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 17 G4157.indd 17 10/11/2012 11:03:25 AM 18 Jankowski et al. 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. G4157.indd 18 10/11/2012 11:03:25 AM A Model of Clinical Judgment 19 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 G4157.indd 19 10/11/2012 11:03:25 AM 20 Jankowski et al. 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 G4157.indd 20 10/11/2012 11:03:25 AM A Model of Clinical Judgment 21 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 G4157.indd 21 10/11/2012 11:03:25 AM 22 Jankowski et al. (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- G4157.indd 22 10/11/2012 11:03:25 AM A Model of Clinical Judgment 23 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. G4157.indd 23 10/11/2012 11:03:28 AM 24 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.” G4157.indd 24 10/11/2012 11:03:28 AM A Model of Clinical Judgment 25 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, G4157.indd 25 10/11/2012 11:03:29 AM 26 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, G4157.indd 26 10/11/2012 11:03:29 AM A Model of Clinical Judgment 27 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 G4157.indd 27 10/11/2012 11:03:29 AM 28 Jankowski et al. 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.” G4157.indd 28 10/11/2012 11:03:29 AM A Model of Clinical Judgment 29 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- G4157.indd 29 10/11/2012 11:03:29 AM 30 Jankowski et al. 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 G4157.indd 30 10/11/2012 11:03:29 AM A Model of Clinical Judgment 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 G4157.indd 31 10/11/2012 11:03:29 AM 32 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. REFERENCES Ægisdóttir, S., White, M. J., Spengler, P. M., Maugherman, A. S., Anderson, L. A., Cook, R. S., et al. (2006). The meta-analysis of clinical judgment project: Fifty-six years of accumulated research on clinical versus statistical prediction. Counseling Psychologist, 34(3), 341–382. Angus, L. E., & Greenberg, L. S. (2011). Working with narrative in emotion focused therapy: Changing stories, healing lives. Washington, DC: American Psychological Association. Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77(4), 693–704. Bavelas, J. (2011). Connecting the lab to the therapy room: Microanalysis, co-construction, and Solution-Focused Brief Therapy. In C. Franklin, T. Trepper, W. J. Gingerich, & E. McCollum (Eds.), Solution-focused Brief Therapy: From practice to evidenceinformed practice (pp. 144–162). Oxford, UK: Oxford University Press. Boss, P., Dahl, C. M., & Kaplan, L. (1996). The use of phenomenology for family therapy research: The search for meaning. In D. H. Sprenkle & S. M. Moon (Eds.), Research methods in family therapy (pp. 83–106). New York: Guilford Press. Botella, L., Herrero, O., Pacheco, M., & Corbella, S. (2004). Working with narrative in psychotherapy: A relational constructivist approach. In L. E. Angus & J. McCleod (Eds.), The handbook of narrative in psychotherapy: Practice, theory, and research (pp. 119–136). Thousand Oaks, CA: Sage. Bray, J. H. (2009). Couple and family assessment. In J. H. Bray & M. Stanton (Eds.), The Wiley-Blackwell handbook of family psychology (pp. 151–164). West Sussex, UK: Wiley-Blackwell. Carr, A. (2000). Editorial: Empirical approaches to family assessment. Journal of Family Therapy, 22(2), 121–127. Charmaz, K. (2000). Grounded theory: Objectivist and constructivist methods. In N. K. Denzin, & Y. S. Lincoln (Eds.), Handbook of qualitative research (2nd ed., pp. 509–535). Thousand Oaks, CA: Sage Publications. Chwalisz, K. (2003). Evidence-based practice: A framework for twenty-first-century scientistpractitioner training. Counseling Psychologist, 31(5), 497–528. G4157.indd 32 10/11/2012 11:03:29 AM A Model of Clinical Judgment 33 Chwalisz, K. (2006). Statistical versus clinical prediction: From assessment to psychotherapy process and outcome. Counseling Psychologist, 34(3), 391–-399. Crane, D. R., Wampler, K. S., Sprenkle, D. H., Sandberg, J., & Hovestadt, A. J. (2002). The scientist-practitioner model in marriage and family therapy doctoral programs: Current status. Journal of Marital and Family Therapy, 28(1), 75–83. Dimaggio, G. (2006). Changing the dialogue between self voices during psychotherapy. Journal of Psychotherapy Integration, 16(3), 313–345. Dimaggio, G., Hermans, H. J. M., & Lysaker, P. H. (2010). Health and adaptation in a multiple self: The role of absence of dialogue and poor metacognition in clinical populations. Theory & Psychology, 20(3), 379–399. Elliott, R. (1986). Interpersonal Process Recall as a psychotherapy process research method. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 503–527). New York: Guilford. Elliott, R., & Greenberg, L. S. (1997). Multiple voices in process-experiential therapy: Dialogues between aspects of the self. Journal of Psychotherapy Integration, 7(3), 225–239. Garb, H. N. (2005). Clinical judgment and decision making. Annual Review of Clinical Psychology, 1, 67–89. Grove, W. M., Zald, D. H., Lebow, B. S., Snitz, B. E., & Nelson, C. (2000). Clinical versus mechanical prediction: A meta-analysis. Psychological Assessment, 12(1), 19–30. Harvie, G., Strong, T., Taylor, L., Todd, N., & Young, F. (2008). Turning points in therapy: Discursive analyses and therapist comments. Journal of Systemic Therapies, 27(2), 33–49. Heatherington, L., Friedlander, M. L., & Greenberg, L. (2005). Change process research in couple and family therapy: Methodological challenges and opportunities. Journal of Family Psychology, 19(1), 18–27. Hermans, H. J. M. (2004). The innovation of self-narratives: A dialogical approach. In L. E. Angus & J. McLeod (Eds.), The handbook of narrative and psychotherapy: Practice, theory, and research (pp. 175–191). Thousand Oaks, CA: Sage. Hesse-Biber, S. N., & Leavy, P. (Eds.) (2008). Handbook of emergent methods. New York: Guilford Press. Hoffman, L. (1985). Beyond power and control: Toward a “second order” family systems therapy. Family Systems Medicine, 3, 381–396. doi:10.1037/h0089674 Hoffman, L. (1990). Constructing realities: An art of lenses. Family Process, 29, 1–12. Hoffman, L. (1991). A reflexive stance for family therapy. Journal of Strategic & Systemic Therapies, 10, 4–17. Ivey, D. C., Scheel, M. J., & Jankowski, P. J. (1999). A contextual perspective of clinical judgement in couples and family therapy: Is the bridge too far? Journal of Family Therapy, 21(4), 339–359. Jacobs, S., Kissil, K., Scott, D., & Davey, M. (2010). Creating synergy in practice: Promoting complementarity between evidence-based and postmodern approaches. Journal of Marital and Family Therapy, 36(2), 185–196. Jankowski, P. J. (1999). A qualitative study of how marriage and family therapists make clinical judgments. (Doctoral dissertation, Texas Tech University, 1998). Dissertation Abstracts International, 59(11-B), 6068. G4157.indd 33 10/11/2012 11:03:29 AM 34 Jankowski et al. Jankowski, P. J., & Ivey, D. C. (2001). Problem definition in marital and family therapy: A qualitative study. Contemporary Family Therapy, 23(4), 419–439. Kerr, M. E., & Bowen, M. (1988). Family evaluation. New York: W. W. Norton. Lichtenberg, J. W. (2009). Effects of experience on judgment accuracy. Counseling Psychologist, 37(3), 410–415. Ridley, C. R., & Shaw-Ridley, M. (2009). Clinical judgment accuracy: From meta-analysis to metatheory. Counseling Psychologist, 37(3), 400–409. Rober, P., Elliott, R., Buysse, A., Loots, G., & De Corte, K. (2008a). Positioning in the therapist’s inner conversation: A dialogical model based on a grounded theory analysis of therapist reflections. Journal of Marital and Family Therapy, 34(3), 406–421. Rober, P., Elliott, R., Buysse, A., Loots, G., & De Corte, K. (2008b). What’s on the therapist’s mind? A grounded theory analysis of family therapist reflections during individual therapy sessions. Psychotherapy Research, 18(1), 48–57. Sandage, S. J. (2010). Intergenerational suicide and family dynamics: A hermeneutic phenomenological case study. Contemporary Family Therapy, 32(2), 209–227. Skowron, E. A., Holmes, S. E., & Sabatelli, R. M. (2003). Deconstructing differentiation: Self-regulation, interdependent relating, and well-being in adulthood. Contemporary Family Therapy, 25(1), 111–129. Sorsoli, L., & Tolman, D. L. (2008). Hearing voices: Listening for multiplicity and movement in interview data. In S. N. Hesse-Biber & P. Leavy (Eds.), Handbook of emergent methods (pp. 495–515). New York: Guilford Press. Sparks, J. A., & Duncan, B. L. (2010). Common factors in couple and family therapy: Must all have prizes? In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed., pp. 357–391). Washington, DC: American Psychological Association. Spengler, P. M., White, M. J., Ægisdóttir, S., & Maugherman, A. S. (2009). Time keeps on ticking: The experience of clinical judgment. Counseling Psychologist, 37(3), 416–423. Spengler, P. M., White, M. J., Ægisdóttir, S., Maugherman, A. S., Anderson, L. A., Cook, R. S., et al. (2009). The meta-analysis of clinical judgment project: Effects of experience on judgment accuracy. Counseling Psychologist, 37(3), 350–399. Sperry, L. (2005). Case conceptualizations: The missing link between theory and practice. Family Journal, 13(1), 71–76. Sprenkle, D. H. (2010). The present and future of MFT doctoral education in research-focused universities. Journal of Marital and Family Therapy, 36(3), 270–281. Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. New York: Guilford Press. Stake, R. E. (2005). Qualitative case studies. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (3rd ed., pp. 443–466). Thousand Oaks, CA: Sage Publications. Stanton, M., & Welsh, R. (2011). Specialty competencies in couple and family psychology. NewYork: Oxford University Press. Strong, T., Zeman, D., & Foskett, A. (2006). Introducing new discourses into counseling interactions: A microanalytic and retrospective examination. Journal of Constructivist Psychology, 19(1), 67–89. G4157.indd 34 10/11/2012 11:03:29 AM A Model of Clinical Judgment 35 Vaughn, M. J. (2004). Creating “maneuvering room:” A grounded theory of language and influence in marriage and family therapy. Contemporary Family Therapy, 26(4), 425–442. Volf, M. (1996). Exclusion & embrace: A theological exploration of identity, otherness, and reconciliation. Nashville, TN: Abingdon. Wampler, K. S. (2010). Challenge and urgency in defining doctoral education in marriage and family therapy: Valuing complementary models. Journal of Marital and Family Therapy, 36(3), 291–306. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum Associates. Wampold, B. E. (2010). The research evidence for common factors models: A historically situated perspective. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed., pp. 49–81). Washington, DC: American Psychological Association. White, M. (2006). Working with people who are suffering the consequences of multiple trauma: A narrative perspective. In D. Denborough (Ed.), Trauma: Narrative responses to traumatic experience (pp. 25–85). Adelaide, South Australia: Dulwich Centre Publications. G4157.indd 35 10/11/2012 11:03:29 AM Copyright of Journal of Systemic Therapies is the property of Guilford Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.