Cognitive and social factors influencing clinical judgment in psychiatric practice
Authors: Howard N. Garb
Journal: World Psychiatry (2013)

M. Gladwell, in his popular book Blink: The Power of Thinking Without Thinking, stated that the “important task of this book is to convince you that our snap judgments and first impressions can be educated and controlled… Just as we can teach ourselves to think logically and deliberately, we can also teach ourselves to make better snap judgments” 1, p. 15). To help determine if psychiatrists should make snap judgments and rely on first impressions, one can turn to research on cognitive and social factors that influence clinical judgment 2. A number of studies have described how mental health professionals, including psychiatrists, make judgments. Results will be described for three of these factors: the primacy effect, cognitive heuristics, and confirmatory hypothesis testing. Gladwell 1 encouraged people to make snap judgments. Surprisingly, to a large degree, people already do this. In everyday life, people often make judgments about other people very quickly. This phenomenon is called the primacy effect, and it is also true of clinical practice. For example, as described by Kendell, “accurate diagnoses can often be reached very early in an interview, even within the first two minutes, and after five or ten minutes further expenditure of time is subject to a law of rapidly diminishing returns” 3, p. 444). Making judgments quickly saves time and energy. And judgments made quickly may frequently be correct. Still, on a personal level, we might be hurt if someone formed a negative impression of us while barely getting to know us. And when clients seek help, they might object if they learn that the psychiatrist very quickly formed impressions that were unlikely to change. Cognitive heuristics are simple rules for making judgments 4. They describe cognitive processes that allow us to efficiently process vast amounts of information, but they can cause us to make characteristic types of mistakes. As with research on the primacy effect, studies on cognitive heuristics suggest that people, including psychiatrists, will often make judgments quickly. One of the cognitive heuristics, the affect heuristic, will be discussed here. The affect heuristic refers to the effect of emotions on judgments. The impact of the affect heuristic may be especially pronounced when a judgment is based on first impressions or intuition. The affect heuristic has grown in importance for the understanding of judgments made in everyday life, but its role in the cognitive processes of mental health professionals has rarely been studied, perhaps because the effect of emotions on judgments can lie outside of our awareness. Gladwell 1 argued that people can make better snap judgments by trusting their emotions. For example, he described how several art experts had a strong negative emotional response upon seeing a statue that had been bought by the Getty Museum (a response that Gladwell labeled “intuitive repulsion”). It later became clear that the experts were right to attend to their emotional reactions as the statue was found to be a forgery. Can psychiatrists be trained to make better judgments by relying on their emotions? Everyone, including psychiatrists, already makes judgments and decisions that are based, in part, on their feelings. A training intervention for helping psychiatrists make better judgments by changing the way they rely on their emotions has not yet been described and evaluated. Research on clinical judgment supports strategies that can run counter to attending to one's emotions to guide judgments. People often become overconfident and, to counter their overconfidence, they are not told to attend to their emotions. Rather, they are typically advised to: a) consider more alternatives, b) ask more questions, and c) adhere to criteria when making diagnoses 5. Confirmatory hypothesis testing refers to seeking and remembering information that can confirm, but not refute, a hypothesis. Although it does not describe how snap judgments are made (or how initial hypotheses are generated), it does help to explain Kendell's finding that “accurate diagnoses can often be reached very early in an interview, even within the first two minutes, and after five or ten minutes further expenditure of time is subject to a law of rapidly diminishing returns” 3, p. 444). One should not encourage psychiatrists to make snap judgments if they tend to not seek or remember information that could refute those judgments. Several of the most famous studies on clinical judgment have described how social factors affect clinical judgment. Social factors include client characteristics (e.g., race) and context effects (e.g., clinical setting). Judgments and decisions made by psychiatrists are said to be biased when their accuracy varies as a function of group membership. For example, if diagnoses of schizophrenia are more accurate for White than for Black clients, then race bias is said to be present. Bias may not be present when a diagnosis is made more frequently for one group than another, because prevalence rates for the disorder may differ across groups. Biases, including gender, race, and social class biases, will not be less likely to occur if psychiatrists rely on their emotions to make snap judgments. To illustrate this point, the effect of race bias on clinical judgments will be briefly described. Research on clinical judgment suggests that race bias is more pervasive than gender bias and social class bias 2, 6. This is an especially important area of research in psychiatry, particularly with regard to the use of psychotropic medication. The methodology of the research has been sound, with race bias occurring for judgments made in real-life settings. Race bias is of gravest concern for the treatment of psychotic patients. Results from one study 7 demonstrate that it is due in part to a failure to collect information that would lead clinicians to consider additional hypotheses about their clients. This is quite different from arguing that clinicians should rely on their first impressions and make snap judgments. In this study, Black patients, compared to other patients, received a significantly larger number of psychotropic medicines, a significantly larger number of injections of antipsychotic medicine, and a significantly larger number of doses of antipsychotic medication. These differences in treatment were obtained even though the research investigators controlled for the following factors: a) level of functioning, b) presence of a psychotic disorder, c) danger to self or others or severely disabled, d) history of mental disorder, and e) whether physical restraints were used. Psychiatrists spent significantly less time with the Black patients than the other patients. When they spent more time evaluating the Black patients, the dosage of antipsychotic medicine decreased. Setting has a strong influence on treatment. For example, in a study of 338 patients treated for major depressive disorder 8, clinical setting was a better predictor of treatment than severity of depression. Large differences in the amount and type of treatment (medicine, electroconvulsive therapy, psychotherapy) were found across five medical centers. Even admission to a hospital depends in part on context. When 96 clinicians made 432 different emergency room assessments, the strongest predictor of both admission and involuntary commitment was whether the individual was self referred, accompanied by the police, or accompanied by a family member or friend 9. As noted by the authors, “the presence of violence against others or suicide appear to have considerable influence, but even these do not appear as strong as who accompanies the patient” 9, p. 50). For example, when individuals were accompanied by the police, they were almost always hospitalized. Can we teach ourselves to make better snap judgments, as hoped for by Gladwell? In the clinical judgment literature, there is no evidence that this can be done. Gladwell argued that one can become better at making snap judgments by attending to one's emotions (which clinicians already do) and by gaining a variety of experiences. For example, Gladwell recounted how an expert recognized that a statue was a forgery because it did not resemble long-buried statuary that the expert had unearthed. However, one of the most interesting findings on clinical judgment is that it can be very difficult to learn from clinical experience 10, in part because clinicians often do not receive accurate feedback on whether their judgments are right or wrong, but also because clinicians are not always aware of how social factors affect their judgments, and because cognitive processes are imperfect. Forming sudden impressions and being influenced by one's emotions are an ingrained part of the process of how we make judgments. This is unlikely to change. Nor should it change. But after quickly forming an impression of a client, clinicians should collect additional information and consider alternative hypotheses. Our goal should be to think logically and deliberately – not to become better at making snap judgments. The views expressed in this article are those of the author and are not the official policy of the Department of Defense or the United States Air Force.