clinical judgment as a function of experience and information

Demographic Variables 721

9. HUBBARD, R. M. and ADAMS, C. F. Facton affecting the succws of child guidance treatment.

10. KELLNER R. The evidence in favor of sychotherapy. Brit. J. med. Paychol., 1967,40,341-358. 11. LEVINE, b. and WITTENBORN, J. R. gelation of expressed attitudes to improvement In func-

12. LEVITT, E. E. The results of psyckotherapy with children: An evaluation. J. consult. Psychol.,

Amer. J . Orthopsychid., 1936, 6, 81-102.

tional psychosis. Psychol. Rep., 1970 $6, 275-277.

1957. bl. 189196. 13.

14.

L E v I ~ , E. E. Psychotherapy with children: A further evaluation. Behuv. R e . Ther., 1963, 1, 45-51.

LEVITT, E. E., BEISER, H. R. and ROBERTSON, R. E. A follow-up evaluation of cases treated at a community child guidance clinic, H. R. Fontenzer, discussant. A w . J. Orthopsychid., 1959, 39, 337-349.

15. RICH, G. J. Preschool clinical service and follow-up in a city health department. A m . J. Otthopsychzat., 1948, 18 134139.

16. ROSENTHAL, A. J. and LEVINE, S. V. Brief psychotherapy with children: A preliminary report. Amer. J. Psychiat., 1970, 197, 646-651.

17. SALZBERO, H. C. Group psychotherapy screening scale: A validation study. Intetnat. J. group Psychother., 1969, 19, 226-228.

18. SALZBERO, H. C. and BIDUS, D.R. Development of a group psychotherapy screening scale: An attempt to select suitable candidates and predict successful outcome. J. clin. PSYChol., 1966, 19, 478-481.

19. SALZBERO, H. C. and HECKEL, R. V. Psychological screening utilizing the group approach. Inlernat. J. group Psycfwther., 1963, 15, 214215.

20. SIFNEOS, P. E. The motivational process: A selection and prognostic criterion of psychotherapy of short duration. Psychiat. Quart., 1968, 42, 278-280.

21. SIFNEOS, P. E. Change in patients' motivation for psychotherapy. A m . J. Paychat., 1971, 198, 718-721.

22. WAHLER, R. G. and ERIKSON, M. Child behavior therapy: A community program in Appalachia. Beh. Res. Ther. 1969, 7, 71-78.

23. WITMER, H. h. A comparison of treatment results in various types of child guidance clinics. Amer. J. Orthopsychirct., 1935, 36, 351-360.

CLINICAL JUDGMENT AS A FUNCTION O F EXPERIENCE AND INFORMATION

DAVID BRENNER' AND KENNETH HOWARD

Colgate University Northwestern University and Institute for Juvenile Research

PROBLEM Calvin and Cutin(2) have described cliriical judgment as a synthesis of impres-

sions-a process that involves reaching a decision by weighing and combining bits of information. It commonly is assumed that the more information one has relevant to a particular judgment, the more likely it is that the judgment will be accurate. However, the research in this area is contradictory. For example, Bartlett and Green (l) asked experienced psychologists to predict student grade-point average under two conditions4 predictors and 22 predictors-and found that the use of 4 predictors resulted in significantly better performance than did the use of the full set. Gordon(5* *. 11) found predictions of success in the Peace Corps to be equally accurate with four quantities of information available, "the cheapest approach being as effective as the most complex and costly." Similar results have been obtained elsewhere", 8 p lo, 16- le).

On the other hand, Potkay and Ward(la), who used 195 clinical psychologists, found, in some instances, that personal data alone resulted in more accurate judgments than personal data plus Rorschach responses, but that in other instances the opposite was true. Moxley'") found that accuracy of prediction of length of

'This article is based on the senior author's doctoral dissertation at Northwestern University.

722 Journal of Clinical Psychology, July, 1976, Vol. 32, No. 3.

hospital stay did increase as amount of information available to the judges increased. Moxley also studied the extent of experience of clinical psychologists and found a lower proportion of correct judgments for less experienced judges under the reduced levels of information. However, her finding that, in general, experienced clinicians were no more accurate than less experienced clinicians is not an uncommon one. For example, after an extensive review of this literature Smith

“Are professional psychologists more sensitive than graduate students in psychology? No. Are clinical psychologists more sensitive than experimental psychologists? No. Are professional psychologists more sensitive than physical scientists, actors, personnel managers, and members of other professional groups? No.”

(18, PP. 7-8) stated:

More recent studies support these conclusions

Because of the need to obtain quantifiable data, many of the above-cited studies have used tasks of questionable relevance to the daily activities of clinical psychologists-e.g., predictions have involved grade-point average, success in graduate school, success in the Peace Corps, length of hospital stay, and scores on personality tests. Although some special groups do make such predictions from time to time, there is really no reason to presume that a clinician not involved in such practices regularly would be particularly skilled at them. However, one ability that virtually is indisputably essential to the day-to-day activities of those clinicians involved in psychotherapy is empathy with their clients. Regardless of one’s therapeutic bent, there is overwhelming agreement that, other factors being equal, the more a therapist empathizes with a client, the more potentially helpful is that therapist.

The present study examined the effects of experience and information on the empathic clinical judgments of clinical psychologists of three experience levels and with four amounts of available information. The questionnaire used was the Therapy Session Report (TSR) , which is described extensively elsewhere ( l 2 ) . The TSR is a structured-response questionnaire in which a client describes personal thoughts and feelings during and about an actual psychotherapy session.

It was predicted that, on the areas of the TSR that allowed the most room for speculation and interpretation, as more information was made available to the experienced therapists, their efforts to integrate and use it would result in con- fusion, a distancing from the client, and a corresponding decline in empathic accuracy. On the other hand, the accuracy of the neophyte therapists would increase as the amount of information increased. Although initially the neophyte therapists would be much less “tuned in” to the client (11), they would become more accurate over time by focussing on only a small amount of information, ignoring complex information, and very infrequently interpreting what they heard.

11* 14).

METHOD Subjects. Six groups of 18 judges were used. Three of these groups were of

therapists, and for each of these groups there was a control group of approximately equivalent age and intelligence.

The mean age of the least, intermediate, and most experienced therapists was 25, 30, and 39 years, respectively. The mean amount of psychotherapy experience for each of these groups was 4, 400, and 3,000 hours, respectively.

Second- and third-year graduate students in some branch of psychology other than clinical psychology comprised the control group for the least-experienced therapists. For the intermediate-level therapists, third- and fourth-year graduate students and three very recent Ph.Ds comprised the control group. For the most experienced therapists, the control group consisted of Ph.D. university professors in various disciplines. The mean age of the three control groups were 23,31, and 44.

Clinical Judgment as a Function of Experience and Information 723

The Tapes. Six psychotherapy audio tape recordings were used. Within each of the six groups, each tape was heard by three judges.

The Therapy Session Report. For purposes of data analysis, the TSR was divided into 13 sections. All items on the TSR concerned the patient during the therapy session just completed. These sections (and the number of items in each section) were :

1.

2. 3. 4. 5.

6. 7.

8.

9.

10. 11.

12. 13.

Session Evaluation - one item that asked the patient how he felt about the session. Goals - 14 items that asked what the patient’s goals were. Concerns - 12 items that asked what his problematic concerns were. Feelings - 33 items that asked what his feelings were. Interpersonal Behavior - eight items related to his interactions with the therapist. Motivation - one item that asked how he felt about coming to the session. Progress - one item that asked how much progress he made with his problems. Personal Functioning - one item that asked how he is getting along at this time. Anticipation - one item that asked how much he is looking forward to the next session. Satisfactions - 13 items that asked what he felt he got out of the session. Therapist Understanding - one item that asked how well his therapist seemed to understand him. Therapist Helpfulness - one item that asked how helpful his therapist was. Self-experience - eight items that asked about how he experienced him- self.

Procedure. All judges filled out the TSR before they heard the tape-recorded session. Judges who were to hear a recording of a female client were asked to fill out the TSR “like a typical female client.” Those who were to hear a recording of a male client were asked to fill out the TSR “like a typical male client.”

One-third of the tape was played (approximately 16 minutes). The tape then was shut off, and the judges were asked to fill out the TSR just as they thought the client did at the end of the session. Then, they heard the next third of the tape and again were asked to fill out the TSR as they thought that client did at the end of that session. Finally, the remaining third of the recording was heard, and the TSR was completed for the final time.

It was felt that different thirds of the tape might be more relevant or useful to the judges; consequently, the order of persentation of the taped material was counterbalanced across the six groups. One-third of each group heard the material in its natural order ( i e . , beginning, middle, end). One-third of each group heard the middle first, then the end, and then the beginning. And, finally, one-third of each group heard the end, then the beginning, and then the middle. All judges filled out the TSR four times.

Confidence estimates were obtained on each trial (except the stereotype trial) on those TSR sections with more than one item. The “Interpersonal” and Intra- personal” scales were combined. Thus, there were five “confidence percents” for each judge on each of the final three trials.

RESULTS Two-way repeated measures analyses of variance(lg) were used to test the

experimental hypothesis. Two groups were used in these analyses (the least and the most experienced psychotherapists).

Absolute difference scores were used in the data analyses. For each of the four trials that the TSR was filled out, every response of each judge (there was a

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total of 95 items across all 13 sections) was subtracted from the response actually made by the client on that item. Thus, a low absolute difference score on any given item or section of the TSR represents a more accurate matching with the client than a high score. A mean difference score then was computed for each of the 13 sections of the TSR. Finally, each of these 13 means was converted to a common metric with a range of possible absolute mean difference scores from “0” (most accurate) to “20” (most inaccurate).

Generally speaking, the judges performed reasonably well on the experimental task. The actual difference scores were less than half of what they maximally might have been. For example, in Tables 1 and 2 below the highest absolute difference score was 7.8. These scores are quite representative of those obtained for all six groups.

The hypothesis was that, on the more inferential sections of the TSR, as amount of available information increased, the accuracy of the most experienced therapists would diminish and the accuracy of the least experienced clinicians would increase. The inferential sections were: Session Evaluation, Motivation, Progress, Anticipation, Satisfactions, Therapist Understanding, Therapist Help- fulness, and “Intrapersonal.” The content areas represented by these sections are discussed directly in sessions much less than are the other areas (e.g., Feelings, Concerns). The stereotype trial was not included in the analyses reported below unless otherwise indicated.

The hypothesis was supported on four inferential TSR sections. These were: Progress ( F = 4.3, df = 2/68, p < .05), Anticipation ( F = 7.2, df = 2/68, p < . O l ) , Satisfactions ( F = 5.2, df = 2/68, p < .Ol), and Intrapersonal ( F = 5.6, df = 2.68, p < .01). On these four sections the Experience X Information interaction was statistically significant. Also, in these four sections the interaction was in the predicted direction.

The amount of information available was a significant variable for Goals ( F = 3.3, d f = 2/68, p < .05) and Concerns ( F = 3.2, df = 2/68, p < .05). On both sections, accuracy increased as amount of information increased. For 11 of the 13 sections, accuracy did not increase significantly as the clinicians heard more of the session.

Experience as a therapist was significant on Therapist Underst,anding ( F = 5.4, df - 1/34, p < .05) and Therapist Helpfulness ( F = 5.4, df = 1/34, p < .05). In both sections the least experienced therapists were significantly more accurate than the most experienced therapists.

When the data from all six groups (three experimental and three control) were combined, the intermediate-level therapists (who had 400 therapy hours of experience) were the most accurate 7 of 13 times. The probability that this would occur by chance is less than .05 according to Seigel’s‘”) binomial test. The most experienced clinicians were the least accurate 6 of 13 times ( p < .05). Next, analyses were done for the six groups including the stereotype trial. For Session Evalua- tion ( F = 7.5, df = 3/306, p < .O l ) and Therapist Helpfulness ( F = 7.4, d f = 3/306, p < .Ol), the stereotype trial was significantly more accurate than the others. For each level of information, the effect of profession (clinician vs. non-clinician) was analyzed. Significance was found only a few times in the 52 analyses (4 amounts of information by 13 TSR sections); there was no trend to these few significant differences.

Very few reached statistical significance. But, again using Seigel’s binomial test (17),

when the confidence estimates of the 54 therapists were combined 11 of the 15 confidence ratings were correlated positively ( p < .05) with accuracy. The 54 control judges also had 11 of 15 correlations in the correct direction ( p < .05). When the correlations of each of the six groups were examined separately, only the most experienced clinicians had a statistically significant number of positive correlations (13 out of 15, p < .Ol ) .

Finally, the correlations of confidence with accuracy were examined.

726 Journal of Clinical Psychology, July , 1976, Vol. $2, No. 3.

DISCUSSION The hypothesis was that-on the inferential TSR sections-as amount of

information increased, the accuracy of the most experienced therapists would decrease and the opposite would occur for the least experienced therapists. The hypothesis was supported on four of the inferential TSR sections (Progress, Antic- ipation, Satisfactions, Intrapersonal). As predicted, this interaction did not occur on the less inferential TSR sections, the content of which actually was discussed on the tape recording. When asked to make abstract, inferential judgments, as opposed to concrete, objective ones, the most experienced therapists became less empathic with the clients the more they heard them. This decrease in empathic accuracy did not occur for the least experienced therapists.

It seems reasonable to assume that, as the most experienced therapists heard more of the taped therapy sessions, they attempted to integrate as much of the information as they possibly could. These efforts led to a decrease in empathic accuracy on many of the inferential TSR items. On the other hand, the least experienced therapists (with an average of 4 hours of experience as psychotherapists) probably were overwhelmed by the complexity of the the therapy session itself and the experimental task and, as a consequence, became more accurate the more they heard.

It may be that to attend to all of the subtleties, inflections of voice, slips of the tongue, etc., does not help one to understand a patient at any given moment. It may not be possible for even the most experienced therapists to use accurately the overwhelming amount of information presented in one psychotherapy hour. It may be that the patient is not attending to these cues, and in the empathy process it is the patient’s feelings and experiences that. must be identified. For example, one clinician in the most experienced group (with many thousands of hours of psychotherapy experience) said, when he was attempting to fill out the TSR like a female patient he had just heard, “I know what’s going on with this woman, but I don’t know if she does.” A clinician’s hypothesis with regard to unconscious material or one that is based on a combination of much disparate information may be valid, yet, paradoxically, may distance him from the patient.

A finding similar to the main finding of this study was reported by Howard”), who attempted to estimate the reliability and validity of projective test ratings as a function of the objectivity of the traits rated. It was found that the further one moved from the actual test performance, the poorer was the reliability of the estimate. Accuracy increased as the ratings became less inferential.

In addition, there is mathematical support for the notion that when one attempts to increase the accuracy of his clinical judgments, attempts should not be made to integrate as much information as possible, even if all of the information is relevant to the judgment at hand. Cronbach@) has pointed out that in this type of empathy research, when a judge increases the amount of information he considers while he is making a judgment, the variance of his responses increases. As a consequence, the magnitude of his errors increases. He concluded that this mathematical consideration contradicts the view that judgment always is im- proved by taking into account additional valid information. This reasoning of Cronbach supports our speculation that the most experienced clinicians decreased in accuracy as amount of information increased because they tried to use too much of it.

Another significant finding of the present study was that on the Therapist Understanding and Therapist Helpfulness sections of the TSR, the least-experienced therapists were significantly more accurate than the most experienced. These two TSR sections were the only ones in which the patient reported perceptions of the therapist. The data revealed that in both of these sections, the experienced therapists erred consistently in one direction-they were excessively critical of the therapists on the tape recordings. That is, if a patient judged his therapist as, say, “very helpful,” the majority of experienced therapists rated that therapist


as “not at all helpful” or “somewhat helpful.” This tendency was not found in any other experimental or control group. This finding may have many implications, some of which are relevant to psychotherapy supervision and consultation done by tape recording. Namely, one may be critical of the therapist on the tape, and this criticism may result in a diminished understanding of the patient.

The most dramatic evidence for the notion that inferential judgments might best be made without maximum amounts of information available was obtained when the stereotype trial was included in the data analysis. On four inferential TSR sections (Session Evaluation, Therapist Helpfulness, Therapist Understanding, and Progress) the stereotype ratings-ratings made before the tape. recording was heard-were more accurate than any other. On two of these (Sesslon Evaluation and Therapist Helpfulness) this difference in accuracy was statistically significant. This result is quite consistent with a finding of Knestrick and Gorlow@) in which information relevant to a series of predictions failed to provide a significant increase in accuracy beyond predictions made with only gross stereotype information available.

Overall, the most accurate group was the intermediate-level therapists. It is possible that they used an optimal amount of information ( i e . , more than the least-experienced therapists and less than the most-experienced therapists). The fact that the three therapist groups combined did perform better than the three nontherapist groups is consistent with much of the literature reviewed above.

One of the few encouraging findings with respect to the most experienced therapists is that, according to the correlations of confidence with accuracy, they were more sensitive to themselves than any other group. More than any other group, they knew when they were empathizing with the patients, and they knew when they were not. It is likely that the years have taught them what a difficult task it is to empathize with another person.

Finally, we wish to underscore the potential of the TSR as a measuring in- strument in this type of research. When the TSR is used, clinicians make judgments relevant to their day-to-day activity, a feat seldom achieved in the clinical judgment literature. As a consequence, findings obtained with the TSR are of particular interest. In this initial study, we have located specific areas of strength and weakness of clinicians of different degrees of experience. Such findings may help alert clinicians to the types of judgments that are the most difficult for them.

SUMMARY This study of empathic clinical judgments of audio tapes of therapy sessions

employed three groups of psychotherapists with differing amounts of experience. It was predicted that, on the more inferential judgments, the most experienced group would decrease in accuracy as more information was made available to them and that the opposite trend would occur with the least experienced therapists. The hypothesis was supported for many of the inferential judgments made. Overall, the intermediate-level therapists were the most accurate group. The most experienced therapists were best at evaluating their accuracy. These and other results, and the unique potential of the measuring instruments used, are discussed.

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2.

BARTLETT, C. J. and GREEN, C. G. Clinical prediction: Does one sometimes know too much? J . counsel. Psychol., 1966, 13, 267-270.

CALVIN, J. S. and CURTIN, M. E. Learning of probabilistic cue judgments. Paper presented a t Southwestern Psychological Association, Atlanta, 1958. Cited by Lee, J. S. and Tucker, B. R. An investigation in clinical judgment: A study in method. J . abn. SOC. Psychol., 1962, 64, 272-280.

CRONBACH, L. J. Processes affecting scores on “understanding others” and“assumed similarity.”

CURTIS, G. C., SMITH, W. G., KORDASY, F. and FOGEL, M. L. The influence of amount and type of information on the rating of effect. J . nero. ment. Dis., 1967, 144, 123-132.

GORDON, L. V. Clinical, psychometric, and wbrk-sample approaches in the prediction of success in Peace Corps training. J . uppl . Psychol., 1967, 61, 111-119.

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HORNSTEIN, D., HOUSTON, B. K. and HOLMES, D. S. Clients', therapists', and judges' evalua- tions of psychotherapy. Counsel. Psychol., 1973, 10, 149-58.

HOWARD, K. I. Ratings of projective test protocols as a function of degree of inference. Educ. psychol. Monogr., 1963, 23, 267-75.

HUNT. W. A. and WALKER, R. E. Validity of diagnostic judgment as a function of amount of test information. J . c l h . Psychol., 1966, 17, 1.54-155.

KNESTRICK, J. L. and GORLOW, L. Effect of information, subject age, and instructional set on predictive 'udgmcnts. J . consult. elin. Psychol., 1969, 3.9, 691-698.

10. MERRENS, i f . R. and RICHARDS, W. S. Length of personality inventory and the evaluation of a generalized personality interpretation. J . pers. Assess., 1973, 37, 83-85.

11. MOXLEY, A. W. Clinical judgment: The effects of statistical information. J . pers. Assess.,

12. ORLINSKY, D. E. and HOW-ARD, K. I. The experience of psychotherapy: A prospectus of the Research Report, 1966, 3-8, Institute for Juvenile Research,

13. POTKAY, C. R. and WARD E. F. Clinical judgment under varied informational conditions:

14. SATTLER, J. M. and RAYAN, J. J. Scoring agreement on the Stanford-Binet. J . elin. Psychol.,

15. SCHUM, D. A. Prior uncertainty and amount of diagnostic evidence as variables in a probabilis-

16. SCHWARTZ, M. L. Validity and reliability in clinical judgment of C-V-S protocols as a function

17. SIEGEL, S. Nonparametric Statistics for the Behavioral Sciences. New York: McGraw-Hill, 1956. 18. SMITH, H. C. Sensitivity to People. New York: McGraw-Hill, 1966. 19. WINER, B. Statistical Principles in Experimental Design. New York: McGraw-Hill, 1962.

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A COMPARISON OF BLACK AND WHITE ADOLESCENTS ON T H E H T P THOMAS L. KUHLMAN VYTAUTAS J. BIELIAUSKAS

Case Western Reserve University Xavier (Ohio) University

PROBLEM A growing body of research has been reported in which personality differences

between American blacks and whites have been investigated through projective techniques. Many of these studies report findings none too flattering to the minority group. Price(12) and Ames") with the Rorschach; Mussen@) with the TAT; Peter- son and Telford'lO), Lindner("', and Vane and Kessler(la) with human figure drawing techniques-all obtained results that indicated or intimated the poorer psychological adjustment of their black Ss.

Pettigrew'll) has criticized such studies on a number of grounds, the most cogent (and remediable) of which are methodological. He argues that the black and white groups studied are frequently not comparable due to differences in intelligence and/or socioeconomic level. Furthermore, blacks typically have been ex- cluded from the standardization samples of these tests, a criticism echoed by Megargee @).

hammer's('^ 6 , research with the House-Tree-Person (HTP) drawing test was a specific focus of Pettigrew's criticisms. He conducted a study that compared the H T P drawings of black and white school children. The drawings were assigned 'ratings for psychological adjustment and hostility and aggression by three clinical psychologists. Hammer concluded from the results that black children are more maladjusted and hostile and aggressive than white children. However, his conclusions seem contestable in view of the fact that Hammer drew his black and white samples from different schools and made no attempt to control for either intelligence or socioeconomic level.

clinical judgment as a function of experience and information

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