Cognitive Aging: A Normal Process

Excerpt from the course Alzheimer’s Disease & Dementia: A Practical Guide by, Laura More, MSW, LCSW

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The National Academy of Medicine (NAM, 2015) published a guide to cognitive aging to help healthcare professionals advise patients about normal and abnormal cognitive health. Key information includes:

• The brain ages, just like other parts of the body. The brain is responsible for cognition, a term that describes mental functions including memory, decision making, processing speed, and learning. As the brain ages, these functions may change—a process called cognitive aging.
• Cognitive aging is not a disease. It is not the same as Alzheimer’s disease or other types of dementia. Cognitive aging is a natural, lifelong process that occurs in every individual.
• Cognitive aging is different for every individual. Some people may experience very few effects, while others may undergo changes that affect the cognitive abilities needed to carry out daily tasks, such as paying bills, driving, and following recipes.
• Some cognitive functions improve with age. Wisdom and knowledge often increase with age, and older adults report greater levels of happiness and satisfaction than their younger counterparts.
• There are steps people can take to protect their cognitive health. Although aging is inevitable, it is possible to promote and support cognitive health and adapt to age-related changes in cognitive function.

For most aging adults, fear of dementia is a worry that clouds their expectations of what is to come with advancing years. A forgotten name or a wrong turn on the way to a familiar destination evokes fear of cognitive decline and, worse, the loss of self. It can be helpful to educate older adults about the normal changes in cognition that can be expected with age. Fjell and colleagues (2014), writing for the Alzheimer’s disease Neuroimaging Initiative, describe normal aging changes in contrast to pathological neurodegeneration. The issue, according to the authors, is that three of the primary symptoms of Alzheimer’s disease are found in many healthy older adults. These symptoms include poor episodic memory function (a person’s memory of life events), brain atrophy, and accumulation of amyloid protein.

Another problem is that the major risk factor for Alzheimer’s disease is age itself. With increasing age come normal cognitive declines in mental speed, executive functioning, and episodic memory. Episodic memory starts to decline at age 50. Fjell et al. (2014) note that there are three categories of older adults in terms of memory decline: maintainers (18%), typical age decliners (68%), and decliners (13%). Maintainers were more likely to be female and live with someone. Decliners tended to be male, have lower education, and be unemployed.

Brain atrophy – shrinking of the brain mass – has been studied extensively. The yearly rate of decrease is about .5% in most regions of the brain. The frontotemporal lobes, responsible for high-level cognition and executive functions, tend to be more vulnerable to shrinkage. These lobes are more complex, are the last to develop in a young person, and tend to be more at risk in the aging process.

Age-related dementia is a slow process. Brain atrophy may show on scans years before symptoms appear. However, atrophy itself does not mean the person has or will have dementia. A person’s mental activity over the lifespan has positive, protective effects on cognitive functioning. High cognitive engagement may even slow the deposit of amyloid proteins associated with Alzheimer’s disease. Fjell et al. (2014) reports that the presence of Alzheimer’s disease markers is positively affected by the person having purpose in life. However, the authors note that progression from the normal, mild cognitive decline of aging to dementia is a poorly understood process that varies widely between individuals.

The diagnosis of dementia includes a significant disruption in social function as well as impairment in independent living. A person with dementia has difficulty shopping alone, managing money, and monitoring appropriate social behavior. Symptom severity in relation to dementia varies between people. For example, if a person never handled a checkbook because her husband took care of family finances, a struggle with balancing the checkbook when she is a new widow would be normal. The differences between normal aging and Alzheimer’s disease or dementia can be seen in the chart below and is explained in detail in the following section (National Institute on Aging, 2020).

Normal Age-Related Changes	Signs of Alzheimer’s Disease or Dementia
Making a poor decision occasionally.	Consistently poor judgment and decision-making.
Failing to make the car payment one month.	Unable to manage a budget or finances.
Forgetting the day of the week but remembering later.	Unable to remember the day, dates, and seasons.
Occasional word-finding difficulty.	Difficulty carrying on a conversation.
Losing keys or glasses occasionally.	Unable to retrace steps and find lost items.

Memory problems that disrupt everyday life: An older person may report forgetting a doctor’s appointment when planning lunch with a friend. They later remember, call the friend, and reschedule lunch. Or they forget where they laid down their eyeglasses, but can go through the house, retracing their steps until they remember setting the glasses down in the bathroom to use eye drops. This is normal. However, one of the early signs of dementia is the inability to recall recently learned information. The person with cognitive impairment may ask the same question multiple times, not remembering the answer. Or they may accuse family members of stealing their eyeglasses or the remote control, because they don’t remember where the remote control is located.

Planning problems: An older adult may make an occasional error counting money to a cashier during a purchase. A person with dementia may not be able to follow a recipe, struggling with the measurements and multiple-step instructions. It can be difficult for a person with dementia to concentrate on a task and routine tasks take longer. Multiple-step verbal directions are a problem because the person with dementia loses the sequence of the directions midway.

Familiar task problems: An older adult may need a reminder on how to record a favorite television show on the DVR. A person with dementia may forget the directions to a familiar location such as their daughter’s home. Or they may not be able to play a favorite card game, forgetting the rules or being unable to manage the scoring and rules.

Confusion of time and place: A retired older person may ask, “What day is it today?” but remember a little while later. A person with dementia may dress in long pants and a sweater in the middle of summer, not remembering what season it is. They may become disoriented, not remembering where they are. This can be a frightening experience for both the person and family members. It can be exacerbated by changing their familiar location, such as moving in with family or placement in a skilled nursing facility.

Perceptual problems: An older adult may have cataracts, which affect acuity and color perception (dulling colors and blurring vision). A person with dementia may not be able to judge distances accurately or determine color. They may look in a mirror and not recognize themselves, thinking there is another person in the room.

Difficulty speaking or writing: Many older adults have word-finding problems. They may inadvertently use the wrong word or use substitutions or descriptions to get their meaning across when the correct word cannot be retrieved, but they are able to be understood. A person with dementia may not be able to follow or respond in a conversational setting. They may not participate, may stop in the middle of a sentence, or repeat themselves. It can be difficult to understand what the person is trying to communicate.

Poor judgment: Every now and then an older adult makes a poor decision: paying too much for a new car, for example, or buying a technology item they end up not using. A person with dementia may agree to donate hundreds of dollars to a telemarketer for a charity, not verifying the cause or the validity of the organization. Daily judgment is significantly impaired, and family members need to limit access to the checkbook or credit cards. The person may not be able to judge their ability to drive safely; family may need to take away the car keys to keep the person (and others) safe.

Withdrawal: Many busy older adults express their desire to slow down social activities and family obligations. The person with dementia may have trouble understanding what is going on during a football game and stop watching, even though it was once a favorite pastime. They may refuse to go to social events due to difficulty conversing and following what is happening around them. Previous hobbies are abandoned because they can no longer easily participate.

Personality and mood changes: As people age, they may become fond of routine and specific ways to participate in activities or tasks, but their basic personality does not change. A person with dementia may show gradual changes in personality, becoming anxious, fearful, suspicious, or depressed. They can easily be upset when they do not understand what is happening or are uncomfortable.

Reassure clients that many changes in memory are normal. The areas most affected are episodic (where did I park the car?) and source (who told me about the new restaurant?). Words, facts, and concepts are little affected. How to do a task, such as how to use a power drill, are also spared. The issue is generally in setting down the memory (encoding) or pulling the memory out (retrieval). Distraction or anxiety while learning something can disrupt encoding, as can trying to multi-task while learning.

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Visit https://www.pdresources.org/searchlisting?search_input=31-50&search_course_number=on to access the course, Alzheimer’s Disease & Dementia: A Practical Guide.

CE Credit: 3 Hours

Target Audience: Psychology CE | Counseling CE | Speech-Language Pathology CEUs | Social Work CE | Occupational Therapy CEUs | Marriage & Family Therapy CE | Nutrition & Dietetics CE

Learning Level: Introductory

Course #31-50 | 2024 | 65 pages | 20 posttest questions

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CE INFORMATION

Professional Development Resources is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. Professional Development Resources maintains responsibility for this program and its content. Professional Development Resources is also approved by the National Board of Certified Counselors (NBCC ACEP #5590); the Association of Social Work Boards (ASWB #1046, ACE Program); the Florida Boards of Social Work, Mental Health Counseling, and Marriage and Family Therapy (#BAP346), Psychology & School Psychology (#50-1635); the New York State Education Department’s State Board for Psychology as an approved provider of continuing education for licensed psychologists (#PSY-0145), the New York State Education Department’s State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors (#MHC-0135), licensed marriage and family therapists (#MFT-0100 – Note: New YorkMFTs will receive 3 continuing education credit(s) for completing this self-study course), and licensed social workers (#SW-0664); the Ohio Counselor, Social Worker, and Marriage & Family Therapist Board (#RCST100501 – Note: Ohio MFTs completing this course will receive 3 clinical continuing education credit(s)); the South Carolina Board of Professional Counselors & MFTs (#193); the Texas Board of Examiners of Marriage & Family Therapists (#114) and State Board of Social Worker Examiners (#5678); and is CE Broker compliant (#50-1635 – all courses are reported within two business days of completion).

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Communication Failures: A Leading Cause of Medical Errors

Excerpt from Course #21-59 Preventing Medical Errors & Improving Patient Safety by, Leo Christie, PhD

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According to The Joint Commission (2023), communication errors are the leading root cause of reported sentinel events. Such errors can occur between the clinician and the client, among various clinicians, or within written communications such as medical records or patient instructions. Among the causes of miscommunication are inadequate time spent with the patient, inadequate communication about patients between healthcare professionals, failure on the part of the healthcare professional to document treatment data in a timely and accurate fashion, or use of language that the client does not understand.

Communication among Professionals

Patient “handoff,” when a patient is handed off to another healthcare professional for further care, is prone to errors in communication. Handoff, which occurs not only between shifts in hospital environments, but also every time one healthcare professional refers a patient to another, creates opportunities for missed communication.

Many factors may be involved when handoff communication is inadequate. These include the healthcare professional’s training, cultural considerations, depth of training, language barriers, time pressure, and poor documentation (The Joint Commission, 2017).

Different professions can have different communication styles and different vocabularies. For example, when a speech-language pathologist and an occupational therapist are treating the same client and have occasion to communicate treatment information, they need to have a way of using the same descriptive words so that important treatment information is communicated accurately.

Professionals’ use of different styles can result in miscommunication or omission of key patient care information that may jeopardize patient safety. For example, Stewart and Hand (2017) point out that nurses and doctors have generally been taught to communicate using styles suited to the needs and thought processes of their respective professions. Physicians tend to communicate tersely in an action-oriented style. Nurses often use a narrative style that reflects their direct care responsibilities.

Research shows that many professionals work hard to effectively collaborate across disciplines. One of these is bridging gaps. This refers to the differences in professional perspectives in the most effective way to treat patients. Another is setting up opportunities for different disciplines to communicate informally in social settings, leading to improved transfer of information. Another interesting way to enhance communication is to “translate” the information in terms the other person understands. This is especially important with specialized jargon for a particular discipline, or when helping patients understand what the physician just told them (Schot et al., 2020). In view of the vital necessity for accurate and timely exchange of patient care information, there is a clear need for employing a common vocabulary that is understood the same way by both/all parties. Healthcare professionals should actively contribute to interprofessional collaboration.

Case Example The following example of successful communication and collaboration between an OT and an SLP is from the Leader Live (Sigal, 2016), an online publication of the American Speech-Language-Hearing Association (ASHA).

A father of a client we both saw asked us to collaborate. “Ethan,” age 2, worked on fine and sensory motor skills with Michelle, an occupational therapist, while I worked with him on articulation and oral motor skills.

Michelle and I instantly clicked and started carrying over each other’s treatment activities to meet Ethan’s goals. Michelle helped emphasize speech goals by addressing target articulation sounds in play. She already used Chewy Tubes for sensory purposes, but now, instead of asking Ethan to simply chew on the tubes, he followed regimented rules to improve jaw strength, stability, symmetry, and tongue retraction.

In addition, Michelle taught me positioning and seating necessary for increasing Ethan’s core strength and posture. These modifications increased his breath control for speech. I began using a therapy ball for sensory-based input to improve overall affect, attention, and speech. We addressed Ethan’s goals more consistently each week because of our collaborative approach to treatment.

The two professionals were able to teach each other about fine and sensory motor skills – an OT therapeutic activity – and articulation and oral motor skills – an SLP therapeutic activity for use with a common client. The differing terms and procedures used by two practitioners from different specialties, which might have caused miscommunication and potential treatment gaps, instead were creatively employed by the two in collaborative methods to benefit their shared client.

Communication with Clients

When clients do not understand information or terminology communicated to them by their treating professionals, negative outcomes are likely. It is always the responsibility of the healthcare professional to gauge the level of understanding of the client and ensure that communicated words and instructions are accurately understood. There are three areas that can impact clinician-client communication and the occurrence of medical errors: health literacy, health consumerism, and cultural competency.

Health Literacy and Patient Safety

Many organizations, such as The Joint Commission and the American Medical Association, have recognized the link between patient safety and clearly communicating with patients about health-related issues. Healthy People 2030 notes that health literacy involves “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (National Library of Medicine, ND). Health literacy includes three categories: personal, organizational, and digital.

Personal health literacy includes the ability to understand instructions on prescription drug containers, appointment slips, medical education brochures, doctor’s instructions and consent forms, and the ability to negotiate complex health care systems. Health literacy is not simply the ability to read. It requires a complex group of reading, listening, analytical, and decision-making skills, and the ability to apply these skills to health situations. High general literacy does not guarantee high health literacy. 90% of adults have problems with health literacy. This is not surprising when you consider that health literacy is usually needed when a person is sick, stressed over a family member’s symptoms, or fatigued from caring for an ill spouse.

Mor-Anavy et al. (2021) surveyed physicians, administrators, and administrative staff to assess health literacy. The survey included examples of a consent form, a nutrition label, and a brochure included in medical packaging. The survey further asked the participants where to find patient rights information and if they knew how to make an appointment. Study results found the following:

The health literacy level was high among 53% of providers, sufficient among 22%, average among 17%, problematic among 2%, and inadequate among 6%. Additionally, 22% of administrators and 14% of physicians reported difficulty in understanding informed consent documents, and 13% of administrators and 8% of physicians had difficulty understanding how to get an appointment.

It can be easy for a healthcare professional to concentrate on clinical matters, and not pay attention to consent forms or other administrative parts of patient care. However, this can negatively affect patient care and outcomes (CDC, 2023).

Organizational Health Literacy and Occupational Therapy

Organizational health literacy involves helping patients understand and use health-related information appropriately. It can include, for example, an easier scheduling process, brochures that are easy to read, and using the Teach Back method to assure the patient understands (NLM, ND).

The American Occupational Therapy Association’s (AOTA) Societal Statement on Health Literacy (2017) states that people with inadequate health literacy are more likely to experience adverse health outcomes. “Occupational therapy practitioners can assist in ensuring that all health-related information and education provided to recipients of occupational therapy or other health-related services match each person’s literacy abilities; cultural sensitivities; and verbal, cognitive, and social skills” (p. 1). Further,

The American Occupational Therapy Association strives to ensure that occupational therapy practitioners have appropriate communication and education skills to help enable all people gain access to and understand occupational therapy and other health-related services. This effort includes information and education that promote self-management for optimum health and participation. In addition, occupational therapy practitioners may facilitate clients’ health literacy. (AOTA, 2017, p. 1)

The emphasis on health literacy is carried out within the AOTA’s specialty groups. The Rehabilitation and Disability group notes that occupational therapists should “understand health literacy and why it is important, and…identify what occupational therapy practitioners (OTPs) can do to increase patient understanding for improved health outcomes” (Montgomery, 2023).

Health Consumerism

In contrast to the issue of low health literacy among patients is that of health consumerism. Due largely to the ease of obtaining information from the internet, consumers are becoming increasingly proactive in their own healthcare. Researchers call this “e-health information consumerism” (Seckin, 2020).

This is a positive aspect of the growing health consumerism – that it challenges practitioners to stay current on clinical issues, which they should be doing, to meet their professional and ethical responsibilities as licensed health care providers. It is for this reason that licensing boards and accrediting bodies require continuing education for renewal.

Another positive aspect of the growing consumerism in healthcare is that it empowers patients. Knowledge allows them to become more involved in treatment and make more informed decisions, which improves compliance and ultimately satisfaction. More problematic is deciphering the vast amount of information that is available, particularly when it is confusing and, often, contradictory. You may spend more time explaining why a “miracle treatment” found on the internet has not been proven safe or effective. There is also an issue with consumers attempting to self-diagnose. The best defense moving forward is a good offense. Be prepared and stay current on clinical issues. It may help to do internet searches on topics you work with frequently to anticipate questions you may encounter. You will also need to be able to distinguish science from pseudoscience, both for yourself and for your patients.

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How can healthcare professionals and facilities make an impact on the problem of medical errors at the grass roots level? Visit http://www.pdresources.org to access the course, Preventing Medical Errors & Improving Patient Safety, to find out.

https://www.pdresources.org/course/index/5/1450/Preventing-Medical-Errors-Improving-Patient-Safety

Course 21-59 | 2024 | 40 pages | 15 posttest questions

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CE INFORMATION

Professional Development Resources is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. Professional Development Resources maintains responsibility for this program and its content. Professional Development Resources is also approved by the National Board of Certified Counselors (NBCC ACEP #5590); the Association of Social Work Boards (ASWB #1046, ACE Program); the Florida Boards of Social Work, Mental Health Counseling, and Marriage and Family Therapy (#BAP346), Psychology & School Psychology (#50-1635); the New York State Education Department’s State Board for Psychology as an approved provider of continuing education for licensed psychologists (#PSY-0145), the New York State Education Department’s State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors (#MHC-0135), licensed marriage and family therapists (#MFT-0100 – Note: New YorkMFTs will receive 2 continuing education credit(s) for completing this self-study course), and licensed social workers (#SW-0664); the Ohio Counselor, Social Worker, and Marriage & Family Therapist Board (#RCST100501 – Note: Ohio MFTs completing this course will receive 2 clinical continuing education credit(s)); the South Carolina Board of Professional Counselors & MFTs (#193); the Texas Board of Examiners of Marriage & Family Therapists (#114) and State Board of Social Worker Examiners (#5678); and is CE Broker compliant (#50-1635 – all courses are reported within two business days of completion).

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Winner will receive one of each required course for license renewal. Winner will be announced on April 30th, 2024.

Still need the remaining general hours for license renewal? View our full list of courses available for credit for psychologists at https://www.pdresources.org/courselisting/newarrival/1.

 

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Professional Development Resources is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. Professional Development Resources maintains responsibility for this program and its content. Professional Development Resources is also approved by the National Board of Certified Counselors (NBCC ACEP #5590); the Association of Social Work Boards (ASWB Provider #1046, ACE Program); the Continuing Education Board of the American Speech-Language-Hearing Association (ASHA Provider #AAUM); the American Occupational Therapy Association (AOTA Provider #3159); the Commission on Dietetic Registration (CDR Provider #PR001); the Alabama State Board of Occupational Therapy; the Arizona Board of Occupational Therapy Examiners; the Florida Boards of Social Work, Mental Health Counseling and Marriage and Family Therapy, Psychology and Office of School Psychology, Speech-Language Pathology and Audiology, Dietetics and Nutrition, and Occupational Therapy Practice; the Georgia State Board of Occupational Therapy; the Louisiana State Board of Medical Examiners – Occupational Therapy; the Mississippi MSDoH Bureau of Professional Licensure – Occupational Therapy; the New York State Education Department’s State Board for Psychology as an approved provider of continuing education for licensed psychologists (#PSY-0145), State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors (#MHC-0135) and marriage and family therapists (#MFT-0100), and the State Board for Social Workers an approved provider of continuing education for licensed social workers (#SW-0664); the Ohio Counselor, Social Worker and MFT Board (#RCST100501) and Speech and Hearing Professionals Board; the South Carolina Board of Examiners for Licensure of Professional Counselors and Therapists (#193), Examiners in Psychology, Social Worker Examiners, Occupational Therapy, and Examiners in Speech-Language Pathology and Audiology; the Tennessee Board of Occupational Therapy; the Texas Board of Examiners of Marriage and Family Therapists (#114) and State Board of Social Worker Examiners (#5678); the West Virginia Board of Social Work; the Wyoming Board of Psychology; and is CE Broker compliant  (#50-1635 – all courses are reported within a few days of completion).

 

Why Do We Need Critical Thinking Skills?

Excerpt from the course The Power of Skepticism and Critical Thinking by Leo Christie, PhD

In clinical practice, regardless of specialty, there are multiple reasons for using advanced critical thinking skills. In the mental health profession, critical thinking skills help professionals examine and challenge their own beliefs and the beliefs of others. Gambrill and Gibbs (2017) emphasize that our beliefs are important because they shape what we do:

Critical thinking is essential to helping people because it encourages practitioners to evaluate the soundness of beliefs, arguments, and claims. What helpers believe influences what they do. Thus, it is important to examine beliefs in relation to their accuracy. Will sending a youthful offender to boot camp be more effective in decreasing future offenses than placing him on probation? Will a prescribed drug forestall the progression of confusion among Alzheimer’s patients in a nursing home? Will children with learning disorders learn better if mainstreamed into regular classrooms? Professionals make many such judgments and decisions daily. Deciding which actions will help clients is an inescapable part of being a professional. Thinking critically about claims, beliefs, and arguments can help professionals arrive at beliefs and actions that are well reasoned. (p. v)

The ultimate goal of every clinical decision is, of course, a positive outcome in terms of the patient’s therapy experience. Does competent critical thinking result in more positive patient outcomes? The relationship – at least a linear one – has not yet been clearly demonstrated. Festinger (1962) notes:

Critical thinking is a construct that overlaps the conceptual boundaries of clinical judgment. However, … critical thinking is a form of problem solving, but … the difference between the two processes is that critical thinking is non-structured, whereas problem solving is more narrow in scope. Clinical decisions and solutions (actions taken) result in patient outcomes. (p. 64)

In other words, the expanded process might look like this:

Critical Thinking > Clinical Judgements > Clinical Actions > Patient Outcomes

In reality, the diagram is likely to be more complex, with several feedback loops and critical thinking employed at more than one point in the process. Nevertheless, the elements of critical thinking provide an essential link in the chain of events that result in patient outcomes, whether positive or negative.

When certain factors, undermine or shortcut a competent critical thinking process, less-than-satisfactory healthcare outcomes can result and potential benefits to the patient are compromised.

Patient Safety

Much has been made of the problems around patient safety and medical errors in the practice of medicine and other health care fields. In their article on patient safety, Ruedinger et al. (2017) proposed a resident curriculum on medical decision-making.

Key components of the curriculum included demystifying the medical decision-making process, building skills in critical thinking, and providing strategies for mitigating diagnostic errors. A major focus of the program emphasized the importance of focusing on the decision-making process over content knowledge, redirecting conversations if the learners became bogged down in case details. Their learning processes included group discourse, introspection, and other components of critical thinking as outlined in this course.

When a medical error occurs, patients are not the only victims. Ruedinger et al. (2017) noted that – in addition to the association of medical errors with poor patient safety and outcomes – diagnostic and treatment errors are also associated with what they termed the “second victim” effect (p. 625). That is, physicians also suffer significant negative consequences when they are involved in a medical error. This can include lowered quality of life, more burnout, and decreased empathy.

Evidence-Based Practice (EBP)

One of the most important applications of critical thinking in health care is to the implementation of the principles of evidence-based practice (EBP). The essential idea of EBP is that it starts with a critical mindset. High-quality decisions are based on a combination of three elements: (1) critical consideration of the available evidence, (2) consideration of one’s own clinical experiences, and (3) attention to the client’s needs and values. Although most practitioners use evidence in their decisions, many do not pay enough attention to the quality of that evidence. As seen throughout this course, “available evidence” is subject to many forms of distortion, fallacies, blind spots, and biases. The result of relying on poor-quality evidence is a bad decision based on unfounded beliefs, fads or ideas promulgated by popular gurus. Other results include poor outcomes and limited understanding of why things go wrong.

Barends et al. (2014) point out that when we use EBP we seek to improve the way decisions are made. It is an approach to decision-making and day-to-day work practice that helps practitioners to critically evaluate the extent to which they can trust the evidence they have at hand. It also helps practitioners to identify, find and evaluate additional evidence relevant to their decisions.

Correctly understanding EBP requires a process of critical thinking. Barends et al. (2014) note that there are a number of misconceptions about EBP. It is important that misconceptions are challenged and corrected. In most cases they reflect a narrow or limited understanding of the principles of evidence-based practice. The six misconceptions are:

1. Evidence-based practice ignores the practitioner’s professional experience. Evidence-based practice does not mean that any one source of evidence is more valid than any other. Even the professional experience and judgment of practitioners can be an important source if it is appraised to be trustworthy and relevant. Evidence from practitioners is essential in appropriately interpreting and using evidence from other sources.
   
2. Evidence-based practice is all about numbers and statistics. Evidence-based practice involves seeking out and using the best available evidence from multiple sources. It is not exclusively about numbers and quantitative data, although many practice decisions involve figures of some sort.
   
3. Practitioners need to make decisions quickly and don’t have time for evidence-based practice. Many decisions do have to be made quickly, but even split-second decisions require trustworthy evidence. EBP is about preparing yourself (and your organization) to make key decisions well – by identifying the best available evidence you need, preferably before you need it.
   
4. Every organization is unique, so the usefulness of evidence from the scientific literature is limited. Although it is true that organizations do differ, they also tend to face very similar issues, sometimes repeatedly, and often respond to them in similar ways. Peter Drucker, a management thinker, was noted for being the first to assert that most management issues are “repetitions of familiar problems cloaked in the guise of uniqueness” (Lowenstein, 2006).
   
5. If you do not have high-quality evidence, you cannot do anything. It is crucial to understand that EBP is based upon careful consideration of the “best available evidence.” For some decisions, there may be no evidence from the scientific literature at all. Thus “we may have no option but to make a decision based on the professional experience of colleagues or to pilot test different approaches and see for ourselves what might work best.”
   
6. Good-quality evidence gives you the answer to the problem. Even the best evidence is only input for your critical decision-making process. It does not speak for itself and save you the work. No piece of evidence can be viewed as a universal truth. In most cases evidence comes with a large degree of uncertainty. In short, evidence does not tell you what to decide, but it does help you to make a better-informed decision.

Diagnosis

The initial and pivotal step in any successful therapeutic process is, of course, an accurate diagnosis. The thinking errors that will be described in this course provide multiple opportunities for getting the diagnosis wrong, either by distorting the lens through which the clinician perceives the client or by leading to incorrect conclusions about why the client’s symptoms are occurring. Either way, an incorrect diagnosis cannot lead to effective treatment planning and implementation.

In her book Critical Thinking in Clinical Assessment and Diagnosis, Probst (2015) observes that making an accurate diagnosis is no simple task and deserves all the attention and expertise clinicians can muster in order to get it right. She notes that:

…a report compiled in 1888 listed seven types of mental illness (dementia, alcoholism, epilepsy, mania, melancholia, monomania, and paresis). The American Psychiatric Association’s 1917 manual included 22 diagnoses. The most recent edition of the DSM [Diagnostic and Statistical Manual of Mental Disorders], published in 2013, lists more than 300. (p. 37)

Probst gives the example of attempting to make a distinction between a cat and a dog by listing its distinguishing features. In attempting to do so, you might begin to appreciate the complexity of determining how many characteristics you would have to include in order to make the distinction. If you list fur, four legs, whiskers, and a tail, you have not yet attained the diagnostic specificity needed to tell the difference (p. 37).

In terms of diagnosing mental disorders in humans, the problem is even more acute. Probst (2015) observes, for example, that studies have shown that:

…two-thirds of the children diagnosed with bipolar disorder also meet criteria for ADHD (imagine if two-thirds of your pets could be classified equally well as cats or dogs). Many people have features that seem to belong to one category and features that belong to another, or meet some but not all the criteria for a particular disorder. (p. 37)

The other challenge of diagnosis – even more relevant to the issue of critical thinking – is diagnostic sensitivity, or how accurate we are in assigning an individual to a specific diagnostic category. In the next section we will discuss Type 1 and Type 2 errors, referring to mistakes in either identifying a condition when it is not there or failing to identify it when it is there. This part of diagnosing is particularly vulnerable to the kinds of biases and deductive malfunctions we will study in this course. There are challenges to thinking and diagnostic accuracy within the DSM itself. Among other problems she sees in the manual, Probst (2015) discusses the issue of circular reasoning. This phenomenon, she says,

…most often occurs in mental health when behavior is used to explain behavior. An observer sees that a person runs away when they encounter dogs. When asked why the person runs away, the observer says it is because the person has a specific phobia of dogs and that this causes fear and avoidance. Now, the only evidence for the phobia is the person’s fear and avoidance. When asked for the causes of the fear and avoidance, the phobia is given as the reason. In this instance, cause and effect are indistinguishable, and hence, no real explanation is provided. (p. 51)

While there is no immediate solution to the kinds of limitations Probst (2015) finds in the DSM, she proposes that mental health clinicians could adopt a “more empirically grounded system of biologically based conditions, and those seen as the result of a person’s learning history, upbringing, past and current environmental contexts, and present experience of reinforcing and aversive experiences” (p. 63). This approach would be consistent with a critical thinking mindset. The benefits provided by employing advanced critical thinking skills during diagnosis include an approach that embraces a cognitive process that involves “clearly describing and taking responsibility for claims and arguments, critically evaluating our views (no matter how cherished) and considering alternative news and related evidence” (Probst, 2015, p. 6).

Client Education

Possibly the only certainty in the process of treating clients is that we will not be with them forever. In fact, we may see a patient only a handful of times. Therefore, we must make the most of our time with them if we want to make a long-lasting and beneficial impact on their lives. This means we must consider what we want clients to take away from their time with us when the final session is over. Patient education (including training in critical thinking skills) is one of the best ways to address this need. In the final section of this course, we will describe numerous strategies for cultivating a critical thinking mindset, in both ourselves and our clients.

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The Power of Skepticism and Critical Thinking is a 3-hour online continuing education (CE) course that examines why positive skepticism and critical thinking skills are necessary in clinical practice.

Human beings are endowed with the ability to reason and the need to find connections between things and events. Unfortunately, the need to find connections can be so strong, practitioners and patients can sometimes convince themselves that there are links between treatment plans and patient outcomes, even if there is a lack of evidence to support them. In health care, arriving at the wrong conclusion can be an error of life and death proportions.

These “deductive malfunctions” and other fallacies, heuristics, and biases, are described, discussed, and illustrated in this course. The author begins by defining the concept of ‘critical thinking,’ and follows with a discussion on why practitioners must take an objective approach when evaluating patients, analyzing treatment plans, assessing the effectiveness of interventions, and challenging their own beliefs.

The factors (such as cognitive error, fallacies, assumptions, blind sports, pseudoscience, and quackery) that challenge one’s ability to think critically are highlighted. The author examines strategies for developing critical thinking skills across all ages and provides a review of assessment tools that can be used to gauge the quality of critical thinking before teaching begins and as a measure of progress throughout the training.

The final section of the course provides methods and techniques for cultivating and applying a critical thinking mindset. ‘How-To’ lists for evaluating new treatments, the scientific quality of conference speakers, published studies, and internet content are included.

Course #31-52 | 2024 | 57 pages | 20 posttest questions

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CE Credit: 3 Hours

Target Audience: Psychology CE | Counseling CE | Speech-Language Pathology CEUs | Social Work CE | Occupational Therapy CEUs | Marriage & Family Therapy CE | School Psychology CE | Teaching CE

Learning Level: Introductory

Course Type: Online (Text-Based/Downloadable PDF

CE INFORMATION:

Professional Development Resources is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. Professional Development Resources maintains responsibility for this program and its content. Professional Development Resources is also approved by the National Board of Certified Counselors (NBCC ACEP #5590); the Association of Social Work Boards (ASWB #1046, ACE Program); the Florida Boards of Social Work, Mental Health Counseling, and Marriage and Family Therapy (#BAP346), Psychology & School Psychology (#50-1635); the New York State Education Department’s State Board for Psychology as an approved provider of continuing education for licensed psychologists (#PSY-0145), the New York State Education Department’s State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors (#MHC-0135), licensed marriage and family therapists (#MFT-0100 – Note: New York MFTs will receive 3 continuing education credit(s) for completing this self-study course), and licensed social workers (#SW-0664); the Ohio Counselor, Social Worker, and Marriage & Family Therapist Board (#RCST100501 – Note: Ohio MFTs completing this course will receive 3 clinical continuing education credit(s)); the South Carolina Board of Professional Counselors & MFTs (#193); the Texas Board of Examiners of Marriage & Family Therapists (#114) and State Board of Social Worker Examiners (#5678); and is CE Broker compliant (#50-1635 – all courses are reported within two business days of completion).

Professional Development Resources is also an AOTA Approved Provider of professional development. Course provider ID# 3159. This distance learning-independent course is offered at 0.3 CEUs, intermediate level, professional issues. The assignment of AOTA CEUs does not imply endorsement of specific course content, products, or clinical procedures by AOTA. Professional Development Resources is also approved by the Alabama State Board of Occupational Therapy; the Arizona Board of Occupational Therapy Examiners; the Florida Board of Occupational Therapy Practice; the Georgia State Board of Occupational Therapy; and is CE Broker compliant (#50-1635) (all courses are reported within two business days of completion). Participant successfully completed the required assessment component for this activity.

Professionals Development Resources is also an ASHA Approved Provider of professional development. Introductory Level | 0.3 ASHA CEUs | ASHA credit is available until 01/31/2029. ASHA CEUs are awarded by the ASHA CE Registry upon receipt of the monthly completion report from the ASHA Approved CE Provider (#AAUM5186). Please note that the date that appears on ASHA transcripts is the last day of the month in which the course was completed.

Professional Development Resources is also approved by the Florida Board of Speech-Language Pathology and Audiology, the Ohio Board of Speech-Language Pathology and Audiology, the South Carolina Board of Examiners in Speech-Language Pathology and Audiology, and is CE Broker compliant (#50-1635).

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