The Clinician’s Illusion: A Powerful Source of Bias, Possibly Even Harm

[Olm the Water King]

The Clinician’s Illusion: A Powerful Source of Bias Three Decades On. | MHChat

The Clinician’s Illusion: A Powerful Source of Bias Three Decades On

30 years ago, two statistically minded psychologists published a brief but elegant paper describing a phenomenon they called “the clinician’s illusion”. Patricia and Jacob Cohen were a highly distinguished academic couple who are better known for co-authoring a dense book on statistical technique that every research psychologist surely has on their shelves.

The Cohens were concerned with the judgements of clinicians, which even at their best are necessarily distant from the ideal of the precision of a carefully conducted statistical study. They noticed that clinicians tended to overestimate the severity of serious mental health problems, and reasoned there may be some systematic bias going on.

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Imagine the average psychiatric inpatient unit. On any given day, it is likely to be populated by a higher proportion of the people who have been using the service over a long period of time than the people who have only brief contact. Extrapolating over the course of several months, a small handful of people with very long term problems are likely to become more mentally available to the clinician than the people who used the service for a short time and then moved on.

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The clinician's illusion. - PubMed - NCBI

The clinician's illusion.
Cohen P, Cohen J.

Abstract

There are several diseases, including schizophrenia, alcoholism, and opiate addiction, for which the long-term prognosis is subject to disagreement between clinicians and researchers and also among researchers. Part of this disagreement may be attributable to a difference in the populations they sample. The clinician samples the population currently suffering from the disease (a "prevalence" or census sample), while research samples tend to more nearly represent the population ever contracting the disease (an "incidence" sample). The clinician's sample is biased toward cases of long duration, since the probability that a case will appear in a prevalence sample is proportional to its duration, hence "the clinician's illusion." The statistical mechanism of this bias is illustrated and its consequences detailed. Other sources of sampling bias in clinical and research samples are briefly described and partial remedies are suggested.

The Clinician’s Illusion: How Mental Health Agencies Reinforce Mental Illness | Trauma Informed Systems

The Clinician’s Illusion: How Mental/Behavioral Health Agencies Suggest and Reinforce Mental Illness

By Elizabeth Power, M.Ed.

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Thus is born the horrifying generalizations that help keep “those people” hopeless, helpless and homeless. Everyone else who has a similar diagnosis who functions, makes a living, has solid relationships and does well… becomes invisible. And the people with diagnoses who live full and functional lives are lumped into a category with those who don’t: it is assumed that all people diagnosed with various disorders may commit gun violence, tax mental health resources, and behave outrageously.

The real problem? The people functioning well despite a diagnosis who hide their label because of the stigma associated with it. No one wants to be “like them”—the people represented by the Clinician’s Illusion.

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By the way, you don’t have to be a clinician to experience the Clinician’s Illusion. A similar illusion is at the root of all stereotypes – the belief that everyone in category X behave in Y manner.

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New York Association of Psychiatric Rehabilitation Services, Inc.

Why Don't Clinicians See Enough Recovery?
By Larry Davidson Recovery to Practice May 28, 2010

If so many people recover from serious mental illnesses, why is it that we don't see them? This is one of the most common questions raised by mental health professionals when confronted with the long-term outcome literature. That literature suggests that between 45-65% of people diagnosed with schizophrenia-the most severe of the severe mental illnesses-will recover from the disorder over time. This literature has now been around, and consistently replicated, since the 1970's, but still has not made its way into the training of most mental health professionals. So, many mental health professionals, when exposed to this body of research, ask the question above. If so many people get better, then why don't I ever see them? A reasonable enough question, to be sure, and one for which we fortunately have several answers.

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Most People With Addiction Simply Grow Out of It: Why Is This Widely Denied? - Substance.com

Most People With Addiction Simply Grow Out of It: Why Is This Widely Denied?

Maia Szalavitz

The idea that addiction is typically a chronic, progressive disease that requires treatment is false, the evidence shows. Yet the "aging out" experience of the majority is ignored by treatment providers and journalists.

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The average cocaine addiction lasts four years, the average marijuana addiction lasts six years, and the average alcohol addiction is resolved within 15 years. Heroin addictions tend to last as long as alcoholism, but prescription opioid problems, on average, last five years. In these large samples, which are drawn from the general population, only a quarter of people who recover have ever sought assistance in doing so (including via 12-step programs). This actually makes addictions the psychiatric disorder with the highest odds of recovery.

While some addictions clearly do take a chronic course, this data, which replicates earlier research, suggests that many do not. And this remains true even for people like me, who have used drugs in such high, frequent doses and in such a compulsive fashion that it is hard to argue that we “weren’t really addicted.” I don’t know many non-addicts who shoot up 40 times a day, get suspended from college for dealing and spend several months in a methadone program.

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This is one of many reasons why I prefer to see addiction as a learning or developmental disorder, rather than taking the classical disease view. If addiction really were a primary, chronic, progressive disease, natural recovery rates would not be so high and addiction wouldn’t have such a pronounced peak prevalence in young people.

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The data supports this idea: If you start drinking or taking drugs with peers before age 18, you have a 25% chance of becoming addicted, but if your use starts later, the odds drop to 4%. Very few people without a prior history of addiction get hooked later in life, even if they are exposed to drugs like opioid painkillers.

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[Magic Poriferan]

This reminds me of a similar issue faced by people who worked at corrections facilities. The nature of the job is such that you never really see the people who leave the system and don't come back. You only see the ones who stay for the long term and the recidivists.

 

[AphroditeGoneAwry]

Very interesting. The prevalence vs incidence data is compelling, and makes sense. That is why you hear experienced psychologists saying they believe incidence is higher than it is, because they see a skewed version of society.

I find myself questioning the validity of the data on addictions though. I'd have to read the studies myself and see how many have been done to believe that. Though I ABSOLUTELY believe once and addict, not always an addict.

Thanks for this.


On a side note, I have also heard anecdotal accounts of abusers outgrowing their abusive natures.

 

[Kheledon]

Excellent and informative. Thanks for posting!

 

[Lark]

This is true but I can think of other structural and systemic factors reinforcing mental illness too, such as the fact that it can be connected to welfare benefits in parts of the world (I favour UBI in part because it should eliminate differentiation, incentivisation etc. on that basis).

There are also what may be considered "existential" or "identity" factors too, people who have suffered episodic crisis or situational depression may be inclined to accept diagnosis of underlying disorders because they can feel better about lost time and opportunities, the threat of further crisis or episodes, the threat of failure or relapse.

I have known people whose illness becomes their "story", that which they can tell if someone says "what do you do?", or it becomes their "work", ie creative out let and channel for productivity.

There are also theories to do with social interaction and attachment styles, years ago and in particular cultural contexts I remember members of the priesthood talking about the, generally, elderly, isolated and female population who went to confession almost as often as it was possible, loneliness rather than sinfulness was generally thought to be the motivation.

The same thing can and does happen in the context of health services, particularly public health services, sometimes there really are my health complications accompanying the seeking out of repeated contact but sometimes that can be the individual's sole or most significant social tie.

 

[Lark]

This reminds me of a similar issue faced by people who worked at corrections facilities. The nature of the job is such that you never really see the people who leave the system and don't come back. You only see the ones who stay for the long term and the recidivists.

In part that's what I was posting that other thread about.

In an even broader strokes contact with "the authorities" idea.

Although, I'm a bit wary of the reasoning which might suggest "no service beats any service" when it comes to certain intractable problems such as mental illness.

Its music to the ears of people who want to cut services but not necessarily people in need.