Clinical Judgment and Truth

As mental health professionals, we are quite earnest and take pride in having assiduously high standards for delivering and judging our own work. However, how often and in what ways are we held accountable for our results?

Here is what I mean. In last quarter’s newsletter, I discussed Owen, our 21-year-old disheveled college dropout who was in treatment with me (Steve Frankel). There is no question that I desperately wanted Owen to progress. How, though, could I have been entirely objective about Owen’s progress? If Owen remained stuck in his life for the year he was in treatment with me, pending his return to college, I could have comforted myself with the notion that he hadn’t been a good candidate for psychotherapy or that I hadn’t had enough time to work with him. After all, I did all the right things and even got psychological testing, although admittedly I waited until he was well into treatment before doing that.

So, please give me a break. There was nothing more I could do.

Or was there?

Time to take out the magnifying glass. Well, OK, I did leave out of my list the semi-formal personality evaluations that clinicians can make by themselves as treatment progresses. I am referring to the disciplined review available to any practitioner in our field. These “truing measures” are a bit time consuming and many clinicians, like myself in this instance, may regard them as a an inconvenience.  An example of the kind of personal housekeeping available to the therapist is the self-monitoring method I describe as an “SO analysis” in my first three books, or the self-supervision that Patrick Casement describes in his books. Using these techniques the  therapist becomes his or her own critic, momentarily stepping  back from the emotion generated in the treatment. It also took a while for me to get a second clinical opinion, in this case from the psychologist who would do the psychological or neuropsychological testing. Again, these both are steps that mental health professionals typically bypass either because they are time consuming or not reimbursed.

Compare this approach to medical treatment. If the patient has an anemia, what would you think of a doctor who didn’t follow up a complete blood count with an extensive search for occult bleeding, or a screen to determine if nutritional factors such as iron or vitamin B12 or maybe even a parasite could be implicated in causing the anemia? Follow-through in medicine is rarely accomplished in a single step. Multiple specialists may need to be called in. In medicine, this level of rigor and follow-through would not surprise any of us. It’s not rocket science. In our own fields, however…

This reasoning leads me to think about Eduardo, a patient I discuss in Evidence from Within: A Paradigm for Clinical Practice (2008). It’s a bit embarrassing, but I worked with Eduardo for several years off and on, always believing I knew who he was diagnostically and personally. No reason to question my clinical judgment, after all I had already been doing this kind of stuff for 25 years when I began to work with him. During the initial work we got along swimmingly and he clearly progressed. As I saw it, at bottom he was a decent, albeit somewhat moralistic, young man who had been scapegoated by his parents. That was my clinical judgment. “Sociopath” was the furthest diagnosis from my seasoned clinical mind. And yet that turned out to be what he was: unattached, out for what he could get. The testing clinched it.

Doctor Frankel! You shoulda gotten a second opinion and testing years earlier. Careful of that ego, Doc.

Of course, it is no surprise that we are stuck with both the comfort and uncertainty of opinion as we do our clinical work. However, remembering that our clinical judgments — even when backed up by endless experience, good training, and even data — are all ultimately reflections of our opinion, should keep us on track. And, there are ways to repeatedly bring these judgments into focus, making them progressively more true to what will ultimately prove to be the clinical reality of that treatment situation.

Here we must examine our methods of verification. In addition to psychological and neuropsychological testing, we have the powerful benefit of patient-therapist collaboration. Whatever else we use for confirmation of our clinical hypotheses, this process of deliberate collaboration between clinician and patient and respect for the inadvertent yet continuous feedback between the two, in fact, is at the heart of our clinical  philosophy at the Center for Collaborative Psychiatry, Psychology and Medicine. We believe that if the collaborative methods I  mention  in Making Psychotherapy Work: Collaborating Effectively with Your Patient (2007), namely, those involving ongoing evaluation of progress with our patients, are attended to regularly, most errors in clinical judgment will eventually show up. One of you, therapist or patient, will catch them. Apart from your discerning mind and clinical rigor, all you need is collaboration with your patient in a truly bilateral and open manner. You are then likely to succeed in your clinical enterprise.

References:

Engelman, D. and Frankel, S. (2002). “The Three Person Field: Collaborative Consultation to Psychotherapy.” The Humanistic Psychologist. 30:49-62

Finn, S (2007). In Our Client’s Shoes, New Jersey: LEA.

Henderson, R. and Keiding, N. (2005). J. Med. Ethics, 2005, 31:703-706.

Meyer, G. J., Finn, S. E., Eyde, L. D., Kay, G. G., Moreland, K. L., Dies, R. R., et al. (2001). “Psychological testing and psychological assessment: A review of evidence and issues.” American Psychologist, 56, 128-165.

Meyer, G. (2004). “The Reliability and Validity of the Rorschach and Thematic Apperception Test (TAT) Compared to Other Psychological and Medical Procedures: An Analysis of          Systematically Gathered Evidence.” In: M. Hilsenroth and D. Segal (eds). Comprehensive Handbook of Psychological Assessment, Hoboken, N. J., Wiley.

Viglone, D. and Meyer, G (2008). Handbook of Forensic Rorschach Assessment, an Overview of Psychometrics, New York, Routledge.