, LaFollette,
& Wright, 2013). However, for many practitioners research remains distant

http://dx.doi.org/10.1037/14711-009
Clinical Decision Making in Mental Health Practice, J. J. Magnavita (Editor)
Copyright © 2016 by the American Psychological Association. All rights reserved.

223
and broad and includes nonspecific findings with clients and problems that
are not familiar. It is no surprise that those in practice frequently see research
as having little impact on daily clinical decision making. Although both
research and clinical experience are important, we still know little about
how they can be successfully integrated into the daily practice of clinical
professionals.
One thing we do know is that the therapist is a critical element in the
delivery of any type of psychological treatment. Growing empirical support
shows that treatment outcomes are systematically related to the provider, above
and beyond the specific treatment, which suggests the importance of under-
standing clinical decision making in enhancing positive client outcomes (Crits-
Christoph et al., 1991; Huppert et al., 2001; Kim, Wampold, & Bolt, 2006;
Wampold & Brown, 2005). These findings should not be a surprise. In a real-life
clinical setting it is the clinician who must make the ongoing decisions about
adapting treatment on the basis of whether a client is improving, remaining sta-
ble, or deteriorating. Sexton (2007) described the role of the therapist as one of
a translator between the assumptions and mechanisms of the treatment model
and the interactions with the client necessary to promote change. It is through
the clinical decision-making process, conducted by the therapist, that the trans-
lation of treatment models (whether general or specific) to client occurs. The
APA Presidential Task Force on Evidence-Based Practice (APA Presidential
Task Force, 2006) suggested that the clinical expertise needed for good decision
making is the skillful and flexible delivery of treatment with the highest prob-
ability of success. As such, clinical decision making plays an important part of
the clinical expertise needed to integrate research, theory, and experience into
the complex formula of successful psychological treatments.
Our understanding of the components and processes of clinical deci-
sion making is still in its early stages. We do know that effective clinical
decision making requires more than clinical experience and individual ther-
apist judgment. When reviewing the relationship between clinician expe-
rience (based on years of experience and amount of training) and clinical
outcomes, the conclusions of the major reviews are mixed at best (Beutler
et al., 2004). Clinicians have not demonstrated high levels of reliability
at the tasks of diagnosis, prediction, and case formulation (Garb, 2005).
Clinical judgment alone seems vulnerable to the same sources of error that
often distort ordinary human judgment, including confirmatory bias, self-
enhancement bias, the availability heuristic, and a greater emphasis on per-
sonal experience than general information. Clinical decision making requires
more than just experience. Shapiro, Friedberg, and Bardenstein (2006) sug-
gested that clinical reasoning consists of therapists’ informal analysis, deci-
sion making, and planning based on a wide variety of inputs. These include
research findings, observations of the client, assessment of etiology, theories

224 SEXTON AND FISHER

considered credible, authors and trainers found to be compelling, graduate
education, conversations with colleagues, and past experiences with vari-
ous techniques.
Magnavita (Chapter 1, this volume) has defined optimal decision making
as a process involving the gathering of relevant information; consideration and
evaluation of alternatives; making judgments that are relatively free of biases;
and finally, appraising the outcome of one’s decisions. Magnavita suggests that
clinical decision making is a dynamic process that requires information beyond
the beliefs and judgments of the clinician. One approach to bringing ongoing
measurement to clinical decision making is the use of measurement feedback
systems (MFS). Bickman, Kelley, and Athay (2012) described MFS as bring-
ing systematic measurement tools and clinically relevant real-time feedback
to clinical decision making. MFS integrate reliable and valid measurement
of relevant client factors, clinical process, progress, and client improvement
with clinically useful “feedback” that can easily be adopted into short- and
long-term clinical decision making and case planning. MFS are also a tool to
conduct practice-based research by systematically monitoring client status,
identifying patients not benefiting from treatment, and providing feedback
to clinicians about client progress (Lambert, 2001). Practice-based research
can also provide critical data to the clinician for the many within-treatment
decisions that go into good clinical decision making and data to the researcher
to find trends and common patterns of successful interventions. In fact, with
relevant and reliable client information, the clinician can address changes
in progress and be flexible in provision of treatment while being able to use
client-based information and clinical judgment to adjust and adapt treatment
to better fit the client and improve outcomes.
MFS offer clinically relevant information through ongoing measurement
of both progress and the process of treatment. The feedback provided enhances
clinical decision making through the integration of two essential elements:
(a) systematic and theory-based measurement and (b) specific and clinically
useful feedback from clients (Sexton, Patterson, & Datchi, 2012). More than
a technical tool, MFS represent a dynamic part of providing comprehensive
treatment to clients by not only gathering information but also providing a
mechanism for translating client and psychotherapy data into clinical feedback
using real-time technology. This allows clinicians to focus on interpreting the
information delivered by the MFS, examine the effect of treatment session by
session, and make decisions about the course of psychotherapy. In addition, the
technology of MFS makes it possible to visualize change at both the individual
and systemic levels, to assess how each family member or partner is respond-
ing to treatment, and to compare their experiences of the family and couple
relationships. Clinical feedback from MFS can provide information about what
does and does not seem to be working so that clinicians can be more responsive

INTEGRATING ONGOING MEASUREMENT 225

to the needs of their clients by continuing, modifying, or discontinuing treat-
ment plans (Bickman et al., 2012).
In this chapter we define, describe, and illustrate the central role that
ongoing measurement and MFS can play as part of effective clinical deci-
sion making. We begin with an overview of the role that participant-based
data may play. To illustrate the practical uses of MFS we review three spe-
cific models that range from systems for common integrative practice and
modality-specific practice to evidence-based treatment programs. We focus
more specifically on one method used to integrate an evidence-based family
treatment (functional family therapy) into a systematic measurement and
feedback approach. Within this discussion we illustrate the manner in which
MFS can be, when specified to the treatment model being used, a core part of
treatment and case planning as well as ongoing within-session decision making.
Finally, we suggest some future research directions to further this work.

MEASUREMENT FEEDBACK: USING DATA

IN CLINICAL DECISION MAKING

Although experienced as a personal, emotional, and relational inter-

change between the professional and the client, therapy for the clinician also
involves a complex series of thoughtful choices. These choices can either
contribute to or detract from finding an effective treatment plan or making
useful process choices to facilitate implementation of a successful therapeutic
endeavor. The clinical decision making behind the adaptations and adjust-
ments that provide an added and unique benefit above and beyond the treat-
ment type are complex. To adapt treatment successfully, clinicians require
sources other than clinical observation to understand the therapeutic process
and monitor treatment progress. In fact, the APA Presidential Task Force
(2006) suggested that the expertise required for clinical expertise entails the
monitoring of patient progress that might suggest the need to make treatment
adjustments. As a result, there has been an increased interest in the role of
ongoing measurement to systematically gather client-based and reliable evi-
dence to inform clinical decision making.
Using feedback to enhance clinical practice is a relatively new devel-
opment in the mental health field (Bickman et al., 2012). The importance
of feedback can be illustrated by considering the development of any other
difficult skill. Sapyta, Riemer, and Bickman (2005) used archery as an exam-
ple, suggesting that though some archers might be “naturals,” it still takes
practice, training, and information feedback to hone their skills. Without
feedback, the archer never learns to be effective and is unable to adapt to
conditions and circumstances even after he or she may demonstrate mastery.

226 SEXTON AND FISHER

Systematic training, ongoing guidance, and comprehensive information
feedback make the difference between trial-and-error learning and an effi-
cient, effective pathway to skills development. MFS are a tool to provide the
needed information to fine-tune both the overall skills of a therapist and the
ability of the therapist to match the treatment to the unique client, family,
or couple context. Adding feedback reduces the time to learn a complex skill
and improves the performance of those skills under diverse situations and
contexts.
As described by Bickman et al. (2012), MFS have two components. The
first is reliable and clinically sensitive measures administered regularly through-
out treatment to collect information concerning the process and progress
of treatment. Assessment in measurement feedback not only requires good
psychometric quality but also emphasizes clinical usefulness The second,
equally important, component is timely and clinically useful feedback about
the progress and process of treatment. Typical availability of computers in
practice settings now makes it possible to present data-based measurement in
engaging, useful, and timely ways that positively impact practice outcomes.
MFS use the emerging electronic technology to transform measurement data
into information that can influence treatment as it occurs. In other words,
information electronically entered into MFS generates automatic feedback
that is available to the clinician for immediate use. This immediate informa-
tion can then be incorporated into the treatment planning for the very next
clinical session or even for use in the current session.
The work of Bickman et al. (2012) also has brought attention to the com-
ponents of MFS that are core and potentially necessary if they are to actually
result in clinician behavior change. They have suggested that three principles
form the theoretical foundation of an effective MFS: Goal commitment, infor-
mation relevance, and cognitive dissonance. Goal commitment is the amount of
interest a person has in accomplishing a goal. To be useful in clinical decision
making, information relevance is crucial, that is, feedback needs to be related
to a goal (e.g., task or outcome) that the clinician finds valuable. According
to cognitive dissonance theory, the contradiction between what one wants to
accomplish and what one has actually accomplished creates dissonance, which
is psychologically uncomfortable. It is dissonance that motivates change. When
presented with discrepant information, the person either makes changes in his
or her behavior to attain the goal or becomes less committed to the goal itself.
The clinician must perceive the source of the information as credible and the
information must have value (Ilgen, Fisher, & Taylor, 1979). The informa-
tion value of feedback can be enhanced by attention to the format, time, and
type of information received. Feedback should be delivered as promptly as pos-
sible after data collection to allow clinicians to perceive the connection of the
feedback to their behavior. Feedback should also be given frequently so that

INTEGRATING ONGOING MEASUREMENT 227

changes in processes and outcomes can be observed as they occur and correc-
tive actions can be applied if necessary (Sapyta et al., 2005).
A number of pioneering MFS research approaches are now underway.
Bickman et al. (2012) implemented a practical application of the contextual-
ized feedback system (CFS), a model of guided clinician behavior change to
enhance effective practice. Their intervention has four major components:
(a) organizational assessment, (b) treatment progress measurement, (c) feed-
back, and (d) training (Bickman et al., 2012). The treatment progress
measurement includes assessment of therapy process (e.g., therapeutic alli-
ance, treatment motivation) and of clinical outcomes (i.e., life satisfac-
tion, hope, symptoms, and functioning). Assessment measures are based
on a comprehensive common factors–oriented measurement system called
the Peabody Measures. Feedback reports summarize treatment measurement
information and provide comparisons through data aggregated across clini-
cians, provider organizations, or types of treatment, and the reports provide
suggestions for interventions and training. The CFS is used for professional
development and continuous quality improvement and “enables provider
organizations to make data-based decisions and transform themselves into
learning organizations” (Bickman, 2008, p. 1117).
As MFS begin to develop, research on their potential benefit have also
begun to emerge. For example, Anker, Duncan, and Sparks (2009) compared
clients randomly assigned to treatment as usual (TAU) with feedback versus
TAU without feedback in couples therapy. The couples in the TAU plus feed-
back had significantly better outcomes. Reese, Toland, Slone, and Norsworthy
(2010) replicated this study and also found that the clients in the feedback
condition improved more rapidly. Lambert, Harmon, Slade, Whipple, and
Hawkins (2005) found positive results from their measurement feedback system
built around the Outcome Questionnaire-45: Clinicians who received feed-
back had clients who decreased in total negative outcomes from 21% to a 5%
to 15% range. Lambert et al. concluded that clients of clinicians who are not
alerted to the negative responses have “unacceptably high” rates of deteriora-
tion. At the same time, it appears that feedback has the greatest benefit with
clients who may require changes in their current treatment. This finding is
consistent with theories that describe feedback results in therapist changes as
the consequence of a discrepancy between the feedback information and some
standard (Carver & Scheier, 1981). For example, for clients who were flagged
as doing poorly, the effect of feedback effect size was 0.39 (65% of the treatment
group was better off than the average of the control group), whereas the effect
of feedback on the overall sample was much smaller (0.09; only 54% of the
treatment group was better off than the average person in the control group).
Bickman, Kelley, Breda, de Andrade, and Riemer (2011) compared
a TAU with feedback with a TAU without feedback, randomly assigned to

228 SEXTON AND FISHER

different centers. They collected data on symptoms from youth clients, thera-
pists, and caregivers at each session. Therapists in the feedback group received
weekly computerized reports about clients’ functioning, statistically significant
change, and notification if clients’ scores fell within the most severe quartile of
the sample. Bickman et al. (2011) found that clients whose therapists received
feedback improved more quickly than control clients. The frequency with
which therapists accessed feedback was positively correlated with improve-
ment on two different measures of functioning, and there was a dose–response
relationship between feedback viewing and clinical outcomes. Data from the
clinician, the youth, and the caregiver showed that the more reports viewed
by the clinician, the faster clinical improvement the youth made. MFS have
been used successfully to improve outcomes in treatment with couples (Anker,
Duncan, & Sparks, 2009), in treatment with families (Bickman et al., 2011),
and in general health care (Carlier et al., 2012).
Thus, it appears there is growing evidence that MFS may add to success-
ful outcomes above and beyond that attributed to the treatment or therapist.
We view MFS as a technology that brings unique and needed evidence to
therapists’ clinical decision-making processes. As such, these systems have
the potential to aid in general TAU and in specific evidence-based treat-
ments (Sexton, Datchi, Evans, LaFollette, & Wright, 2013). In fact, as
Pinsof, Goldsmith, and Latta (2012) noted,
The good news is that as the result of developments in psychotherapy
research and information technology, we have arrived at the point where
it is possible to diminish if not eliminate the scientist-practitioner gap.
The psychotherapy research development is the emergence “patient
focused,” “progress” or “feedback” research.” (p. 254)

ILLUSTRATIVE EXAMPLES

We present here a number of illustrative examples of MFS that are cur-

rently in use. Each demonstrates the critical role of reliable measurement and
feedback that are incorporated into the workflow of clinicians in a way that
adds to their ability to adapt and adjust treatment to specific clients.

OQ-Analyst

The OQ-Analyst (OQ-A) is a computer-based system designed to mon-

itor and feed back progress information about clinical treatment (Lambert,
2012) and to alert therapists to cases that are at a high risk for failing prior to
early termination (Lambert et al., 2005). The OQ-A utilizes two main mea-
sures, depending on the client being seen: the Outcome Questionnaire 45

INTEGRATING ONGOING MEASUREMENT 229

(OQ-45; Lambert, 2004) and the Youth Outcome Questionnaire (Y-OQ;
Burlingame, Wells, Lambert, & Cox, 2004). The OQ-A is utilized every week
and prior to each session, with clients entering their responses on a computer,
handheld device, or hard copy (Lambert, 2012).
The OQ-45 provides information every week on the client’s progress
in therapy, specifically addressing areas such as symptoms of anxiety and
depression, interpersonal relationships, and quality of life (Lambert et al.,
2005). There is also a shorter version, the OQ-30, available for adult popu-
lations. The Y-OQ consists of 64 items related to parent or guardian report
of how a child (ages 4–17) is progressing in treatment across subscales such
as Interpersonal Distress, Social Problems, and Behavioral Dysfunction.
(Lambert, 2012). A Y-OQ self-report measure is also available for youth ages 12
to 17, as is a shorter, 30-question version of the Y-OQ (Lambert, 2012).
Finally, the OQ-A also includes a 40-item therapeutic alliance measure
when feedback suggests that it may be necessary (Lambert, 2012). After a
client takes a questionnaire, a report is generated for the therapist on the
progress of the client in graph form, which includes all of the weekly scores
to date (Lambert et al., 2005). This report also clearly alerts the therapist
on whether the client is progressing, deteriorating, or stagnating (Lambert
et al., 2005). For ease of use, alerts are color-coded as white (functioning
in normal range, consider termination), green (rate of change adequate, no
change of treatment plan is needed), yellow (rate of change is not adequate,
consider modifying the treatment plan), and red (early termination likely,
and therapist should consider new course of action). This information can
assist a therapist’s decision-making process. The therapist has the option of
sharing these data with the client (Lambert, 2012).

Systemic Therapy Inventory of Change

The Systemic Therapy Inventory of Change (STIC), developed at the

Family Institute at Northwestern University, is a multisystemic and multi-
dimensional measurement feedback system designed for monitoring alliance
and client progress in individual, couple, and family therapy (Pinsof et al.,
2009, 2012). The creators of the STIC view therapy as an intervention not
only with an individual client but also with a system that includes anyone
involved in the presenting problem (Pinsof et al., 2012). The STIC system
includes sets of questionnaires completed by clients before the intake (STIC
INITIAL), and before each session (STIC INTERSESSION).
The STIC INITIAL forms begin with demographic questions, followed
by anywhere from two to six systems scales, based on a client’s demographics.
These systems scales address individual problems and strengths, recollections
regarding family of origin, relationship with romantic partner, family and

230 SEXTON AND FISHER

household issues, parental perception of child functioning, and the quality of
the parent–child relationship. As an example, a client with a romantic partner
and children would fill out all six scales, whereas an adolescent would complete
two (individual problems and strengths; family and household). All six take
about 45 minutes to complete. Based on these initial results, primary targets of
change become the first to be focused on in therapy. Before each subsequent
session, clients complete the shorter STIC INTERSESSION forms, in addi-
tion to alliance measures fit to the modality of therapy (Pinsof et al., 2012).
All of the data becomes part of the Clinical Profile, provided online. The
Clinical Profile provides graphs and an outcome analysis and guides the clini-
cian in the decision-making process through highlighting the primary targets
of change. These targets typically include six key factors per case (Pinsof et al.,
2012). The feedback from the STIC also facilities treatment plans throughout
the course of therapy in a collaborative manner (Pinsof et al., 2012). Pinsof
et al. (2012) viewed the STIC as being empowering for clients through the
facilitation of collaboration with therapists and providing clients with oppor-
tunities for recognition of problem areas in their relationships. For example,
the STIC is able to show a client their own and their partner’s ongoing data,
and gives the client a key role in how they are interpreted and used in therapy.

Partners for Change Outcome Management System

The Partners for Change Outcome Management System (PCOMS) was

designed for clinicians to identify clients who are not progressing in treat-
ment and to guide therapists in addressing this in a collaborative manner
(Duncan, 2012). Because of its atheoretical nature and general framework,
PCOMS is a measurement feedback system that can be integrated with any
model of clinical practice (Duncan, 2012). PCOMS consists of two four-item
measures completed by clients: the Outcome Rating Scale (ORS), which
assesses client progress, and the Session Rating Scale (SRS), which assesses
therapeutic alliance (Miller, Duncan, Sorrell, & Brown, 2005).
The ORS assess the dimensions of individual well-being, including dis-
tress from symptoms, relationships, work or school satisfaction and an overall
sense of well-being (Duncan, 2012). When scores on the ORS are decreas-
ing, clinicians can utilize this information in their decision-making process
in a collaborative manner with the client, including whether to continue
therapy (Duncan, 2012). Problems in the alliance are also discussed if they
arise (Duncan, 2012). Miller et al. (2005) noted that clients often drop out
of therapy before bringing up issues in the relationship with the therapist,
hence the need for the SRS. PCOMS monitors the alliance through the SRS
at every session, as opposed to Lambert’s MFS, which only addresses alliance
in cases of a lack of progress (Duncan, 2012).

INTEGRATING ONGOING MEASUREMENT 231

 INTEGRATING PATIENT INFORMATION INTO CLINICAL
DECISION MAKING WITHIN AN EVIDENCE-BASED
FAMILY TREATMENT

Evidence-based treatment models provide a useful example to illustrate

the potential of MFS in clinical decision making. Evidence-based models pro-
vide a useful illustration because they are specific in the description of the
treatment, allowing for measures of specific treatment goals as well as ongoing
measurement of phase and session-based therapeutic process that are hypoth-
esized to contribute to positive change. Functional family therapy (FFT) is an
evidence-based treatment model for youth and families with behavior prob-
lems (Alexander, Robbins, & Sexton, 2000; Sexton, 2010). Like many evi-
dence based treatments, FFT has a number of efficacy and effectiveness trials
showing its success in reducing youth behavior problems, improving family
functioning, and reducing family conflict (Sexton, 2010). The most recent
FFT outcome study found that in community-based settings, FFT was most
successful when practiced by therapists who followed the model (Sexton &
Turner, 2010). Thus, it became clear that in order to maximize potential out-
comes in complex community settings, therapists needed help in implement-
ing the model with fidelity and adherence (Sexton & Turner, 2010). The
FFT–Clinical Feedback System (FFT-CFS; Sexton, 2010) is a product of that
effort and the work of Bickman, Sexton and Kelly (NIMH: RO 1 MH087814;
Bickman, Sexton, & Kelly, 2010).
FFT-CFS uses a state-of-the art web-based computer system to admin-
ister and collect information using brief questionnaires completed by the
clinician, caregiver, youth, and teacher. Using electronic data entry, user-
friendly feedback reports are immediately available to the clinicians and
their supervisors. The FFT-CFS system is unique in that it is a single system
that provides real-time information to therapists, supervisors, administrators,
evaluators, and researchers regarding model fidelity, client outcomes, and
service delivery profiles. The specificity of the FFT model allows for the moni-
toring of treatment, training, and clinician model adherence in a systematic
manner that is not possible with other, less specific treatment interventions.
The FFT-CFS system is, therefore, both a clinical decision-making and a
participant-based research tool.
As recommended by Bickman (2008), the FFT-CFS has both a measure-
ment core and a systematic feedback system. The FFT Clinical Measurement
Inventory (FFT CMI) is the measurement core and is built on the assump-
tion that continuously measuring the major domains of clinical practice will
improve the quality of FFT if it is done in a relevant way (Sexton, 2010). The
FFT CMI consists of brief and psychometrically sound measures to be com-
pleted by clients, therapists, and supervisors. These measures can be taken

232 SEXTON AND FISHER

electronically or on paper (to be put in the system manually) and inform four
central domains of clinical decision making: Treatment Planning (service
delivery, case conceptualization, and session planning), Treatment Progress
and Process (family relational factors, alliance, phase-specific progress, gen-
eral improvement, and symptom level), Model Fidelity (therapist model
fidelity from supervisor–client perspective), and Client Outcomes (family
and symptom changes).
The clinical feedback is designed to inform the clinical decision making
of the therapist by providing information that leads to actionable model-
specific adaptations in a way that incorporates an understanding of how cog-
nitive processes influence responses to feedback (Cannon & Witherspoon,
2005). There are three primary domains of clinical feedback in the FFT-CFS.
First, measures target the symptom level of youth functioning, which is central
given the primary goal of youth behavior change in FFT. In addition, because
of the phasic nature of FFT, the CFS design includes the impact of session on
the accomplishment of phase goals that are the change mechanisms of the
treatment model. Finally, the system has a central feature for client report
phase and overall progress. Because FFT is a conjoint family therapy, both
measurement and feedback are based on individual perspectives (youth, care-
giver, etc.), increasing the complexity and utility of the system.
There are also four specific mechanisms through which feedback in these
areas is delivered. First, status feedback, which is where the client–family are
in the present with regard to how they view progress, the impact of the treat-
ment, and the symptom level of their youth. Status feedback is designed so
that merely glancing at the feedback report can offer a useful interpretation.
At-a-glance clinical feedback indicates broad levels of current status in a way
that does not require significant attention or resources. The FFT-CFS also pro-
vides feedback on symptoms, impact, and progress over time, or trend-based
feedback. This information allows therapists to make judgments regarding
changes in treatment plans and interventions. Feedback is also provided in
more extensive ways if needed by the clinician. A Comprehensive Feedback
Report provides information at the level of each question on each measure.
This level of analysis allows for a greater understanding of the meaning of the
broad status indicators, further improving clinical decision making. Finally,
the system provides clinical alerts in response to high scores on critical items,
high overall scores, or other indicators of dropout and clinical importance.
Figure 9.1 illustrates the four domains of clinical feedback.
Figure 9.2 illustrates the three domains of information in the FFT-CFS
system. Scheduling appointments is the major mechanism through which
client contacts, measurement scheduling, and case planning is built. An
appointment produces the designated case planning tools and the measure
designed for that particular session and adds them automatically to the to-do

INTEGRATING ONGOING MEASUREMENT 233

234
SEXTON AND FISHER

Comprehensive Feedback Report Trends

(specific detail regarding client symptoms, (specific, impact, & progress over time
impact, & functioning) displayed by each participant)

Clinical
Feedback

Alerts Status
(requiring immediate attention)
(intended for a “quick look”)

Figure 9.1. Information domains in the functional family therapy–clinical feedback system.
 Treatment Planning
(progress notes & session plans) Clients & Clinical Measures

Therapist
Information
Treatment History Deomographic Information (Therapist)
Service Delivery Profile

FFT
INTEGRATING ONGOING MEASUREMENT

Treatment Model Adherence Level

Client Clinical Feedback
Information Systems

Current Clinical Treatment Status

(symptom level, treatment impact, & progress)

Critical Events

Session
Information
session and activity management Session Type, Time, Location, Participation
& scheduling

Client Progress (therapist rating) Session Success Level (therapist rating)

235

Figure 9.2. Domains of the functional family therapy (FFT)–clinical feedback system.
list. This prompts clinicians, in a very user-friendly way, to complete the needed
material in a timely manner. The Therapist Information section includes adher-
ence rates, which consist of service delivery information that can be compared
with other cases within the therapist caseload, or to others in the same agency
or to the entire FFT database. These comparisons give content to the feedback.
Session Information includes basic data about sessions (date, length, session
goals, focus, critical incidents) as well as rating of client improvement and
session success. Integrating these three domains of information into a platform
for the primary work functions of the clinicians (scheduling, therapist informa-
tion, and session information) allow for these major functions of the clinician
to be represented so that the FFT-CFS is thus designed to move the MFS into
the center of all clinical activities (see Figure 9.2).

INTEGRATING ONGOING MEASUREMENT AND FEEDBACK

INTO CLINICAL DECISION MAKING

Combining FFT with systematic feedback on treatment progress and pro-

cesses provides the guidance that therapists need to tailor FFT to youth, thus
improving youth and family outcomes. However, to be successful, MFS are
much more than technical tools to provide data. When only “added on” to the
treatment provided, the information that comes from ongoing measurement
does not become part of the treatment, and its clinical utility decreases. To be
relevant to clinicians, the FFT-CFS was designed be central to the user work-
flow. For the therapist, FFT-CFS is a treatment-planning tool used to record
the events of each encounter with the family, make next session plans, and
integrate each of the core elements of the clinical model into practice. As such,
it was designed to be a platform to engage therapists by moving case planning
into a system in which client feedback plays a central role in decision making
to help keep the therapist focused on the relevant goals, skills, and interven-
tions for each phase of FFT. It was also designed to identify when cases are going
poorly, when families are not responding, and when a service delivery profile is
not model adherent. It helps supervisors with specific, focused, and session-by-
session information that reflects how therapists think, the decisions they make,
and the outcomes of their work. Agencies use it as an outcome measurement
and program evaluation tool. Researchers use it to gather participant-based
research data, which is integrated into training, treatment, clinical consul-
tation, and supervision to focus clinical work, facilitate accountability, and
improve outcomes. In this approach, ongoing measurement is an integral part
of treatment occurring at each therapeutic encounter.
It is the treatment session that initiates measurement and case planning.
As illustrated in Figure 9.3, session information can include both descriptive

236 SEXTON AND FISHER

 Treatment Session Clinical Decision Making

Therapist Input
(Progress Notes)
-Assessment
-Anticipated Session Goals
- Observed Session Progress
Individualized
Session Next Session Plan
(type of session/ Clinical Feedback updated treatment goals
contact/time/treatment
INTEGRATING ONGOING MEASUREMENT

phase) adjusted session goals

-treatment goals & progress technique adjustment
-client reports (symptom level,
Family Input weekly impact, progress) to…
Youth & Caregiver reprots on: Individualize and fit the family better
to improve implementation of FFT
-youth symptoms
-impact of therapy
-perceived progress
CPQ
Youth and Caregiver

Client:
Completed by: Date:

INSTRUCTIONS:
Please answer the following questions as honestly as you can based on your individual experience of
the counseling session that you have just attended. Your answers to these questions will NOT be used
to evaluate the therapist.

Completely Completely
1 2 3 4 5
Disagree Agree

1. The therapist cares about me. 0 1 2 3 4 5 6

2. The therapist and I agree on what my

Family &
0 1 2 3 4 5 6
struggles are.

3. I now see how both my family and I have

some responsibility for the problems 0 1 2 3 4 5 6
that brought us to counseling.

4. I believe that my family and I can help

Family & Family &

each other solve the problems that have 0 1 2 3 4 5 6
brought us to counseling.

Youth reported
5. I think what is going on in counseling is
0 1 2 3 4 5 6
important and I am taking part.

© copyright FFT Associates, not to be used without permission.

Your Behaviors, Thoughts and Feelings

Youth reported
This Youth’s Behaviors, Thoughts
and Feelings SFSS-Weekly-Youth

session Impact Youth reported

SFSS-Full Caregiver Client:
Completed by: Date:
Client:
Completed by: Date: INSTRUCTIONS:
Please answer the following questions as honestly as you can based on your individual experience.

Symptom
INSTRUCTIONS:
Please answer the following questions as honestly as you can based on your experience of your ado -
Never Hardly Ever Sometimes Often Very Often
lescents behavior.
1. ...feel unhappy or sad? 1 2 3 4 5

Treatment
Never Hardly Ever Sometimes Often Very Often

2. ...get into trouble? 1 2 3 4 5

1. ...feel unhappy or sad? 1 2 3 4 5

3. ...have little or no energy? 1 2 3 4 5

2. ...get into trouble? 1 2 3 4 5
4. ...disobey adults (not do what adults told
3. ...have little or no energy? 1 2 3 4 5 1 2 3 4 5
you to do)?

Severity
4. ...disobey adults (not do what adults told
you to do)?
1 2 3 4 5
SIS-EM 5. ...threaten or bully others? 1 2 3 4 5

6. ...feel afraid that other kids would laugh

5. ...threaten or bully others? 1 2 3 4 5 Youth and Caregiver at you?
1 2 3 4 5

6. ...feel afraid that other kids would laugh 7. ...have a hard time waiting your turn? 1 2 3 4 5
1 2 3 4 5
at you?

Progress
Client: 8. ...feel nervous and/or shy around other
7. ...have a hard time waiting your turn? 1 2 3 4 5 Completed by: Date: people?
1 2 3 4 5

8. ...feel nervous and/or shy around other 9. ...have a hard time sitting still? 1 2 3 4 5
1 2 3 4 5
people? INSTRUCTIONS:
Below are several statements about the session or meeting you just had with your counselor. 10. ...cry easily? 1 2 3 4 5
9. ...have a hard time sitting still? 1 2 3 4 5
11. ...annoy other people on purpose? 1 2 3 4 5
10. ...cry easily? 1 2 3 4 5

Not at all Only a little Some A lot Entirely 12. ...argue with adults? 1 2 3 4 5
11. ...annoy other people on purpose? 1 2 3 4 5
1. I feel blamed for the problems in my 13. ...drink alcohol (beer, wine, hard
12. ...argue with adults? 1 2 3 4 5 family.
1 2 3 4 5
liquor)?

13. ...drink alcohol (beer, wine, hard 2. I feel negative toward other members of 14. ...want to runaway (go AWOL)? 1 2 3 4 5
1 2 3 4 5
liquor)? my family.

14. ...throw things when he/she was mad? 1 2 3 4 5 3. I understand better something about
others (my parents/child, brothers/sis -
15. ...interrupt others? 1 2 3 4 5 ters).

4. I think we are all part of the problems in

our family.

5. I think we can find a solution to the

problems in our family.

6. What we are doing is important and I am

taking part.

INSTRUCTIONS:

Not at all Only a little Some A lot Entirely

1. Things have gotten better in our family

since we first came to therapy.

2. I tried to do what my counselor sug -

gested.

3. I used things I learned in counseling.

ONGOING TREATMENT
Figure 9.3. Clinical decision-making process in functional family therapy (FFT)–clinical feedback system.
237
information about the session itself (e.g., its length, type, focus) and infor-
mation from clients (about their status and the change trajectory they are
experiencing) and therapist (from their case and session planning notes).
At the end of a session, client measures are taken by each family member
either by paper and pencil (to be entered into the system later) or electroni-
cally through tablet or computer devices that allow the client to directly
enter information. Once entered, the MFS translates the data into useful
and digestible feedback on the initial baseline status of the youth and family
based on their level of family functioning and youth symptom levels. The
multidimensional nature of this MFS makes two levels of feedback available
to review after each treatment session. First, clinicians can quickly review
the status of each family member on the level of youth symptoms, the impact
of treatment, and the level of progress they experience. This is intended to
alert the clinician to areas that need immediate attention. There is also client-
specific feedback that details each measure, subscale, and question answer for
detailed case planning. In treatment planning the system allows the clinician
to look broadly at data (using the at-a-glance status indicators) or more specifi-
cally through the extensive feedback reports that show client score and how
that score compares with the norms of the instrument. Once the clinician
has reviewed the client feedback on the family’s functioning level and the
youth symptom level, the clinician completes a session planning guide that
integrates client feedback on level of youth symptom and family functioning
into the next session plan. Over time that process continues, resulting in a
focused and tailored approach to matching the treatment intervention with
the specific client.
Client, therapy, and session information can also be useful at the specific
phases of treatment. For example, assessment at baseline or intake allows the
clinician to gather broad and general diagnostics to help in deciding how
to deliver treatment. Baseline assessments provide an opportunity to systemati-
cally understand the client variables that might be important to consider
in planning the types of therapeutic interventions needed. In the FFT-CFS
system, there are two baseline measures used to ensure fit for the intervention
(family and symptom) and to identify areas of functioning that might be targets
of understanding the problems or change (family and symptoms—internalizing
and externalizing). Two specific domains are represented: family functioning
and the other youth symptom level. Both are important because they help
adjust treatment if it is not working and results are not apparent, and they also
serve as clinically relevant measures of treatment outcome.
In the early phases of treatment (the engagement and motivation
phase) the FFT model focuses on the within-family risk factors, systematically
addressing within-family blame, negativity, problem alignment, and alliance.
Changing these within-family relational interactions is intended to result

238 SEXTON AND FISHER

in improvement in youth behavior. Process and progress measures are inte-
grated into each treatment encounter. These measures represent the degree of
engagement and improvement in family functioning. In the middle phase of
treatment (the behavior change phase) the focus is on identifying and imple-
menting specific behavior changes within the family that result in building
within-family protective factors. To accomplish the goal, the family needs to
know what to do, and the therapist needs to monitor the family attempts at
implementing the changes. The clinician is helped by knowing how to make
ongoing adaptations to overcome barriers.
In the final phase of treatment (generalization phase), the primary goals
are to generalize, support, and maintain the changes made in treatment. To
accomplish this, the family needs to demonstrate the ability to apply skills to
other areas within the family, use existing community resources to support
them, and overcome barriers to prevent relapse. As symptoms improve, treat-
ment termination is planned. Using the FFT-CFS, initial clinical hypotheses
are measured and delivered by client feedback, which leads to revised session
and treatment plans.

WHAT IS NEXT: CREATIVITY, CLIENT DATA,

AND CLINICAL DECISION MAKING

MFS bring an important element to clinical decision making: client

real-time data for use in both the macro (which treatment to use) and micro
(how to respond to an event in a single session) clinical decisions. When
integrated into the workflow of the clinician, MFS can become the golden
thread that ties together good treatment, quality improvement, and ongoing
evaluation and research (Kelley & Bickman, 2009). MFS also give patients a
voice in treatment. In implementing clinical treatments for individual clients,
MFS bring a source of information and perspective that adds to the therapist
experience to result in therapeutic and helpful clinical decisions. In a recent
review of psychotherapy research, Newnham and Page (2010) concluded
that “use of patient monitoring and feedback in routine practice is impera-
tive. The focus on the individual rather than the average patient empowers
the patient and encourages dialogue about progress, the direction of treat-
ment and achievement of treatment goals” (p. 136).
In many ways MFS have the potential to become an essential compo-
nent of treatment. “Much like manuals added specificity, MFS bring specific-
ity to the actual delivery of therapy which is dependent on the contributions
and interactions that take place between . . . people” (Koss & Shiang, 1994,
p. 675). In this way MFS are interventions that stand alongside treatments
and the interventionists as core components of treatment because they bring

INTEGRATING ONGOING MEASUREMENT 239

information that cannot be generated by clinical experts alone or the effi-
cacy of the treatment model being used. MFS bring research-informed evi-
dence that becomes part of the structure within which the expert develops
systematic and complex case conceptualizations by providing a reliable and
clinically relevant way to understand clients, problems, and context. It is this
scaffolding that forms the structure within which cases are conceptualized,
forms the foundation of how “in the room” decisions are made, and provides
a road map of the steps to take to promote successful change process. It is also
the information that helps treatments stay relevant by helping specify, tailor,
and focus on effective interventions of treatment by providing “context” to
the case.
MFS also represent an important future research tool. In addition to
providing the clinical decision-making assistance described in this chapter,
MFS are also a platform upon which systematic research data can be gathered
for participant-based research on clinical practice. Whether for individual
therapist, organization, or model-specific analysis, the ongoing measurement
of MFS provides a useful slice of evidence about treatments in real-life con-
texts. Because data will be gathered on a routine basis, clinical practitioners
may actually be best situated to conduct systematic inquiry into the outcomes
and processes at the center of clinical intervention research. Stricker and
Trierweiler (1995) coined the term “local clinical scientist” to describe an
approach for clinicians to move research into their practice by studying their
own practices and profiles of service delivery, types of interventions, out-
comes, and even process measures, which over time accumulate to produce a
“local” set of “evidence” for that practitioner in that setting.

SUMMARY

Growing empirical support shows treatment outcomes are systematically

related to the provider, above and beyond the specific treatment, which suggests
the importance of understanding clinical decision making in enhancing posi-
tive client outcomes (Crits-Christoph et al., 1991; Huppert et al., 2001; Kim
et al., 2006; Wampold & Brown, 2005). These findings should not be a surprise.
In a real-life clinical setting, it is the clinician who must make the ongoing
decisions about adapting treatment based on whether a client is improving,
remaining stable, or deteriorating. It is through the clinical decision-making
process, conducted by the therapist, that the translation of treatment models
(whether general or specific) to client occurs. Clinical decision making is a
complex process requiring more than clinical judgment alone.
Understanding the components and processes of clinical decision making
is still in its early stages. One approach to bringing ongoing measurement to

240 SEXTON AND FISHER

clinical decision making is MFS. MFS integrate reliable and valid measure-
ment of relevant client factors, clinical process, progress, and client improve-
ment with clinically useful feedback that can easily be adopted into short- and
long-term clinical decision making and case planning. MFS are also a tool to
conduct practice-based research by systematically monitoring client status,
identifying patients not benefiting from treatment, and providing feedback
to clinicians about client progress. Practice-based research can also provide
critical data to the clinician for the many within-treatment decisions that go
into good clinical decision making and data to the researcher to find trends
and common patterns of successful interventions. When integrated into
the workflow of the clinician, MFS can become the golden thread that ties
together good treatment, quality improvement, and ongoing evaluation and
research (Kelley & Bickman, 2009) and gives patients a voice in treatment
while providing information that adds to the therapist experience to result in
therapeutic and helpful clinical decisions.

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 10
CLINICAL DECISION MAKING
AND RISK MANAGEMENT
STEVEN A. SOBELMAN AND JEFFREY N. YOUNGGREN

Any letter, e-mail, or contact from your licensing board certainly grabs
your attention. For most, the contact is generally associated with license
renewal. However, receiving notification from your licensing board that a
complaint by a current or former patient or client has been filed against you
surely gets the heart pumping at near panic rate. Making good clinical decisions
and using good judgment, providing good standards of care, and using sound
risk management procedures will keep those latter types of letters either to a
minimum or nonexistent. Obviously, some patient populations who are seen
in a psychotherapy practice—such as those involved with custody issues and
evaluations, parent coordination, and forensic evaluations as well as high-
risk mental health patients/clients (those with personality disorders)—may
involve more contentious interactions. These patient population groups
have a higher risk of licensing board complaints than others. However, most
psychologists, especially those in private practice, adhere to ethical and

http://dx.doi.org/10.1037/14711-010
Clinical Decision Making in Mental Health Practice, J. J. Magnavita (Editor)
Copyright © 2016 by the American Psychological Association. All rights reserved.

245
professional standards of care and have an understanding of proper risk
management. If the standards are followed, the potential of interacting
with a licensing board in a negative way becomes greatly reduced.
There are many reasons why we chose to become psychologists. Those
of us who have chosen to go into private practice, whether independent
or group, have dedicated ourselves to providing high-quality care to those
we serve. But there are events (external or internal stressors) that seem to
close the door to good judgment and decision making. So, let’s jump into
the deep end of the pool right at the outset of this chapter with a case study
to begin illustrating what we mean by clinical decision making and risk
management.
A well-known and well-liked psychologist (Dr. A.) accepted a new patient
into his practice. The 37-year-old woman (Ms. Z.) presented on time for
her appointment, was appropriately attired, was pleasant in mood, and
seemed comfortable in the office as she engaged in small talk about the
amount of rain they were having during the first few moments of the intake
session. As the patient and psychologist settled in for the intake session,
the psychologist followed his normal procedure of providing written
information on the Health Insurance Portability and Accountability Act
(HIPAA), his office policies (to include confidentiality, emergencies, and
even social networking), and his fees, and then he verbally explained
issues related to confidentiality and further explained his “fee for ser-
vice” policy, which included some narrative on how he does not belong
to any insurance panels but would be happy to provide the patient with
an invoice or statement of office visits that she could submit for possible
reimbursement. Ms. Z. then told him that she would check with her hus-
band’s insurance carrier although she didn’t believe her insurance carrier
provided for “out of network” providers and therefore her sessions with
him would not be covered. She indicated that she would pay by check or
credit card for each session. When she was asked whether she had any
questions, the patient, who worked in a hospital setting, indicated that
she was well aware of HIPAA and issues related to confidentiality, billing,
and so on and signed an informed consent form.
After the paperwork and business of psychology was put behind him,
Dr. A. began the task of developing a therapeutic alliance as he carefully
and empathically listened to what brought the patient to his office. At
the end of the first session, Dr. A. summarized what he had heard and
developed a treatment plan with the patient for future sessions. They
both agreed that his understanding of her situation and his approach for
working with her seemed appropriate.
Dr. A. and Ms. Z. for all intents and purposes were engaged in an
appropriate therapeutic relationship. The good news is that they seemed
well suited for each other in that he felt very comfortable dealing with her
issues and she was active in responding to new insights and perspective on

246 SOBELMAN AND YOUNGGREN

her situation. After five sessions, Ms. Z. told Dr. A. that she had always
been skeptical of psychotherapy but was seeing the benefits as she now
knew that she would gain some control of the distress that had brought
her to his office.
At the seventh office visit, Ms. Z. said, “My husband informed me
that our insurance has changed and my sessions will now be covered.
He said that you would need to fill out a treatment plan.” Dr. A. said he
was familiar with treatment plans and that he’d be willing to do so since
she would now have coverage. She thanked him, and they continued
discussing issues related to her psychotherapy.
In the next session, Ms. Z. said the following:
My husband asked me to ask you two things. Would you be okay if he
referred one of his colleagues to you? And, as I mentioned last week,
we have new insurance. My husband also wanted to know if there
is any way you could help us out with our insurance and your bill. I
began seeing you on February 15th and had two sessions in February.
Our new insurance started on March 1st. So, would it be possible for
you to rebill my new insurance company for the February sessions as
though I saw you in March? It would save us a lot of money as they
are paying 70% of your fee. Is there any way you could do that? You
know, it is weird, but if I had waited just 2 weeks to see you in March,
we wouldn’t be having this conversation.
Dr. A., who had purchased a practice management software system, did
his own billing and record keeping, so it was easy to comply with Ms. Z’s
request. And at the end of the day, he went into his billing system and
changed the dates on the February sessions.
Dr. A. and Ms. Z. had a positive next 6 months of psychotherapy as
she examined issues related to her self-worth, lack of assertiveness, and
being the adult child of an alcoholic; she related that “both my par-
ents were alcoholics, and I had to take care of them from middle school
through high school.” And Ms. Z.’s husband referred not one patient but
two to Dr. A. It appeared that psychotherapy was assisting Ms. Z. in her
efforts to feel better about herself, and Dr. A. had a new referral source.
In August, Dr. A. received a frantic phone call from Ms. Z., who was
crying. Through her tears she said, “My husband has been having an
affair at work for years and now he wants to leave us. He is going to pack
his clothes, tell the kids, and just move out. I need to see you today, if
possible.” Dr. A. made arrangements to see Ms. Z. later in the day and
helped calm her down—or at least as reasonably as one could do given
the circumstances.
In the next month, Mr. Z. moved out and told Ms. Z. that now that
money was tight, he would not be paying for her “frivolous spending,”
which included her psychotherapy sessions with Dr. A., who he now
believed was one of the problems with their marriage. Ms. Z. reported

CLINICAL DECISION MAKING AND RISK MANAGEMENT 247

 that Mr. Z. said, “All of the crap you’re being told by Dr. A. has caused
you to be a different person. He has brainwashed you into believing
you’re somebody you’re not.” However, Ms. Z. was still on his insurance
plan and told him that she would continue to see Dr. A.
In November of that year, Dr. A. received notification from his licensing
board that a complaint had been filed against him. The complaint alleged
that Dr. A. had (a) “brainwashed Ms. Z.,” which was described in a Google
search description as Dr. A. causing “alienation of affection,” and (b) per-
petrated insurance fraud for billing two sessions to an insurance carrier that
actually took place during a prior time period. And two cancelled checks
were submitted as evidence.
In the end, Dr. A. was sanctioned by his licensing board, not for the
allegation of brainwashing Ms. Z. but for insurance fraud. Dr. A. spent
a lot of money on attorney fees in addition to having to collect all the
information the licensing board required regarding his private psycho-
therapy practice. Additionally, there is no way of measuring the wear and
tear on Dr. A.’s emotional system because he knew he was guilty, knew
he was wrong, and yet he could not control the outcome. He only hoped
that his livelihood would not be taken from him by the licensing board
suspending or revoking his license.
Oops! Now if you were thinking “no good deed goes unpunished,” you are not
thinking clearly about this situation.
When initially confronted with the option to bill February sessions in
March (after all, it was just 14 days difference between having no insurance
coverage and having great insurance coverage for the patient), Dr. A. stopped
using critical thinking, which led him down the path of making a poor clini-
cal decision. Dr. A.’s emotional decision and possible countertransference
created a risky situation that ended poorly for him. So no, this wasn’t really
about “no good deed goes unpunished” but was instead about poor clinical
decisions leading, in this case, to licensing board sanctions.
We hope reading this case study gets your attention and spurs you to
read further and that the information we provide in this chapter will make
you think about your role as a psychologist. Just having the title by virtue of
one’s academic studies (classroom and internships) and passing the require-
ments of a licensing board does not fully ensure that one has the ability to
manage the responsibilities of maintaining a high standard of care. Just like
most relationships in life, the relationship we have with our profession and
those we serve requires a certain level of continued work.
What does “continued work” mean? In the context of this chapter
we discuss two areas: (a) the work involved in making good clinical deci-
sions and (b) the work involved in reducing one’s risk when working with
clients–patients.

248 SOBELMAN AND YOUNGGREN

 CRITICAL THINKING

Although we understand the words clinical decision making, we don’t always

understand what components serve as its foundation or basis. Before delving
into a discussion of clinical decision making, it is important to remember that
the process for making good clinical decisions rests on our ability to use criti-
cal thinking. Critical thinking in society and education is not a new concept.
Somewhere in our studies, usually in an Introduction to Psychology course,
we learned that Socrates (469–399 BC) taught his students how to analyze
their critical thinking processes. Even the word critical comes from the Greek
word kritikos, which means to question or to analyze.
W. G. Sumner (1940) provided the generally accepted foundational defi-
nition of critical thinking when he stated that it is “the examination and test
of propositions of any kind which are offered for acceptance, in order to find
out whether they correspond to reality or not” (p. 632).
Definitions of critical thinking were sharpened to encompass other ele-
ments of skills and thought:
Critical thinking is that mode of thinking—about any subject, content, or
problem—in which the thinker improves the quality of his or her thinking
by skillfully analyzing, assessing, and reconstructing it. Critical thinking is
self-directed, self-disciplined, self-monitored, and self-corrective thinking.
It presupposes assent to rigorous standards of excellence and mindful com-
mand of their use. It entails effective communication and problem-solving
abilities, as well as a commitment to overcome our native egocentrism and
sociocentrism. (Scriven & Paul, 2008)
In layperson’s terms, critical thinking consists of seeing both sides of an
issue, being open to new evidence that disconfirms your ideas, reasoning
dispassionately, demanding that claims be backed by evidence, deducing
and inferring conclusions from available facts, solving problems, and so
forth. (Willingham, 2007, p. 8)
In short, the purpose of critical thinking is to weed out prejudice
and bias to allow well-reasoned views to take root in order to motivate
proper action. Many have studied the characteristics of a critical thinker,
and these include being a self-directed, active learner (Browne & Keeley,
2011; Duckworth & Seligman, 2005); being open and fair minded about
other points of view (Paul & Elder, 2006; Stanovich, 2009); being keenly
aware of one’s own biases and assumptions (Browne & Keeley, 2011; Paul
& Elder, 2006); respecting evidence and reasoning (Nickerson, 1986; Paul
& Elder, 2006); and learning to tolerate uncertainty (Nickerson, 1986;
Paul & Elder, 2006). The Foundation for Critical Thinking (2014) pro-
posed the following “valuable intellectual traits” associated with critical

CLINICAL DECISION MAKING AND RISK MANAGEMENT 249

thinking, and they strongly suggested that all who use critical thinking learn
to embrace the following:
! Intellectual humility: Having a consciousness of the limits of one’s
knowledge, including sensitivity to circumstances in which
one’s native egocentrism is likely to function self-deceptively;
to bias and prejudice; and to limitations of one’s viewpoint.
Intellectual humility depends on recognizing that one should
not claim more than one actually knows. Intellectual humility
does not imply spinelessness or submissiveness. It implies the
lack of intellectual pretentiousness, boastfulness, or conceit,
combined with insight into the logical foundations, or lack of
such foundations, of one’s beliefs.
! Intellectual courage: Having a consciousness of the need to face
and fairly address ideas, beliefs, or viewpoints toward which one
has strong negative emotions and to which one has not given
a serious hearing. This courage is connected with the recogni-
tion that ideas considered dangerous or absurd are sometimes
rationally justified (in whole or in part) and that conclusions
and beliefs inculcated in us are sometimes false or misleading. To
determine for ourselves which is which, we must not passively
and uncritically “accept” what we have “learned.” Intellectual
courage comes into play here because, inevitably, we will come
to see some truth in some ideas considered dangerous and absurd
and distortion or falsity in some ideas strongly held in our social
group. We need courage to be true to our own thinking in such
circumstances. The penalties for nonconformity can be severe.
! Intellectual empathy: Having a consciousness of the need to
imaginatively put oneself in the place of others in order to
genuinely understand them, which requires the consciousness
of people’s egocentric tendency to identify truth with their
immediate perceptions of longstanding thought or belief. This
trait correlates with the ability to reconstruct accurately the
viewpoints and reasoning of others and to reason from prem-
ises, assumptions, and ideas other than our own. This trait also
correlates with the willingness to remember occasions when we
were wrong in the past despite an intense conviction that we
were right and with the ability to imagine our being similarly
deceived in a case at hand.
! Intellectual integrity: Recognition of the need to be true to one’s
own thinking, to be consistent in the intellectual standards
one applies, to hold oneself to the same rigorous standards of
evidence and proof to which one holds one’s antagonists, to

250 SOBELMAN AND YOUNGGREN

 practice what one advocates for others, and to honestly admit
discrepancies and inconsistencies in one’s own thoughts and
actions.
! Intellectual perseverance: Having a consciousness of the need
to use intellectual insights and truths in spite of difficulties,
obstacles, and frustrations; firm adherence to rational principles
despite the irrational opposition of others; and a sense of the
need to struggle with confusion and unsettled questions over
an extended period of time to achieve deeper understanding
or insight.
! Faith in reason: Confidence that in the long run, one’s own higher
interests and those of humankind at large will be best served by
giving the freest play to reason and by encouraging people to
come to their own conclusions by developing their own rational
faculties. This also means having faith that with proper encour-
agement and cultivation, people can learn to think for them-
selves, form rational viewpoints, draw reasonable conclusions,
think coherently and logically, persuade each other by reason,
and become reasonable persons despite the deep-seated obsta-
cles in the native character of the human mind and in society
as we know it.
! Fair-mindedness: Having consciousness of the need to treat all
viewpoints alike, without reference to one’s own feelings or
vested interests or the feelings or vested interests of one’s friends,
community or nation. This implies adherence to intellectual
standards without reference to one’s own advantage or the
advantage of one’s group.
Critical thinking, whether one is seeing a patient for individual psycho-
therapy or evaluating a patient for a learning disability, creates a paradigm for
understanding the complexities of patient treatment or rendering an opinion
about the patient. Many—it is hoped most—but probably not all, psychol-
ogists are taught to use critical thinking while engaging in their academic
studies. What was learned in the classroom should be applied to professional
world, too.
The following summarizes the steps for critical thinking:
1. Determine the facts of a new situation or subject without
prejudice;
2. place these facts and information in a pattern so that you can
understand them; and
3. accept or reject the source values and conclusions on the basis
of your knowledge, experience, judgment, and beliefs.

CLINICAL DECISION MAKING AND RISK MANAGEMENT 251

 Wade and Tavris (2005) expanded on these points when they defined
critical thinking as “the ability and willingness to assess claims and make
objective judgments on the basis of well-supported reasons and evidence
rather than emotion or anecdote” (p. 12). In their analysis, critical thinking
has eight premises, as they have clearly detailed (pp. 13–17):
1. Ask questions; be willing to wonder. Always be on the lookout
for questions that have not been answered in the textbooks,
by the experts in the field, or by the media. Asking “What’s
wrong here?” and/or “Why is this the way it is, and how did it
come to be that way?” leads to the identification of problems
and challenges.
2. Define the problem. An inadequate formulation of a question can
produce misleading or incomplete answers. Ask neutral ques-
tions that don’t presuppose answers. Be very concrete and very
absolute in defining terms because vague or poorly defined terms
can lead to misinformation, misleading conclusions, and incom-
plete answers.
3. Examine the evidence. Ask yourself, “What evidence supports
or refutes this argument and its opposition?” Just because many
people believe, including so-called experts, it doesn’t make it
so. How reliable is the evidence? If checking the reliability of
the evidence directly is not possible, the person should consider
whether it came from a reliable source.
4. Analyze assumptions and biases. All of us are subject to biases,
beliefs that prevent us from being impartial. Evaluate the assump-
tions and biases that lie behind arguments, including your own.
Researchers, for example, put their own assumptions to the test
by stating a hypothesis in such a way that it can be refuted or
disproved by counterevidence.
5. Avoid emotional reasoning: “If I feel this way, it must be true.”
Passionate commitment to a view can motivate a person to
think boldly without fear of what others will say, but when “gut
feelings” replace clear thinking, the results can be disastrous.
Making sound, reasoned decisions and being very emotional
when a decision is made are incompatible; you can’t be reason-
able and completely rational if you’re very emotional about
something.
6. Don’t oversimplify. Critical thinkers avoid either–or reasoning
because life—and science—is rarely that simple. Look beyond
the obvious, resist easy generalizations, and reject either–or
thinking. Don’t argue by anecdote.

252 SOBELMAN AND YOUNGGREN

 7. Consider other interpretations. A crucial aspect of critical thinking is
not to limit oneself to only one or two possibilities. Before settling
on an explanation of some behavior, however, critical thinkers are
careful not to shut out alternative possibilities. They generate as
many interpretations of the evidence as they can before choos-
ing the one that is most likely. Formulate hypotheses that offer
reasonable explanations of characteristics, behavior, and events.
8. Tolerate uncertainty. Sometimes there is little or no evidence
available to examine. Sometimes the evidence permits only ten-
tative conclusions. Sometimes the evidence seems strong enough
to permit strong conclusions—until, exasperatingly, new evi-
dence throws our beliefs into disarray. Critical thinkers are will-
ing to accept this state of uncertainty. They are not afraid to say
“I don’t know” or “I’m not sure.”
Through our understanding of how to think “critically” we can now
embark on a journey of learning to navigate the world of clinical decision
making. As such, clinical decision making consists of a core process (what
decisions are made about a patient’s mental health problems or concerns, the
appropriate therapeutic intervention strategy to use, what are the optimal
modes of interaction, and what methods of evaluation will I use) that is depen-
dent on attributes of the task such as difficulty, complexity, and uncertainty.

CLINICAL DECISION MAKING

Once critical thinking is learned and understand, as well as accepted,

the foundation for clinical decision making begins. Decision-making research
in the field of behavioral and mental health has established that attributes of
individuals influence decision making, with particular reference to decision-
making biases. This is important information because confounding variables
interfere with our abilities to make sound decisions. More specifically, our
own capabilities, confidence, self-efficacy, emotions, frames of reference, and
degree of expertise will influence our decision making. Thus, we, as decision
makers, may deviate systematically from normative models of decision making.
Such deviations are referred to as biases in decision making (Keren & Teigen,
2004). Thus, we, as psychologists, seem to be the problem. Some examples of
reasoning biases include misinterpreting findings as confirming a hypothesis
when they indicate that an alternate finding should be considered (Elstein &
Schwartz 2000); overemphasizing the likelihood of rare conditions (Dowie &
Elstein 1988); and making different decisions for individuals than for groups of
people, even though they have the same condition (Chapman, 2004).

CLINICAL DECISION MAKING AND RISK MANAGEMENT 253

 This becomes problematic because quality decision making is an essen-
tial component of good clinical practice. Believing that just understanding
the concerns that brought the patient through your office door will open
the door for effectively resolving those issues is myopic. Remember Dr. A.
in our example? If Dr. A. were truly to understand, critique, and improve his
clinical decision making, then it would be imperative for him, in addition to
understanding the elements of the immediate clinical problem or concern
that Ms. Z. brought to him, to make explicit the contextual factors (his cog-
nitive, metacognitive, emotional, and social capabilities) that should have
been taken into account when he made his clinical decision to change the
dates of the insurance billing form.
Because contextual factors play such a salient and key role in the clinical
decision making process, Smith, Higgs, and Ellis (2008) proposed the follow-
ing delineation:
1. Cognitive capabilities. Capability to (a) identify and collect rel-
evant information (task and contextual) and process these data
in order to make decisions in the focal areas of problems, inter-
vention, interaction and evaluation; (b) form relevant mental
representations of decision-making situations; (c) predict the
consequences of decisions; (d) process and interpret a multi-
tude of decision inputs (task and contextual) to make ethical
and justified decisions; (e) make pragmatic decisions in the face
of uncertainty and/or under-resourcing; and (f) adapt practice
decisions to new and changing circumstances.
2. Metacognitive/reflexive capabilities. (a) Awareness of the process
of decision making and factors that influence one’s decision
making; (b) capability to monitor and evaluate decision mak-
ing throughout the process of making decisions; and (c) capa-
bility to self-critique experience of and effectiveness of decision
making and use this critique in the development of knowledge
structure to inform future decision making.
3. Emotional capabilities. (a) Awareness of emotions and when
they are having an impact on decision making, particularly
awareness of self-efficacy; (b) capability to deal with problem-
atic emotions in order to make difficult decisions required
for patient management; (c) motivation to learn and improve
quality of decision making in the face of potentially conflicting
emotions that impact on decision making; and (d) capability to
establish and maintain effective relationships in the workplace,
if applicable, with patients, caregivers, and work colleagues by
managing the emotions of others.

254 SOBELMAN AND YOUNGGREN

 4. Social capabilities. Capability to (a) interact effectively with others
in the decision-making context; (b) critically learn from others;
(c) manage relationships where differentials in power exist and
to achieve effective decision making autonomy; and (d) involve
others meaningfully and appropriately in collaborative decision
making (including team members and at times patients).
As mentioned previously, the “continued work” of being a psychologist
involves a fairly consistent review of all the previously mentioned factors.
One way of engaging in the review process is for the psychologist (you) to
participate in one (or more) of the suggested following activities: (a) self-
reflection; (b) personal psychotherapy; (c) professional supervision; (d) peer
consultation; and (e) remaining informed of current research trends in the
field through continuing education activities, seminars, additional training,
or other forms of staying abreast of research findings. If we’re committed to
providing a quality service to our patients, then we need to ensure that we
are also committed to being a quality service provider.
Dr. A. would have avoided his troubles with the licensing board and
everything that went along with that process if he simply had consulted with
a peer, quite aside from following a preventive model involved in making a
good clinical decision with his patient.

STANDARD OF CARE

Many would advocate that an evidence-based practice is a means for

improving the quality of one’s clinical practice. Many treatment protocols
that adhere to the strict guidelines required for being designated as evidence-
based treatment also need to be integrated with many other influences on
one’s practice. More specifically, and as already mentioned in the previous
pages, consideration of critical thinking and social and organizational dimen-
sions of context (contextual factors) associated with critical thinking will
determine the quality of clinical decision making. Each psychologist must
remain open to understanding and recognizing that the immediate clinical
decisions involved in first making a diagnosis and then selecting an interven-
tion strategy come only as a result of managing the multiplicity of factors that
influence them, starting with the critical thinking process.
There is no doubt that what puts us, as mental health practitioners, in the
best position to make sound clinical decisions is our understanding (and prac-
tice) of high-quality standards of care. It is probably sound thinking to accept
that the standard of care is one of the most important constructs in mental
health and psychotherapy practice. In a very generic sense, the standard of care

CLINICAL DECISION MAKING AND RISK MANAGEMENT 255

can be defined as the usual and customary professional standard practice in the
community. Zur (2010) described standard of care as “the qualities and condi-
tions which prevail, or should prevail, in a particular mental health service, and
that a reasonable and prudent practitioner follows.” Zur further stated that the
standard is based on “community and professional standards” (Caudill, 2004;
Doverspike, 1999; Woody, 1998; Zur, 2007). Zur (2010) asserted the following:
Compliance with the standard of care means that therapists have acted
in a prudent and reasonable manner and followed community and pro-
fessional standards as have others of the same profession or discipline
with comparable qualification in similar localities. Demonstrating com-
pliance with the standard of care is done primarily via documentation in
the clinical records.
Caudill (2004), Doverspike (1999), Reid (1998), Williams (1997, 2003),
Zur (2010), and others have concluded that standard of care measures are
derived from the following six elements:
1. Statutes: Individual state laws—This is the “what” the law says.
2. Licensing boards’ regulations: Individual state licensing board
regulations that govern the state laws—In other words, this is
the “how” the law is imposed.
3. Case law: You should see this as an important element of stan-
dard of care, to include your knowledge of HIPAA regulations.
4. Ethical codes of professional associations: These are guidelines
proposed by American Psychological Association (APA) and
generally adopted by many states as part of their ethics codes in
their regulations.
5. Consensus of the professionals: This is established by expert wit-
nesses about the consensus of other professionals practicing in
the same discipline and is more oriented toward forensic psy-
chology or within the context of charging documents at the
state or federal level.
6. Consensus in the community: This standard of care might be dif-
ferent across various contexts such as working with specific reli-
gious groups or cultures, practicing in the military environment
or Veterans Affairs facilities, and services in a rural area.
As was just mentioned, the standard of care is the usual and customary
standard of practice in the community for the same profession or discipline
(Caudill, 2004; Doverspike, 1999; Williams, 2003). Many psychologists don’t
understand the concept even though it is important when dealing with liabil-
ity claims and issues as well as concepts that should be used to guide one’s psy-
chotherapy practice. This is further discussed when risk management issues
are addressed later in this chapter.

256 SOBELMAN AND YOUNGGREN

 In the end, however, the standard of care is a legal concept that is used
to evaluate whether a professional’s activities meet the “standard.” More spe-
cifically, this is also what licensing boards address when a complaint is made
against a psychologist. All professions have standards, and if you meet the
standards of care, there is a low likelihood that you’ll hear from a licensing
board. Thus, the standard of care is what most reasonable psychologists under
similar circumstances do. To put it another way, if you do what most of your
colleagues do, you are meeting the standard of care. It is important to note
that this isn’t what most of your colleagues think they should do or what an
expert has identified as a “best practice,” and some would not see that as an
aspirational standard. For example, if all psychologists invited their patients
to lunch in order to assess their social skills, then that would be considered
a “standard of care,” but it wouldn’t be considered a “best practice.” In other
words, there are probably many other ways of assessing a patient’s social skills
rather than having lunch with a patient. Thus, the standard of care is what
most of your colleagues are actually doing.
When thinking about a definition of standard of care, there isn’t one
particular set of specifics one should follow as much as trying to determine
what ingredients make up the standard of care recipe. Reid (1998) suggested
that much like the way in which words that were obsolete 50 years ago are
now accepted and in the dictionary, standard of care “is usually correlated
with professionally accepted clinical texts, clinical journal articles, clinical
training programs, and what real doctors do across the country” (p. 1). Thus,
it appears that we are responsible for recognizing and knowing the current
laws (and trends) within our own profession. As we’ve learned throughout
our training and throughout lessons learned in life, ignorantia legis neminem
excusat, or ignorance of the law excuses no one.
In further understanding the issues related to standard of care, it is best
to have the mind-set that a standard of care is a minimum (and sometimes
aspirational) standard as opposed to something concrete, specific, and perfect.
Mental health practitioners are not expected to be perfect, nor are patients–
clients guaranteed positive or desired results (Caudill, 2004). It is important
to note that licensing boards more traditionally may sanction a psychologist
if the board finds that the psychologist worked below the standard of care,
which again is defined as a minimal standard.

CLINICAL JUDGMENT

Understanding what is being written in this chapter—that is, the issues

related to critical thinking, standards of care, and clinical decision making,
all important keys to providing quality services to our patients—is well and

CLINICAL DECISION MAKING AND RISK MANAGEMENT 257

good as long as it is followed in one’s practice. But there are times when
understanding evidence-based practice, for example, doesn’t guarantee that
a psychologist will follow the tenets of the data in her or his practice of psy-
chology. Why would a psychologist who is bright, well versed in the research
of a particular psychological intervention strategy, and well respected in the
community, “choose” (consciously or unconsciously) to violate professional
and ethical standards?
What we do know is that there is a power differential between the ther-
apist and patient–client. Lammers, Stapel, and Galinsky’s (2010) research
revealed that power and influence can cause a severe disconnect between
public judgment and private behavior, and as a result, the powerful are
stricter in their judgment of others while being more lenient toward their
own actions, whereas the powerless collaborate in reproducing social inequal-
ity because they don’t feel the same entitlement. “Ultimately, patterns of
hypocrisy perpetuate social inequality” (p. 737).
Licensing boards continue to receive complaints regarding boundary and
ethical violations that reveal the power differential between the seemingly
powerful and the vulnerable. Examples include “My psychologist asked me
to walk her dog”; “My psychologist hired me as her secretary to help me build
my self-confidence while continuing my on-going psychotherapy sessions
with her”; “I was sent letters and cards, we prayed together, and eventually we
engaged in sexual relations”; and “The psychologist invited several patients to
her apartment, which included consumption of alcohol and sexual activities.”
(These excerpts were taken from public orders.)
Using critical thinking as a core base on which to build clinical decision
making is a first step in providing quality treatment to your psychotherapy
patients. Your understanding and adherence to the elements of high standards
of care further ensures that your patients will be safe and secure. The APA
(2010) Ethical Principles of Psychologists and Code of Conduct provides five gen-
eral principles to guide and inspire psychologists toward the very highest ethi-
cal ideals of the profession. Principle A, Beneficence and Nonmaleficence, is
most pertinent to this chapter because nonmaleficence is related to primum non
nocere, commonly translated as “first, do no harm.”
Good risk management and good clinical decision-making thinking
would remind us to be mindful to “first, do no harm” by using evidence-based
or empirically based practices to ensure that standards of care are kept within
minimally accepted standards. However, the issue of evidence-based or empir-
ically based practice has recently received a great deal of attention in the
mental health literature, and policy statements from a variety of professional
and governmental organizations have been formulated on this subject. This
issue has stimulated discussion and debate about how to define “best treatment
practices” within the health and mental health professions. In the end, there

258 SOBELMAN AND YOUNGGREN

is no universal consensus on what constitutes “evidence” in evidence-based
practice (e.g., case-based vs. experimental studies; evidence from efficacy tri-
als vs. clinical experience and expertise; process therapies that emphasize
practitioner competency–skills–qualities; therapeutic alliance vs. specific
techniques). All types of evidence may be important in making professional
decisions.

RISK MANAGEMENT

The Trust, a major malpractice carrier for psychologists, has defined risk
management as “prospective assessment of retrospective evaluation” (Knapp,
Younggren, VandeCreek, Harris, & Martin, 2013, p. 34). Although to some
this might be seen as just another cliché, the guidance it gives is actually the
essence of good risk management. Effective risk management requires prac-
ticing psychologists to be aware of how their conduct today might be evalu-
ated at a later date by another person or entity, like a licensing board, that has
full knowledge of the outcome of that past conduct. What is key here is that
when the decision was made by the psychologist to do what he or she did, that
psychologist did not know what the outcome of that service was going to be.
Yet, when the appropriateness of that professional service or conduct is later
evaluated retrospectively, the outcome will be a part of the evaluative pro-
cess. Consequently, it is very easy for the evaluator to engage in hindsight bias
when determining not only what could have been done to avoid the outcome
in question but, and more dangerously so, to determine what should have
been done. This retrospective analysis, often a key component of licensing
investigations and civil actions against psychologists, clearly runs risk of fall-
ing prey to this hindsight bias, making the whole process potentially unfair.
Because of their fears about being sued or having a licensing board com-
plaint filed against them, practicing psychologists have dealt with the reali-
ties of professional risk in both maladaptive and adaptive ways. Maladaptive
solutions to reduce risk can be found among those who simply refuse to treat
populations of people who present a risk to them. Psychologists who do this
can frequently be heard saying, “I just don’t treat people who . . .” Other
maladaptive solutions include those who have adopted a series of “rules”
that they believe will protect them and, consequently, reduce their risk.
Psychologists who do this can frequently be heard saying, “You never . . . with
a patient.” Both of these risk management styles are, in reality, bad and reflect
a black-and-white approach to a world that is filled with gray. In addition,
each of these is a least-common-denominator solution to risk management
that is designed only to protect the professional, with little focus on patients
and their needs. Psychologists who utilize either of these approaches can

CLINICAL DECISION MAKING AND RISK MANAGEMENT 259

be termed risk-averse psychologists and differentiated from what we call risk-
managed psychologists.

THE RISK-AVERSE PSYCHOLOGIST

As previously stated, the risk-averse psychologist will frequently oper-

ate in a world of absolutes and find safety in doing so. For example, they
say that they do not see patients who have certain disorders or who present
with certain kinds of problems simply because of the risk. Although they
might be more than capable of assisting these people, they avoid doing so
because they see potential danger ahead for them professionally if they do.
As a result, they deny the patients the care that they need and fail to provide
care that they are qualified to do. Examples of this style of risk management
abound. Many capable psychologists avoid treating children whose parents
are involved in a divorce because of the risk that they might become involved
in litigation related to the child or become involved in the parents’ dispute
in some way. Other capable psychologists refuse to see depressed patients
who have a history of suicidal risk because of the fear that the patient might
be successful in committing suicide and that this could later involve the
psychologist in a legal action alleging that the psychologist had a role in
causing the suicide and seeking damages for this. Finally, some psychologists
avoid treating patients who are concurrently involved in a legal action that
involves the condition for which the patient is seeking care. Although not
a single one of these decisions may be in the best interests of the consumer
in need, the goal of professional protection is all that is important in this
approach to risk management.
The risk-averse psychologist is also rule bound. He or she avoids engag-
ing in boundary crossings because of the fear that others might allege that
this conduct was a violation of some standard of practice, even though they
know that these boundary crossings, in and of themselves, might be appro-
priate and even therapeutic. Examples of this type of conduct include taking
gifts, hugging, touching, engaging in out-of-office services, and self-disclosure
(Zur, 2007). They fail to demonstrate insight into the reality that although a
boundary crossing on the part of the psychologist could be problematic, it is
not the act itself that makes the boundary crossing a problem, it is the purpose
of the crossing that creates the risk. The risk-averse psychologist, however,
does not approach the problem in this way. This psychologist finds comfort
and safety in the rule and lacks understanding of the fundamental principles
that create the rule. For example, it is not the hugging of a patient that is,
in and of itself, a violation of professional conduct, it is why a psychologist
would hug a patient and whom they hug. Whereas hugging a patient who

260 SOBELMAN AND YOUNGGREN

has suffered a serious loss, like the death of a child, and with whom the
psychologist has had a good alliance might be seen as an appropriate act
of empathy, it would not be appropriate to hug a patient who had been the
victim of sexual assault. The difference is key. Because of his or her lack of
understanding regarding the fundamental differences between these two
examples, the risk-averse psychologist simply does not hug. Consequently,
he or she is willing to sacrifice the benefits of honest empathy in order to
avoid any allegation, no matter how remote, of inappropriate conduct on
his or her part.

THE RISK-MANAGED PSYCHOLOGIST

The risk-managed psychologist approaches professional decisions differ-

ently than does the risk-averse psychologist. This psychologist has an under-
standing of the fundamentals of professional ethics and conduct (APA, 2010)
and knows how to apply this knowledge to a specific question being asked
or a problem being faced. There are few absolutes for this professional, who
manages risk by evaluating ethical dilemmas in a thoughtful, conceptual, and
thorough way. This psychologist makes decisions on the basis of the needs of
both the professional and the consumer. To this professional, risk manage-
ment is a part of good therapy, an approach that is much more effective than
the rule-based approach used by his or her risk-averse colleague. Finally, this
professional not only makes use of the many rational models of risk manage-
ment that are available (Cottone, 2012) but also is in touch with the feel-
ing component of good and ethical decision making (Rogerson, Gottlieb,
Handelsman, Knapp, & Younggren, 2011).
In 1956, psychologist and educator Benjamin Bloom developed a tiered
taxonomy that reflects a classification of thinking according to six cognitive
levels of complexity. The goal of this conceptual model was to lead people
away from simple thinking and problem solving into more complex styles of
thinking that reflect creativity and thoughtfulness and not just a rote under-
standing of information. According to Bloom and his colleagues, the low-
est three levels of thinking are knowledge, comprehension, and application.
Simply put, if you know something, understand it, and apply it, you have
accomplished the lowest level of thinking. Creative thinkers, however, make
use of higher levels of thinking, which include analysis, synthesis, and evalu-
ation. These thinkers analyze and integrate information into new concepts
and evaluate the outcome of that process (Bloom & Krathwohl, 1956).
This taxonomy was later modified and updated in order to make it more
useful (Anderson & Krathwohl, 2001). The revised taxonomy, still tiered in
six conceptual levels, is composed of remembering, understanding, applying,

CLINICAL DECISION MAKING AND RISK MANAGEMENT 261

analyzing, evaluating, and creating. The lowest levels of thinking are found
in remembering, understanding, and applying. That is, if a person remem-
bers something, understands it, and applies it, they have accomplished the
lowest level of thinking. This process does reflect learning and understand-
ing, but key here is that it is not creative; it is not higher order thinking.
To be creative, the learner must learn to engage in analyzing what has been
learned, evaluating the results of that process and creating something new
from that synthesis. According to the models proposed by Bloom and his
colleagues, higher order thinking requires this integration of information in
order to arrive at the right decision—the decision that is unique to all of the
information involved in the process. This is exactly what the risk-managed
psychologist does.
For the risk-managed psychologist, a decision about what to do is not
simply based on the avoidance of risk or knowledge about a rule but also on an
understanding of that risk and how it applies to a specific and unique circum-
stance. The risk-managed psychologist knows how to make unique decisions
based on these unique circumstances. Good risk management is not simply
professionally protective conduct but is done in the best interests of both the
psychologist and the patient. It is based on the specifics of the circumstance,
an understanding of the principles that are the foundation of the rules of pro-
fessional conduct, and knowledge about how to integrate this understanding
into a decision about what to do. It is not reflexive nor is it rote. It is good
thinking. However, it is not easy thinking; it takes time and an understanding
of the ethics of professional conduct and the law.
As pointed out already, good risk management makes use of the unique
nature of the circumstance within which the psychologist finds him- or her-
self. It does not focus just on the conduct of the professional but requires an
understanding of patient characteristics, the psychologist’s skills, the setting
within which the psychologist finds him- or herself, and the potential disci-
plinary consequences of the conduct in question (Knapp et al., 2013). An
understanding of patient characteristics reflects respect for the unique nature
of those we treat, including their individual and social realities. Risk is a vari-
able that changes with each one of these variables. For example, if a patient
is a self-pay, choices regarding interventions to be used and goals that can be
achieved are different than are those for patients who have a managed care
insurance benefit, the latter requiring decisions made with an understanding
of how the insurance company’s oversight might affect the provider’s profes-
sional choices. The patient’s psychological condition also drives the direction
of risk management choices. If the patient is highly disturbed with a history
of erratic and unpredictable emotion and behavior, the therapist’s choices
would be vastly different than those made for a patient with a more stable
and predictable emotional style.

262 SOBELMAN AND YOUNGGREN

 The skills of the therapist are another factor driving risk management
decisions. Psychologists providing services to individuals must always be able
to answer the following questions: “Am I qualified to do this by my education,
training and/or experience?” and “Could I defend my qualifications to do this
if I were asked to do so on a witness stand?” If the answer to these questions
is either “no” or “maybe,” then the psychologist should reconsider what he or
she is doing. Only under emergent or unusual circumstances can a psycholo-
gist provide services they are only questionably qualified to provide through
education, training, and/or experience (APA, 2010).
Risk changes with both setting and circumstance, so the setting in
which the service is being provided also warrants careful evaluation when
making a risk management decision. For example, a psychologist providing
recommendations to parents regarding custody of children in a forensic mat-
ter runs substantially more risk of an allegation of unprofessional conduct
than does one who is involved in helping those same parents learn how to
manage a the same child within a stable parental family system. The former
forensic matter obviously requires significantly higher levels of structure and
consistency than does the latter, where all parties are likely to be cooperating
and sharing a common therapeutic goal.
The potential for disciplinary action being taken against the psycholo-
gist is the final factor that must be weighed when making a risk management
decision. This requires that a psychologist know ethics, the law, and the nature
of the licensing board that regulates their professional conduct. In addition,
it requires a respect for the conduct of entities that might also be involved.
For example, seeing a patient who pays out of pocket for sessions removes the
oversight of a third-party payer regarding the appropriateness of conduct of
the psychologist. Those who treat patients covered by insurance companies
always run the risk of having to deal with audits and recoupment of fees if
the company disagrees with the service provided in some way. Conversely,
the psychologist who only sees self-pay cases does not have to be concerned
about any of this. Finally, a lack of understanding of the law and specifically
issues regarding consent, confidentiality, and privilege, to name only a few,
can drive risk through the ceiling.
The risk-managed psychologist also intuitively makes use of what have
been termed the “three keys to effective risk management” (Knapp et al.,
2013). She or he engages in a formal informed consent process at the outset
of any professional relationship. This informed consent process informs the
patient about not only the state and federal laws that affect the profession
of psychology and the professional relationship being established but also
the specific policies by which the psychologist operates. It outlines payment
responsibilities and requirements, the psychologist’s relationship with any
insurance company, consent issues, and confidentiality policies. For example,

CLINICAL DECISION MAKING AND RISK MANAGEMENT 263

this policy might include the statement that the psychologist reserves the
right to contact others, to include family members, if the patient becomes
suicidal or dangerous. It also might outline the need to keep some things
confidential when treating a minor and solicits the agreement of the parents
to do so. If the patient agrees to these conditions, the psychologist has the
freedom to enforce them without worries about exceptions to law that might
allow this. He or she has an agreement with the patient that this is exactly
what will happen.
The risk-managed psychologist also makes use of informed consent
throughout the treatment process (Pope & Vasquez, 2007). Given that ther-
apy is an ever-changing dynamic, informed consent must change as therapy
changes. These changes and agreements are reflected in the patient’s chart,
and significant changes in original agreements need to be formally executed.
Record keeping is key to the risk-managed practice, and poor record
keeping is directly related to an increase in professional liability claims
(Gallegos, 2013). The risk-managed psychologist understands the federal and
state laws that impact record keeping and incorporates these requirements
into his or her professional record keeping style. This psychologist under-
stands that record keeping is a dynamic that changes with treatment, such
that some sessions require detailed record keeping whereas others require
much less, all the time bearing in mind that incomplete records are the most
common error made by health care professionals (Gallegos, 2013). This pro-
fessional also knows what should be written down in a chart and what should
not. Because confidentiality is always a risk, this professional knows that
excessive detail in a chart is as risky as inadequate detail and is comfortable
operating in the midst of this. Finally, this professional knows that because
the information in the record almost always belongs to the patient and there
is always the likelihood that the patient will see the record, nothing should
be written in a chart that should not be read by the patient.
The risk-managed psychologist also makes effective use of consultation
as a tool to reduce risk. He or she consults with others whenever neces-
sary and sees consultation as key to the treatment process. Not only does
this increase the likelihood that the psychologist will glean new ideas on
how to deal with an issue, but consultation assists with meeting the judicial
standard of conduct, that being what other practitioners would do under
similar circumstances. Finally, the risk-managed psychologist uses the law of
parsimony when doing consultations because these are likely not privileged,
and information related to a specific consultation on a patient could be dis-
covered if identities were revealed as a part of this process. The risk-managed
psychologist welcomes input from other psychologists in assisting him or her
in treatment.

264 SOBELMAN AND YOUNGGREN

 RISK MANAGEMENT IN ACTION

No specific area of professional conduct is more professionally risky than

that which brings the psychologist into the forensic setting. Whether the psy-
chologist is providing clinical services within that setting or is operating as an
expert providing guidance to the court, the psychologist’s risk exponentially
rises with increased forensic involvement. As is clear from the thesis of this
chapter, this increase in risk does not mean that psychologists should avoid
providing these services but that they should do so and, in the process, make
use of a risk management strategy that is protective of their conduct.
Perhaps good risk management is best taught through real examples of
bad risk management. The following are three examples of patients who are
seen in a psychologist’s practice.

The Divorcing Family

Psychologists must be very careful when treating children whose par-

ents are divorcing. Not only is this almost always something that is quite
painful to the minor being treated, but the parents, with the best of inten-
tions, frequently become lost in disputes that revolve around their chil-
dren. Consequently, the risk-managed psychologist establishes the rules for
involvement in legal proceedings at the outset of treatment. The treatment
plan clearly states what the psychologist will and will not do, and the psy-
chologist seeks legally binding stipulated agreements with the parents regard-
ing that plan. Frequently, psychologists can even obtain stipulations that
prevent either parent from pulling them into their disputes. Although their
involvement in the treatment of a minor whose parents are divorcing is posi-
tive for the child, their involvement in the legal proceeding may not be and
is, at a minimum, fraught with professional risk. Under these circumstances
it is vital for the psychologist to establish the rules at the outset of therapy
and then to act to enforce them throughout the process. This also requires
cautious conduct on the part of the professional to avoid anything that might
appear to be “choosing sides” in the case. This includes notifying parties
when requests are made for the records and to respect the roles that others,
such as a guardian ad litem, play in the case.
Too often psychologists involved in the treatment of minors whose
parents are divorcing choose to become advocates for the children at the
expense of themselves. This also is bad risk management because this can
only result in a decrease of therapeutic effectiveness on the part of therapist
and an increase in the risk of a legal action taken against the therapist.

CLINICAL DECISION MAKING AND RISK MANAGEMENT 265

The Toxic Therapeutic Relationship

Few areas of professional conduct are more confusing to psychologists

than the areas of termination and abandonment. In spite of the clear evi-
dence that clinicians have rights to stop seeing any patient (Younggren,
Fisher, Foote, & Hjelt, 2011), many therapists maintain nonproductive alli-
ances with patients out of a fear that if they stop seeing them, they will have
to deal with charges of abandonment or wrongful termination. They do this
out of a fear that if they terminate the patient against their wishes, they will
be charged with abandonment. This view is simply wrong and is reflective of
terrible risk management.
Heather Ensworth was a California psychologist, and Cynthia Mullvain
was her patient from November 1982 until September 1984 (Ensworth v.
Mullvain, 1990), when Ensworth terminated the treatment. The record indi-
cates that Mullvain did not accept the termination very well, and Ensworth
decided to see her again for a period of time to “resolve the termination issues
to help her disengage from Ensworth.” Subsequently, a series of harassing
incidents occurred, including Mullvain following Ensworth’s car, trying to
stop her car in the middle of the street, circling around her office building,
keeping her house under surveillance, driving repeatedly around her house,
making numerous phone calls, sending threatening letters to Ensworth, and
making phone calls to other professionals in the community in an effort to
harm Ensworth’s reputation. She also wrote a letter to Ensworth alluding
to committing suicide in her presence. Consequently, Ensworth was forced to
terminate contact with Mullvain again, and this time she stuck to it.
In May 1987, after the second termination, Ensworth sought a restrain-
ing order against Mullvain. The restraining order was granted from May 29,
1987, until November 29, 1988. Mullvain objected to the restraining order
and testified to the court that she had business contacts at a local library,
which is located approximately 150 feet from Ensworth’s home. Those “con-
tacts” included doing research at the library for movie productions and teach-
ing calligraphy classes, not as a library employee but on a community service
basis. She also used the library “for time in between seeing clients to do some
research or do studying or write papers or to use the bathroom facilities and
computer there.” She also mentioned three different door-to-door sales jobs
she had in the area. Mullvain testified that as a result of the restraining order
sought by Ensworth, she had not gone to the Altadena Library, not contacted
her photography clients, and not conducted research for her film projects. As
a result, she lost money and referrals. Although her arguments were strong
and direct, they failed to convince the court that they had merit in light of
the evidence about Mullvain’s behavior and Ensworth’s testimony, which
Mullvain did not refute.

266 SOBELMAN AND YOUNGGREN

 In Ensworth v. Mullvain, it is clear how serious a toxic treatment rela-
tionship can become. The records of this case demonstrate clearly that
Mullvain was willing to do whatever she could do to stay in contact with
Ensworth. This included not only the lengthy list of inappropriate conduct
on her part but also incurring substantial legal expenses to overcome her
therapist’s wishes to be left alone. Although no risk management strategy
can guarantee this would never occur, it is best for the therapist who decides
on an adversarial termination to maintain that decision and discontinue any
interactions with the client. To do otherwise can only further confuse the cli-
ent and drive emotional levels higher. In addition, it is important to bear in
mind that when patients behave in ways that are inconsistent with any claim
of confidentiality, psychologists can take action, to include legal actions, to
protect their rights.

The Unnecessary Multiple Relationship

Multiple relationship violations are a much written about subject area

in psychological ethics. Views on what constitutes a multiple relationship
violation extend from those that are very liberal (Zur, 2007) to those that
are quite conservative. Theoretical debate aside, what the risk-managed
psychologist knows is that it is not the existence of the multiple relation-
ship on its own that is problematic, it is the “why” of the relationship and
what impact it has on treatment and the patient. Although not all multiple
relationships can be avoided, because they occur naturally, unnecessary ones
can and should be avoided (Gottlieb, 1993; Younggren & Gottlieb, 2004).
The multiple relationships that cannot be avoided need to be addressed and
solved in an ethically responsible way. If they cannot be resolved in this
fashion, and if they interfere with treatment, solutions like termination and
transfer need to be considered.
In 1999, psychologist Tom Spencer Allison was found in an adminis-
trative law hearing to have been grossly negligent in his practice and treat-
ment of two patients with whom he formed multiple relationships (Board of
Psychology v. Tom Spencer Allison, 1999). Among other allegations, it was
proven at the hearing that Allison involved a husband and wife couple, as
patients, in his Amway multilevel marketing business and also became per-
sonally involved with them, paying for personal travel and other activities
deemed patient boundary violations. His defense was that these activities
were therapeutic. The administrative law judge and the California Board of
Psychology rejected this argument. Allison’s license was revoked, the revoca-
tion stayed, and a term of probation imposed.
With respect to Allison’s case, one might ask, “Why was it necessary to
involve patients in an Amway business as part of their treatment?” Clearly,

CLINICAL DECISION MAKING AND RISK MANAGEMENT 267

the logic that this was part of effective therapy was not compelling to the
administrative law judge who heard the case. What is clear from the rul-
ing is that the judge felt that the secondary relationship was unprofessional,
unnecessary, and exploited the therapeutic alliance the psychologist had with
his patients.

SUMMARY

It should be apparent that the business of psychology is not easy, and

it seems to become more complex with each passing year. Even so, the risk
of some type of adverse action happening to a psychologist because of his or
her professional conduct is actually rather low. For example, recent research
shows that even among the high-risk population of child custody evaluators,
out of complaints filed the actual likelihood that a board would sanction a
psychologist is less than 2% (Bow, Gottlieb, Siegel, & Noble, 2010), which is
consistent with other research done in this area (Van Horne, 2004). Coupled
with the reality that civil actions are a far less likely occurrence (Knapp et al.,
2013), this makes psychology a relatively safe, if not perfectly safe, profession
to be a part of from a legal perspective.
Psychologists must remain in touch with their competence and make
sure they have a thorough understanding of both the law and the standards of
professional practice. This is probably best done by being a part of the profes-
sion in some way or making the review of “what is happening in psychology”
a regular activity. One important risk management skill that psychologists
need to develop is conceptual decision making in which theoretical concepts
are tied to specific legal and risk management questions. Finally, psycholo-
gists should avoid finding safety in concrete rules because it is the reality of
professional life that any rule will have an exception.
Further, we make the following suggestions to the reader:
! Remember, it is not the existence of a legal action that is profes-
sionally dangerous; it is losing a legal action that is profession-
ally dangerous. People always have the right to question.
! At some time in your career, someone will complain about you.
That is to be expected considering the populations with which
we work. That complaint, however, does not mean you did any-
thing wrong.
! If you do not know what to do when a dilemma surfaces, do not
do anything. Guidance will surface or be found.
! Make sure that your records are complete and are an accurate
reflection of what you did and what happened.

268 SOBELMAN AND YOUNGGREN

 ! Consult frequently with colleagues, and make regular consulta-
tion a part of your standard practice.
! Make sure that your informed consent forms reflect what you
do, are consistent with the law, and clearly state your policy.
! If you are not a lawyer, do not practice law.

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 11
TEACHING CLINICAL
DECISION MAKING
GREGG HENRIQUES

When you look for it, it is everywhere—it permeates almost every aspect
of professional practice. Whether one is setting up one’s office, consulting on
a referral, deciding what assessment instrument to use, meeting a client for
the first time, reviewing and assessing the literature, or advocating for a par-
ticular treatment approach for a particular case, one is engaged in a form of
it. The “it” can be termed clinical decision making, and it’s not too much of a
stretch to say that the fundamental goal of doctoral training in professional
psychology or training in any advanced mental health discipline is to produce
budding clinicians who have the knowledge, skills, and attitudes that enable
them to make and carry out good clinical decisions.
Despite the centrality of this concept, professional psychologists are
generally less likely than some other health professionals, such as nurses and
physicians, to deliberately frame their work and teach their craft in terms of
clinical decision making, although there are exceptions (e.g., O’Donohue &

http://dx.doi.org/10.1037/14711-011
Clinical Decision Making in Mental Health Practice, J. J. Magnavita (Editor)
Copyright © 2016 by the American Psychological Association. All rights reserved.

273
Henderson, 1999). The failure to explicitly frame our training in this manner
may be a function of the old debate about clinical versus empirical judgment
or the fact that “clinical” is still used to denote one of the three broad prac-
tice areas (with “counseling” and “school” being the other two) or the fact
that conflict remains between the romantic and empirical visions of profes-
sional psychology. Whatever the reasons, it is my hope that this volume will
change the current state of affairs. Emphasizing clinical decision making is
apt because it encourages a deliberate, reflective, and intentional stance with
regard to how to go about one’s work as a professional psychologist.
Because clinical decision making is such a broad term, it has, not surpris-
ingly, many facets and can be approached from many different angles. For
example, Magnavita and Lilienfield (Chapter 2, this volume) offer a powerful
analysis that deconstructs the key elements of the clinical decision-making
process from the vantage point of cognitive psychology (Kahneman, 2011).
Part of that analysis includes a review of how people make decisions in gen-
eral. Perhaps most central to understanding general decision making is that
human’s process information via two related but separable streams of menta-
tion. The first stream is a fast, relatively automatic, perceptual, holistic, affec-
tive system of processing that sizes up a situation via “thin slicing” (Gladwell,
2005) and forms quick, intuitive judgments. The second system is a slower,
more explicitly self-conscious and deliberate form of thought, mediated largely
by processes of verbal justification. From an educator’s perspective, this is a
basic and central feature of the human mind of which students of profes-
sional psychology should be very aware. For example, a training exercise that
I find useful when the class is viewing video is to stop the tape as soon as the
patient (or client) appears on the screen and ask students for their report of
their immediate perceptions, feelings, and intuitions about the client. Often
trainees are initially reticent to say anything, generally because they don’t
want to appear as though they “judge a book by its cover.” But once they are
given permission, the associations flow, and we see that many impressions are
formed almost instantaneously. They first notice the obvious demographics
of the patient. Then they will notice how attractive they perceive the client
to be and the manner of dress, hygiene, and body position, all which serve as
indicators of socioeconomic status. Following that, a host of more imagina-
tive wonderings will begin. These impressions are examples of thin slicing,
an inevitable aspect of being human, and students need to be aware that they
will then begin to form narratives and expectations on the basis of this very
brief exposure.
Building on this basic formulation of the human mind, Magnavita
and Lilienfeld (Chapter 2, this volume) further articulate how individuals
develop heuristics, the general rules of thumb that are acquired over time that
help consolidate the massive amounts of incoming information into relatively

274 GREGG HENRIQUES

reliable interpretations and guides. Although heuristics are necessary and cen-
tral features of our cognitive system that enable us to get along in our everyday
lives, it is also the case that they can be characterized as “lazy” and “miserly,”
meaning that in the service of efficiency they frequently result in inaccurate
and misinformed judgments. Because the biases and traps are so easy to fall
into, it is essential to teach clinical trainees about these cognitive mechanisms.
Students should be shown explicit examples of how such biases and traps can
lead practitioners astray and should be given training opportunities that allow
them to build self-reflective awareness regarding their own heuristic processing
tendencies that might result in them deviating from best practice.
Because the mechanics of clinical decision making are well examined
elsewhere in this volume, I do not review them in detail here. From a training
perspective such processes can be subsumed within a broader context—that
is, within the identity and conceptual framework employed by the professional
practitioner. The foundational elements that ground the more microlevel and
situation-dependent cognitive processes can be considered, from the vantage
point of decision making, as the “frame” of the practitioner. The frame of the
practitioner refers to his or her worldview and practice orientation, and it is of
tremendous importance in clinical decision making.
Magnavita and Lilienfeld (Chapter 2, this volume) offer the example
that a psychoanalytic therapist will hear and respond to a patient’s symptoms
in a very different way than a psychopharmacologist. This gives rise to the
question “What is the appropriate frame for a professional psychologist?” My
position as an educator and scholar of the field is that practitioners should
operate from the most coherent and comprehensive frame possible for under-
standing the key elements of a particular situation that requires clinical deci-
sion making. Unfortunately, this is difficult because the field of psychology
is rife with competing, conflicting, overlapping, and somewhat redundant
models and paradigms that attempt to offer practitioners a frame for under-
standing their patients or clients. This chapter introduces a framework that
emphasizes key elements of the training of professional psychologists that
enable them to make good clinical decisions. This framework is grounded
in what is known as a combined–integrated approach to training professional
psychologists (Shealy, 2004) and a more unified approach to the field of psy-
chology as a whole (Henriques, 2011).
The first section of this chapter describes the general scientific human-
istic philosophical approach and key values that we attempt to instill in our
students, followed by a discussion regarding the implications for decision
making. The second section provides a brief overview of the field and articu-
lates why decision making needs to be grounded in a conceptual knowledge
base. Following that an integrative approach to conceptualizing people is
offered that directly informs budding clinicians in a wide variety of different

TEACHING CLINICAL DECISION MAKING 275

contexts, including consulting and assessing patients. The fourth section
addresses what is perhaps the most well-known and important frame of the
clinical decision making of professional psychologists, the position of the
American Psychological Association (APA) on evidence-based practice
(EBP; APA Presidential Task Force, 2006). The history of EBP is reviewed,
highlighting some of the major historical tensions that went into the emer-
gence of EBP and how we train our students to approach the issue. Finally, an
overview of a new unified approach to psychotherapy is offered that sets the
stage for a heuristic that we train our students to use to frame their decision
making in psychotherapy, called “TEST RePP.”

CORE VALUES AND A SCIENTIFIC HUMANISTIC PHILOSOPHY

One of the most perplexing challenges for the field of professional psy-
chology has been its struggle to navigate the tensions between the cold logic
of science and the moral necessities of humanism. Indeed, in a seminal article,
Kimble (1984) empirically documented the split between science and human-
ism in the broader field. It is the obligation of professional psychologists to
understand the historical and epistemological issues that have contributed to
this split and to be informed by both scientific and humanistic lenses when
engaged in professional practice. First, by virtue of a core institutional identity,
professional psychology is grounded in science, which means that it embraces
the epistemic values and methods associated with science (Henriques &
Sternberg, 2004). As such, it is crucial that a scientific attitude is instilled in
budding professional psychologists. Some of the key ingredients of this atti-
tude are skepticism and critical thought, a worldview that frames cause and
effect with certain assumptions based on scientific plausibility, and reliance on
evidence acquired in a systematic way (see Lilienfeld & O’Donohue, 2012).
Although a scientific attitude is crucial, it is not all there is to being a
professional psychologist. Indeed, the primary identity of professional psychol-
ogy is as an applied health service profession, and this means that the primary
charge of professional psychology is prescriptive (Henriques & Sternberg,
2004). Ultimately, the function of professional psychologists is to change an
existing state. This can be conceived as having the goal to move individuals
or systems toward more valued states of being, which requires having a broadly
philosophical—some might say metaphysical (O’Donohue, 1989)—position
regarding the values that are guiding one’s actions. The ethical code offered
by the APA prescribes some of the key values that all psychologists need to
consider in their professional behavior but, although essential, leaves much
ambiguity in the details of how to be an ethical, values-driven practitioner.
Because an individual psychologist has the potential for great influence over

276 GREGG HENRIQUES

others, and because much clinical work and professional practice can be inher-
ently subjective, it is essential that students be willing and able to understand
and critically explore who they are; what they believe and why; and what they
must do—personally and professionally—to become highly knowledgeable,
skilled, and competent scientific practitioners. Thus, it is incumbent on the
practitioner to be self-reflective and aware of the assumptions and the broader
worldview that guides their actions. And there must be a narrative associated
with that view that ties together core moral values, such as promoting human
dignity and well-being with integrity (Henriques, 2011). These ingredients
are fundamentally humanistic in nature.
To understand how training in a broad scientific humanistic philosophy
has implications for clinical decision making, consider the following case:
A 19-year-old college freshman is referred by the office of disability of her uni-
versity for an evaluation because she believes she might have attention-deficit/
hyperactivity disorder (ADHD). The scientific methodological perspective
should inform the clinician to approach this case in a number of different ways.
Specifically, a clinician should be informed regarding the empirical research
that discriminates this disorder from other possible presenting conditions and
be aware of the most reliable and valid assessment measures. Thus, a scientifi-
cally informed clinician would know that impressions formed in the course of
a brief interview are a poor way to diagnose ADHD. Instead, what is needed is
a detailed history of prior behavior patterns such as impulsivity, inattention,
hyperactivity, poor organization, and poor academic performance relative to
intellectual potential, supplemented via perspectives of an informant such as a
parent, coupled with records from past school performance. In addition, reliable
symptom inventories, both self- and observer report, a cognitive and academic
profile suggesting difficulties with attention and processing speed, clinical obser-
vations, and a detailed interview assessing the nature and trajectory of the symp-
toms are all essential to make a diagnosis that would be “scientifically” valid.
But a scientifically informed methodological approach to assessment,
although crucial, is not enough. Indeed, from the vantage point of a larger
metaphysical humanistic philosophical approach, a pristine application of the
scientific method that results in reliable diagnoses and points to evidence-based
interventions might be seriously problematic when viewed from a broader per-
spective. Why? Because diagnostic entities such as ADHD have huge socio-
logical implications. It carries meaning for how individuals understand their
very natures, and there are good reasons to be extremely concerned about
the “medicalization” of human experience. Indeed, the rising epidemic of
mental health concerns (i.e., depression, anxiety, ADHD, etc.) has been linked
by some scholars to the rise of the “disease–pill” model of human experience
(Whitaker, 2010). Because humans are meaning-making entities, a professional
psychologist in this context would be obligated to understand the personal

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significance of this diagnosis and its meaning in the context of this individual’s
social system. It is also the obligation of the professional psychologist to con-
sider his or her role in the context of a system that creates policies that have
broad social implications. There are no simple decision-making algorithms that
can be applied at this level of analysis. However, if we are teaching leaders in
mental health who will attempt to guide the system toward wise policies, it is
incumbent on us to instill in our students a broad awareness of the implica-
tions of our actions beyond the narrow application of the scientific method to
develop reliable, evidence-based answers in specific situations.

IS SCIENTIFICALLY INFORMED DECISION MAKING GROUNDED

IN A METHOD OR A CONCEPTUAL KNOWLEDGE BASE?

When asked how he defined science, Robyn Dawes, well known for his
work on fostering empirically based decision making, answered,
I would define it as testing hypotheses through the systematic collection
and analysis of data whether via what are called “randomized trials,”
where we randomly assign people to be given a vaccine or not or to a
placebo group, all the way to informed observation. These are really the
two essences of science. (Gambrill & Dawes, 2003; cited in Lilienfeld &
O’Donohue, 2012, p. 59)
Dawes captured the methodological view of science. This view is
embraced by many psychologists, both researchers and practitioners alike.
Indeed, some argue that grounding psychology in the scientific method is
the defining and unifying feature of the discipline (see, e.g., Stam, 2004).
However, from the vantage point of a broad scientific humanistic philosophy,
the purely methodological view of science is inadequate. In isolation, the
scientific method (i.e., generating hypotheses and conducting studies) yields
data and information. However, the professional psychologist needs to oper-
ate first from knowledge and wisdom. The incompleteness of method is obvi-
ous on reflection. Consider the question of why we engage in the scientific
method in the first place. It generally is not solely for the specific data it yields
about the specific phenomena under investigation. Indeed, if the data gath-
ered were not generalizable at all, they would be largely irrelevant because
scientific findings from specific studies—in the absence of a nomological net-
work of scientific understanding—are essentially meaningless. The data and
information from scientific studies become meaningful only when they are
linked with data from other investigations and then placed within a network
of understanding. Thus, science must include attention to the conceptually
grounded meaning-making schema that organizes scientific knowledge.

278 GREGG HENRIQUES

 A bit of probing of even the most committed methodologists reveals
this necessity. Consider, for example, the spirited call for the “clinical scien-
tist” model of training in professional psychology offered by Baker, McFall,
and Shoham (2009). Like Dawes, these authors have strongly equated sci-
ence with the scientific method. Yet they acknowledged that the informa-
tion gathered from science must be assessed for its external validity and
generalizability. How do we accomplish this? The authors proclaimed that
the “scientific plausibility” of the information gleaned from the scientific
method must be considered. Consider, for example, that on the basis of the
authors’ articulation of scientific plausibility, it seems highly likely that they
would dismiss empirical data derived via the scientific method that pointed
to the existence of parapsychological phenomena (see, e.g., Radin, 2011) or
the utility of energy psychology methods in reducing psychological distress
(Feinstein, 2008).
All of this, of course, raises the question “What is ‘scientifically plau-
sible’?” We must have a way of answering this question or else we will simply
generate a mountain of data and information without genuine understanding.
To be a mature science, psychology must have an answer to the following:
Is there a scientifically grounded conception of the human condition that is
rich enough to speak to the complexities of the human experience while also
assimilating and integrating major lines of information gleaned from various
empirical investigations? To the extent that the answer is no, the field of pro-
fessional psychology is destined to be deeply divided. Those who are impressed
with the advances in the natural sciences will lean more toward the epistemic
values of accuracy, objectivity, and reliability of knowledge and will emphasize
the scientific method. In contrast, those who question the extent to which the
natural sciences have effectively elucidated the nature of the human condition
and who value meaning, relationships, subjectivity, and the unique and idio-
graphic nature of the human experience will view the empirical commitment
as sacrificing too much and missing the essence of what it means to be human.
This is the fundamental reason the field has been pulled into two cultures.
The argument here is that the field of professional psychology needs to
evolve from a conception of “science” as consisting solely of the method of
hypothesis testing and data collection as Dawes described it to thinking about
science as a knowledge system that provides a map of the human condition
and our place in the universe. To be a credible system, the map must make
sense out of the field of scientific psychology and point to a way of thinking
about human behavior that offers a sophisticated guide to the practitioner.
The construction of just such a formulation has been the focus of my efforts
over the past decade (Henriques, 2003, 2004, 2008, 2011, 2013a).
Consider that it is not uncommon for students, in the course of their
professional training, to be exposed to approaches such as person-centered

TEACHING CLINICAL DECISION MAKING 279

therapy, cognitive–behavioral and emotion-focused therapy, family systems,
and psychodynamic frameworks. Each of these perspectives has “data” sup-
porting its views, yet they all have quite different fundamental assumptions
that can overwhelm a student (or even a seasoned practitioner!). In addi-
tion, the conceptual connection between the various therapeutic paradigms
and the science of human psychology as articulated by major domains of sci-
entific inquiry, such as evolutionary, personality, developmental, cognitive,
social, and cultural psychology, can easily result in contradictory messages
and confusion.
For example, many ideas in evolutionary psychology seem to conflict
with a cultural psychological perspective (Henriques, 2011). Even domains
that seem like they should be obviously connected frequently are not. Consider
that as a graduate student I took a personality theories class that was followed
by a personality assessment class, and I found that the two courses were largely
independent from one another. This was so even though they were taught
by the same instructor! The main personality assessment instrument covered
was the Minnesota Multiphasic Personality Inventory—2, and that seemed to
introduce a whole different set of concepts than those that were covered in
the personality theories class, which itself consisted of a series of schools of
thought that were different and often disconnected and contradictory (e.g.,
radical behavioral, psychodynamic, humanistic, social cognitive). And when
I was taught psychotherapy, the perspectives I was introduced to there were
only loosely related to concepts in personality or personality assessment.
Given the enormous diversity, pluralism, and conceptual fragmentation
in the field of psychology, I became deeply concerned that psychology in gen-
eral and psychotherapy in particular were producing vast amounts of infor-
mation but little cumulative knowledge (Henriques, 2011). In the 1990s, I
began work on a project that sought to remedy this problem with a frame-
work that would ultimately become known as the unified theory (Henriques,
2003, 2008). Because the term unified theory might sound to some like an
all-encompassing idea that explains everything and makes precise predictions
about how humans behave, it can also be characterized as a unified approach,
which refers to an integrative metatheoretical framework that can define
the field of psychology; integrate key insights from the major paradigms; and
resolve long-standing philosophical disputes, such as the debates between
mentalists and behaviorists (Henriques, 2004).
The unified approach works via the introduction of several new broad
ideas (the tree of knowledge system, behavioral investment theory, the influ-
ence matrix, and the justification hypothesis) that allow for the key ideas of
the major domains of psychological inquiry (e.g., evolutionary, cognitive,
personality, social, cultural, developmental) and the major therapy paradigms
(e.g., psychodynamic and cognitive–behavioral therapy perspectives) to be

280 GREGG HENRIQUES

effectively assimilated and integrated into a more coherent whole. In short,
the unified theory allows for both the “vertical” integration of the biological,
psychological, and sociocultural dimensions of human functioning and the
“horizontal” integration of perspectives on the human mind and behavior
at the level of the individual (Henriques, 2013b).
The specific details of the unified approach are beyond the scope of
this chapter, and the reader is referred elsewhere for an overview of the ideas
that make up the system (see, e.g., Henriques, 2011, 2013a). What it offers
in terms of teaching good clinical decision making is the position that it is
both possible and useful to pull together, in a conceptually sound way, the
primary lenses that are offered from the major perspectives in psychotherapy
(i.e., behavioral, cognitive, existential, humanistic, psychodynamic, and
family systems). In addition, it allows a foothold for organizing the vast data
that researchers have gathered about human nature under the broad head-
ing of psychology and the more specific research on psychotherapy such that
those data can be brought to bear on real-life clinical situations in a holistic,
nuanced, and effective way (see also Melchert, 2014).

AN INTEGRATIVE MODEL FOR CONCEPTUALIZING PEOPLE

THAT INFORMS CLINICAL DECISION MAKING

In this approach, concepts and theories are the bridges that link
data and information gleaned from the scientific method to wise practice.
Consequently, a major goal I have as a trainer of budding clinicians is to pro-
vide them with a broad framework that effectively maps the discipline, clears
up the current psychotherapy tower of Babel, and allows the key insights from
myriad perspectives and traditions to be coherently integrated into a whole.
Directly related to clinical decision making in a wide variety of contexts is
the approach to conceptualizing people based on analyzing five systems of
character adaptation and the biological, learning and developmental, and
sociocultural contexts in which the individual is immersed (Henriques, 2011;
see Figure 11.1). The systems of character adaptation refer to the hierarchical
arrangement of mental systems that enable an individual to respond to the
current situation. The character adaptation system theory (CAST) approach
refers to the hierarchical arrangement of mental systems that enable an indi-
vidual to respond to the current situation. From the most basic to the most
advanced, the five systems are as follows: (a) the habit system, which refers to
the basic procedural processes shaped by learning and stimulus control; (b) the
experiential system, which refers to the core of experiential consciousness that
is organized by the flow of perception, motivation, and emotional reactions;
(c) the relationship system, which is an outgrowth of the experiential system

TEACHING CLINICAL DECISION MAKING 281

282

Three Contexts, Five Systems

GREGG HENRIQUES

Sociocultural Context
Macro,
Meso,
Micro
Language based beliefs and values; Public to Private Filtering;
Justification System Attributions; Identity and Self Concept; Existential Meaning Making

Defense Mechanisms; Dissonance Reduction; Filtering

Defensive System
Learning & between Experiential and Justification Systems Current and
Development Context Future
Early Attachments; Power, Love, Dependency and Freedom;
Relational System Agentic or Communal Orientations; Internal Working Models
Environmental
Distal Proximal
Stressors and
Perceptual, Motivational and Affective Experiences (P - M =>E);
Affordances
Experiential System Layering of emotions; Overregulated or Underregulated; Images
Physiology

Daily routines; Subconscious action patterns; Associative

Habit System Conditioning; Patterns of eating, sleeping, exercise, substance use
Genetic

Biological Context

Figure 11.1. The five systems of character adaptation. From A New Unified Theory of Psychology (p. 230), by G. Henriques,
2011, New York, NY: Springer Science+Business Media. Copyright 2011 by Springer Science+Business Media. Reprinted
with permission.
that tracks self–other exchanges in an intuitive way on the dimension of rela-
tional value and social influence; (d) the defensive system, which refers to the
ways the individual manages psychic equilibrium in the form of experiential
avoidance, dissonance reduction, and defense mechanisms; and (e) the justifi-
cation system, which refers to the verbally mediated explicit beliefs, values, and
attributions people use to make sense of themselves and others.
As articulated by Henriques and Stout (2012), the five systems of char-
acter adaptation provide a framework for assimilating and integrating the key
insights from major traditions in psychotherapy, placed in a biopsychosocial
context. For example, behaviorists have historically tended to think and focus
on habits, whereas humanistic and experiential practitioners have focused on
core emotions and experiences; psychodynamic practitioners have focused on
underlying relationship patterns and psychological defenses, and cognitive
and narrative therapists have emphasized semantic meaning making in vari-
ous ways. The CAST approach provides a way to understand how these are
all component systems of adaptation that can be effectively woven together
in to a more coherent whole.
How does this system influence clinical decision making? As O’Donohue
and Henderson (1999; cited in Lilienfeld & O’Donohue, 2012) pointed out,
“choosing appropriate treatment methods involves knowing and instanti-
ating causal relations” (p. 51). To do this, a clinician needs to be able to
understand the key variables and their hypothesized causal relations, and the
CAST approach guides students on how to accomplish this. To see this, let’s
continue with the example that was introduced earlier, that of a college stu-
dent who receives a referral for assessing the presence of ADHD and possible
accommodations. Let’s add the following background to the formulation and
then apply the CAST approach to fostering a conceptualization:
Tina is a 19-year-old college freshman. She grew up in a small rural
town in southwestern Virginia. She is a first-generation college student
and entered college with hopes of being a physician. She did extremely
well in high school and has always been very driven and conscientious.
However, her first semester at college did not go very well. She expe-
rienced difficulty making friends, and she was uncomfortable with the
drinking and party atmosphere. She focused a lot on her studies and
studied several hours a day, but she struggled to get the As she expected
(her first semester grade point average was 3.2). Now she is reporting
problems taking tests and staying focused and is worried that she has
ADHD. She is starting to have trouble sleeping; she can’t fall asleep
because she is constantly worrying about what she needs to do the next
day. She is also having nightmares about failing out of school. She
also is reporting frequent stomachaches, and she is now considering
whether she should transfer to a different college because it is closer
to home.

TEACHING CLINICAL DECISION MAKING 283

 As O’Donohue and Henderson (1999) pointed out, people consult psy-
chologists because they possess a form of specialized expertise. Specifically, they
are able to understand key psychological variables and causal processes that
contribute to the situation, have knowledge about what might foster adaptive
change, and have a skill set that enables them assist with this process. Yet,
exactly what scientific and professional information is considered relevant,
and how psychologists are to maintain a reasonable level of awareness so that
they understand people’s presenting problems and make epistemologically
informed and ecologically valid clinical decisions, remain extremely difficult
and contentious. The volume of information and the markedly disparate lines
of thought within our field makes this issue particularly daunting, and the
CAST approach offers a heuristic to delineate key psychological variables that
will enable the effective conceptualization of psychological problems. Here is
an example of a formulation that might emerge if one was to apply the CAST
approach:
Tina is at a key developmental time in her life and is experiencing signifi-
cant distress and psychological dysfunction due to a host of interrelated
variables. Perhaps most salient issue is that Tina seems to be struggling
with her identity and her sense of competence (Justification System),
which is generating significant levels of negative affect, especially anxiety
(Experiential System). It seems that her confusion is tied to her difficul-
ties in adjustment associated with the change in her social context, from
a rural setting to a university setting (Social Context). In the former con-
text, she likely shared many of the social values and was able to perform
in a way that was both personally and relationally affirming (i.e., she
achieved academically and had friends—Justification and Relationship
Systems). However, at college, the social values are deviating from hers
in a way that leaves her more likely to feel isolated and uncomfortable
(Experiential and Relational Systems). In addition, she is finding aca-
demic success more challenging than she expected. Thus, compared with
high school, she is having trouble in two key life domains, academic
and social. It seems that in an attempt to cope with her difficulties and
control what she could (Defensive System), she has tried to increase her
academic performance and has isolated herself a bit from her social con-
nections. Unfortunately, it seems likely that the intense pressure she has
placed on herself to succeed (Defense and Justification Systems) likely
created additional problems because her anxious arousal (Experiential
System) probably had the function of impairing her ability to perform in
high-stakes situations like taking tests, thus creating a vicious, anxiety-
producing cycle. As her general stress level increases, it seems likely that
her basic biological and habitual patterns (e.g., eating and sleeping) have
become disrupted, which will likely contribute to a dysfunctional spiral.
It will be crucial to assess Tina’s family history (past Social and Learning
and Developmental Contexts) and what her status as a first-generation

284 GREGG HENRIQUES

 college student and desire to be a physician means in that context
(Justification System). It would also be important to assess for any history
of illnesses (in Tina or her family), especially for anxiety or depressive
disorders (Biological Context). From the vantage point of diagnosis, it
does not appear Tina has problems indicative of ADHD, but depending on
additional information, she might meet criteria for a generalized anxiety
disorder or an adjustment disorder with anxious features.
The CAST approach is a useful heuristic that is justified by its util-
ity, parsimony, and conceptual coherence and is based on the argument that
clinicians need to be guided by rationally coherent systems, which brings us
to the point of exploring existing systems of decision making. It is helpful
to review the history of the concept of EBP and then offer a framework that
extends it on the basis of a metatheoretical approach to the field grounded in
a scientific humanistic philosophy.

A BRIEF HISTORY OF EVIDENCE-BASED PRACTICE

Professional psychology has long been torn between two visions, the
practice of psychology as an art versus an empirically based science. The artis-
tic vision promotes the image of the master clinician as a wise and insightful
healer guided by a deep intuitive knowledge. A prototype of such a clinician
was offered by Caldwell (2004; cited in Garb, 2005), who, on receiving an
award for his work in personality assessment, gave the following example of
successfully interpreting a Minnesota Multiphasic Personality Inventory:
We got a severe 4-6-8 profile on a young woman. I looked at the tortured
implications of the pattern and somehow said, “She will have something
like cigarette burn scars on her hands, where her father prepared her to
steel herself to the suffering of life.” The round burn marks were on her
hands and extended a little way up her arms. (Caldwell, 2004, p. 9)
In contrast to the vision of the master practitioner as a wise artisan, the
empiricist vision cautions psychologists against such ideals (Garb, 2005) and
emphasizes judgments and decision making based not on intuition and the
like but on existing empirical evidence. The practitioner’s skill is in know-
ing how to acquire, interpret, and apply good empirical data to the question
at hand. Empirically trained practitioners tend to dismiss with skepticism
anecdotes like the one in the previous paragraph and point out the incred-
ible biases of the human mind in seeing spurious patterns in nature. As a
consequence, proponents of the empirical tradition argue that there is a great
need to ground assessments and treatments in those validated by the scien-
tific method. As alluded to earlier, the empirical tradition is now explicitly
represented in “clinical science” training programs (Baker et al., 2009) that

TEACHING CLINICAL DECISION MAKING 285

define clinical psychology solely as a science and generally reject the notion
that clinical practice is in any way an art form.
Historically, these two traditions have been framed as the competition
between the empirical and romantic visions of professional practice (Garb,
2005), but I believe this is an unfortunate way to characterize the split. In
philosophy, there are two broad positions on the mechanisms humans use to
achieve knowledge. The empirical tradition, epitomized by individuals like
John Locke and David Hume, posits that the most fundamental and reli-
able way to achieve knowledge comes from systematic observations and data
collection. This accords very well with the methodological view of science
articulated by Dawes. The rationalist tradition, epitomized by individuals
like René Descartes and Immanuel Kant, argues that the best approach to
knowledge is achieved by using reason to arrive at conclusions about the most
justifiable claims. Whereas empiricists emphasize “show me the evidence,”
rationalists emphasize “show me the logic and rationale.” Consistent with
my emphasis on approaching human psychology and the profession from the
vantage point of conceptual coherence (Henriques, 2013a), my view is that
the rationalist position has not received enough attention in the identity of
professional psychology. This chapter can be characterized as a call for how to
teach clinical decision making grounded in a rationalist approach. Of course,
empirical data and the honed, artistic skills of the practitioner are valued, but
from this perspective, the central guiding key to wisdom that informs best
practice is a comprehensive system of justification.
Returning to the history of EBP, the competition for the core iden-
tity of practitioners and for the conceptual groundwork for making clini-
cal decisions in psychotherapy reached a fever pitch in the 1990s. Much
of it centered on the debate about the role and place of empirically sup-
ported treatments (ESTs) in psychological practice. For a host of reasons—
managed care being a primary one—pressure was mounting on the field
in the 1980s to demonstrate the effectiveness of psychotherapy interven-
tions. At the same time, there emerged interventions that offered models
and manuals for treatment that could be tested empirically relatively easily.
For example, A. T. Beck produced a model and treatment for depression,
the effectiveness of which he and his colleagues were able to test using a
randomized controlled design. Studies began to emerge that suggested that
cognitive therapy (or cognitive–behavioral therapy) was more effective in
reducing symptoms than either no treatment or control conditions like sup-
portive therapy. From the empirical–methodological perspective such find-
ings were exactly the kind of data needed to ground the field in science.
Many academics began to promote the idea that students of psychotherapy
must be taught empirical approaches and that such interventions ought to
be the first line of treatment in practice.

286 GREGG HENRIQUES

 Given that virtually all agree that by virtue of its history and iden-
tity, professional psychology is tied in some way or another to science, one
might think at first glance that the EST movement would not inspire much
controversy. It seems to represent a straightforward scientific advance, and
indeed, from a pure methodological view of science and practice, ESTs are
a straightforward advance. However, from the vantage point of a rational-
ist informed by a broad scientific humanistic view of the field, the issues
are enormously complicated. I offer a brief discussion of just a few of them
and refer the reader to Marquis and Douthit (2006) and Wachtel (2010)
for more detailed critiques. The overall point here is that from a broad sci-
entific, humanistic, philosophically informed view, it is naive and a form of
scientism (i.e., an overreliance on power of the procedures and methods of
science) to believe that data and information derived from studies empha-
sizing sound scientific methodology should be the sole guide in clinical
decision making.
We can start unpacking the debate surrounding ESTs by considering
that virtually all ESTs are grounded in concepts from the Diagnostic and
Statistical Manual of Mental Disorders (DSM). Many have criticized the DSM,
which was produced largely by the field of psychiatry, as offering an overly
simplistic, medicalized descriptive categorization of psychopathology that
ignores psychosocial etiology and, as such, does not lead to effective treat-
ment plans because it is blind to the dimensions of functioning that are cru-
cial to understand in psychotherapy. Psychodynamically oriented clinicians
were so frustrated by what the DSM failed to capture that they developed
their own Psychodynamic Diagnostic Manual to guide practitioners in assess-
ment and case formulation (PDM Task Force, 2006). Humanistic, critical,
and positive psychologists have all been critical of the DSM system in vari-
ous ways. Even biologically oriented scientists who study mental disorders
have started to abandon the DSM (including researchers at the National
Institute of Mental Health; see, e.g., Insel, 2013). The fact that the major
mental health research institution in the United States is abandoning the
DSM must raise a host of questions about the foundational validity of so
many EST research projects.
The conceptual structure of the EST movement does not implicitly
endorse just the DSM but also the medical model of treatment. By that I
mean that the EST model of psychotherapy assumes that psychological dis-
orders exist within individuals, are of a specific identifiable type, and are ame-
nable to specific interventions that result in helpful change. Conceptually,
the medical model places the disorder as the “figure” to be analyzed, along
with the impact of the specified and generalizable intervention. In the tradi-
tional medical model of researching disorder–intervention match, the per-
sonality of both the individual and the treating professional and the nature

TEACHING CLINICAL DECISION MAKING 287

of their relationship become the “ground” and are generally treated as error
or noise, both in the way the interventions are presented and the way data
are analyzed in randomized controlled trials.
The potential problem with this framing is that many view psycho-
therapy as a psychosocial or human relational process. In this view, the
personality of both individuals in the therapy room and the nature of their
healing relationship are front and center. In his now classic work, The Great
Psychotherapy Debate, Bruce Wampold (2001) argued that the scientific data
were clear on the best way to conceptualize psychotherapy: It should be
considered a human relational process rather than a depersonalized medi-
cal intervention. Why? According to Wampold, the scientific data strongly
support the notion that it is the quality of the therapeutic alliance that is
more closely associated with good outcomes than is the process of specifically
matching particular techniques to DSM-type problems.
To understand the differences between the two perspectives, consider an
individual diagnosed with clinical depression being treated with a behavioral
activation intervention (e.g., Martell, Dimidjian, & Herman-Dunn, 2010).
The EST approach focuses on the nature of depression as a state of behav-
ioral shutdown, and the key ingredient of change is considered increases in
mastery, pleasure, and rewarding activity. Randomized controlled trials focus
on comparing whether those in a behavioral activation condition show more
symptom relief than those in a different condition. The specific personalities
of the individual and the therapist and their relationship might be exam-
ined as moderating influences but generally are not considered central. In
contrast, the process approach emphasizes that the key ingredient is not the
specific intervention but the extent to which the therapist and client form a
positive, trusting relationship; agree on the formulation; and are able to set
tasks that foster change. This angle on psychotherapy research points out
that widely different approaches to thinking about conditions like depres-
sion (e.g., behavioral, cognitive–behavioral, emotion focused, interpersonal,
modern psychodynamic) tend to get very similar results. The key ingredients,
according to Wampold and other outcome-informed therapists (e.g., Duncan,
2013), are not the model of the disorder or intervention per se. Instead, these
scholars have argued that as long as the model is credible, the key ingredients
are whether the healing relationship is strong, the formulation of the prob-
lem is shared, and the work leads to change-oriented tasks in which both
individuals are invested. Thus, in this case, the key ingredients are whether
the individual is at a stage of change that makes him or her receptive to the
conceptualization of depression offered by behavioral activation, whether the
therapist is seen as trustworthy and knowledgeable, and whether the indi-
vidual is motivated to comply with the tasks designed to change the current
state of affairs. Wampold pointed out that if these ingredients are present, the

288 GREGG HENRIQUES

data suggest the outcomes are the same for all the credible kinds of therapy,
which raises serious questions about a host of issues.
In addition to debates about how to think about psychotherapy in gen-
eral (i.e., whether we approach it via a medical model or a psychosocial pro-
cess), there are many theoretical approaches to psychological treatment, and
when one takes a broad view of the field it must be noted that the EST debate
has been deeply entangled with the competition between the schools of
thought on the various ways to conceptualize people in general and psycho-
pathology and psychotherapy in particular. Compared with psychodynamic
and humanistic approaches, cognitive and behavioral approaches were more
closely connected with empirical traditions in academic psychology and
were structured in a way to be more readily examined via traditional research
methods. Thus, historically, support for ESTs basically translated into support
for behavioral or cognitive approaches over psychodynamic and humanistic
ones. All these forces set the stage for a deep and complicated debate, which,
as is evident from the growth of “clinical science” programs, has yet to be
settled.
Largely in response to the conflict the EST debate sparked in the field,
the APA developed a broad framework for clinical decision making with
its position on EBP (APA Presidential Task Force, 2006). EBP is defined as
approaching practice via “the integration of the best available research with
clinical expertise in the context of patient characteristics, culture and prefer-
ences” (p. 273). Sometimes conceptualized as a three-legged stool, EBP thus
has three predominant elements that should go into considerations of best
practice: (a) the available research evidence applicable to the current situa-
tion, (b) the professional expertise of the practitioner, and (c) the values of
the client in the given cultural context. The EBP concept is broader than the
focus of ESTs and was issued in part by APA to provide a form of conceptual
rapprochement between the various factions in the debate over the relevance
and power of ESTs to influence practice. For example, the acknowledgement
of both available research and professional expertise in the unique context
of the specific client and culture attempts to speak to both sides of the issue.
The basic framing of EBP provides a generally useful heuristic to guide prac-
titioners in the key elements that should go into the decisions surrounding
assessments, interventions, and consultations. However, despite its usefulness
as a general framework, I have found as an educator that EBP requires more
clarification to serve as an effective guide.
Grounded in the same integrative metatheoretical approach that gener-
ated the CAST approach for conceptualizing individuals, we have developed
TEST RePP to provide students in behavioral and mental health programs
with a heuristic that informs them of how to make effective, holistic, clinical
decisions in a wide variety of professional contexts. It is a framework that is

TEACHING CLINICAL DECISION MAKING 289

embedded in a course on integrative psychotherapy for adults, although it
could extend to other related domains of practice, such as consultation and
assessment. To apply it, we must first articulate a how a broad and general
view of psychotherapy can set the stage for resolving the great psychotherapy
debate and allow practitioners a truly comprehensive framework for ratio-
nally integrating research, professional wisdom, and unique contextual ele-
ments and client values into effective practice.

A GENERAL, UNIFIED VIEW OF PSYCHOTHERAPY

The argument laid out so far is that if students are going to be informed
consumers of scientific research applied to professional practice, they must
operate from a broad scientific humanistic philosophy of the field. Such a
view will enable them to consolidate findings into meaningful information
that guides their decision making. Without such a framework, the field and
its practitioners are destined to endless debates because of foundational dis-
putes about assumptions that are not resolvable at the level of scientific data
gathering. Earlier I described how a broad scientific humanistic philosophy
is necessary to reflect on and make decisions about diagnoses and develop
holistic conceptualizations that elucidate key variables and their causal inter-
relations in a way that leads to informed clinical decision making. In this
section of this chapter, the focus turns to therapy and how the unified system
offers a new way to approach the field of psychotherapy, one that is quite dif-
ferent from other approaches.
The field of psychology in general and the practice of psychotherapy in
particular have been “pre-paradigmatic,” meaning that there was no avail-
able broad framework from which professional psychologists could operate.
This is apparent when one considers that the emergence of the major schools
of thought were generally through a master practitioner gaining insights
based on useful techniques in the therapy room. Although they were all
students of human nature, the founders of the great therapy endeavors like
Freud, Rogers, and Beck largely started with observations about the thera-
peutic process and generalized from there about insights for the field of psy-
chology. These gurus then generated a following of individuals who tried to
apply their insights and argue for the best approach to psychotherapy on the
basis of this process.
The unified approach advocated for here works in the opposite direc-
tion. It specifically concerns itself with the construction of an integrative
metatheoretical framework that then can be used to assimilate and inte-
grate key insights and findings from both the science of human psychology
(e.g., personality, cognitive, affective, developmental, neuroscience, social,

290 GREGG HENRIQUES

abnormal) and psychotherapy from a multitude of perspectives (e.g., cognitive–
behavioral therapy, psychodynamic). Thus, the unified approach enables
the psychotherapist to move beyond specific paradigms and toward a general
model of psychotherapy that is grounded in the science of human psychology
(Henriques & Stout, 2012; Magnavita & Anchin, 2014; Melchert, 2014).
Because the unified framework enables us to take a broad view of the
field, it is well positioned to advance the search for a more effective way to
approach psychotherapy integration. First, it can offer a general conception of
psychotherapy, one that other perspectives cannot do because they are not tied
to a coherent conception of human psychology. Via the unified view, psycho-
therapy can be defined as a professional relationship between a patient (or
client) and a professional psychologist who is trained in applying psychologi-
cal knowledge toward improving human well-being. In addition, the integra-
tive metatheoretical perspective can also serve as a way to unify the various
approaches to psychotherapy integration. One such perspective that has been
quite influential has been the common factors approach, which is based on
the early work of Jerome Frank. This view, supported strongly by Wampold’s
(2001) analysis of the field, emphasizes the fact that generally speaking, the
different bona fide treatments yield very similar outcomes (the so-called dodo
bird effect) and thus the primary curative agents are likely in the “common
factors” of the various treatment protocols. One of the most robust findings
in the research on psychotherapy has been the association between a strong
working or therapeutic alliance and good outcomes. Consistent with Bordin’s
(1979) early formulation and much subsequent research, the working alli-
ance consists of three primary components: (a) the bond or quality of the
therapeutic relationship; (b) the shared goals of the therapy, which emerge
out of a shared conceptualization of the problems; and (c) the tasks, which
are the changes and interventions that are hopefully going to take place to
achieve the stated goals. In accordance with this view, students can be taught
to think about general psychotherapy as consisting of the three elements that
together make up the concept of the therapeutic alliance.
Although some tend to think about the therapeutic alliance only in
terms of the process and quality of the relationship, it is, of course, much
more than that. In addition to the human bond, it also involves develop-
ing an effective, shared narrative of the problem and useful tasks that foster
reaching specified therapeutic goals. This is where the CAST approach to
conceptualizing is placed in the system because it attempts to ensure that a
comprehensive, holistic picture of the individual can be formed and in a way
that is both systematic and that can be shared with clients (Henriques &
Stout, 2012). If successful, the conceptualization results in the collaborative
weaving together of the key forces and domains that tell a story of how the
person got to where they are and what will influence their trajectory in an

TEACHING CLINICAL DECISION MAKING 291

adaptive as opposed to maladaptive way. The CAST approach is integrative
because, as mentioned earlier, the five systems of character adaptation align
with the dominant perspectives in individual psychotherapy. The conceptual
foundations that drive behavioral, experiential, modern, psychodynamic,
cognitive, and narrative approaches can now be integrated into a holistic
biopsychosocial formulation. Thus, students can now effectively transcend the
competing insights from these grand traditions and coherently integrate them
into a more cohesive framework.
If this is done well, the case formulation gives rise to the goals of the
therapy, which can be framed as a description of what would influence the
ultimate outcome to be desirable and adaptive (e.g., if an individual could
be less negative in their self-talk, be more assertive in their relationships,
become aware of ways they defend against certain feelings). In this light,
the goals of therapy can be now framed as decreasing distress and dysfunc-
tion and increasing valued states of being. Finally, these goals can then
be matched with the empirical literature in psychotherapy, and a series of
therapeutic tasks can be developed that can be expected to have a positive
impact on the stated goals. In short, for the first time there is now a model
of psychotherapy that can be effectively corresponded with the science of
human psychology, allowing for much more unity and synergy between these
two branches of our field.

A FRAMEWORK FOR CLINICAL DECISION

MAKING IN PSYCHOTHERAPY

The three broad domains of a general psychotherapy (relationship,

case formulation, and intervention assessed via clear outcomes) grounded
in the conceptual map provided by the unified theory enables students to
disentangle the complicated process of psychotherapy into more discrete,
but clearly related, parts. To foster a deliberate working conception of the
kinds of thought processes that ought to be guiding them in their clinical
decision making, students are introduced to the mnemonic TEST RePP,
which stands for “Theoretically and Empirically Supported Treatment and
Relationship Processes and Principles.” It provides a heuristic that cap-
tures the key elements that evidence-based practitioners ought to be aware
of and adhering to. It is specifically organized in a way that allows the field
to transcend the current “midlevel” paradigms, build bridges between psy-
chotherapy research and meaningful practice, and move toward resolving
the great psychotherapy debate by holding both the “disorder–intervention”
and “healing relational process” perspectives in complementary relation to
one another.

292 GREGG HENRIQUES

 TEST REPP APPLIED TO THE CASE OF TINA

Each element of TEST RePP is described in greater detail in the sub-

sections that follow. To help see how its elements have implications for clini-
cal decision making, it is applied to Tina, with the context being that she
has come to see a staff psychologist at a college counseling center, seeking
guidance on what she should do and greatly desiring to reduce her distress.
Note that TEST RePP guides the clinician within the context of an appropri-
ate, ethical, and professional therapeutic relationship, and the assumption is
made here that the proper considerations have been taken in setting up the
frame for the relationship.

Theoretically Supported Treatment

A basic principle stemming from the argument thus far is that, as phi-
losophers often point out, “facts are theory laden.” Professional psychologists
must be aware that humans do not perceive the world directly as it truly is
(whatever that might mean), but we have perceptual and conceptual catego-
ries that enable us to actively make meaning out of the patterns in the world.
This is the first meaning of the word theory here. Because the background
conceptual structure “frames” what the practitioner sees in making decisions,
it is crucial that the practitioner be as fully aware of those structures as pos-
sible. This starts at the level of broad philosophy and worldview and includes
the views the professional psychologist has for how the world works, his or
her religious and political perspectives, beliefs about the nature of human
nature, and beliefs about humanity’s place in the universe at large. If these
sound deeply philosophical, they are. This is central because we relate to our
clients at the level of meaning and inevitably hear their stories through a
particular lens defined by our worldview.
Applied to Tina, consider how a Christian psychological practitioner
might hear and respond to her story differently than a secular skeptical prac-
titioner. To do so, let’s make the reasonable assumption, on the basis of Tina’s
story and the demographics of southern rural Virginia, that she was raised in
a socially conservative, Christian home. If so, it follows that some of her cur-
rent anxiety and confusion likely would stem from the potentially conflicting
messages she has received in the context of her transition from a socially and
religiously conservative environment where she felt comfortable to one that
is more secular and has looser mores regarding drinking and sexual activity. If
so, then it is highly likely that a socially conservative Christian psychological
practitioner will hear Tina’s story differently than a purely secular practitio-
ner. This is the case even when both practitioners are engaged in “secular”
psychotherapy and are appropriately ethical and sensitive about imposing

TEACHING CLINICAL DECISION MAKING 293

their own personal beliefs on the therapy practice. The issue here regarding
clinical decision making is one of awareness as opposed to explicit formula-
tions regarding what one ought to do. Because these deep structures will have
a profound impact on how we practice, a foundational pillar of good prac-
tice is to have strong self-reflective awareness of one’s identity, deep-seated
beliefs, and values and the capacity to clearly identify the ways in which
those frames influence how one hears and responds to a client’s presentation.
The second meaning of the term theory refers to the practitioner’s
knowledge of human psychology. This consists of the biological, develop-
mental, and social understanding of personality, psychopathology, relational,
and human change processes through which both the individual and the
process of intervention will be understood. Professional psychologists should
have basic knowledge of elements such as behavioral genetics and their influ-
ence on mental illnesses; personality traits (e.g., neuroticism and conscien-
tiousness); emotions and motivations; social psychological processes of first
impressions, stereotypes, attitudes, and attributions; and general knowledge
of intelligence and academic aptitude, along with categories and classifica-
tion of mental disorders (i.e., the DSM).
This second level of theory, knowledge of human psychology, is usu-
ally organized around and telescoped into the primary paradigm of practice
that the professional operates from (e.g., third wave cognitive–behavioral
therapy, eclectic therapy, emotion-focused therapy). A humanistic psychol-
ogist operating from a person-centered approach would likely emphasize the
external pressures that Tina is experiencing that “force” her to feel com-
pelled to fit into a specific socialized mode. The assumption that she has
within her an organizing growth force will position the humanistic prac-
titioner to make choices in the therapy room to focus on Tina’s internal
emotional experience and create a relational context of empathy, congru-
ence, and positive regard in which she can begin to discover and give voice
to her “true” self, which is seen as central to healthy development from the
vantage point of the humanistic tradition. In contrast, from a traditional
cognitive–behavioral perspective, a psychological practitioner will attend
to the interpretations and beliefs that Tina has about herself, others, and
her situation. These beliefs will be seen to be the key to understanding the
negative emotions and maladaptive behaviors that follow. Here the thera-
pist will listen for how Tina’s story indicates the presence of beliefs that she
is incompetent or that she must get all As in order to be successful. From the
current perspective, it is the obligation of the practitioner to be able to iden-
tify the general paradigm from which he or she is operating in understanding
Tina and explain how it is consistent with the body of human psychological
knowledge in general. This is deemed to be a basic requirement of doing
psychological therapy.

294 GREGG HENRIQUES

 One of the distinguishing features of the unified approach that fos-
ters advances in this area is that because its starting point is a holistic view
of human psychology, it sets the stage for a much greater correspondence
between the body of psychological knowledge and the conceptual under-
standing of the current situation. For example, as articulated when describing
how Tina might be conceptualized, lenses from a wide variety of different
domains were combined in a holistic picture, including biology and behav-
ioral genetics, learning and development, interpersonal and sociological,
behavioral (habits), experiential and emotion focused, psychodynamic (i.e.,
defenses and relational schema), and cognitive–narrative perspectives.
In short, to effectively decide how to frame the therapy with Tina, the
professional psychologist must be clear about his or her theoretical and con-
ceptual frame. The reason for this is that it guides how the psychologist sees
Tina, conceptualizes her problems, and inquires about and deciphers Tina’s
valued states of being. It also informs the psychologist of how to think about
the current condition, the key causal variables that led up to it, and the pro-
posed mechanisms of change. The argument here is that the more coherent,
clear, and comprehensive one’s approach is and the more it aligns with our
knowledge of human psychology, the better the decision making that will
ensue about a particular case. That said, I am not advocating for a “purely”
rationalist approach to intervention. Coherent and comprehensive formula-
tions must be buttressed and informed by the empirical literature that has
been done on cases similar, and that brings us to the next piece of TEST
RePP, the EST.

Empirically Supported Treatment

As valuable as theory is, it needs to connect to and correspond with

empirical research. Indeed, research and theory are complementary ingredi-
ents to growing our scientific knowledge. In this context, we can be reminded
of Eysenck’s (1952) famous early challenge to the field of psychotherapy,
which was an important motivator to examine whether psychotherapy is
actually helpful. Decades of empirical research have since demonstrated
that, generally speaking, psychotherapy is an effective health intervention
(Lambert & Bergin, 1994). In addition, much has been learned about the
elements that are effective and associated with positive outcomes, and prac-
titioners have an obligation to be aware of the research on the validity of the
assessment instruments and treatment interventions they use. In addition,
psychologists should be aware of their personal biases and seek to check their
beliefs against objective research, be cognizant of the way motives and needs
influence one’s beliefs and perceptions, and be aware of alternative perspec-
tives. They should also be aware of the way the research they are interpreting

TEACHING CLINICAL DECISION MAKING 295

was conducted, be able to critique issues of methodology that might raise
questions of internal validity, and have a conceptual map that allows them
to consider issues of generalizability.
More concretely, practitioners operating in well-researched domains,
as when working with anxious adults like Tina, should be aware of empirical
findings associated with different treatment interventions, such as cognitive–
behavioral and psychodynamic approaches, as well as common medications.
Intervention principles that have consistent connections with good out-
comes, such as those involving exposure with response prevention, should be
at least acknowledged and seriously considered in a case like Tina’s. Indeed,
if there is a clear desire by the patient to reduce his or her anxious symptoms
and there is good reason to believe that the levels of anxiety are contributing
to dysfunction in important areas (as in Tina’s case), it is the obligation of the
practitioner to provide guidance toward interventions that have been empiri-
cally shown to be effective at reducing anxiety and improving performance.
In the case of Tina, for example, it seems that the minimum a pro-
fessional psychologist should be aware of in terms of the broad empirical
literature on reducing anxiety is summed up well by the renowned cognitive–
behavioral psychotherapy researcher David Barlow. Reviewing a large litera-
ture on ESTs, Barlow and his colleagues have suggested that practitioners be
able to view depressive and anxiety disorders from the general perspective of
negative affect (Barlow, Allen, & Choate, 2004). From this, he argued that
research has demonstrated three broad principles that foster effective treat-
ment: (a) reducing catastrophic or overly pessimistic expectations for future
events, (b) reducing avoidance patterns and increasing the capacity to stay
with aversive emotions, and (c) training individuals to develop antithetical
emotional responses to their dominant response style (e.g., fostering general
relaxation skills for anxious individuals). Thus, high on the decision-making
list of the clinician working with Tina are the following questions: When
should Tina’s anxiety symptoms become the focus of the intervention, how
should they be conceptualized with her, how should she be motivated to
engage in interventions known to be effective, and how can the utility of
these interventions be tracked?
Generally speaking, the term treatment here evokes a “medical model”
conception, in which the individual is thought of as having an identifi-
able problem that can be matched with a set of interventions that will
alleviate the difficulty. This model is the dominant frame of thinking in
cognitive–behavioral literatures, and from our broad scientific humanistic
view of human psychology and psychotherapy, it is a useful framework. But it
is limited in scope. It often fails to consider deeply other issues of personality,
especially identity and relational functioning. And it frames psychotherapy
in a particular way that can blind practitioners to equally important aspects

296 GREGG HENRIQUES

of treatment. As mentioned earlier, referencing the great psychotherapy
debate, the other major perspective is to consider the process of psycho-
therapy as a psychosocial or relational one, whereby two individuals enter
into a meaningful professional relationship with the intent of relieving
distress and improving functioning. Students should be taught and profes-
sionals should be able to think about the psychotherapeutic process both
as matching a presentation to an intervention and as a unique human rela-
tionship process that unfolds between two individuals. This brings us to the
“Re” in TEST RePP.

Relationship

Whereas the “EST” stands for thinking about systematic interventions

that might reduce suffering and improve functioning, with “relationship” the
focus shifts to the nature of the exchange between the practitioner and client
and their personalities as well as the broader social variables at play. At a
basic descriptive level, this would include attention to the gender, age, and
socioeconomic and ethnic background of both parties. But it is much more
than that. Every psychotherapy encounter consists of two unique individu-
als experiencing one another at a unique moment in time. The individual
uniqueness of both the therapist and the client tend to be considered either
error or noise in traditional treatment research. That is, for research purposes,
the treatment is standardized, a set of inclusion and exclusion criteria are
developed based on symptoms, and then the results are reported in aggregate
form, averaging across groups.
Humanistic and psychodynamic thinkers have done the most developed
systematic work on the therapeutic relationship and how it can be used to
foster healing. As noted previously, a strong empirical claim can be made that
the effectiveness of psychotherapy is related to and dependent on the qual-
ity of the therapeutic relationship. There are several crucial key relationship
variables. First, it is important that the therapist be seen as competent, trust-
worthy, and someone who has the best interests of the client at heart. The
client must experience positive regard from the therapist as well as empathy
and warmth. Moreover, therapists are expected to have interpersonal grace
and be able to understand how they feel about their clients and maintain a
helpful, professional stance.
Second, the unique interpersonal relationship provides a wonderful
opportunity for psychosocial learning. Thus, the therapist ought to be skilled
in the art of interpersonal process, and should be dialoguing, when appropri-
ate, about the way the exchange is unfolding and eliciting narrative from
the client about how his or her experience of the therapist relates to past
experiences. The opportunity for this kind of conversation should be present

TEACHING CLINICAL DECISION MAKING 297

in all meaningful therapy, certainly not just analytic therapies that emphasize
working with transference.
Third, the therapist should be effective at tracking the nature of the
relationship and pacing it appropriately. Interpersonal process comments
need to be timed appropriately relative to the nature and development of the
relationship. For example, strong feelings toward the therapist are much less
likely to be present very early in the process. In addition, recognizing poten-
tial ruptures and subtle changes in the patient’s attitudes about either the
therapy or therapist is crucial to maintaining an effective working alliance.
With regard to Tina, the relationship factors will likely be central in a
successful intervention. They are also likely to be complicated. It is reason-
able to surmise that Tina is both feeling extremely vulnerable and at the
same time desperately seeking guidance. In addition, given the context of
her emergence into the therapy system via a referral for ADHD, it is highly
likely that Tina will already feel frustrated with the system. If she wanted a
label, a pill, and accommodations to foster her academic performance and
she gets referred for the reflective work of psychotherapy, then there already
is a mismatch between what she anticipated and what she is receiving. And,
given that her anxiety symptoms are likely a function of the fact that her core
emotional self is feeling overwhelmed by deep existential conflicts, it seems
highly likely that she will be defensive about exploring such issues, espe-
cially when she is feeling the pressure to make a life decision quickly (i.e., to
transfer or not). Because of all of these factors, she likely will not have much
tolerance for a slowly developing therapy (i.e., a therapy that does not help
her feel grounded and better quickly). And yet there is the very real concern,
which many therapeutic perspectives would emphasize, that a therapy that
moves too quickly and a therapist who is too directive might short-circuit a
key developmental task, that Tina needs to sort these issues out for herself,
and that the job of therapy is to provide her with a context for doing so
but not necessarily to be an advice-giving guide. The point here is that the
decisions that will go into establishing a working relationship with Tina will
have a number of potentially competing considerations that require thought-
ful reflection. This point raises the question regarding the final elements of
TEST RePP, which involve a description of the key processes and principles
that ought to guide practitioners in their work.

Processes and Principles

The last two elements of TEST RePP remind practitioners of how to

be guided by their knowledge systems. Historically, the emphasis on empiri-
cism has been so strong in certain domains (i.e., academia) that the mes-
sage seemed to be that rigid adherence to specific procedures enacted by a

298 GREGG HENRIQUES

practitioner following a step-by-step treatment manual were the key to sci-
entific treatments. Thankfully, it now appears that the majority in the field
are moving away from the attempt to reduce the therapeutic process to a
series of prespecified steps, like what one would do when baking a cake, and
more toward a view that recognizes therapy as an organic process that should
not be overly structured like some algorithmic recipe. The latter has long
been the model of humanistic and psychodynamic practitioners and is now
becoming the general way many cognitive–behavioral practitioners operate.
For example, acceptance and commitment therapy, a new wave cognitive–
behavioral treatment, emphasizes a set of guideposts for clinicians as they
form a relationship and foster commitments toward valued goal states (Hayes
& Spencer, 2005).
“Processes and principles” is an attempt to remind wise practitioners of
the guideposts that are shaping their work and orient them toward the rest
of the TEST RePP formulation. With regard to processes, I emphasize three
broad domains of process that I encourage students to keep in mind as
they make decisions about what to do in their psychological interventions:
(a) awareness, (b) acceptance, and (c) active change. Central to all therapeu-
tic encounters is assessment—problem formulation and fostering systematic
awareness in relative parties regarding the nature of the problem and the
variables that are contributing to it. Human behavior is enormously com-
plex, and humans notoriously are unaware of how much they do not know or
understand. Much of the work of a psychologist is the process of developing
a shared formulation that fosters clarity about the current situation. As such,
a key treatment process variable for the psychologist to keep in mind when
making decisions is awareness, in terms of understanding what level of aware-
ness the client has, how greater clarity might be achieved, and self-reflective
awareness of the psychologist.
Although traditionally psychoanalytic practitioners deemed awareness
(or insight) as fundamental to a successful intervention, it is now generally
understood that treatment must be geared to more than fostering awareness.
The other two process variables, acceptance and active change, are both quite
complicated, but they can serve as guideposts to the process of therapy. For
example, learning to accept the aspects of the world that cannot be controlled
is now broadly recognized as a key ingredient to mental health. The rise of
mindfulness as a key ingredient to many therapeutic perspectives is a testa-
ment to the centrality of enhancing capacities for acceptance. And for as long
as people have being doing therapy, acceptance of past losses, unfinished busi-
ness, failures, or traumas (usually via fostering a more compassionate attitude)
and of warded-off feelings have been salient aspects of the therapeutic process.
Of course, sometimes people need to actively learn how to be dif-
ferent so that they are in a better place to flourish and avoid the vicious,

TEACHING CLINICAL DECISION MAKING 299

maladaptive cycles associated with their distress and impairment. When
this is the case, the focus of therapy is on fostering active change. Individuals
often need to learn to do things differently, whether this involves altering a
maladaptive habit, training themselves to think differently, or developing
a new relational skill. Here, understanding the process of human change is
crucial, including recognizing the client’s stage of change, how gradual and
dramatic change can happen, and how changes can be maintained. The
twin processes of acceptance on the one hand and active change on the
other can seem almost contradictory. However, it is worth noting that both
psychodynamic (Wachtel, 2011) and cognitive–behaviorally oriented
(Linehan, 1987) practitioners have helpfully pointed out that acceptance
and change can be thought of as existing in dialectical relationship to one
another. This dialectical emphasis offers a more useful holistic view of
the two processes than when they are viewed separately or in conceptual
contrast to one another.
With regard to Tina, issues of awareness, acceptance, and change are
all very salient. Sooner rather than later she needs to develop a better way of
understanding her character and her situation and the origins and nature of
her anxious symptoms. It seems likely that she lacks awareness about many
of the features that are contributing to her distress, and if so, this needs to be
addressed. At the same time, she needs ways of coping with her immediate
problems that will help improve her functioning. My approach would be to
take an active stance, helping Tina in a fairly direct way to come as quickly as
possible to the understanding of her situation that is spelled out in the formu-
lation described earlier. That is, I would likely use the approach of a “thera-
peutic assessment” (Finn & Tonsager, 2002) to attempt to generate such an
understanding. From there, a shared plan could be developed that teaches
her evidence-based strategies to (a) reduce her test anxiety; (b) enable her
to increase her social support; and (c) adopt a longer term, hopeful perspec-
tive about what she might learn about herself in the context of this difficulty
with adjustment. If this stage was initially successful and her symptoms were
stabilized, then a focus on her core identity, purpose in life, and relational
style and needs could be employed to build a deeper, more aware and resilient
character structure that would enable her to make more adaptive interpreta-
tions and decisions, both in the short and long term.
The final “P” in TEST RePP stands for principles. It serves two related
functions. First, the goal is to remind budding practitioners that they are
guided by principles—values, goals, and knowledge bases—and that effec-
tive clinical decision making involves a frame that keeps these ideas salient
and keeps the practitioner reflective and aware of his or her actions. The
second function of “principles” is to help elucidate the more specific guid-
ing frames that inform practitioners regarding their practice. It encourages

300 GREGG HENRIQUES

them to consult both the literature and existing practice guidelines in their
work. A sample of key treatment principles is offered in Appendix 11.1.

SUMMARY

If we are to produce ethical, self-reflective, and effective professional

psychologists, we must be able to teach them the capacity to deeply answer
the questions “If this is the case, what should you do and why?” and “In that
situation, why did you do what you did?” These basic questions provide the
frame for thinking about clinical decision making, and it is crucial that prac-
titioners of psychotherapy have solid justification systems that guide them.
The field of professional psychology has historically not attended
systematically to the process of clinical decision making as much as other
health care professions, such as nursing and medicine. In addition, the field
has often been characterized as being split between empirical and romantic
visions of practice, with the former emphasizing decisions grounded in data
derived from the scientific method and the latter emphasizing the deep, intui-
tive skills of the seasoned practitioner. It is time that we transcend this old
dichotomy and move toward a different conception of science and a more
rationalist approach to intervention. It has always been the case that the
only effective bridges between the worlds of research and practical knowledge
are found in concepts and theories. Thankfully, for the first time, there are
comprehensive, scientifically grounded visions for human psychology that
effectively bridge to the world of practice. Thus, we are set for a new era of
unification and synergistic growth between the fields of professional practice
and human psychology.
This chapter has outlined some of those emerging perspectives and
articulated how a unified view of practice and human psychology can give
rise to a scientific humanistic perspective on decision making that speaks
both to methodological issues of precision, reliability, and validity and to
broader philosophical questions. There is also now a model for conceptualiz-
ing the human condition that transcends the traditional midlevel paradigms
and affords practitioners a systematic approach to conceptualizing that is
grounded in scientific rationality.
APA attempted to bridge the disputes between clinical researchers and
practitioners with its guidelines for EBP, which emphasizes the three domains
of best available research, clinical experience, and patient values in the par-
ticular cultural and policy context as being the primary sources that practitio-
ners ought to be relying on when developing their interventions. However,
more specificity is needed in helping students approach their clinical deci-
sion making about psychotherapy interventions. The reason for this is that

TEACHING CLINICAL DECISION MAKING 301

the vast field of psychotherapy is conceptually fragmented at a multitude of
levels. To address the conceptual fragmentation, a heuristic frame going by
the acronym TEST RePP, which stands for “Theoretically and Empirically
Supported Treatment and Relationship Processes and Principles,” was devel-
oped that attempts to delineate the key conceptual elements that ought to
guide decision making in developing and enacting such psychotherapeutic
interventions. This perspective allows future practitioners to address the
competing paradigms in the field, provides them with an integrative meta-
perspective, and allows them to appreciate and consider major debates in
the field of psychotherapy research (e.g., medical model vs. psychosocial
process). We hope practitioners informed by this model will make more
effective clinical decisions.

302 GREGG HENRIQUES

 APPENDIX 11.1

The following list offers some of the key principles that guide effec-
tive psychotherapy. This attempts to breakdown the elements of TEST RePP
in a way that is congruent with the empirical literatures in psychology and
psychotherapy.
1. Set an appropriate, ethical frame. Psychotherapy is a relationship
that is grounded in professional obligations and constraints,
and it is crucial that all stakeholders involved understand the
purpose and function of the relationship; issues of confidenti-
ality; financial reimbursement; general focus of the work; and,
where appropriate, expected time frame.
2. Begin to foster a strong therapeutic relationship. It is crucial that
the psychologist exhibit a level of competence and respect
toward the client such that the client feels valued and heard
and believes the therapist can help where appropriate.
3. Identify cultural context variables. Consideration of the social
construction of identities is crucial for both the therapist and
the client. When the client and psychologist do not share the
same broader cultural background, particular attention should
be paid to how the influence of cultural context might lead to
differences in communication patterns, expectations of roles,
core values, and so forth.
4. Identify client values and hopes. The central goal of psychother-
apy is to enhance adaptive ways of living, a central element of
which is the client’s value states of being.
5. Identify risk of harm. A fundamental tenet of practice is to min-
imize the risk of harm. A practitioner must be reflective about
the possible ways an intervention might have unintended side
effects. If there is anticipated possible harm, all parties should
be informed, and that must be carefully weighed against prob-
able benefits.
6. Begin to formulate an ongoing case conceptualization. A compre-
hensive assessment includes a general categorization of the
major symptoms, character, key developmental factors, rel-
evant biological and sociocultural variables, current relational
context, and major stressors and affordances in the environ-
ment. In addition, a systematic approach to assessing rela-
tional style, identity, and presenting problem (i.e., diagnosis)
should be included.
7. Begin to identify realistic, adaptive treatment outcomes. The ther-
apist should work with the client to identify therapy goals in

TEACHING CLINICAL DECISION MAKING 303

 the context of the client’s values and stage of change within
a holistic, biopsychosocial, developmental conceptualization.
In cases of excessive maladaptive symptoms, these goals are
often straightforward (e.g., reducing levels of depressive symp-
toms). Sometimes, however, goals need to be more focused on
awareness (i.e., increasing values or clarifying identity issues)
or acceptance of past losses or current injury.
8. Tailor treatment to level of client functioning. More than any-
thing else, treatment outcomes are determined by the client’s
history, level of impairment, and attitude about therapy. It is
crucial that the goals of therapy consider this fact. It is also
recommended that therapists increase their levels of direction
and guidance when impairment is high.
9. Consider therapy as a nonlinear process of fostering awareness,
acceptance, and compassion and of engaging in active efforts to
change. Although therapists should have a clear road map of
their work, it is also the case that therapy is rarely a simple,
linear, stepwise process. Instead, many times individuals have
symptoms that are the consequence of tangled and confused
psychological processes that require an unfolding of aware-
ness, acceptance, and active change, in varied sequences.
10. Reducing maladaptive levels of negative affect. When the major
treatment goals include reducing the levels of negative affect,
the treatment plan should consider the following: (a) altering
maladaptive antecedent cognitive appraisals, (b) identifying
layers of emotional–experiential processing and preventing
problematic avoidance (i.e., foster exposure and acceptance),
and (c) facilitating action tendencies antithetical to the dys-
regulated emotion (teaching clients to relax when they are
anxious or becoming active and to focus on mastery or pleasure
when they are depressed).
11. Altering problematic aspects of relationships and identity. When
the major treatment goals include altering aspects of iden-
tity and maladaptive relationship patterns, the practitioner
should consider (a) patterns between old relationships and
current relationships, looking especially for vicious relation-
ship cycles; (b) role functions and conflicts relative to core
relational needs; (c) developing awareness of purpose in life,
existential narratives, and problematic core beliefs and con-
sidering ways to renarrate self or life in a healthier way;
(d) fostering compassion for both self and other and flexibility
in human relating; (e) making conscious defense mechanisms

304 GREGG HENRIQUES

 and working toward restructuring maladaptive defenses; and
(f) ways to increase agency, coherence in identity, or coping
self-efficacy.
12. Monitor changes in desired goals. Once problem areas and treat-
ment goals are identified, therapists should monitor changes
in symptoms and problem areas (e.g., with appropriate test
instruments).
13. Monitor client satisfaction and attitudes about the therapist. In
addition to monitoring symptom outcomes, it is crucial that
regular feedback is solicited about the satisfaction the client
has with the therapist and the treatment. Ideally, there should
be intermittent opportunities designed to solicit authentic
opinions about the treatment.
14. When there are ruptures or failure to make adequate progress,
process this and be open to making changes.
15. Plan for termination, monitor changes, and taper therapy if neces-
sary. Therapy, especially when financed by an outside source,
should be conducted in a time-sensitive way. It is the obli-
gation of the health care professional to foster treatment
advances as efficiently as possible and not to extend treatment
beyond what is necessary.

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TEACHING CLINICAL DECISION MAKING 307

 INDEX

Abbass, A., 163 automatic processing, 69–74, 76–78

actuarial prediction, 36–38 automatic thoughts (cognitive
adaptive treatment, 148 therapy), 83
addictive disorders, 177 availability heuristic, 40, 47, 135, 224
ADHD (attention-deficit/hyperactivity avoidant personality disorder, 210
disorder), 277, 283 awareness (process variable), 299
adversial collaborations, 129
affect, negative, 304 Baker, T. B., 279
affective disorders, 177 Bardenstein, K. K., 224
Agency for Healthcare Research and Bargh, J. A., 30, 78
Quality (AHRQ), 108, 115 Barlow, D. H., 149, 155, 165
Allison, Tom Spencer, 267 Barnum effect, 45
Ambady, N., 35 base rate neglect, 48
ambulatory monitoring, 154 Bayesian approaches to clinical decision
American Psychiatric Association, making, 50–51
128, 130 Bazian Limited, 116
American Psychological Association Beck, A. T., 286
(APA) behaviorism, 283. See also Cognitive
and clinical practice guidelines, 11, and behavioral therapies
105, 108–110, 116, 125–126 Bell, H. H., 66
Ethics Code of, 256, 258, 276 Benjamin, L. S., 198
Task Force on Evidence-Based Berger, T., 162
Practice, 25, 65, 126, 196, Best Practices in Clinical Supervision
224, 289 (Association for Counselor
analytic processing. See Slow thinking Education and Supervision), 163
mode (System 2) Betan, E., 189
analytics, 28–29 Beutler, L. E., 155, 164, 195
Anchin, J. C., 41, 80 bias
anchoring bias, 5, 39–40 analysis of, 252
Andersson, G., 151 anchoring, 5, 39–40
Anker, M. G., 228 attributional, 7, 11, 40
antidepressants, 128, 152 biological, 11
antisocial personality disorder, 197 and clinical practice guidelines, 109,
anxiety disorders, 194 116–118
APA. See American Psychological confirmation, 5, 40–41, 43, 50, 128
Association in deliberative decision making, 76
Apgar, Virginia, 52 function of, 71
Ariely, Daniel, 25, 39 gender, xiii
Association for Counselor Education hindsight, 45, 259
and Supervision, 163 inevitability of, xiii
associative processing. See Fast thinking minimization of, 27
mode (System 1) overconfidence, 6, 46–47
Athay, M., 153, 225 publication, 49, 116, 132
attention-deficit/hyperactivity disorder recall, 47
(ADHD), 277, 283 and risk management, 253
attributional bias, 7, 11, 40 safeguards against, 189

309
bias, continued errors commonly influencing, 39–50.
selection, 5, 48–49 See also Bias
survivorship, 49 and evolutionary basis of decision
in System 1 thinking, 34 making, 8–9
Bickman, L., 153, 225–229, 232 and expertise. See Clinical expertise
Big Data (Viktor Mayer-Schonberger & fast vs. slow thinking in, 33–36
Kenneth Cukier), 16 heuristics for, 3–4
“Big data,” 16, 32 knowledge of, 12
biofeedback, 152 pillars of effective, 9–12
biology, 8–9, 11 pragmatics of, 27–28
blended treatment, 157 rationality and emotionality in,
Blink (Malcolm Gladwell), 30, 35 29–31
Bloom, Benjamin, 261 risk management in. See Risk
Board of Psychology v. Tom Spencer management
Allison, 267 schemata and prototypes in, 14
Bodenhausen, G. V., 78 shared, 15
borderline personality disorder, 5, 40, sunk costs in, 4–5
44, 47, 48, 189, 196, 197, 210 uncertainty of analytics in, 28–29
Bordin, E. S., 291 clinical expertise, 23–27
Borkovec, T. D., 196 definitions of, 25–26
Breda, C., 228–229 development of, 4, 10–11
Buchanan, T., 152 in three-circle model of evidence-
based practice, 106–107
care, standard of, 255–257 training and experience required for,
case conceptualization, 160–162, 24–25, 34
205–216, 303 clinical judgment, 257–259
case management models, 187–188 clinical practice guidelines (CPGs),
Caspar, F., 147–148, 162, 167 105–121, 125–142
Castonguay, L. G., 195, 196 advantages of decision making with,
Caudill, C. O., 256 118–119
CBTs. See Cognitive and behavioral and American Psychological Asso-
therapies ciation, 11, 105, 108–110,
CFS (contextualized feedback 116, 125–126
system), 228 and bias, 109, 116–118
chaos theory, 176 criteria for, 108–109
character adaptation system theory and hierarchy of evidence, 136–138
(CAST), 281–285, 289, 291–292 history of, 109–111
children, treatment of, 265 implementation of, 119–120
chronic fatigue syndrome, 177 Institute of Medicine standards for,
Claxton, K., 15 105, 111–115, 126–134
clinical decision making, 3–16, 23–55. limitations of, 108
See also High-stakes clinical as link between research and
decision making; specific headings practice, 106–107
and actuarial prediction, 36–38 overview, 106
analytics for, 15 selection of appropriate, 134–136
approaches for enhancing, 50–54 systematic reviews of, 108–109, 113,
basics of, 38–39 115–116
and big data, 16 and treatment efficacy, 138–142
and decision theory, 5–6 Clinical Practice Guidelines We Can Trust
elements of, 31–33 (Institute of Medicine), 111

310 INDEX
clinical prediction contextualized feedback system
actuarial prediction vs., 36–38 (CFS), 228
effectiveness of, 35 Conway, M. A., 78
clinical support tools (CSTs), 156 cost–benefit analysis, 7
clinical training, 158–164. See also countertransference–transference
Teaching clinical decision making reactions, 188–189
Clinical Versus Statistical Prediction (Paul CPGs. See Clinical practice guidelines
Meehl), 35 Creighton, L. A., 69
Clinician’s Guide to Evidence-Based Critchfield, K. L., 196
Practices (J. C. Norcross, T. P. “Criteria for Evaluating Treatment
Hogan, & G. P. Koocher), 25 Guidelines” (APA
cognitive and behavioral therapies document), 110
(CBTs) critical thinking, 249–253
for anxiety disorders, 194 Croskerry, P., 68, 72, 90, 91
patterns in, 216 Cross, G., 10, 52
processes in, 299, 300 Crossing the Quality Chasm (Institute of
psychoanalytic treatment vs., 180 Medicine report), 52
research support for, 138, 141 Csikszentmihalyi, Mihaly, 30
semantic meaning in, 283 CSTs (clinical support tools), 156
theory in, 64 Cuijpers, P., 139
cognitive bias. See Bias Cukier, Kenneth, 16
cognitive capabilities, 254
cognitive continuum theory, 77 Dahlin, M., 151
cognitive dissonance theory, 227 data
cognitive restructuring, 194 “big,” 16, 32
cognitive theory, 82–83 in clinical decision making, 226–229
Cohen, J. T., 15 defined, 32
coherence, 160 and knowledge databases, 150
COIs (conflicts of interest), 112, patient, 151–155
128–129 Dawes, Robyn, 278
collaborative problem solving, 158, 164 de Andrade, A. R., 228–229
collaborative shared decision-making decision analysis, 26
model, 178–180, 183–187 decision-making research, 253–255. See
combined–integrated approach to also Clinical decision making
training, 274–275 decision theory
Comer, J. S., 149, 155, 165 history of, 13–14
common factors in psychotherapy, 291 influence of, 9
comorbidities, patient, 177–178, 196 overview, 5–6
complexity theory, 176 study of, 12
complex trauma, 177 default-interventionism model, 77
computer-assisted testing, 151–152 deliberative processing, 69, 73–78
computer-based training, 159–162 depression, 44, 46, 65, 128, 140, 288
confirmation bias, 5, 40–41, 43, DeRubeis, R. J., 135, 152
50, 128 Diagnostic and Statistical Manual of
conflicts of interest (COIs), 112, Mental Disorders (DSM), 71, 287
128–129 diagnosticity, 51
Conklin, C., 189 diagnostic labels, 5
consultation, 154–155, 264, 284 dialectical behavior therapy, 159, 196,
contact and communication technolo- 197, 216
gies, 156–157 divorce, 35, 52, 260, 265

INDEX 311
dodo bird effect, 291 case examples, 205–216
dopamine, 30 in moment-by-moment therapy
Doverspike, W., 256 process, 201–205
DSM (Diagnostic and Statistical Manual norms in, 201
of Mental Disorders), 71, 287 principles of, 196–198
dual process model, 79–94 and structural analysis of social
applications of, 79 behavior, 198–201
automatic processing and decision empirically supported treatments
making in, 69–74, 76–78 (ESTs). See also Evidence-based
clinical recommendations, 89–94 practice
clinical vignette, 79–89 and clinical practice guidelines, 106
deliberative processing and decision treatment efficacy of, 138
making in, 73–78 empiricism (philosophy), 286
development of, 68 endowment effect, 42
overview, 68–78 Ensworth, Heather, 266
dual process model of explicit and Ensworth v. Mullvain, 266–267
implicit theory, 79–94. See also Epstein, S., 78
Theory e-SOFT (System for Observing Family
applications of, 79 Therapy Alliances), 158–159
clinical vignette, 79–89 ESTs. See Empirically supported
recommendations with, 89–94 treatments
Dumont, F., 92 e-texts, 149–150
Duncan, B. L., 228 ethical frameworks, 12
ethical violations, 258
eating disorders, 177 EU (expected utility) theory, 180
EBM (evidence-based medicine), 107 EUV (expected utility value), 74–75
EBP. See Evidence-based medicine Evans, J. St. B. T., 69, 76, 77
ecological momentary assessment Evans, W. J., 162–163
(EMA), 154 evidence
efficacy, treatment, 138–142 empirical, 9–10
egocentrism, 43 hierarchy of, 136–138
Ellis, E., 254 evidence-based medicine (EBM), 107
EMA (ecological momentary evidence-based practice (EBP). See also
assessment), 154 Empirical evidence
EMDR (eye movement desensitization defined, 13
and reprocessing), 194 history of, 285–290
eMedicine Clinical Knowledge for posttraumatic stress disorder, 10
Database, 150 and teaching clinical decision
emotional reasoning, 252 making, 285–290
emotions evolutionary psychology, 8–9, 280
awareness of, 254 expected utility (EU) theory, 180
in clinical decision making, 29–31 expected utility value (EUV), 74–75
empathy, intellectual, 250 experiential practitioners, 64, 283
empirical evidence, 9–10 experiential processing. See Fast
empirically grounded relational thinking mode (System 1)
principles, 193–217 expertise. See Clinical expertise
across treatment approaches, explicit theory, 64–65
195–196 external review, 114
for case conceptualization and external validity, 137
interventions, 205–216 eye contact, 4

312 INDEX
eye movement desensitization and game theory, 13
reprocessing (EMDR), 194 Gawronski, B., 69
Eysenck, H. J., 295 GDP (guideline development panels),
111–113, 126–131
fair-mindedness, 251 gender bias, xiii
“Faith in reason” (trait), 251 Gervind, E., 151
family systems therapists, 64 Gladwell, Malcolm, 30, 35, 50
fast thinking mode (System 1), 33–36 Goethe, Johann Wolfgang von, xi
biases with, 53 Goodman and Gilman’s Pharmacological
overview, 14 Basis of Therapeutics (L. Brunton,
feedback systems, 153. See also B. Chabner, & B. Knollman),
Measurement feedback systems 149–150
FFT (functional family therapy), Gosch, E., 28
232–236 Gottman, J. M., 40
FFT-CFS (Functional Family Therapy Gottman, John, 52
Clinical Feedback System), GRADE (Grading of Recommendations
232–236 Assessment, Development, and
FFT-CMI (Functional Family Therapy Evaluation), 116
Clinical Measurement Inven- Graves’ disease, 44
tory), 232 Grawe, K., 153
fibromyalgia, 177 The Great Psychotherapy Debate (Bruce
fight–flight response, 34 Wampold), 288
financial conflicts of interest, 128–129 Greenberg, R. P., 154
Finding What Works in Health Care: Gregory, R., 154
Standards of Systematic Reviews Groopman, J., 27, 28, 38, 53
(Institute of Medicine), 111 guideline development panels (GDP),
Fischer, U., 72 111–113, 126–131
Fiske, S. T., 27
Fitzgerald, F. Scott, 44 Hammond, K. R., 77
fixed frames, 43–44 Harmon, C., 228
flow, 30 Harwood, T. M., 155, 164
Foundation for Critical Thinking, Hassin, R. R., 30
249–250 Hautle, I., 162
Four Horseman of the Apocalypse Hawkins, E. J., 228
(algorithm), 52 Health Insurance Portability and
Frank, Jerome, 291 Accountability Act (HIPAA),
Frederickson, J., 163 164, 256
Friedberg, R. D., 224 Heim, A. K., 189
functional family therapy (FFT), 232–236 Henderson, D., 283, 284
Functional Family Therapy Clinical Henriques, G. R., 283
Feedback System (FFT-CFS), Henry, W. P., 196
232–236 heuristic(s), 3–6
Functional Family Therapy Clinical availability, 40, 47, 135, 224
Measurement Inventory defined, 26–27
(FFT-CMI), 232 errors with, 39
Furr, J. M., 28 function of, 71–72
representative, 5, 48
Galinsky, A. D., 258 and teaching clinical decision
Gallinger, L., 154 making, 274–275
gambler’s fallacy, 41–42 Higgs, J., 254

INDEX 313
high-stakes clinical decision making, intellectual integrity, 250–251
175–190 intellectual perseverance, 251
aids for, 183 internal validity, 137
case management models for, Internet, 149–151
187–188 Internet-based testing, 151–152
collaborative shared decision-making Internet-based training system
model for, 178–180, 183–187 (ITS), 158
and expected utility theory, 180 interpersonal psychotherapy, 65, 79,
managing countertransference– 138, 194, 216
transference reactions in, interpersonal reconstructive therapy
188–189 (IRT), 210–214
overview, 176–177 interventions, 205–216
with patient comorbidities, 177–178 intuition, 30–31, 34–35, 51, 80. See
pattern recognition in, 188 also Clinical prediction; Fast
quadratic decision-making model for, thinking mode
181–183 intuitive processing. See Fast thinking
risk management in, 187 mode (System 1)
and safeguards against cognitive IOM. See Institute of Medicine
biases, 189 IRT (interpersonal reconstructive
simplified decision-making model therapy), 210–214
for, 180–181 ITS (Internet-based training
hindsight bias, 45, 259 system), 158
HIPAA (Health Insurance Portability
and Accountability Act), joint collaborative care meetings, 186
164, 256 Jones-Smith, E., 64
Hogan, T. P., 25
Hollon, S. D., 152 Kagan, Jerome, 11
Holmes-Rovner, M., 180 Kahneman, Daniel, 6
hormone replacement therapy on clinical expertise, 26, 179
(HRT), 137 on clinical prediction, 37–38
How Doctors Think (J. Groopman), 27 on clinicians and algorithmic
humanistic psychologists, 64, 283, thinking, 52
294, 299 development of decision theory by,
humility, intellectual, 250 13–14
hyperthyroidism, 44 on evidence, 50, 53
and heuristics, 26
illusory correlations, 46 and priming, 11
ILT (instructor-led training System 1 and System 2 thinking
workshops), 159 developed by, 33–36
implicit theory, 65–68 Karlin, B. E., 10, 52
information, 32 Keillor, Garrison, 47
insight, 299 Kelley, S. D., 153, 225, 228–229
Institute of Medicine (IOM), 12, 52, Kendall, P. C., 28
105–107, 111–115, 126–134 Kiesler, D. J., 80
instructor-led training workshops Kimble, G. A., 276
(ILT), 159 Klein, G., 26, 66, 70, 179
integrative psychotherapy, 64 Knight, Frank, 13
intellectual courage, 250 knowledge, 32, 294
intellectual empathy, 250 knowledge databases, 150
intellectual humility, 250 Koocher, G. P., 25

314 INDEX
Lake Woebegone effect, 47 Minnesota Multiphasic Personality
Lambert, M. J., 33, 47, 228 Inventory—2 (MMPI–2), 46,
Lammers, J., 258 280, 285
latent semantic analysis (LSA), 161 moment-by-moment therapy process,
Lehrer, J., 29 201–205
licensing boards, 245–246, 256, 258 Morgenstern, Oskar, 13
Lilienfield, S. O., 274–275 Mosier, K. L., 72
Linardatos, E., 128 Mullvain, Cynthia, 266
Linehan, M., 196 multiple personality disorder, 40
Lohr, S., 32 multiple relationship violations,
LSA (latent semantic analysis), 161 267–268
Luhrmann, T. M., 43
Najavits, L. M., 66, 93
Maggio, L. A., 149, 150 Naked Statistics: Stripping the Dread From
Magnavita, J. J., 41, 188, 225, 274–275 the Data (C. Wheelan), 47
malpractice, 258–259 narcissism, 5, 40, 43, 196
Manring, J., 154 narrative fallacy, 46
Månsson, K. N. T., 151 narrative therapists, 283
manuals. See Treatment manuals National Guidelines Clearinghouse, 108
Maslow, A., 31 National Institute for Health and
Matthews, A. M., 128 Clinical Excellence (NICE), 127,
Mayer-Schonberger, Viktor, 16 129–130
McFall, R. M., 279 National Institute of Mental Health
measurement feedback systems (MFS), (NIMH), 12
153, 223–241 naturalistic decision making (NDM), 70
benefits of, 225 negative affect, 304
in clinical decision making process, Neumann, P. J., 15
236–239 neurofeedback, 153
in functional family therapy, Neuropsychotherapy (K. Grawe), 153
232–236 neuroscience, 11, 30–31
future directions of, 239–240 Newnham, E. A., 239
OQ-Analyst, 229–230 The New Unconscious (R. R. Hassin,
overview, 226–229 J. S. Uleman, J. A. Bargh), 30
Partners for Change Outcome NICE (National Institute for Health
Management System, 231 and Clinical Excellence), 127,
Systemic Therapy Inventory of 129–130
Change, 230–231 NIMH (National Institute of Mental
medical model of treatment, 287, 296 Health), 12
Meehl, Paul, 35, 37, 132 nonmaleficence, 258
memory, 47–48 Norcross, J. C., 25
mentalization, 31 Norman, G., 90, 91
metacognition, 254 Norsworthy, L. A., 228
metacommunication, 80–82, 84
methodological view of science, O’Donohue, W. T., 24, 283, 284
278–281 Of Two Minds: An Anthropologist Looks
MFS. See Measurement feedback systems at American Psychiatry (T. M.
Miller, K. L., 162–163 Luhrmann), 43
Miller, S. M., 162–163 online supervision, 162–164
Miller, Scott, 33 online testing, 151–152
mindfulness, 92 online textbooks, 149–150

INDEX 315
optimal decision making, 9, 13, 31–33, Psychology’s Ghosts: The Crisis in the
54, 73, 225 Profession and the Way Back
OQ-Analyst (computer feedback (Jerome Kagan), 11
program), 229–230 psychopathy, 5
outcome research, 109 psychosocial learning, 297
overconfidence bias, 6, 46–47 psychotherapy
common factors in, 291
Page, A. C., 239 definitions of, xi–xii
paranoid personality disorder, 29, 197 integrative, 64
Parkinson’s disease, 44 interpersonal, 65, 79, 138, 194, 216
Partners for Change Outcome Manage- supportive, 139
ment System (PCOMS), 231 and theory, 63–64
passive-aggressive personalities, 197 unified theories of, 280–281,
patients 290–292
data of, 151–155 Psychotherapy Training e-Resources,
values and preferences of, 159–160
106–107, 181 PTSD (posttraumatic stress disorder), 10
pattern recognition publication bias, 49, 116, 132
in high-risk cases, 188
overview, 38–39 quadratic decision-making model,
Patterson, R. E., 66 181–183
PCOMS (Partners for Change Outcome
Management System), 231 randomized controlled trials (RCTs),
peer consulting, 154–155 137, 194–195
personality disorders (PDs), 177, 196– rationalism (philosophy), 286
198. See also specific rationality, 29–31
disorders, e.g.: Borderline person- Rationality and the Reflective Mind (Keith
ality disorder Stanovich), 33
personality systematics, 188 rational processing. See Slow thinking
PICOTS (populations, interventions, mode (System 2)
comparisons, outcomes, time, RCTs (randomized controlled trials),
and settings), 133–134, 137, 194–195
137–138, 141 recall bias, 47
Pierce, B. J., 66 recency effect, 7, 47–48
Pincus, A. L., 80 recognition-primed decision making
posttraumatic stress disorder (PTSD), 10 (RPD), 70–72
practice parameters. See Clinical record keeping, 264
practice guidelines Reese, R. J., 228
prescriptive indices, 134 referrals, 44
priming, 11 reflective processing. See Slow thinking
probability, 42, 50–51, 155–156 mode (System 2)
prognostic indices, 134 reflexive processing. See Fast thinking
prototypes, 14, 38, 39. See also Bias; mode (System 1)
Heuristics reframing, 44
psychiatry, 43–44, 49 Reid, W. H., 256, 257
psychoanalytic treatment, 64, 180 reimbursement policies, 108
Psychodynamic Diagnostic Manual, 287 relational processes in therapy. See
psychodynamic psychologists, 64, 194, Empirically grounded relational
283, 287, 300 principles
psychoeducative information, 151 relational psychoanalysis, 79n3

316 INDEX
representative heuristics, 5, 48 Shoben, E. J., Jr., 63, 65, 67
research. See also Evidence-based Shoham, V., 279
practice Siegle, G. J., 152
components of best available, simplified decision-making model,
106–107 180–181
decision-making, 253–255 Singer, J. A., 78
outcome, 109 Skagius Ruiz, E., 151
Riemer, M., 226, 228–229 Slade, K., 228
risk-averse psychologists, 260–261 sleep disorders, 177
risk-managed psychologists, 261–264 Slone, N. C., 228
risk management, 245–269 Slovic, P., 73, 78
case examples, 246–248, 265–268 slow thinking mode (System 2), 33–36
and clinical judgment, 257–259 biases with, 53
and critical thinking, 249–253 overview, 14
and decision-making research, Smith, M., 254
253–255 social capabilities, 254
in high-stakes clinical decision Society for Psychotherapy Research, 157
making, 187 Socrates, 249
overview, 14, 259–260 Sood, E., 28
by risk-averse psychologists, 260–261 Spada, H., 164
by risk-managed psychologists, Sparks, J. A., 228
261–264 splitting, 184
and standard of care, 255–257 standard of care, 255–257
Roberto, M. A., 26 Stanovich, Keith
Rosen, C. S., 10 on Bayesian instincts, 51
Rosenthal, R., 35, 128 classification of System 1 and 2
Rothert, M. L., 180 thinking by, 33, 36
Rousmaniere, T., 163 on clinical prediction, 35, 37
RPD (recognition-primed decision and decision making errors, 42,
making), 70–72 45, 46
Rummel, N., 164 default-interventionism model, 77
Russell, E. J., 152 and dual process models, 69
and heuristics, 26, 27
Sackett, D. L., 107 on optimal decision making, 31
Sapyta, J., 226 Stanton, M., 176
SASB (structural analysis of social Stapel, D. A., 258
behavior), 198–201, 216 stepped care, 156
schemas, 82, 216 STIC (Systemic Therapy Inventory of
schemata, 14 Change), 230–231
scientific humanistic philosophy, Stout, J., 283
276–278 Strangers to Ourselves: Discovering the
selection bias, 5, 48–49 Adaptive Unconscious (Timothy
selective treatment, 148 Wilson), 30
SEUT (structural analysis of social Stricker, G., 240
behavior), 73–75 structural analysis of social behavior
severe mental illness, 177 (SASB), 198–201, 216
Sexton, T. L., 224 subjective expected utility theory
Shanteau, J., 25 (SEUT), 73–75
Shapiro, J. P., 224 Sullenberger, Chessy, 8
shared clinical decision making, 15 Sumner, W. G., 249

INDEX 317
sunk-cost effect, 4, 48 TEST RePP (Theoretically and Empiri-
sunk-cost fallacy, 5 cally Supported Treatment and
supervision, 154–155, 162–164 Relationship Processes and Prin-
supportive psychotherapy, 139 ciples), 292–301
survivorship bias, 49 “The autonomous set of systems”
System 1. See Fast thinking mode (TASS), 90
System 2. See Slow thinking mode Theoretically and Empirically Supported
systematic reviews (SRs), 108–109, 113, Treatment and Relationship
115–116 Processes and Principles (TEST
System for Observing Family Therapy RePP), 303–305
Alliances (e-SOFT), 158–159 theory, 61–68. See also specific theories
Systemic Therapy Inventory of Change and models, e.g.: Dual process
(STIC), 230–231 model of explicit and implicit
theory
Tavris, C., 252 of automatic processing, 69–74,
Taylor, S. E., 27 76–78
teaching clinical decision making, definitions of, 294
273–302 of deliberative processing, 73–78
and evidence-based practice, explicit, 64–65
285–290 implicit, 65–68
and heuristics, 274–275 role of, 11
integrative model for, 281–285 role of, in psychotherapy, 63–64
and methodological view of science, therapeutic alliance, 196–198, 291,
278–281 297–298, 303
and paradigms in psychotherapy, therapeutic ruptures, 305
290–292 Thinking, Fast and Slow (Daniel
scientific humanistic approach to, Kahneman), 14, 33
276–278 “Thin slicing” (information
TEST RePP model for, 292–301 processing), 35
technology in clinical decision making, Todd, A. R., 78
147–167 Toland, M. D., 228
acceptance of, 165 Tracey, T. J. G., 25, 50
advantages of, 149 training, clinical, 158–164. See also
ambulatory monitoring, 154 Teaching clinical decision making
and clinical training, 158–164 trauma symptoms, 194
contact and communication treatment efficacy, 138–142
technologies, 156–157 treatment guidelines. See Clinical
future developments, 166–167 practice guidelines
and health care, 15–16 treatment manuals, 28
information available on Internet, Trierweiler, S. J., 240
149–151 The Trust (malpractice carrier), 259
patient data, 151–155 Turner, E. H., 128
probability calculations in, 155–156 Tversky, Amos, 13, 26
psychoeducative and therapeutic Type 1. See Fast thinking mode
information, 151 Type 2. See Slow thinking mode
risks with, 165–166
skillful use of, 165 Uleman, J. S., 30
video recordings, 154–155, 158–159 uncertainty tolerance, 52–54, 187, 253
Tell, R. A., 128 unified theories of psychotherapy,
termination, therapy, 266, 305 280–281, 290–292

318 INDEX
U.S. Agency for Health Care Policy and Weigold, A., 152
Research, 109 Weigold, I. K., 152
U.S. Department of Veterans Affairs Welsh, R., 176
(VA), 109, 118 West, Richard, 33
Westen, D., 189
VA (U.S. Department of Veterans Wheelan, C., 47, 49
Affairs), 109, 118 Whipple, J. L., 228
videoconferencing, 157 Williams, M. H., 256
video recordings, 154–155, 158–159 Wills, C. E., 180
virtual reality, 164 Wilson, Timothy, 30
von Neumann, John, 13 wisdom, 33, 34, 78

Wade, C., 252 Youth Outcome Questionnaire

Walfish, S., 47 (Y-OQ), 230
Wampold, Bruce, 288–289, 291
web assessment, 151–152 Zittel, 189
web-based training, 159–160 Zur, O., 256
webinars, 157

INDEX 319
 ABOUT THE EDITOR

Jeffrey J. Magnavita, PhD, ABPP, is a nationally recognized psychologist,

psychotherapist, and clinical theorist who has been in clinical practice for
3 decades. He is the author and editor of eight professional books on psycho-
therapy, personality theory, and the treatment of personality disorders, as well
as numerous chapters and articles. Dr. Magnavita has been recognized for his
work, including the American Psychological Association’s (APA’s) Award
for Distinguished Professional Contribution to Independent or Institutional
Practice in the Private Sector. He is featured in two APA videos demonstrat-
ing his unifying approach to psychotherapy. He also served as the president of
the APA Division of Psychotherapy in 2010 and is the producer of the video
series Psychotherapists Face-to-Face (http://www.divisionofpsychotherapy.
org/face-to-face/).
Dr. Magnavita’s work focuses on the unification of clinical science and
he is the founder of the Unified Psychotherapy Project (http://www.unified
psychotherapyproject.org/) and the coeditor of the Journal of Unified
Psychotherapy and Clinical Science. He is trained in a number of modalities
and approaches to clinical treatment, and his work seeks to combine the
best of all approaches to maximize treatment outcomes. His most recent

321
research interest is decision making and the use of technology in mental
health practice. Dr. Magnavita served as a member and then vice chair of
the APA Steering Committee tasked with the development of Clinical
Practice Guidelines and is a lecturer in the Department of Psychiatry at
Yale University. His most recent volume, with Jack C. Anchin, is Unifying
Psychotherapy: Principles, Methods, and Evidence From Clinical Science.

322 ABOUT THE EDITOR