Journal of Systemic Therapies, Vol. 31, No. 3, 2012, pp. 17–35
RE-VISIONING A MODEL OF CLINICAL
JUDGMENT FOR SYSTEMIC PRACTITIONERS
PETER J. JANKOWSKI
Bethel University
DAVID C. IVEY
Texas Tech University
MARSHA J. VAUGHN
Judson University
Building upon prior research on clinical judgment, the present study contains
a description of a meta-theoretical model of problem definition in systems
therapy. Qualitative analysis yielded an exemplar that illustrated the use of
therapist-specific, interactional, and situational factors, the therapist’s influence in the therapeutic conversation along three positioning dimensions, and
a continuum of implicit to explicit construction of the presenting problem. The
current description of clinical judgment addresses correctives proposed in the
existing literature and advances the study of clinical judgment in couple and
family therapy.
Recent critiques suggest that the time is ripe for re-conceptualizing the traditional
approach to clinical judgment (e.g., Chwalisz, 2006; Lichtenberg, 2009; Ridley &
Shaw-Ridley, 2009). Clinical judgment may be defined as the study of therapists’
decisions on tasks such as assessment, diagnosis, problem definition, case conceptualization, prognosis, and intervention. In addition, there is a need to study
clinical judgment from a qualitative research perspective, with particular attention to “the processes involved in moment-by-moment clinical decision making”
(Chwalisz, 2006, p. 393). There is also a need for more theory-driven (Spengler,
White, Ægisdóttir, Maugherman, Anderson et al., 2009; Spengler, White, Ægisdóttir, & Maugherman, 2009) and theory-building (Ridley & Shaw-Ridley, 2009)
clinical judgment research. With the current study we addressed the identified
needs by offering a model of clinical judgment from a systemic perspective that
extends prior theoretical work (Ivey, Scheel, & Jankowski, 1999) and previous
Address correspondence to Peter J. Jankowski, Ph.D., Counseling Psychology Program, Bethel University, 3900 Bethel Dr., St. Paul, MN 55112. E-mail: pjankows@bethel.edu
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qualitative studies of problem definition (Jankowski, 1999; Jankowski & Ivey,
2001; Vaughn, 2004). In attending to these needs we sought to make the study
of clinical judgment more conducive to systems oriented practitioners.
THE TRADITIONAL APPROACH TO CLINICAL JUDGMENT
The traditional approach to clinical judgment involves (1) focusing on therapists’
judgment accuracy, (2) framing statistical methods over and against interpretative
approaches, and (3) assuming that clinical effectiveness is based on matching accurate judgments to empirically validated interventions (see also, Ivey et al., 1999).
Research within this tradition has generally found clinicians’ informal, subjective,
and/or intuitive decision-making to be inferior to formal statistical methods which
employ mathematical formulas or prediction algorithms; and consistently so,
on a wide range of judgment tasks (Ægisdóttir et al., 2006; Garb, 2005; Grove,
Zald, Lebow, Snitz, & Nelson, 2000). The disparity however is perhaps most notable when comparing decisions about predicting violent behavior and treatment
prognosis, as both consistently favor statistical methods (Ægisdóttir et al., 2006).
Given the general inaccuracy of interpretive methods relative to statistical approaches, researchers focused on identifying biases and heuristics that
influence clinicians’ decision-making (Garb, 2005). Implications for training
and practice therefore typically focus on increasing clinicians’ awareness of
personal biases and common decision-making strategies that impact judgment
accuracy, employing formal empirical assessments to counter the effects of
biases and heuristic mistakes, and practicing empirically validated treatment
approaches (Ægisdóttir et al., 2006; Spengler, White, Ægisdóttir, Maugherman,
Anderson et al., 2009).
Akin to Ivey et al. (1999), we surmise that the scant explicit attention to clinical judgment within the systems practice literature is the perceived incompatibility between the contextual orientation inherent in couple and family therapy and
the largely mechanistic orientation of the traditional approach. Others similarly
observed that systemic practitioners rarely use formal empirical assessments,
in large part because of a perceived incompatibility between the philosophical
orientations inherent in formal, empirical versus informal, subjective, intuitive
approaches to assessment (Bray, 2009; Carr, 2000). Nevertheless, the clinical
tasks of assessment and case conceptualization, close corollaries of problem
definition, have received attention from systemic practitioners (e.g., Bray, 2009;
Carr, 2000; Sperry, 2005; Stanton & Welsh, 2011); yet, this attention highlights
a need for increased engagement with the existing clinical judgment research,
as well as the need for a systematic research focus on clinicians’ decisions by
couple and family therapists.
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Somewhat ironically, a shift toward a more systemic orientation is taking
place within the traditional approach, while systemic practitioners remain peripherally engaged in the systematic study of clinical judgment. Evidence of
a systemic reformulation from within the existing literature consists of (1)
the recent meta-analytic finding that therapists’ interpretive decision making
methods were comparable to diagnostic judgments based on statistical methods
(Ægisdóttir et al., 2006), (2) growing awareness that attending to the therapist-client feedback loop may improve judgment accuracy (Spengler, White,
Ægisdóttir, Maugherman, Anderson et al., 2009), and (3) growing appreciation
for “therapist individual effects” (Spengler, White, Ægisdóttir, Maugherman,
Anderson et al., 2009, p. 383).
OPENINGS FOR STUDYING CLINICAL JUDGMENT
IN SYSTEMS THERAPY
Clinicians, generally speaking, have increasingly adopted a contextual lens for
conceptualizing therapeutic processes and change (Lichtenberg, 2009), and the
recent critiques of the traditional approach signal contextual shifts taking place
within the larger clinical literature, and clinical judgment in particular (Spengler,
White, Ægisdóttir, & Maugherman, 2009). In addition to movements taking
place outside of the couple and family therapy literature, there appears to be
a shift in the systems practice literature toward increased meta-theoretical and
trans-disciplinary conceptualization and research. This shift seems to suggest an
opportunity for making the study of clinical judgment more amenable to couple
and family practitioners.
First, Wampold (2001, 2010) connected increased contextual clinical practice
to the research on common change factors in psychotherapy. Increased attention
to common change factors exists in the couple and family therapy literature
(e.g., Sparks & Duncan, 2010; Sprenkle, David, & Lebow, 2009), and seems
to represent a move toward meta-theoretical, trans-disciplinary thinking about
systemic practice. Second, recent integrative efforts have attempted to translate evidence-based practices from the larger clinical literature grounded in
“positivist explanation” (Chwalisz, 2003, p. 500) to couple and family therapy
grounded in more contextual philosophical assumptions (e.g., Jacobs, Kissil,
Scott, & Davey, 2010), again reflecting meta-theorizing and trans-disciplinary
thinking about clinical practice.
As significant as the shift toward meta-theorizing might be in advancing clinical
judgment within couple and family therapy, perhaps the most important opening
for bridging the gap between clinical judgment research and systemic clinical
practice is the consistent concern about the lack of research that advances couple
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and family therapy as a viable mental health treatment option (Crane, Wampler,
Sprenkle, Sandberg, & Hovestadt, 2002; Sprenkle, 2010; Wampler, 2010). Research on the processes of couple and family therapy is needed (Heatherington,
Friedlander, & Greenberg, 2005), and detailed descriptions of the processes of
systems therapy have begun to emerge (e.g., Harvie, Strong, Taylor, Todd, &
Young, 2008; Rober, Elliott, Buysse, Loots, & De Corte, 2008a, 2008b; Strong,
Zeman, & Foskett, 2006). However, it seems to us that, as Wampler (2010) noted,
couple and family therapy research simply has not kept pace with research in
the other clinical disciplines. The lack of the formal study of clinical judgment
appears to be a prime example of this misstep, particularly given the assumption
that a focus on clinical judgment is essential to effective clinical practice (Ridley
& Shaw-Ridley, 2009).
CONTEXTUAL CLINICAL JUDGMENT
Ridley and Shaw-Ridley (2009) suggested that what was needed to advance
clinical judgment was a meta-theory. They proposed that this correction to the
traditional approach should involve increased attention to the client-in-context
as the unit of analysis, clinical judgment as a process, and the self-reflexive
capacities of clinicians. These correctives are consistent with a second-order
application of systems theory (e.g., Hoffman, 1985, 1990, 1991) thereby further
supporting the contention that the time is ripe for couple and family therapists
to more formally study clinical judgment. In many ways, Ivey et al. (1999)
offered a meta-theory that contained the proposed correctives. They framed
clinical judgment as a dialogical and dialectical process between therapist and
clients. Their initial model was dialogical in the framing of clinical judgment
as a conversation between each person’s uniquely situated self, with the emerging judgment represented as an integration of therapist and clients’ respective
experiences, perspectives, and meaning-making processes (see also, Botella,
Herrero, Pacheco, & Corbella, 2004). Clinical judgment was also described as
dialectical in the sense that the uniqueness of each person in reflexive dialogue
inevitably results in contradiction, without which gains in understanding and
change are not possible (see also, Angus & Greenberg, 2011).
Qualitative Research Perspectives
Jankowski and Ivey (2001) found that clinicians differed as to how overtly they
made their internal judgment of the problem a part of the therapeutic conversation, and how much they explicitly relied on client feedback when constructing
a solvable problem. Despite these differences, all of the clinicians formed their
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judgments by means of a complex consideration of: (1) therapist-specific factors
such as prior clinical experience with a particular diagnosis or information about
the clients from a referral source, (2) therapist-client interaction factors such as
the therapist’s awareness of his or her emotional reactions during the conversation or observations about a client’s in-session behavior, and/or (3) situational/
contextual factors such as clients’ ethnicity or the effects of poverty.
Vaughn (2004) examined the problem definition process by focusing on the
different ways therapists positioned themselves and exerted influence on their
clients during a therapeutic conversation. She examined specific change moments
in a session, and described clinical judgment from problem definition through
to therapist intervention. In-session change was defined by differences in client
language about the problem that reflected shifts in clients’ understanding, perspective taking, and/or receptivity to alternative understandings. Vaughn identified
three dimensions to therapists’ positioning within the therapeutic relationship: (1)
expert-nonexpert, which refers to the therapist’s movement between informing
the client about the problem and being informed by the clients, (2) separationconnection, which involves negotiating between a self-reflective stance and one
that seeks shared experiences with clients, and (3) observer-participant, which
consists of a therapist’s movement to include her/himself in the change process
and movement toward fostering client responsibility for change.
THE CURRENT STUDY
Given the shifts taking place within the existing literature on clinical judgment
and the meta-theoretical trends within the systems literature, the time is ripe
for updating and revising a contextual clinical judgment model. In the current
study we sought to synthesize the existing descriptions of clinical judgment in
couple and family therapy (Jankowski & Ivey, 2001; Vaughn, 2004), and did so
by examining whether therapist-specific, interactional, and situational factors
and the three dimensions of therapist influence could be found in therapists’
descriptions of their clinical judgment process. We employed a qualitative case
study approach (Stake, 2005) to revise a model of the clinical judgment task of
problem definition, with attention to both the categories of clinical judgment
factors and the three therapist positioning dimensions.
Method
Guided by the assumption of “the person of the researcher as instrument” (Boss,
Dahl, & Kaplan, 1996, p. 96) and the emergent nature of qualitative inquiry
(Hesse-Biber & Leavy, 2008), we utilized archival data to identify a single case
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(Stake, 2005) that best exemplified a synthesis of clinical judgment factors and
therapist positioning dimensions. To be specific, we re-coded the ten archival
transcripts comprised of clinicians’ narrative accounts of problem definition in
couple and family therapy (see Jankowski, 1999) to assess for the presence of
Vaughn’s (2004) three dimensions of therapist positioning. The primary questions
that guided the present analysis were “do therapists’ descriptions of their problem
definition process contain the positioning dimensions of (1) expert-nonexpert, (2)
separation-connection, and (3) observer-participant?” and “if so, how can those
descriptions be integrated with the clinical judgment factors to expand and revise
an earlier depiction of a contextual clinical judgment model?”
Rationale
Re-analysis of archival transcripts is consistent with a variety of qualitative approaches to data analysis. Constructivist grounded theory (Charmaz, 2000), hermeneutic/phenomenological (Boss et al., 1996; Sandage, 2010), and narrative
(Sorsoli & Tolman, 2008) research methods posit that different questions may
be asked of the data as the researcher evolves in understanding the phenomenon.
Differing and multiple interpretations of the data are always possible, and localized interpretations offered at one point in time may evolve as the self-identity
and social location of the researcher changes. The uniquely situated researcher
interacts with the data based on who she/he is in the particular moment of the
interpretive act, and as the researcher changes, so might interpretations of prior
phenomena. Interpretations are judged by the checks used during data analysis
and a coherent, compelling presentation of the current findings.
Coding Procedure
In the present study, we re-analyzed the archival data by initially identifying
change events (see Vaughn, 2004). A change event refers to indicators of therapist influence which correspond to clients’ movement toward resolution of the
problem, however slight those movements might be. We utilized a constructivist
informed constant comparative method of data analysis (Charmaz, 2000) to then
code for the three positioning dimensions of therapist influence. To increase
credibility of the present analysis, we utilized self-reflexivity (Charmaz, 2000),
that is juxtaposing our prior understandings with emerging understandings from
the current analysis, and peer consultation (Sandage, 2010), having one of the
co-authors check the emerging interpretation of the data for consistency with
previous theoretical formulations of therapist positioning dimensions.
More explicitly, we compared the archival transcripts containing coded problem definitions for indicators of in-session change using linguistic markers that
reflected clients’ movement toward resolution of the problem. We then com-
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pared transcripts with each other for the presence of linguistic indicators that
corresponded to Vaughn’s (2004) definitions of the three therapist positioning
dimensions. Comparison of the transcripts continued until one of the transcripts
emerged as the most representative of both the originally coded clinical judgment
process comprised of therapist-specific, interactional, and situational factors
(Jankowski & Ivey, 2001) and the newly coded dimensions of therapist positioning
(Vaughn, 2004). The exemplar manuscript then underwent more detailed line-byline comparison of linguistic indicators to further identify the therapist positioning dimensions. The original model depicting the judgment process of family
therapists (Jankowski & Ivey, 2001) was then updated and revised to include the
dimensions of therapist positioning (see Figure 1). A theoretical understanding
of the judgment process was then constructed to describe the model depicted
in Figure 1. The theory is an expansion of earlier ideas about clinical judgment
as a dialogical and dialectical process (see Ivey et al., 1999; Jankowski & Ivey,
2001). The revised model fulfills Ridley and Shaw-Ridley’s (2009) criteria for a
FIGURE 1. Re-visioned meta-theoretical model of the problem definition
process in couple and family therapy.
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Jankowski et al.
meta-theory, and so we offer the notion of the negotiation of self-in-relation as
a meta-theory for clinical judgment.
RESULTS
Figure 1 is an illustration of the meta-theoretical model derived from the data
analysis. As illustrated in the diagram and the interview excerpts highlighted
below, in constructing a problem definition the therapist moved along all three
positioning dimensions and employed all three judgment factors. The case example consists of the initial judgment of the problem as “comfort-able.” The
therapist responded during the interview that “Probably I think the most important
thing would be for the two of them to feel comfortable enough, as a couple, with
me, just to be able to relax enough to be honest with each other.” The therapist’s
language of “as a couple,” “with me,” and “with each other” suggested a need
to receive comfort from each other and the therapist and to give comfort to each
other and their child. The therapist referred to the here-and-now need within the
therapeutic conversation but also the need for them to learn to be able to comfort
each other outside therapy. For example, the therapists stated
I am not sure they know how to work through that, and how to look at those things in
a way that is not threatening or that is not criticizing the other. So I feel I want to give
them a space to learn how to talk to each other, and deal with each other, at a point in
their life that is different from the past.
The defining of “comfort-able” also occurred along a continuum of implicit to
explicit inclusion of the clients in the judgment formation process. Implicitexplicit negotiation was evident as the therapist navigated the multiple relationships, included each person in the definition process, and continuously
integrated internal impressions with direct input from clients. For example, the
therapist stated, “Subtly, just in terms of making sure they both had times to talk
and asking for some help.” The term “subtly” connotes that in some instances
client contributions were more implicitly derived. In some instances defining
the problem was even more implicit, comprised of the therapist’s construal
about the clients, “I think what I sensed about them mostly was that there was a
connection that was strong there.” And, at other times, the therapist was explicit
about obtaining client input, for example, “[I was] trying to emphasize what
their strengths were . . . I wanted to find out.” Inclusion of each person in the
therapy system as part of negotiating the problem definition was also seen in
the therapist’s comment “I paid attention to the daughter, because I figured if
the daughter was going to be uncomfortable or crying it was going to be hard
for the parents to pay much attention, and to feel comfortable.”
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Five indicators that the therapist was influencing movement toward increased
comfort-ableness were identified. In four instances movement toward comfortableness was assessed by an observation of the clients’ non-verbal behavior: “I noticed
her smile somehow,” “I had to pay attention to what that was and particularly with
him and the daughter, the way he was holding her there was a sweetness there that I
didn’t anticipate,” “there was just, an easiness. With both of them, there was a comfort I thought with each other, in how they held their bodies and how they talked,”
and “the way they were interacting made me think there were some strengths in
there that needed to be considered.” In another instance, movement was indicated
by the client’s engagement in therapy; for example the therapist stated
It didn’t need to be a challenge so much as a question and it could be helpful because
there was some engagement on his part, and it could be taken as an interest in what
can happen. My sense was someone asking ‘Can this get better, is there any hope?’
Once I framed it that way I could answer and say that there were some things that I
thought we could work on.
Therapist Positioning
There were times when the therapist negotiated between a hierarchical, expert
positioning and a more open, exploratory positioning. For example, the therapist
consulted the physician’s expertise as represented in the formal assessment and the
referral to therapy. The therapist then juxtaposed that knowledge with here-andnow experience of the clients, “I was also thinking that he wasn’t acting anything
like the stuff I had read about him.” Moving to a non-expert positioning occurred
when the therapist indicated “I didn’t know what that was all about . . . and I just
wanted to see what they would do.” Here, a non-expert positioning coincided
with an observer positioning. An explicit acknowledgment of not-knowing was
tied to seeing what they would do, and connoting that responsibility for the next
contribution to therapy rested on the clients.
The therapist similarly navigated the separation-connection dimension. At times
the therapist needed to connect, that is to say move in and seek shared experiences
and identify with the clients, for example, “part of it was just imagining . . . what
it would be like for a young couple with little kids to live with parents.” At other
times the therapist sought increased internal and interpersonal separateness in
order to reflect on the therapy, “I just tried to listen to how they talk to each other,
and pick up where I felt like there was a connection [between them] . . . and I
wanted there to be a place for that to come out.”
Last, there were times when the therapist joined as a participant in the change
process by stating “there were some things that I thought we could work on.”
Other times the therapist distanced to an observer position to influence the clients
to take more responsibility for change,
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Jankowski et al.
Making sure they both had times to talk and asking for some help . . . and I wanted
to see how she would say that . . . I wanted to hear from him, to give him a chance
to know I would also come to him and that he had a voice in this conversation too.
Here, not only was the therapist negotiating between observer and participant
positioning to suggest that responsibility for change rested on them, but the
therapist also negotiated with them along the dimension of separation-connection
with the statement “I would also come to him.”
Clinical Judgment Factors
The clinician in the exemplar also made use of all three categories of clinical
judgment factors. Interactional factors involved in the judgment were apparent
in the therapists’ observations. For example, the therapist indicated, “Once she
came into the room she was really nervous and started crying and I didn’t know
what that was all about, but then the dad took her and I just wanted to see what
they would do.” Therapist-specific factors were also present when the therapist
was relying on previous clinical experience and comparing knowledge emerging
from the therapeutic conversation with prior clinical knowledge. For example,
the therapist referenced an encounter with another couple,
It wasn’t like a couple that came in and there was just intense hostility and overt stuff.
And, I think they do get into that, but at the same time I just tried to see what I was
sensing from them.
Elsewhere, the clinician referenced prior knowledge obtained from a formal
assessment and reflected on personal experience as important sources of information in negotiating the problem definition with the clients. For example, the
therapist reflected “I have more of an experience of myself within my family, or
when I was in [my spouse’s] family . . . And, there has been, where you do have
to separate.” Last, the therapist made use of situational factors in forming the
judgment. For example, the therapist responded,
They are in a situation that is real difficult, and the stresses on them at that point—from
outside, and also from his illness in particular and from her pregnancy—I think that
kind of caring could get overwhelmed by all this other stuff.
DISCUSSION
The meta-theoretical model of clinical judgment (see Figure 1) represents an
updated and expanded version of the original model (see Jankowski & Ivey,
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2001). The present version was derived from integrating the three positioning
dimensions into the process of defining a problem. The model in Figure 1 depicts clinical judgment as a therapist’s ongoing negotiation of his/her decision
about the presenting problem. Forming a judgment about the problem involved
the internal and interpersonal exchange and synthesis of the therapist’s previous
experiences and prior knowledge, with attention to interactional processes taking
place in the therapist-client system, and awareness of the larger situation in which
the clients were immersed. Forming a judgment also involved movement within
the three positioning dimensions as the therapist negotiated space internally and
interpersonally within the therapeutic relationship so as to be informed by the
family and influence them toward increased comfort-ableness.
Clinical Judgment as Negotiating Self-in-Relation
Negotiating self-in-relation has been framed as a process of “‘taking in’ and ‘keeping out’” (Volf, 1996, p. 66), such that there is a “distinction from the other and
the internalization of the relationship to the other” (p. 66). Volf (1996) referred
to this complex process as differentiation, “in which both the self and the other
take part by negotiating their identities in interaction with one another” (p. 66).
Differentiation can also be said to involve regulating whatever is activated during
social interaction such as one’s emotional states and corresponding internalizations of prior relational experiences, current sense-making constructions, and
behavior, as well as regulating interpersonal closeness and distance (Kerr &
Bowen, 1988; Skowron, Holmes, & Sabatelli, 2003).
Internalized relational experiences of the self-in-relation to the other constitute
a dynamic web of internal relationships between different “centers.” According
to Volf (1996), “the self is never without a center; it is always engaged in the
production of its own center” (p. 69). The center moves to wherever the individual directs his/her metacognitive skill (Dimaggio, 2006). Similar ideas have
been described by others who conceptualize the self as a multiplicity of centers
and frame moment-by-moment experience as dialogue between parts of the
self, self-aspects, or voices (Dimaggio, Hermans, & Lysaker, 2010; Elliott &
Greenberg, 1997; Hermans, 2004). As an individual centers his/her attention on
a particular self-aspect it may call forth childhood memories, ideas about her/
himself and associated emotions and behaviors, images of a future self, and/or
prior relational experiences. Voicing or engaging in intra- and/or interpersonal
dialogue about a particular self-aspect facilitates identity construction by either
reinforcing a problem saturated identity or constructing a preferred alternative
identity (White, 2006).
Differentiated functioning is thus a non-reactive, intentional negotiation
between multiple self-aspects and a non-reactive, intentional interpersonal
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negotiation of closeness and distance. In contrast, lack of differentiated functioning consists of a lack of awareness of one’s multiple self-aspects and identity
constructions or the “opposite, an excessive number of voices crowded together
in the stream of consciousness” (Dimaggio et al., 2010, p. 381). Poorly differentiated functioning also involves extremes of interpersonal closeness and
distance. Either extreme would correspond to a lack of dialogic exchange. Too
much closeness suggests that an individual gets lost in the voice of the other and
too much distance suggests that he/she is too isolated to hear the other’s voice.
In both instances reciprocal exchange between self and other is lacking.
Application to clinical judgment. Spatial metaphors are consistently used to
describe the negotiation of self-in-relation. Central to these conceptualizations
is the idea of opening up space, internally and/or interpersonally, to enable differentiated functioning. Opening up space connotes moving to a reflective position in order to non-reactively and intentionally engage the experience of
the other and one’s multiplicity of self. Clinical judgment as negotiation of
self-in-relation involves the therapist’s awareness and integration of her/his
self-aspects, therapist-client relational processes, and larger situational factors
during an ongoing therapy conversation. Opening up space allows the therapist
to be informed by the clients without forcing their contributions to the conversation to fit any particular self-aspect activated within the therapist. The therapist
can open space by positioning him/herself in particular ways along the different
dimensions at different moments during the conversation.
The exemplar highlights the therapist’s use of spatial language, supporting the
contention that the notion of self-in-relation may be employed to describe the
process of clinical judgment. Spatial metaphors used in the exemplar included:
“place” once, “space” twice, and “tight place” and “separate” once each. Negotiating space suggests that at times persons could benefit from increased distance
and opportunity for reflection, and yet, at other times moving closer may be
needed to develop the therapeutic alliance and/or foster connection in the clients’
relationships. For example, the therapist commented “I just tried to listen to how
they talk to each other, and pick up where I felt like there was a connection or
some kind of closeness . . . and I wanted there to be a place for that to come out.”
The need for a particular kind of space within the therapy relational system was
also connected to resolving the comfort-able judgment, for example, “I want to
give them a space to learn how to talk to each other, and deal with each other, at
a point in their life that is different from the past.” Often it was the interpersonal
connotation that was implied, and yet the therapist did connect the spatial metaphor to clients’ internal experience. For example, the therapist referenced clients’
internalized experiences from their past getting activated in their relationship, “I
think by providing a structured space for them to work out some of these issues.
I think they have both come in realizing that they both have childhood issues that
are pretty alive at this point.”
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Implications for the Traditional Approach to Clinical Judgment
The results of this study addressed the need for qualitative descriptions of
moment-by-moment clinical judgment (Chwalisz, 2003, 2006). A qualitative
case study allowed for the detailed depiction of one therapist’s practice of couple
and family therapy. The approach intrinsically captured the real-time feedback
processes that occur in the interaction between therapist and client during the
process of problem definition. It would seem that neglect of feedback processes
in the existing clinical judgment literature could very well account for the relative poor performance of interpretive judgment relative to statistical methods. As
Spengler, White, Ægisdóttir, and Maugherman (2009) noted, research is clearly
needed on the ways in which feedback and self-correction processes influence
clinicians’ decision making. The results of this study suggest that any research
approach that does not take into account the role of feedback misses an essential
element of real-world clinical judgment.
When the starting point for studying clinical judgment is therapists’ experience, it becomes apparent that systemically oriented clinicians can engage in the
integrated clinical practice sought theoretically and proposed in the literature
(e.g., Chwalisz, 2003; Jacobs et al., 2010), and perhaps do so more than is often
assumed. The clinician in the exemplar made use of seemingly dichotomous
philosophical stances and disparate sources of information, and did so rather
fluently. For example, the clinician moved along the expert-nonexpert dimension
and made use of both formal and informal assessments, which are often tied to
categorical and oppositional distinctions between modern versus postmodern
clinical approaches. It would seem that the therapist demonstrated cognitive
and relational complexity, and appeared to make a positive contribution to the
therapeutic process that unfolded (Chwalisz, 2006). The results of this study
therefore suggest that any research effort that seeks to control for, rather than
include, therapist-specific contributions to clinical decision making arrives at an
understanding that is void of what seemingly takes place in actual therapy, and
in this specific case, systems therapy.
Implications for Couples and Family Therapy
The results of this study are consistent with the work of others conducting
qualitative clinical process research on couple and family therapy (e.g., Harvie
et al., 2008; Rober et al., 2008a, 2008b; Strong et al., 2006). In a way, their
work provides a form of triangulation (Stake, 2005) with our work that lends
credibility to our respective descriptions. The process of problem definition
depicted here as an ongoing reciprocal exchange parallels Rober et al.’s (2008a,
2008b) description of therapists’ sense-making of the therapeutic relationship,
and parallels others’ descriptions of the ways therapists initiate new sense-
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making of clients’ problem definitions (Harvie et al., 2008; Strong et al., 2006).
However, as consistent as the respective descriptions may be, the current study is
situated in the literature that covers the nearly six decades of clinical judgment
research and explicit attention to clinicians’ decisions. We believe that such
grounding helps achieve the kind of research needed to advance the practice
of couple and family therapy.
The results of this study also have implications for practice and training. The
model depicted in this paper may be used to assist practitioners to attend to different aspects of their decision making as clinical situations necessitate. For example,
the therapist may attend more closely to the larger situational factors that may be
influencing the conversation about the problem to be resolved. Or, the therapist
may focus more closely on the observer-participant dimension and the need to
promote client responsibility for change. In addition, the meta-theory offers a lens
for therapists to frame their self-reflection, that of negotiating between multiple
self-aspects while simultaneously negotiating multiple relationships within the
therapeutic system. Therapists can facilitate self-reflection during a therapeutic
conversation by conceptualizing clinical judgment tasks as the negotiation of the
self-in-relation to the other.
Supervisors may use the model to guide a therapist’s awareness of her/himself
and identify areas where the therapist may need to direct attention to formulate
a solvable therapy problem and begin to promote change. For example, a supervisor might assist a therapist to make explicit use of feedback by attending to
interactional factors occurring within the therapeutic relationship, particularly
since incorporation of client feedback has demonstrated improved effectiveness
in therapy with couples (Anker, Duncan, & Sparks, 2009). Supervisees could
also be asked to attend more closely to their emotional responses to the client
or asked to reflect on memories, images, or lived experiences that become activated during therapeutic conversations. Supervisees could then be encouraged
to consider how these responses may be used to position themselves differently
within their therapeutic relationships, perhaps by moving closer and seeking ways
to identify with clients and thereby strengthening the therapeutic alliance. Last,
the exemplar revealed that multiple sources of data can be used to construct a
problem definition, including seemingly disparate sources of information such
as formal assessments and more subjective, intuitive information obtained during
the clinical conversation.
Limitations and Future Research Directions
One limitation, and perhaps one applicable to most, if not all, qualitative designs,
is the question of validity or credibility. Even with the checks employed in this
project, the possibility exists that our own uniquely situated selves may have
influenced the analysis more than perhaps we were aware. Our preconceived
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31
ideas about clinical judgment and previous reflections of our own and others’
clinical experience may have forced the interview data to fit the meta-theoretical
model. Replication and expansion of the work represented here with more diverse
samples of clinicians is needed. Future research might more explicitly detail the
problem definition processes of less and more experienced clinicians, since the
clinician in the current study was a mid-level professional. The relation between
experience and clinical judgment is a longstanding research question. Increased
experience tends to correspond to minimal gains in judgment accuracy (Spengler,
White, Ægisdóttir, Maugherman, Anderson et al., 2009), and “when judgments
are made by expert clinicians, the difference between clinical and statistical
methods seems to disappear [but] when the clinicians are nonexperts, they are
consistently outperformed by statistical formulas” (Ægisdóttir et al., 2006, p.
366). Nevertheless, questions clearly remain as to whether clinical judgment
processes differ as therapists gain experience.
A second limitation concerns the way in which in-session change events were
coded in this project. Given that change events were not part of the original set of
questions asked of the interviewees in the archival data, nor were change events
a part of the observational procedure in that initial research, it is possible that
when identifying an exemplar case from the archival data we forced indicators
of change onto the data. Nevertheless, we think we offered a compelling story of
the data (Stake, 2005) and our means of defining change events with linguistic
markers is consistent with others’ approaches (Harvie et al., 2008; Strong et al.,
2006); thereby lending credibility to the codes and present interpretation.
Last, in light of the proposed meta-theory of clinical judgment, future research
should include examining the model by employing quantitative and/or mixedmethod designs, which may be done while continuing to expand the qualitative
agenda of describing real-world processes. A mixed-method research program is
consistent with the meta-theoretical focus of the paper and consistent with calls
in the existing literature on clinical judgment (Chwalisz, 2003, 2006). Future
research could make use of observational coding of videotaped therapy sessions,
for example, through the use of a microanalysis of dialogue method (Bavelas,
2011) or interview therapists while they review their video-taped sessions such
as in Interpersonal Process Recall (Elliot, 1986). Research linking both accuracy
and change outcomes to the detailed descriptions of clinicians’ embedded practices and clinical judgment is needed. Change outcomes could include in-session
events and an assessment of pre- and post-treatment change.
CONCLUSION
The proposed meta-theoretical model of clinical judgment addressed each of the
correctives posited by Ridley and Shaw-Ridley (2009). First, the proposed model
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Jankowski et al.
consisted of the therapist-self-in-relation to the client and the client-in-context
as the systemic unit of analysis. In addition, clinical judgment was depicted
as a dynamic and multidimensional process. Last, the self-reflexive capacities
of the clinician were celebrated as integral to an effective problem definition
process. The current re-vision of an earlier contextual model of clinical judgment draws on the notion of negotiating the self-in relation to other in order to
further describe and elaborate the process of problem definition. As such, the
proposed model bridges the gap between research and practice by providing a
meta-theoretical framework grounded in the experience of a therapist engaged
in systemic practice.
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