Developing Your Clinical Decision Making when the Evidence to Guide You is Scant
CLINICAL DECISION MAKING is primarily focused on determining what course of action is in the best interest of those being treated. Determining which interventions are best for a particular client at a particular time, and which ones are inert or might even be harmful, is one of the most challenging and complex aspects of clinical practice. Providing high-quality evidence-based practice informed by the best information through the lens of clinical expertise is the foundation in how to make optimal decisions, given the many choices available. Clinical decision making is a process that guides assessment and treatment planning. Effective decision making involves gathering relevant information, considering, and evaluating alternatives, making judgements relatively free of biases, and appraising the outcomes of our decisions. Decision making should be based on information about options and outcome probabilities, disclosure of conflicts of interest, best empirical evidence, and high quality of decision-making effectiveness.
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Clinical decision making is improved when we are informed about the biases in our thinking. Many of these have been identified in the work of Daniel Kahneman and his associates and have application to clinical practice. We present some of the common cognitive biases. If you are interested in learning more see this volume on Clinical Decision Making in Mental Health Practice.
Clinical decision making
System 1—The “Fast” Processor Essential for Survival but Notorious for Bias
System 1—The “Fast” Processor Essential for Survival but Notorious for Bias
System 1—The “Fast” Processor Essential for Survival but Notorious for Bias
Operating automatically with little or no voluntary control, System 1 is the rapid processor or the fast-thinkingsystem (Kahneman, 2011). It is easy to be seduced by System 1 thinking, which is relatively effortless, non- conscious, and utilizes intuition.
System 2—The "Slow" Deliberate Processor
System 1—The “Fast” Processor Essential for Survival but Notorious for Bias
System 1—The “Fast” Processor Essential for Survival but Notorious for Bias
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. how to cultivate a more present and mindful approach to life, and reduce stress and anxiety.
Decision making biases or cognitive traps
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).
Availability Bias
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).
Confirmation Bias
In confirmation bias, we look for information that supports our beliefs and affirms our perspective while neglecting or selectively reinterpreting evidence that contradicts this perspective.
Endowment Effect
People have a tendency to be biased toward the status quo, a phenomenon termed the endowment effect (Stanovich, 2010). “Endowment effects result from loss aversion and are a special case of even more generic status 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).
Narrative Fallacy
We humans are marked by a tendency to weave together facts and observations into what seems to be a coherent narrative, even when the facts are not meaningfully related.
Overconfidence Bias
It is well known that most professionals (e.g., physicians, psychotherapists, economists, lawyers) tend to overestimate their knowledge and ability, 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.