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:
- 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.
- 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.
- 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.
- 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).
- 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.”
- 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.
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
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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