 The Association for Family Therapy 1999. Published by Blackwell Publishers, 108 Cowley Road, Oxford, OX4 1JF, UK and 350 Main Street, Malden, MA 02148, USA. Journal of Family Therapy (1999) 21: 339–359 0163–4445 A contextual perspective of clinical judgement in couples and family therapy: is the bridge too far? David C. Iveya, Michael J. Scheelb and Peter J. Jankowskic This paper reviews the clinical judgement literature and discusses its applicability to the practice of couples and family therapy. Key findings and conceptual foundations are highlighted. A contextual perspective is advocated to guide future investigations and to enhance the generalizability of the literature to the real-life experiences of therapists. Suggestions for theory development and future research are provided. The ascribed importance of therapist judgement to the clinical and counselling practices of psychology, psychiatry, social work, marriage and family therapy, and other mental health disciplines is perhaps best exemplified by the burgeoning numbers of texts devoted to interviewing and assessment. Articles and volumes are published at an exponential rate detailing the evaluative, diagnostic and treatment planning arts employed by mental health practitioners. Such attention is paralleled in formal training and continuing educational experiences. Over the course of a typical therapist’s career, substantial time and energy is invested in activities designed to enhance his or her ability to accurately and efficiently determine the nature of client concerns and appropriate plans for intervention. Practitioners are consequently impressed early on in their development with the critical, if not central role of clinical acumen. Therapists commonly subscribe to the premise that client outcomes are, in the main, attributable to their personal proficiency in assessment and treatment decision-making. Amplified by the growing influence of managed care, practitioners a Marriage and Family Therapy Program, Texas Tech University, Box 41162, Lubbock, TX 79309–1162, USA. b Department of Educational Psychology, University of Utah. c Marriage and Family Therapy Program, Texas Tech University.  1999 The Association for Family Therapy and Systemic Practice 340 David Ivey et al. often experience trepidation, derived both internally and externally, associated with their evaluative and intervention planning skills. Despite the apparent availability of numerous resources, pragmatic guidance geared towards the enhancement of practitioner judgement is generally limited. In contrast to the proliferation of diagnostic guides, instruments and procedures, few materials address in depth the means by which therapists personally incorporate and employ the presented clinical information. The numerous articles and texts that examine the processes of interviewing and assessment often overlook the complex perceptual, processing and higher-order mental tasks required of therapists. The resources that specifically address clinical judgement are themselves often of limited utility due to their poor correspondence with the real-life activities and needs of therapists. Their applicability is undermined by their failure to account for the individual differences between therapists and the unique demands presented by each clinical situation. Due to the absence of clearly defined and pragmatic resources, practitioners, by and large, rely heavily on personal experience to acquire clinical judgement skills. As a result, many fail to gain confidence regarding their abilities while others are at a loss to recognize areas of weakness and avenues for development. These concerns are nowhere better demonstrated than in the field of couples and family therapy. Practitioners who work with couples and families find very few practical resources to enhance their evaluative and clinical decision-making skills. The apparent simple and straightforward process of determining client concerns, problem severity, treatment needs and intervention modality is often in actuality a cumbersome and stressful enterprise. Dilemmas regarding whom to include in treatment, which methods to use and what the focus of intervention should be present particularly complex demands for the couples and family therapist. As a means to determine the basis for the apparent limited resources, the current discussion examines the applicability of the existing clinical judgement literature to practice. Specifically, this paper addresses whether an oversight has occurred in the study of clinical judgement with respect to the practice of couples and family therapy. For the purposes of this discussion, clinical judgement will initially be defined as the perceptual, evaluative and decision-making processes engaged in by practitioners in an attempt to understand clients and to provide assistance relevant to identified  1999 The Association for Family Therapy and Systemic Practice Clinical judgement 341 problems. Such processes encompass an infinite and interacting array of perceptions, actions, feelings and cognitions (Mahoney, 1988). Couples and family therapy will refer to a therapeutic approach that is based in a systemic orientation. Following a brief review of the clinical judgement literature, conclusions will be offered pertaining to the status and relevance of the existing findings. Implications for a systemic orientation, underlying philosophical and epistemological assumptions, and suggestions for future research will be presented. It will be argued that a contextual perspective presents a means to resolve the identified concerns. In particular, we will suggest that through the development and application of contextually informed models of clinical judgement useful methods for the enhancement of the practitioner’s ability to effectively integrate clinical information and to make therapeutic choices will be most likely to evolve. The study of clinical judgement Interest in the perceptual, diagnostic, prognostic and treatment decision-making activities of mental health clinicians can be traced throughout the history of counselling and psychotherapy (Bieri et al., 1966). Concerted enquiry was not realized however until somewhat recently. The contemporary phase of clinical judgement research is limited to a span of four decades. Meehl’s (1954, 1957) discussions of the comparative utility of subjective or intuitive processing of clinical information (clinical) versus statistical or mechanical information-processing (actuarial) mark the starting point from which systematic scientific enquiry spawned. The results of clinical judgement research obtained during the contemporary era generally provide discouraging evidence (Goldberg and Werts, 1966; Little and Schneidman, 1959; Meehl, 1954; Oskamp, 1965). In a now classic study using the BenderGestalt Test, Goldberg (1959) found that the judgement accuracy of psychologists failed to exceed that of secretaries. Oskamp (1965) found that judgement accuracy did not relate to training in a study comparing the assessments of clinical psychologists and nonclinical judges utilizing detailed case history information. The performance levels in both studies barely exceeded chance. Kendall (1973) found that psychiatrists’ ability to make valid diagnoses for psychological problems was not related to length of experience. Similar results were reported for the ability to predict  1999 The Association for Family Therapy and Systemic Practice 342 David Ivey et al. patient assaultiveness on an inpatient psychiatric unit in a study involving thirty psychologists and psychiatrists (Werner et al., 1983). It was found that the validity of clinical prediction was not significantly related to total years of experience or to length of experience in acute inpatient settings. Gardner et al. (1996) found that actuarial predictions of violence by patients diagnosed with mental illness outperformed predictions by clinicians. Evidence from studies involving projective (Levenberg, 1975; Silverman, 1959; Turner, 1966; Wanderer, 1969; Watson, 1967) and objective personality test data (Graham, 1967; Oskamp, 1967; Walters et al., 1988) generally support the absence of a relationship between training, experience and judgement validity. Similar findings have been produced in studies involving the specialized practices of neuropsychology (Faust et al., 1988), social work (Berman and Berman, 1984) and counselling (Pain and Sharpley, 1989). These studies provide but a small sample of the available evidence. Findings consistently support the contentions forwarded by the early scholars that clinical judgement is unreliable, minimally related to confidence and experience, relatively unaffected by the type or amount of information available, and rather low in validity on an absolute basis (Goldberg, 1968). Conceptual developments Of the three primary theoretical orientations underlying the contemporary study of clinical judgement (Rock et al., 1987), and their many variants (Cooksey, 1996), the information-processing perspective has been dominant. The tenets of information-processing theory have remained the principal source to guide investigations and remain the primary conceptual lens through which available findings are interpreted and applied. Consequently, the history, status and evolution of the clinical judgement literature cannot be fully appreciated without consideration of the assumptions of the information-processing model. The information-processing perspective can be generally categorized as mechanistic and rationalistic. It emphasizes the inward and linear flow of information from the environment to the sense organs and subscribes to the notion that knowledge is a product of sequential and selective processing. Information-processing models maintain that sense data are useful to the extent that accurate and valid cognitive representations of an objective environmental reality are  1999 The Association for Family Therapy and Systemic Practice Clinical judgement 343 developed. Variability in judgement is assumed to occur as a result of faulty or incorrectly utilized methods for integrating and synthesizing information (Anderson, 1990; Merluzzi et al., 1981; Turk et al., 1988). Hogarth’s (1987) conceptual model provides what is perhaps the best example of the information-processing perspective applied to the study of human judgement. The model contends that judgement occurs through a system of linear feedback initially derived from the environment. At the heart of the model are three information-processing activities: acquisition, data processing and output. Judgement output results in an action and an environmental outcome that in turn may serve as additional feedback into the judgement system. Numerous potential sources of variability in clinical perception have been identified through investigations based in the information-processing perspective. Kahneman et al. (1982) suggest that efficient processing of information requires the use of decision rules, termed heuristics. One source of variability in perception and judgement is the clinician’s use of heuristics with the heuristics of availability, representation and anchoring believed to be commonly employed in clinical decision-making (Turk et al., 1988). The availability heuristic is utilized in estimations related to frequency, probability and causality. Objects or events are judged to be frequent, probable or causal, to the extent that they are readily ‘available’ in memory (Tversky and Kahneman, 1973). Reliance on the availability heuristic often proves efficient and useful as long as availability is related to the actual frequency of the events or objects in question. However, many factors that are not related to frequency, such as vividness and recency, can influence availability. Reliance on availability when other factors are more influential can therefore result in perceptions and conclusions that poorly correspond to the situation being observed (Nisbett and Ross, 1980). The representativeness heuristic involves the application of ‘goodness of fit’ criteria to problems of categorization. This process allows individuals to reduce several inferential tasks to judgements of similarity. In using the representative heuristic, objects are assigned to conceptual categories on the basis of their perceived similarity (Kahneman and Tversky, 1971). As is the case with the availability heuristic, the representativeness heuristic is efficient and useful under many circumstances.  1999 The Association for Family Therapy and Systemic Practice 344 David Ivey et al. However, when the representativeness heuristic is used as the only judgement strategy and when the known features of an object or category are insufficient to allow sound classification, error is quite likely. Under these circumstances, the use of statistics for the frequency or base rates of the categories in the population proves more effective. The under-utilization of base-rate information versus single-case information can lead to significant limitations in categorical judgements (Nisbett and Ross, 1980). The third heuristic, anchoring, refers to the tendency to rely on preliminary information as a basis for subsequent judgements and decision-making. Kahneman et al. (1982) suggest that after individuals form preliminary judgements about a situation, they routinely fail to make necessary adjustments to their original impressions. Once judgement occurs, subsequent information fails to exert as much influence as may realistically be desired (Nisbett and Ross, 1980). There are two additional sources of variability in clinical judgement. First, the illusory correlation refers to a tendency to perceive events in terms of causal relations, even when it is evident that the relation between events is incidental and the attributed causality illusory (Tversky and Kahneman, 1980). Second, the confirmation bias relates to the tendency to seek confirmatory evidence when testing hypotheses while underemphasizing or dismissing disconfirming evidence (Lord et al., 1979). Conclusions and considerations for couples and family therapy Despite substantial conceptual and empirical developments in the study of clinical judgement, the findings, by and large, remain poorly integrated by the clinical community. Practitioners are commonly unaware or uninterested in the available evidence or, as is reflected by the continuance of the clinical versus actuarial debate (Dawes et al., 1989; Einhorn and Hogarth, 1982; Kleinmuntz, 1990), dismiss findings due to the assumption that empirical efforts are adversarially motivated and insensitive to actual clinical contexts. Although the advance of cognitive science and the semi-recent cognitive revolution in psychotherapy have enhanced the sensitivity of clinicians to the variable and subjective nature of perception, therapists generally receive limited practical assistance with respect to clinical judgement from the empirical literature. The research community appears to contribute to the  1999 The Association for Family Therapy and Systemic Practice Clinical judgement 345 problem by its preoccupation with diagnostic (in)validity and adherence to an objectivistic and mechanistic conceptual base. Consequently, practitioners find few tangible resources. The absence of pragmatic guidance is particularly apparent for couples and family therapists. In contrast to the intense attention, albeit mechanistically oriented, within the individually oriented literature, the processes employed by couples and family therapists to comprehend client concerns and to make decisions regarding treatment have received limited empirical scrutiny. As a result, practitioners working with couples and families receive minimal assistance from the empirical literature to enhance their abilities in these important areas. Oversight versus paradigmatic differences It could be argued that the evident absence of attention to clinical judgement in couples and family therapy is the product of negligence. A more viable explanation contrasts this conclusion and suggests that the apparent breach is the result of incongruence between the paradigms underlying the mainstream clinical judgement literature and the discipline of couples and family therapy. The contemporary study of clinical judgement has been deficit focused and mechanistic (Holt, 1988; Sarbin, 1986). The term ‘mechanistic’ is drawn from Pepper’s (1942) four world hypotheses: formism, mechanism, organicism and contextualism. Pepper’s hypotheses, also known as root metaphors, worldviews and paradigms, were conceived as four broad categories within which the means employed by individuals to make sense of their world and their personal experiences could be classified. Each world hypothesis or paradigm consists of a set of ontological, epistemological and anthropological axioms. More recently within the adult cognition literature, Pepper’s two analytic world hypotheses of formism and mechanism have been combined into a single mechanistic paradigm (Botella and Gallifa, 1995; Johnson et al., 1988; Kramer et al., 1992). Formism assumes the existence of universal forms or types through which all entities can be classified and understood. The root metaphor of the integrated mechanistic worldview is that the world functions like a machine and as such can be reduced into its parts and understood in isolation from the whole. A mechanistic view is based on the ontological assumption that the universe  1999 The Association for Family Therapy and Systemic Practice 346 David Ivey et al. is composed of discrete and inherently stable component parts that are linearly related in a sequence of cause–effect interactions. Mechanistic epistemology asserts that reality is external to the knower and that objectivity and separation characterize the relationship between the knower and reality. Anthropologically, individuals are assumed to be reactive, passive and determined by their environment, yet separate. Similar axioms can be found underlying the positivist philosophy of science (Lincoln and Guba, 1985), rational cognitive schools of therapy (Mahoney, 1988) and other modernist psychotherapies (Anderson, 1996; Hoffman, 1990). A positivist philosophy of science assumes the presence of a single, tangible reality, external to the investigator that can be objectively understood through examination of isolated and linear associations (Lincoln and Guba, 1985). Such a philosophy has long been dominant in the behavioural sciences, and more particularly with regard to the study of clinical judgement. Rationalist cognitive therapies, as well as other modernist approaches, assume that a single, stable and external reality exists. Knowledge, behaviour and change are conceived as linearly caused with clinical outcomes being derived from a logical validation of accurate and adaptive perceptions, cognitions and behaviour (Mahoney, 1988). Numerous scholars (Amudson et al., 1993; Anderson, 1996; Gonzalez et al., 1994; Hoffman, 1990; Loos and Epstein, 1989; Mahoney, 1988; O’Hanlon, 1993) have delineated the pragmatic clinical implications from a modernist clinical stance. Modernist models of therapy represent an attempt to discover the objective truth and the underlying or ‘real’ problems of clients. The focus for intervention is understood to be an inherent and covert structural deficiency of the individual or system. Client problems, from a modernist perspective, are seen as dysfunctions, pathologies or aberrations from established normative standards. Causal explanations or diagnostic formulations for such problems are derived from the expert and removed knowledge and skills of the therapist. As a consequence, clinicians operate from within a hierarchical, isolated and objective position of power and privilege (Amundson et al., 1993). The incongruence between the mechanistic worldview and the root metaphors underlying the field of couples and family therapy can be traced from the earliest forays of the emerging discipline. The pioneers of the 1950s have been described (Nichols and Schwartz, 1991) as disillusioned psychoanalysts who offered a  1999 The Association for Family Therapy and Systemic Practice Clinical judgement 347 contextually based view of the human condition, in reaction against the prevalent modernist assumptions of their era. Psychoanalysis has itself been referred to as the ‘first wave’ of psychotherapy, characterized by a pathology and reductionism focus (O’Hanlon, 1994). The ‘second wave’ of psychotherapy abandoned linear–causal explanations and adopted a circular view wherein concern with intrapsychic pathology was replaced with attention to adaptability, interaction and context. Despite the guiding influence of the organismic systems root metaphor provided by Bertalanffy (1968, 1969), mechanistic assumptions persisted among many of the early models. The proliferation of constructivist and feminist views during the 1980s led to a ‘third wave’ that challenged the remaining mechanistic allegiance apparent within the major schools of couples and family therapy (O’Hanlon, 1994). Unfortunately, the conceptualization and study of clinical judgement has not evolved in the same way. Although the limited clinical judgement research conducted in couples and family therapy can be considered compatible with the ‘second wave’, mechanistic assumptions remain pervasive. Judgement has been examined almost solely in terms of accuracy, itself operationalized as the degree of concordance between clinician perceptions and preestablished diagnoses. The utility of much of the existing literature is consequently dependent on the ‘validity’ of the adopted diagnostic categories. The employed methods typically seek to determine the presence or absence of clinician deficiency through exposure to various case or test materials. The methods tend to emphasize the outcome assessment of psychopathology and to de-emphasize adaptive adjustment, context, process and relationship factors. A fundamental departure from the paradigm underlying the contemporary practice of couples and family therapy is evident. The available evidence is derived from studies whose methods and conceptual foundations do not lend well to the organismic systems orientation. When reviewing the couples and family therapy literature with sensitivity to this explanation, it becomes evident that concern with clinical judgement and decision-making has been prominent throughout the history of the couples and family therapy discipline and was in actuality an impetus to the field’s birth. Difficulty in recognizing its prominence rests in the divergence in terms and concepts between those used in the existing mechanistically based clinical judgement literature and those of the couples and family therapy field.  1999 The Association for Family Therapy and Systemic Practice 348 David Ivey et al. A contextualist perspective An alternative to the mechanistic conceptualizations of clinical judgement is needed in order to guide future research efforts and to enhance the utility of the literature (Holt, 1988; Sarbin, 1986). We suggest that a contextualist perspective offers a suitable alternative that is particularly compatible with the discipline of couples and family therapy. Just as the mechanistic paradigm can be seen as an integration of two root metaphors, the contextualist paradigm is best depicted as a blend of the world hypotheses of organicism and contextualism. The root metaphor of organicism views the world to be a dynamic, living organism composed of a system of complex and interrelated processes. The contextualist paradigm can be characterized by a constructivist epistemology in contrast to the positivist epistemology of the mechanistic paradigm (Berzonsky, 1994; Botella and Gallifa, 1995). The integrated contextualist paradigm, akin to relativist and dialectical models (Kramer et al., 1992) and Perry’s (1970) contextual relativism, views reality to be unique to each individual’s perspective, experience and situation. This view epistemologically asserts that reality is internal to the knower and that the relationship between the knower and reality is subjective and relative. Individuals are assumed to be proactive, creative, and both influenced by and embedded within their environment. The knower operates from a position of reflexivity (Kitchener, 1983) with an awareness of one’s place in the social context and the reciprocal influence of self on the context and vice versa. Reflexivity involves recognition of the limits of knowledge, certainty and the criteria for knowing (Kitchener, 1983). Internal personal constructions of knowledge can be understood to be created through the dialectical integration of seemingly contradictory information (Labouvie-Vief, 1994). Similar principles can be found within the post-positivist philosophy of science (Lincoln and Guba, 1985), constructivist models of therapy (Mahoney, 1988), and other postmodernist schools. Within each of these areas reality is seen as plural, subjective and constructed. The individual is understood in context both as an influencer and as influenced by multiple, reciprocal and simultaneous factors. Postmodern clinical approaches seek to generate alternative truths and multiple descriptions of client problems. Problems and solutions are co-constructed in contrast to modernist  1999 The Association for Family Therapy and Systemic Practice Clinical judgement 349 reliance on expert and hierarchical diagnoses and interventions by the clinician. Problems may be understood as developmental discrepancies between current adaptive capacity and immediate contextual demands (Mahoney, 1988). An inherent emphasis on client strengths, resources and initiative typifies postmodern models. The therapist functions as a learner, co-researcher and participant observer, assuming a persistent position of curiosity or not knowing coupled with recognition of the limits of clinician knowledge and ability. The therapeutic process can be characterized by collaboration and mutual reliance. The therapist is open to disclose assumptions and thoughts and operates from a secondorder perspective that is sensitive to the dynamics of the therapist–client system (Amundson et al., 1993). A contextualist model of clinical judgment Although the proposed alternative does not abandon the contributions from investigations based in the mechanistic paradigm, a contextualist perspective offers a means to conceptualize the process of clinical judgement in a manner that dramatically departs from the established literature. This alternative draws from fields not traditionally employed by clinical judgement scholars with the field of hermeneutics providing a primary contribution. Gadamer’s pivotal work laid the foundation for expanding the scope of hermeneutics beyond the interpretation of literary texts to include the process of interpretation in the human sciences (Bontekoe, 1996). His contribution challenged the allegiance to the positivist philosophy traditionally characteristic of hermeneutics and argued that interpretation may better be conceived as a conversation between text and reader. He asserted that interpretation is embedded within the relationship between reader and text and coined the term ‘horizon’ to refer to the contexts in which both the reader and text are situated. The reader’s horizon is composed of a fore-structure of preconceived ideas, assumptions, values and beliefs from which the reader is unable to transcend to a position of objectivity. The fore-structure serves as a starting point of interpretation that influences the direction of the process. The text’s horizon is likewise composed of presuppositions and values (Bontekoe, 1996). Gadamer proposed that interpretation or understanding result from the fusion of the horizons of reader and text. As such,  1999 The Association for Family Therapy and Systemic Practice 350 David Ivey et al. understanding of a phenomenon can be seen as a product of mutual collaboration or co-construction. Although the hermeneutic process can be shut down when one of the parties refuses to allow the other to inform his or her fore-structure and the emerging interpretation, understanding is potentially continuously evolving. The conversation between reader and text is a dialogue of question and answer with the evolution of new questions becoming central in the process of co-construction. We suggest as well that a constructivist perspective (Neimeyer, 1995), conceived within the contextualist paradigm, will advance the conceptualization of clinical judgement in relationshiporiented therapy. Constructivism is best defined as a metatheory. Constructivism comprises a family of theories that are related on the basis of a set of shared assumptions. Constructivist metatheory assumes that cognitive processes are proactive in nature. In contrast to mechanistic models, mentation is assumed to be active, anticipatory, multilayered and generative. Utility is emphasized over objectivism and human knowledge is recognized to be peripherally constrained. Individual human systems are viewed to be selforganizing in a manner that protects and perpetuates their integrity (Mahoney et al., 1995). From this view, clinical judgement can be conceptualized as the construction of meaning that is co-created among members of the therapeutic system (for example, therapist, family members, observing team). Meanings are construed through a reflexive process. Tomm (1987, 1988) explains reflexivity as an inherent aspect of relationships among meanings within belief systems that guide communicative actions. Reflexive communication is viewed as recursive and circular. New meanings are co-created through the language of therapy. Judgements then for systemic family and couples therapy are dynamic concepts rather than static objective truths. The traditional use of reflecting teams in couples and family therapy provides an example of an approach that endorses a communal process of meaning-making or clinical judgement. Through dialogue, reflecting teams, often in concert with the client system, seek to develop multiple and potentially contrasting definitions of presenting problems and response. Similar conceptualizations can be found within the adult cognitive literature. King and Kitchener’s (1994) reflective judgement model is based on the assumption that the processes required to solve ill-structured problems depart fundamentally from those  1999 The Association for Family Therapy and Systemic Practice Clinical judgement 351 necessary in hypthetico-deductive reasoning. According to King and Kitchener, reflective thinking refers to a judgement process that is based on the active processes of construction experienced by the knower. They contend that knowledge is uncertain and comprehension is dependent on context. From their model, alternative perspectives and interpretations are considered and incorporated with judgements being tentative and open to ongoing revision. A strong parallel is as well presented by Baxter-Magolda’s (1992) concept of contextual knowing. A contextualist view of clinical judgement no longer adheres to primary concern with the internal subjective processes of the clinician. Judgement is seen as an interactional, evolving, relational, coconstructive process. The notion that a therapist can develop a correct judgement is eschewed. Rather, it is accepted that in order to understand, multiple and potentially conflicting views must be integrated. An observing system reality (the notion that we can only know our own construction of others and the world) is preferred over an observed system reality (the notion that we can know the objective truth about others and the world) (Hoffman, 1990). The therapist in an observing system format diminishes his or her role as expert or judge concerning the clients’ realities while retaining a position that facilitates the process of forming meanings within the system. An observing system perspective attends to how knowledge is constructed. The constructed reality that can be thought of as a clinical judgement receives contributions from each individual perspective within the therapeutic system. In addition, the process of communication among system members produces a new changed reality rather than the application of an objectified pathology, such as a DSM diagnosis, contrived solely by the therapist. A hermeneutic framework incorporates the concepts of heuristics and biases from the mechanistically based literature and conceptualizes them as a component of the clinician’s horizon. The formation of a judgement can thus be understood as the process of fusing the horizons of therapist and client through dialogue or conversation in which the judgements of the clinician and client remain open to change, are offered tentatively, and are continuously informed by recognition of social and cultural contexts and by new information and evolution. The value or quality of clinical judgement is not understood in terms of validity and not determined by the degree of correspondence between clinician views and objective external classification schemes. Utility of a clinical  1999 The Association for Family Therapy and Systemic Practice 352 David Ivey et al. judgement can be assessed by the co-constructed answer to the question: Do perceptions of the problem and client lead to resolution of identified concerns, satisfaction with treatment, and enhanced client independence and welfare? In contrast to traditional mechanistic studies of clinical judgement, contextual models attend primarily to the relationship and interactions between therapist and client. Much of the existing mechanistic clinical judgement literature is potentially informative in this regard given the range of findings that highlight various perceptual and ideational processes of clinicians that may well serve to shape the form and nature of therapeutic relationships. Is the bridge too far? It can be argued that the study of clinical judgement is itself incompatible with the theoretical foundations underlying the field of couples and family therapy. It can also be argued that attempts to incorporate the existing, mechanistically derived, clinical judgement literature are futile given the paradigmatic distinctions previously addressed. Of the numerous associated philosophical questions and dilemmas, one appears particularly important. Does the information-processing model and the positivist philosophy of science more generally have to be dismantled in order for a contextualist-organismic model to be built? In other words, must the mechanistically oriented literature be disregarded or is their benefit available from the existing findings and concepts for clinicians whose orientation is contextual? We suggest that the existing findings can and should be integrated. To disregard findings derived from an alternative perspective is at odds with the tenets of contextualism. A contextualist view embraces diversity in views and recognizes the presence of differences as an opportunity for the expansion of knowledge. We endorse the methodological pluralism advocated by Sprenkle and Moon (1996) and suggest that a parallel conceptual lens is needed. Although differences and alternative explanations should be examined and highlighted, the advance of the literature will not occur simply through the denigration or dismantling of competing findings and concepts. Rather, the growth of knowledge requires attention to new and potentially adversarial ideas. How then can findings based in a mechanistic philosophy be integrated? A considerable dilemma is involved given that many of the  1999 The Association for Family Therapy and Systemic Practice Clinical judgement 353 assumptions and principles underlying the existing literature are themselves contrary to the basic tenets of a contextualist perspective. We suggest that the concept of translation is useful to address such concerns and will employ this language metaphor to explain our position. Concern regarding the mutual exclusiveness of alternative paradigms can be examined in terms similar to the dilemmas encountered in attempting to learn a new language. Can someone whose native language is Russian learn to speak Chinese? If he or she becomes fluent in Chinese, will he or she necessarily lose fluency in Russian or in some manner become less Russian? Does an interest in Chinese reflect a disregard for Russian? Must he or she dismantle their proficiency with Russian in order to acquire fluency in Chinese? We contend that the acquisition of knowledge requires the ongoing development of new languages, in one form or another, and that the exchange of information between any two individuals necessitates translation. Although certain concepts and terms found in one language may not have a corresponding term in another, efforts should be given to developing a dialogue as opposed to attempts to further one’s personal perspective via the denigration of a perceived competitor. The maturation of multilingual ability does not require the abandonment or alteration of one’s worldview or identity, although such openness could be a desirable consequence. Multilingualism is in this sense not synonymous with eclecticism but rather represents an effort to understand individuals whose native form of perceiving and relating differs from one’s own. Inasmuch as multilingualism is embraced, strides in the pursuit of knowledge would seem likely. Despite its utility, the concept of translation is insufficient to resolve the difficulties presented by efforts to integrate contextual and mechanistic views. We consider three additional possibilities in our approach. First, integration might be feasible should one perspective be subsumed within the other. Although intuitively we can envision aspects of mechanism to exist within a broader contextualist view, this notion does not adequately constitute the form of integration to which we aspire. Borrowing again from the concept of multilingualism, to adopt this approach would be synonymous with the assumption that one language exists as a subset or minor form of another. As a consequence, such an approach to integration would likely result in inattention to aspects of the subsumed language which could not be construed within the bounds of the  1999 The Association for Family Therapy and Systemic Practice 354 David Ivey et al. larger. A second possible approach might rely on a hermeneutic metaphor through which the mechanistic and contextual perspectives are viewed as texts in conversation with one another. This process may ultimately lead to a new reading or interpretation that is a blend or integration of the pre-existing views. The last alternative draws from Labouvie-Vief’s (1994) conceptualization of integrated thinking. From this approach, mechanistic and contextual views reciprocally define one another by being held in simultaneous opposition to the other within a dialectical whole. Our sense of integration is best represented by the third alternative. As an example using the lingual metaphor, while an individual can be fluent in both Chinese and Russian, he or she is capable of using only one language at a time. When conversing in one language, the other is held in dialectical opposition to it within the person’s mind. As a consequence, both languages are present but not spoken simultaneously. Suggestions for future study A three-fold process is needed in order for translation and integration to occur within the research community. The three components are comprised of familiarization, dialogue and collaboration. Theoreticians and investigators from each school of thought should seek to inform themselves of the concepts and findings developed through works based in alternative paradigms. For instance, scholars who identify with a positivist perspective should acquaint themselves with the assumptions and models presented within the contextual perspective and vice versa. Unfortunately, contributions from a contextual perspective are in short supply. While mechanistic models and concepts have been available throughout the modern era of clinical judgement research, contextual models are essentially non-existent. We suggest that qualitative studies may be suitable to advance the initial development of contextual theories of clinical judgement. Dialogue and ultimately collaboration will not be possible until such time that a contextual perspective is articulated. When conceptualized from a contextualist perspective, the study of clinical judgement exhibits numerous distinctions from the existing literature. A contextual view contrasts the existing mechanistic emphasis on judgement validity. Contextual models attend to context, reciprocal processes and information exchange. As a  1999 The Association for Family Therapy and Systemic Practice Clinical judgement 355 result, investigations based in this perspective avoid preoccupation with outcomes and the individual deficiencies of practitioners. Although attending to outcomes, factors associated with individual and group differences and the utility of therapist views, contextual studies principally seek to describe the involved processes. Contextual investigations are concerned with the interacting roles of various therapist, client, cultural and situational factors in the formation and expression of clinical judgement. The study of clinical judgement from a contextual perspective consequently emphasizes process and description over diagnosis and classification. We also suggest that efforts are needed within the scientific community to more fully collaborate with the community of practitioners. The paradigmatic breach referenced throughout this paper appears as much to relate to the state of relations between scientists, or those who would study the work of clinicians and practitioners more so than a simple discrepancy in worldviews. The study of clinical judgement requires close consultation and partnership with individuals who grapple with the real life demands of clinical practice. Suggestions for clinicians Integration is needed as well within the clinical community. We suggest that it is insufficient and potentially negligent for practitioners to summarily dismiss the existing clinical judgement findings principally based on the assumption that the evidence and conceptual models are irrelevant due to paradigmatic discrepancies. Although one’s conclusions would unlikely be a literal extension from the available literature, a clinician’s ability to engage in a circular and contextual approach may be readily advanced by familiarization with the existing mechanistically oriented literature. For practical reasons, if for no other, it is advisable as well for clinicians who identify with a contextual perspective to be conversant with the mechanistic worldview in application to clinical practice. Without such familiarity, a productive dialogue would seem less viable between the clinician and multiple other individuals who have a stake in the client’s presentation and access to therapy. Many individuals who may exert considerable influence over the client’s ability to receive clinical assistance may assess the need, efficacy and justification for services from a mechanistic perspective. Integration within the clinical community can be accomplished  1999 The Association for Family Therapy and Systemic Practice 356 David Ivey et al. by familiarization, dialogue and collaboration, not only with other practitioners and practice policy-makers, but also with the research community. We encourage practitioners to assume a share of responsibility for the advance of knowledge with respect to the study of clinical judgement and other aspects of the behavioural sciences. Practitioners can do so by participation in research as well as by personal contributions in theory development and study. Advocation of research by practitioners may promote the much needed reconciliation between the applied and scholarly communities with respect to this particular area of enquiry. Although a breach has occurred, the bridge is not too far. Concern is invariably promoted by efforts to span two seemingly distant worlds. 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