臺灣博碩士論文加值系統

臨床上，臨床判斷的正確性於過去歷史是備受爭議(Groth-Marnat, 2003)，因為此判斷是有偏誤的。臨床工作者對個案所收集到的資料或訊息，到底如何使用？依據認知心理學的觀點來看，訊息處理的方式是可能影響臨床工作者判斷的正確性。Garb(1996)的研究已證實臨床工作者使用臨床判斷時，如何受到訊息處理的影響，其指出當他們看到個案的情況時，會將個案與自己腦中的刻板印象(stereotype)或範型(prototype)做比對，這樣的方式相似於Kahneman與 Tversky(1973)所提出的代表性捷思法(Representativeness Heuristic)。但Garb的研究有些限制，第一，臨床上大多數個案的精神疾病症狀都較不明確，而Garb(1996)的個案內容描述完全符合DSM-III的診斷標準。第二，臨床上會有機會使用一些測驗工具等客觀訊息來幫助下判斷，但Garb的研究中並未操弄這些客觀訊息(包括測驗結果或基準率)，本文想瞭解臨床工作者如何使用客觀的訊息進行判斷？本研究則延續Garb的作法並做部分修正，操弄「個案類型」(已達或未達某一類疾病之DSM-IV的診斷標準)與「訊息情境」(呈現個案內容描述與客觀訊息)。研究結果顯示，無論專業或非專業人員，代表性捷思法顯著影響其臨床判斷。兩者主要差異在於：當精神疾病症狀非常明確時，專業人員判斷個案屬於此精神疾病的可能性大於非專業人員，當在精神疾病症狀較不明確的個案時，專業人員較傾向以個案內容描述作為判斷依據，可能是專業人員受過專業訓練，在做判斷時，腦中會形成對於精神疾病的範型或刻板印象。一般人因沒有專業的訓練，腦中沒有精神疾病的範型或刻板印象，則較受測驗結果影響。依循類似的作法，本研究進一步將「精神疾病診斷」改為「一般日常生活案例」(職業判斷)時，則研究結果與在「精神疾病診斷」一樣，專業人員與非專業人員也都會使用代表性捷思法。這意味著臨床判斷所存在的偏誤與日常生活中的認知偏誤應是類似的。關於臨床判斷的偏誤現象在國外已逐漸被注意，但數量還是有限，在國內這也應算是較為少數的研究，本文主要提出一個初探的作法，研究中的發現應有助於「臨床判斷」偏誤現象後續之探討。

The accuracy of the clinical judgment has been a clinically controversial issue in the past, since that there is bias in the judgments. How does a clinician use the data and information she/he gathers from the client? According to the viewpoint of cognitive psychology, the way the clinicians process the information might influence the accuracy of their judgment. The research of Garb in 1996 has proved that how clinicians were influenced by their information-process when they make clinical judgments; he pointed it out that when clinicians work with their clients, they compare clients with the stereotype or prototype in their mind, which is similar to representativeness heuristic, indicated by Kahneman and Tversky(1973). However, there are some limits in Garb’s research; first, clinically most clients’ symptoms of their mental disorder are not so sure and clear, while in his study, clients’ situations have completely meet the diagnostic criteria of DSM- III . Secondly, clinically there are some opportunities that we can use some testing tools to obtain objective information to help with the judgments, while Garb did not operate with the objective information (including test results and base rate) in his study. In this text, we want to know how clinicians use the objective information to make judgments. The study continued Garb’s research methods and made partial modification as followed; as for “types of clients” (including the clients that meet the diagnostic criteria of certain mental disorder in DSM-IV and also the one that do not meet), and “information situations”
(comprising the content of clients descriptions and objective information). The result of this study showed that representativeness heuristic greatly influences the clinical judgments of both professionals and non-professionals. The major differences between these two groups are as followed: When clients’ symptoms are very obvious, the professional has more possibility to make the judgments the client with the related mental disorder; while with clients who do not have strong or obvious symptoms, the professionals tend to make their judgment based on the content of clients descriptions. It could be due to the training so that the professionals receive that they might have a stereotype impression of mental disorder in their mind when they make judgments. While non-professionals do not have the impression in their mind, since they do not receive the professional training, they are influenced by the testing results more than the professionals. Following the similar method and principle, this study changes “the diagnosis of mental disorders” to “the general life cases”(occupational judgment), the result is the same as the one on “the diagnosis of mental disorders”- professionals and non-professionals both use representativeness heuristic. This implicates that the existed bias of clinical judgment is similar to the cognitive bias of the daily life. The existed bias in clinical judgment has been noticed in other countries but there are very limited amounts of researches. This study is also considered as one of the very few researches in Taiwan. This paper is mainly to provide an initial work, and the findings in the work should be helpful with the further and advanced study of the bias “clinical judgment” in the future.

目次
目次 ………………………………………………………………………i
表次 ………………………………………………………………………v
第一章 緒論 …………………………………………………………1
第一節 臨床判斷於歷史上的爭議 ………………………………3
第二節 診斷偏誤 …………………………………………………6
一、診斷工具使用的問題 …………………………………………6
二、診斷過程的偏誤 ………………………………………………7
第三節 認知訊息傳遞過程 ………………………………………11
一、社會推論過程 …………………………………………………11
二、Kahneman與Tversky的代表性捷思法之研究 …………………11
第四節 代表性捷思法在臨床上的研究 …………………………15
一、Garb的代表性捷思法之研究 …………………………………15
二、測驗工具使用的相關研究 ……………………………………16
第五節 研究架構與研究假設 ………………………………………17
一、研究架構 ………………………………………………………17
二、研究假設 ………………………………………………………20
第二章 研究方法 ……………………………………………………23
第一節 研究對象 …………………………………………………23
第二節 研究設計 …………………………………………………25
一、精神疾病診斷 …………………………………………………25
二、職業判斷 ………………………………………………………25
第三節 研究工具 …………………………………………………26
一、精神疾病診斷 …………………………………………………26
二、職業判斷 ………………………………………………………28
第四節 研究步驟 …………………………………………………30
一、預試 ……………………………………………………………30
二、正式施測 ………………………………………………………30
第三章 研究結果 ……………………………………………………33
第一節 精神疾病診斷 ……………………………………………33
一、判斷標準的分析 ………………………………………………33
二、可能性的分析 …………………………………………………36
三、自信度的分析 …………………………………………………44
第二節 職業判斷 …………………………………………………48
一、判斷標準的分析 ………………………………………………48
二、可能性的分析 …………………………………………………49
三、自信度的分析 ………………………………………………51
第四章 討論 …………………………………………………………53
第一節 精神疾病診斷 ……………………………………………54
第二節 職業判斷 …………………………………………………56
第三節 精神疾病診斷與職業判斷的比較 ………………………57
第五章 結論 …………………………………………………………61
第一節 本研究貢獻與應用 ………………………………………61
第二節 本研究限制 ………………………………………………63
第三節 未來研究方向 ……………………………………………65
參考文獻 …………………………………………………………………69
附錄 ………………………………………………………………………77
附錄一 …………………………………………………………………79
附錄二 …………………………………………………………………93
表 次
表 1-5-1 本文研究和KT、Garb的研究內容比較 ………………………18
表 2-1-1 本研究的人口變項分配情形 ………………………………24
表 3-1-1 三種訊息情境內「判斷標準」的單因子變異數分析 ………34
表 3-1-2 不同身份在訊息情境內「判斷標準」的使用情形 …………36
表 3-1-3 受試於三種訊息情境下「可能性」的平均數分析 ………37
表 3-1-4 專業人員與非專業人員於高相似之典型個案「可能性」的平
均數分析 ………………………………………………………39
表 3-1-5 專業人員與非專業人員於高相似之非典型個案「可能性」的
平均數分析 ……………………………………………………40
表 3-1-6 專業人員與非專業人員於低相似個案「可能性」的平均數分
析 …………………………………………………………42
表 3-1-7 專業訓練與無專業訓練於低相似個案「可能性」的平均數分
析 ……………………………………………………………43
表 3-1-8 「可能性」結果分析一覽表 …………………………………44
表 3-1-9 受試於三種訊息情境下「自信度」的平均數分析 ………45
表 3-1-10「自信度」結果分析一覽表 …………………………………47
表 3-1-11 身份於三種個案類型間「自信度」的平均數分析 ………48
表 3-2-1 兩種訊息情境「判斷標準」的單因子變異數分析 ………49
表 3-2-2 受試於兩種訊息情境下「可能性」的平均數分析 ………49
表 3-2-3 專業人員與非專業人員於兩種訊息情境間「可能性」的平均
數分析 …………………………………………………………50
表 3-2-4 專業訓練與無專業訓練於兩種訊息情境間「可能性」的平均
數分析 …………………………………………………………50
表 3-2-5 受試於兩種訊息情境下「自信度」的平均數分析 ………51
表 3-2-6 身份於兩種訊息情境內「自信度」的平均數分析 …………52
圖 次
圖 1-3-1 社會推論的步驟及其可能的偏誤 ……………………………10
圖 1-5-1 精神疾病診斷(研究架構圖) …………………………………22
圖 1-5-2 職業判斷(研究架構圖) ………………………………………22
圖 2-3-1 六種問卷內容的排列順序 ……………………………………29
圖 3-1-1 專業人員與非專業人員於高相似之典型個案「可能性」的平均
數分析 …………………………………………………………39
圖 3-1-2 專業人員與非專業人員於高相似之非典型個案「可能性」的平
均數分析 ………………………………………………………41
圖 3-1-3 專業人員與非專業人員於低相似個案「可能性」的平均數分
析 ………………………………………………………………42
圖 4-1-1 研究假設及其檢定結果 ………………………………………53

東吳大學心理學系心理實驗法實驗B組（2003）。心理實驗法實驗B組:
「工程師/律師」實驗材料。東吳大學心理學系。
American Psychiatric Association. (1997)。精神疾病的診斷與統計
手冊 (Diagnostic and Statistical Manual of Mental
Disorders: primary Care Version, 4th ed.) (孔繁鐘譯)。台
北：合記。(原作1995年出版)
Bar-Hillel, B. & Fiswchhoff, B. (1981). When do base rates
affect predictions?Journal of personality and social
psychology, 41, 671-680.
Becker, D. & Lamb, S. (1994). Sex bias in diagnosis of
borderline personality disorder and post traumatic stress
disorder. Profession Psychology Research Practice, 25, 55-
61, as cited in Nathan, P. E. & Langenbucher, J. W. (1999).
Psychopathology: Description and Classification. Annual
review psychology,50, 79-107.
Bergus, G. R., Chapman, G. B., Gjerde, C., & Elstein, A. S.
(1995). Clinical reasoning about new symptoms despite
preexisting disease: Sources of error and order effects.
Family Medicine, 27, 314-320.
Brammer, R. (2002). effects of experience and training on
diagnostic accuracy.Psychological assessment, 14(1), 110-
113.
Brannon, L. A. & Carson, K. L. (2003). The Representativeness
Heuristic:Influence on Nurses’ Decision Making. Applied
Nursing Research, 16(3), 201-204.
Campbell, T. W. (1999). Challenging the evidentiary
reliability of DSM-IV. American Journal of Forensic
Psychology, 17(1), 47-68.
Davison, G. C. & Neale, J. M. (2003). Abnormal psychology. N.
Y. : Wiley.
Dawes, R. M. (1986). Representative thinking in clinical
judgment. Clinical Psychology review, l 6, 425-441.
Dawes, R. M. (1994). Prediction and diagnosis: more myths of
expertise. In House of cards: psychology and psychotherapy
built on myth (pp. 75-105). N.Y.: New York.
Dawes, R. M., Faust, D., & Meehl, P. E. (1989). Clinical
versus Actuarial judgment. Science, 243, 1668-1674.
Dumont, F. (1993). Inferential heuristics in clinical problem
formulation:Selective review of their strengths and
weaknesses. Professional Psychology —Research & Practice,
24(2), 196-205.
Eysenck, M. W. & Keane, M. (2003)。認知心理學 (Cognitive
psychology: A student’s Handbook) (李素卿譯)。台北：五南。
(原作2000年出版)
Ferrario, C. G. (2002).The association of clinical experience
and emergency nurses'' diagnostic reasoning. Dissertation
Abstracts International: Section B: the Sciences &
Engineering, 62(10-B), 4464.
Ford, M. R. & Widiger, T. A. (1989). Sex bias in the diagnosis
of histrionic and antisocial personality disorders.
Journal of Consulting and Clinical Psychology, 57, 301-
305, as cited in Garb, H. N. (1996). The representativeness
and past-behavior heuristics in clinical judgment.
Professional psychology —Research & practice, 27(3), 272-
277.
Garb, H. N. (1989).Clinical judgment, clinical training, and
professional experience. Psychological Bulletin, 105
(3),387-396.
Garb, H. N. (1992). The trained psychologist as expert
witness. Clinical psychology review, 12, 451-467.
Garb, H. N. (1996). The representativeness and past-behavior
heuristics in clinical judgment. Professional psychology -
Research & practice, 27(3), 272-277.
Garb, H. N. (1998). Studying the clinician: Judgment research
and psychological assessment. Washington, DC: American
Psychological Association, as cited in McLaughlin, J. E.
(2002). Reducing diagnostic bias. Journal of Mental Health
Counseling, 24(3), 256-269.
Garb, H. N. (2002). Practicing Professional Psychology,
American Psychologist, 57, 990-991.
Gleitman, H. (1995)。心理學 (Psychology) (洪蘭譯)。台北：遠流。
(原作 1991年出版)
Groth-Marnat, G. (2000). Vision of clinical assessment: then,
now, and a brief history of Future. Journal of clinical
psychology, 56(3), 349-365.
Groth-Marnat, G. (2003)。心理衡鑑大全 (Handbook of
psychological assessment)(張本聖、洪志美譯)。台北：雙葉。
(原作1999年出版)
Grove, W. M. & Meehl, P. E. (1996). Comparative efficiency of
informal (subjective, impressionistic) and formal
(mechanical, algorithmic) prediction procedures: The
clinical-statistical controversy. Psychology, Public
Policy, & Law, 2(2), 293-323.
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.
Haverkamp, B. (1993). Confirmatory bias in hypothesis testing
for client-identified and counselor self-generated
hypotheses. Journal of Consulting Psychology, 40, 305-315,
as cited in McLaughlin, J. E. (2002). Reducing diagnostic
bias. Journal of Mental Health Counseling, 24(3), 256-269.
Horowitz, L. M., Wright, J. C., Lowenstein, E., & Parad, H. W.
(1981). The prototype as a construct in abnormal psychology
:1.A method for deriving prototypes.Journal of abnormal
psychology, 90, 568-574, as cited in Garb, H. N. (1996).
The representativeness and past-behavior heuristics in
clinical judgment. Professional psychology — Research &
practice, 27(3), 272-277.
Hutt(1946), W. A. (1946). The future of diagnostic testing in
clinical psychology. Journal of clinical psychology, 2,
311-317, as cited in Groth-Marnat, G. (2000). Vision of
clinical assessment: then, now, and a brief history of
Future. Journal of clinical psychology, 56(3), 349-365.
Jampala, V. C., Sierles, F. S., & Taylor, M. A. (1988). The
use of DSM-III in the United States: A case of not going
by the book. Comprehensive psychiatry, 29, 39-47.
Kahneman, D. & Frederick, S. (2002). Representativeness
revisited: Attribute substitution in intuitive judgment.
In T. Gilovich, D. Griffin & D. Kahneman(Eds.), Heuristics
and Biases: The psychology of Intuitive Judgment (pp. 49-
81). N.Y.: Cambridge University press.
Kahneman, D. & Tversky, A. (1972). Subject probability: A
judgment of representativeness. Cognitive psychology, 3,
430-454.
Kahneman, D. & Tversky, A. (1973). On the Psychology of
Prediction. Psychological review, 80, 237-251.
Kleinmuntz, B. (1990). Why we still use our heads instead of
formulas: toward an integrative approach. Psychological
bulletin, 107(3), 296-310.
Koehler, J. J. (1996). The base rate fallacy reconsidered:
Descriptive, normative, and methodological challenges.
Behavioral & Brain Sciences, 19, 1-17.
Linde, J. A. & Clark, L. A. (1998). Diagnostic assignment of
criteria: Clinicians and DSM-IV. Journal of Personality
Disorders, 12(2), 126-137.
Loftus, E. F. & Ketcham, K. (1998)。記憶vs.創憶:尋找迷失的真相
(The myth of repressed memory : false memories and
allegations of sexual abuse) (洪蘭譯)。台北：遠流。(原作
1944年出版)
McLaughlin, J. E. (2002). Reducing diagnostic bias. Journal of
Mental Health Counseling, 24(3), 256-269.
Meehl, P. E. (1954). Clinical vs. statistical prediction: a
theoretical analysis and a review of the evidence.
Minneapolis: University of Minnesota Press, as cited in
Groth-Marnat, G. (2003)。心理衡鑑大全 (Handbook of
psychological assessment) (張本聖、洪志美譯)。台北：雙葉。
(原作1999年出版)
Meehl, P. E. (1986). Causes and effects of my disturbing
little book. Journal of Personality Assessment, 50(3), 370-
375.
Meyer, G. J., Finn, S. E., Eyde, L. D., Kay, G. G., Moreland,
K. L., Dies, R. R., Eisman, E. J., Kubisyn, T. M., & Reed,
G. M. (2001). Psychological testing and psychological
assessment. American psychologist, 56(2), 128-165.
Morey, L. C. & Ochoa, E. S. (1989). An investigation of
adherence to diagnostic criteria: Clinical diagnosis of
the DSM-III personality disorder. Journal of personality
disorders, 3, 180-192.
Mumma, G. H. (2002). Effects of three types of potentially
biasing information on symptom severity judgments for
major depression episode. Journal clinical psychology, 58
(10), 1327-1345.
Nathan, P. E. & Langenbucher, J. W. (1999). Psychopathology:
Description and Classification. Annual review psychology,
50, 79-107.
Nezu, A. M. & Nezu, C. M. (1989). Clinical prediction,
judgment, and decision making: An overview. Clinical
decision making in behavior therapy: A problem-solving
perspective (pp. 9-34). N.Y.: North Mattis Avenue.
Peyrot, M. (1995). Psychological testing and forensic decision
making: The roperties-in-use of the MMPI. Social Problems,
42(4),574-586.
Potts, M. K., Burnam, M. A., & Wells, K. B. (1991). Gender
differences in depression detection: a comparison of
clinician diagnosis and standaedized assessment.
Psychology assessment, 3, 609-615, as cited in Nathan, P.
E. & Langenbucher, J. W. (1999). Psychopathology:
Description and Classification. Annual review psychology,
50, 79-107.
Reeb, R. N. (2000). Classification and diagnosis of
psychopathology: conceptual foundation. Journal of
psychological practice, 6(1), 3-18.
Robertson, J. & Fitzgerald, L. F. (1990). The (mis) treatment
of men: Effects of client gender role and life-style on
diagnosis and attribution of pathology. Journal of
Counseling psychology, 37, 3-9, as cited in McLaughlin, J.
E. (2002). Reducing diagnostic bias. Journal of Mental
Health Counseling, 24(3), 256-269.
Rosenhan, D. L. (1973). On being sane in insane places.
Science, 179(4070), 250-258.
Silver, R. J. (2001). Practicing Professional Psychology.
American Psychologist, 56, 1008-1014.
Spitzer, R. L., Gibbon, M., Skodol, A. E., Willians, J. B. W.,
& First, M. B. (Eds.). (1994). DSM-IV Casebook: A Learning
Companion to the Diagnostic and Statistical Manual of
Mental Disorders. N.W., Washington, DC.
Taylor, S. E., Peplau, L. A., & Sears, D. O. (8th ed.).
(1994). Social Cognition. In Social Psychology (pp. 70-
80). Prentice-Hall, Inc.
Taylor, S. E., Peplau, L. A., & Sears, D. O. (1999)。社會心理
學 (Social Psychology) (張滿玲譯)。台北：雙葉。(原作1997年
出版)
Taylor, S. E. & Thompson, S. C. (1982). Stalking the elusive ”
vividness “ effects. Psychological Review, 89, 155-181.
Turk, D. C. & Salovey, P. (1986). Clinical information
processing: Bias inoculation. In R. E. Ingram (Ed.),
Information processing approaches to clinical psychology:
personality, psychopathology, and psychotherapy series
(pp. 305-323). N.Y.: New York.
Tversky, A. & Fox, C. R. (1995). Weighing risk and
uncertainty. Psychological review, 102(2), 269-281.
Tversky, A. & Kahneman, D. (1974). Judgment under uncertainty:
Heuristics and biases. Science, 185, 1124-1131.
Tversky, A. & Koehler, D. J. (1994). Support theory: A
nonextensional representation of subjective probability.
Psychological Review, 101, 547-567, as cited in Eysenck,
M. W. & Keane, M. (2003)。認知心理學 (Cognitive
psychology: A student’s Handbook) (李素卿譯)。台北：五南。
(原作2000年出版)
von Talge, J. (1995). Overcoming courtroom challenges to the
DSM-IV: II- Preparing for and overcoming courtroom
challenges to DSM-IV. American Journal of Forensic
psychology, 13(2), 49-59.
Wedding, D. & Faust, D. (1989). Clinical judgment and decision
making in neuropsychology. Archives of clinical
neuropsychology, 4, 233- 265.
Wilke, D. (1994). Women and alcoholism: How amale-as-norm bias
affects research, assessmemt, and treatment. Health and
Social Work, 19, 29-35, as cited in McLaughlin, J. E.
(2002). Reducing diagnostic bias. Journal of
Mental Health Counseling, 24(3), 256-269.