Examining Insensitivity to Probability in Evidence-Based Communication of Relative Risks: The Role of Affect and Communication Format.

Affect can influence judgments of event riskiness and use of risk-related information. Two studies (Ns: 85 and 100) examined the insensitivity-to-probability effect-where people discount probability information when scenarios are affect-rich-applying it to evidence-informed risk communication. We additionally investigated whether this effect is moderated by format, based on predictions from the evaluability and pattern-recognition literatures, suggesting that graphical formats may attenuate insensitivity to probability. Participants completed a prior beliefs questionnaire (Study 1), and risk perception booklet (both studies) that presented identical statistical information about the relative risks associated with two scenarios-one with an affect-rich outcome, the other an affect-poorer outcome. In Study 1, this was presented graphically. In Study 2, information was presented in one of three formats: written, tabular, or graphical. Participants provided their perceptions of the risk for each scenario at a range of risk-levels. The affect-rich scenario was perceived as higher in risk, and, importantly, despite presenting identical relative risk information in both scenarios, was associated with a reduced sensitivity to probability information (both studies). These differences were predicted by participants' prior beliefs concerning the scenario events (Study 1) and were larger for the single-item written format than graphical format (Study 2). The findings illustrate that insensitivity to probability information can occur in evidence-informed risk communications and highlight how communication format can moderate this effect. This interplay between affect and format therefore reflects an important consideration for information designers and researchers.

Understanding Clinicians' Use of Cues When Assessing the Future Risk of Violence: A Clinical Judgement Analysis in the Psychiatric Setting.

UNLABELLED: Research is sparse on how clinicians' judgement informs their violence risk assessments. Yet, determining preferences for which risk factors are used, and how they are weighted and combined, is important to understanding such assessments. This study investigated clinicians' use of static and dynamic cues when assessing risk in individual patients and for dynamic cues considered in the recent and distant past. Clinicians provided three violence risk assessments for 41 separate hypothetical cases of hospitalized patients, each defined by eight cues (e.g., psychopathy and past violence severity/frequency). A clinical judgement analysis, using regression analysis of judgements for multiple cases, created linear models reflecting the major influences on each individual clinician's judgement. Risk assessments could be successfully predicted by between one and four cues, and there was close agreement between different clinicians' models regarding which cues were relevant for a given assessment. However, which cues were used varied between assessments: history of recent violence predicted assessments of in-hospital risk, whereas violence in the distant past predicted the assessed risk in the community. Crucially, several factors included in actuarial/structured risk assessment tools had little influence on clinicians' assessments. Our findings point to the adaptivity in clinicians' violence risk assessments, with a preference for relying on information consistent with the setting for which the assessment applies. The implication is that clinicians are open to using different structured assessment tools for different kinds of risk assessment, although they may seek greater flexibility in their assessments than some structured risk assessment tools afford (e.g., discounting static risk factors). KEY PRACTITIONER MESSAGE: Across three separate violence risk assessments, clinicians' risk assessments were more strongly influenced by dynamic cues that can vary over time (e.g., level of violence) than by static cues that are fixed for a given individual (e.g., a diagnosis of psychopathy). The variation in the factors affecting risk assessments for different settings (i.e., in hospital versus in the community) was greater than the variability between clinicians for such judgements. The findings imply a preference for risk assessment strategies that offer flexibility: either using different risk assessment tools for different purposes and settings or employing a single tool that allows for different inputs into the risk assessment depending upon the nature of the assessment. The appropriateness of these clinical intuitions about violence risk that are implied by our findings warrants further investigation.

Self-insight research as (double) model recovery.

Self-insight assessment compares outcomes from two model-recovery exercises: a statistical exercise to infer a judge's (implicit) policy and an elicitation exercise whereby the judge describes his or her (explicit) policy. When these policies are mismatched, limited self-insight is not necessarily implied: Shortcomings in either exercise could be implicated, whereby Newell & Shanks' (N&S's) relevance or sensitivity criteria for assessing awareness may not be met. Appropriate self-insight assessment requires that both exercises allow the original processes to be captured.

Probability matching in risky choice: the interplay of feedback and strategy availability.

Probability matching in sequential decision making is a striking violation of rational choice that has been observed in hundreds of experiments. Recent studies have demonstrated that matching persists even in described tasks in which all the information required for identifying a superior alternative strategy-maximizing-is present before the first choice is made. These studies have also indicated that maximizing increases when (1) the asymmetry in the availability of matching and maximizing strategies is reduced and (2) normatively irrelevant outcome feedback is provided. In the two experiments reported here, we examined the joint influences of these factors, revealing that strategy availability and outcome feedback operate on different time courses. Both behavioral and modeling results showed that while availability of the maximizing strategy increases the choice of maximizing early during the task, feedback appears to act more slowly to erode misconceptions about the task and to reinforce optimal responding. The results illuminate the interplay between "top-down" identification of choice strategies and "bottom-up" discovery of those strategies via feedback.

If quantum probability = classical probability + bounded cognition; is this good, bad, or unnecessary?

Quantum probability models may supersede existing probabilistic models because they account for behaviour inconsistent with classical probability theory that are attributable to normal limitations of cognition. This intriguing position, however, may overstate weaknesses in classical probability theory by underestimating the role of current knowledge states and may under-employ available knowledge about the limitations of cognitive processes. In addition, flexibility in model specification has risks for the use of quantum probability.

Testing the somatic marker hypothesis in decisions-from-experience with non-stationary outcome probabilities.

Introduction: The Somatic Marker Hypothesis (SMH) posits that in experience-based choice, people develop physiological reactions that mark options as either positive or negative. These somatic markers aid decision making because they differentiate between "good" and "bad" options during pre-choice deliberation. Methods: We examined this proposed role for somatic states in two decision-from-experience tasks (each N = 36) in which participants selected repeatedly with full feedback (i.e., for obtained and forgone outcomes) between two unlabeled options that returned wins or losses, with half receiving an additional summary of past outcomes. The probabilities of good and bad outcomes changed at an unannounced point. Participants completed a 100-trial game with a switch in the optimal option after trial 40 (Study 1) or a 200-trial game with switch points after trial 40 and trial 120 (Study 2). Skin conductance (SC) was measured continuously as an index of emotional intensity, from which we extracted measures of anticipatory SC (pre-choice) and outcome SC (post-choice). Results: Participants reliably selected the optimal option prior to any switches. They also altered their choices appropriately when the payoffs changed, though optimal play following payoff switches was reduced. Losses resulted in a greater outcome SC than wins, but only in Study 1, as did the finding that the outcome SC was greater when the forgone outcome was positive. Anticipatory SC did not reliably predict optimal play in either study. Discussion: These results provide little support for the SMH. Our studies point to the importance of using diverse tasks and measures and very large sample sizes when testing the role of somatic states in decision making.

How and Why the Choice of Success Criteria Can Impact Therapy Service Delivery: A Worked Example From a Psychological Therapy Service for Anxiety and Depression.

Background: Well-defined measures of therapeutic benefit are essential for evaluating therapies and services. However, there is no single gold standard for defining 'successful' outcomes. We therefore examined the potential impact of adopting different success criteria. Method: We analysed data for 7,064 patients undergoing psychological therapy in a single UK IAPT (Increasing Access to Psychological Therapy) Service, each patient being assessed for depression (PHQ-9) and anxiety (GAD-7) both at the start and end of treatment. Predictors of successful outcomes based on these measures were analysed separately for three different success criteria: based either on assessing clinically significant change, or reliable change, in depression and anxiety. Results: The choice of criteria had little bearing on which variables predicted successful outcomes. However, the direction of the relationship between initial PHQ-9 or GAD-7 score and outcome success reverses when the criteria used to judge success are changed: successful outcomes are less probable under clinically significant change criteria for patients entering the service with more severe depression and/or anxiety but are more probable for such patients under reliable change criteria. Conclusion: Relevant for clinicians, researchers, and policymakers, the choice of success criteria adopted can substantially change the incentives for patient selection into a therapy service. Our analysis highlights how the methods used to evaluate treatment outcomes could impact the priorities and organisation of therapeutic services, which could then impact on who is offered treatment. We recommend further investigations of success criteria in other conditions or treatments to determine the reproducibility of the effects we found.

Assessing risk and prioritizing referral for self-harm: when and why is my judgement different from yours?

UNLABELLED: This study investigated individual differences in the use of risk factors when making risk assessments for self-harm. Clinical judgement analysis using 35 hypothetical case scenarios was used to determine how case characteristics influence risk assessment for self-harm by mental health professionals. Seven practitioners made four risk/priority assessment judgements for each case, and individual models of judgement for risk and priority were constructed by regressing 10 case variables onto these sets of judgements. All but two of the variables (potential risk factors) examined were related to risk and/or priority judgements. Risk assessors applied cues to make assessments consistently-broadly consistent with practice guidelines-although precise cue application varied between professionals. The findings demonstrate the potential for ambiguity in risk assessment (terms such as 'low' or 'high' risk had variable interpretation) and that it can be important to specify whether risk is to be assessed for the initiation, continuation, re-occurrence, or escalation of an event or condition. The study shows the importance of clear practice guidelines (not all risk factors were used as might be anticipated from practice guidelines) and illustrates how clinical judgement analysis can be used to understand and enhance the reliability of professional judgement. KEY PRACTITIONER MESSAGE: The process by which risk assessment is undertaken can be reliably statistically modelled to allow an in-depth examination of an individual practitioner or comparisons between practitioners, which can be used to support efforts to improve assessment reliability. Senior practitioners may be more consistent in applying information to clinical judgements of self-harm. Apparent agreement over a categorical judgement of risk may mask an underlying disagreement over numerical probabilities. The term 'low risk' may be particularly subject to variability in its interpretation. The term 'risk' can be ambiguous, reflecting the probability of occurrence for some practitioners and the severity of its occurrence for others, a problem that may be compounded if it is unclear exactly which event is being assessed (e.g., risk of initiating the behaviour versus risk of re-occurrence).

A qualitative investigation of selecting surrogate decision-makers.

BACKGROUND: Empirical studies of surrogate decision-making tend to assume that surrogates should make only a 'substituted judgement'--that is, judge what the patient would want if they were mentally competent. OBJECTIVES: To explore what people want in a surrogate decision-maker whom they themselves select and to test the assumption that people want their chosen surrogate to make only a substituted judgement. METHODS: 30 undergraduate students were recruited. They were presented with a hypothetical scenario about their expected loss of mental capacity in the future and asked to answer some questions about their choice of surrogate. These data were analysed qualitatively using thematic content analysis. RESULTS: Most respondents talked about choosing someone who was caring and competent in certain ways, giving interesting evidence for their judgements. Surprisingly few highlighted how well they thought their chosen surrogate knew their preferences and would be able to make a substituted judgement. Moreover, few specified that their chosen surrogate had similar attitudes and values to their own and so would make a similar decision to theirs in the circumstances presented. Some respondents also referred to the social role of their chosen surrogate or the social dynamics of their situation which influenced their choices, as well as to ideas of reciprocity and characteristics of honesty and loyalty. CONCLUSION: In the event that they lose mental capacity, many people will not select a surrogate to decide about medical treatments on their behalf solely on the basis that they expect their surrogate to make a substituted judgement.

Understanding the relationship between safety beliefs and knowledge for cognitive enhancers in UK university students.

BACKGROUND: Cognitive enhancers (CE) are prescription drugs taken, either without a prescription or at a dose exceeding that which is prescribed, to improve cognitive functions such as concentration, vigilance or memory. Previous research suggests that users believe the drugs to be safer than non-users and that they have sufficient knowledge to judge safety. However, to date no research has compared the information sources used and safety knowledge of users and non-users. OBJECTIVES: This study compared users and non-users of CE in terms of i) their sources of knowledge about the safety of CE and ii) the accuracy of their knowledge of possible adverse effects of a typical cognitive enhancer (modafinil); and iii) how the accuracy of knowledge relates to their safety beliefs. METHODS: Students (N = 148) from King's College London (UK) completed an anonymous online survey assessing safety beliefs, sources of knowledge and knowledge of the safety of modafinil; and indicated whether they used CE, and, if so, which drug(s). RESULTS: The belief that the drugs are safe was greater in users than non-users. However, both groups used comparable information sources and have similar, relatively poor drug safety knowledge. Furthermore, despite users more strongly believing in the safety of CE there was no relationship between their beliefs and knowledge, in contrast to non-users who did show correlations between beliefs and knowledge. CONCLUSION: These data suggest that the differences in safety beliefs about CE between users and non-users do not stem from use of different information sources or more accurate safety knowledge.

Clinical Judgement Analysis: An innovative approach to explore the individual decision-making processes of pharmacists.

BACKGROUND: Pharmacy stands increasingly on the frontline of patient care, yet current studies of clinical decision-making by pharmacists only capture deliberative processes that can be stated explicitly. Decision-making incorporates both deliberative and intuitive processes. Clinical Judgement Analysis (CJA) is a method novel to pharmacy that uncovers intuitive decision-making and may provide a more comprehensive understanding of the decision-making processes of pharmacists. OBJECTIVES: This paper describes how CJA potentially uncovers the intuitive clinical decision-making processes of pharmacists. Using an illustrative decision-making example, the application of CJA will be described, including: METHOD: An illustrative study was used, applying an established method for CJA. The decision to initiate anticoagulation, alongside appropriate risk judgements, was chosen as the context. Expert anticoagulation pharmacists were interviewed to define and then refine variables (cues) involved in this decision. Decision tasks with sixty scenarios were developed to explore the effect of these cues on pharmacists' decision-making processes and distributed to participants for completion. Descriptive statistical and regression analyses were conducted for each participant. RESULTS: The method produced individual judgement models for each participant, for example, demonstrating that when judging stroke risk each participant's judgements could be accurately predicted using only 3 or 4 out of the possible 11 cues given. The method also demonstrated that participants appeared to consider multiple cues when making risk judgements but used an algorithmic approach based on one or two cues when making the clinical decision. CONCLUSION: CJA generates insights into the clinical decision-making processes of pharmacists not uncovered by the current literature. This provides a springboard for more in-depth explorations; explorations that are vital to the understanding and ongoing development of the role of pharmacists.

Losing my loss aversion: The effects of current and past environment on the relative sensitivity to losses and gains.

It is often assumed that most people are loss averse, placing more weight on losses than commensurate gains; however, some research identifies variability in loss sensitivity that reflects features of the environment. We examined this plasticity in loss sensitivity by manipulating the size and distribution of possible outcomes in a set of mixed gambles, and assessing individual stability in loss sensitivity. In each of two sessions, participants made accept-reject decisions for 64 mixed-outcome gambles. Participants were randomly assigned to conditions defined by the relative range of losses and gains (wider range of losses vs. wider range of gains), and the currency-units at stake ('pennies' vs. 'pounds'). Participants showed modest but non-trivial consistency in their sensitivity to losses; though loss sensitivity also varied substantially with our manipulations. When possible gains had greater range than possible losses, most participants were loss averse; however, when possible losses had the greater range, reverse loss aversion was the norm (i.e., more weight on gains than losses). This is consistent with decision-by-sampling theory, whereby an outcome's rank within a consideration-set determines its value, but can also be explained by the gamble's expected-value rank within the decision-set, or by adapting aspirations to the decision-environment. Loss aversion was also reduced in the second session of decisions when the stakes had been higher in the previous session. This illustrates the influence of prior context on current sensitivity to losses, and suggests a role for idiosyncratic experiences in the development of individual differences in loss sensitivity.

Outdoor recreational activity experiences improve psychological wellbeing of military veterans with post-traumatic stress disorder: Positive findings from a pilot study and a randomised controlled trial.

TRIAL REGISTRATION: The authors confirm that all ongoing and related trials for this intervention are registered. The studies reported in this manuscript are registered as clinical trials at ISRCTN: Pilot ID- ISRCTN15325073 RCT ID- ISRCTN59395217.

Further investigations of how rare disaster information affects risk taking: A registered replication report.

Across two experiments, Newell, Rakow, Yechiam, and Sambur (Nature Climate Change, 6(2), 158-161, 2016) demonstrated that providing rare disaster information increased people's tolerance for risk-taking. These results motivated a series of as yet-unpublished follow-up experiments involving new manipulations. However, the failure to replicate the original finding in these follow-ups has led our confidence in the original effect to wane. The aim of this registered report was to reconsider the evidence, published and unpublished, for the rare disaster information effect in light of new data. We conducted a large scale replication (N= 242) in which we failed to find evidence for the effect reported in Newell et al. thus further reducing our confidence. This registered report format provides a transparent framework by which to address the discrepancy between the published and previously-unpublished findings.

Understanding the Effect of Information Presentation Order and Orientation on Information Search and Treatment Evaluation.

BACKGROUND: Past research finds that treatment evaluations are more negative when risks are presented after benefits. This study investigates this order effect: manipulating tabular orientation and order of risk-benefit information, and examining information search order and gaze duration via eye-tracking. DESIGN: 108 (Study 1) and 44 (Study 2) participants viewed information about treatment risks and benefits, in either a horizontal (left-right) or vertical (above-below) orientation, with the benefits or risks presented first (left side or at top). For 4 scenarios, participants answered 6 treatment evaluation questions (1-7 scales) that were combined into overall evaluation scores. In addition, Study 2 collected eye-tracking data during the benefit-risk presentation. RESULTS: Participants tended to read one set of information (i.e., all risks or all benefits) before transitioning to the other. Analysis of order of fixations showed this tendency was stronger in the vertical (standardized mean rank difference further from 0, M = ± .88) than horizontal orientation ( M = ± 0.71). Approximately 50% of the time was spent reading benefits when benefits were shown first, but this was reduced to ~40% when risks were presented first (regression coefficient: B = -4.52, p < .001). Eye-tracking measures did not strongly predict treatment evaluations, although time percentage reading benefits positively predicted evaluation when holding other variables constant ( B = 0.02, p = .023). CONCLUSION: These results highlight the impact of seemingly arbitrary design choices on inspection order. For instance, presenting risks where they will be seen first leads to relatively less time spent considering treatment benefits. Other research suggests these changes to inspection order can influence multi-option and multi-attribute choices, and represent an area for future research.

The role of experience in decisions from description.

We extend research on the distinction between decisions from experience or description to situations in which people are given perfect information about outcome probabilities and have experience in an environment which matches the described information. Participants read a description of a die with more sides of one color than another (e.g., 4 black and 2 white sides) and were then asked either to predict the outcomes of rolls of the die or to select the best strategy for betting on the most likely outcome for each roll in a hypothetical game. Experience in the environment (trials), contingency (probability of the more likely alternative), and outcome feedback all had significant effects on the adoption of the optimal strategy (always predicting the most likely outcome), despite their normative irrelevance. Comparisons of experience with description-only conditions suggested that experience exerted an influence on performance if it was active--making predictions-but not if it was passive-observing outcomes. Experience had a negative initial impact on optimal responding: participants in description-only conditions selected the optimal strategy more often than those with 60 trials of prediction experience, a finding that reflects the seduction of "representative" responding.

Go for broke: The role of somatic states when asked to lose in the Iowa Gambling Task.

The Somatic Marker Hypothesis (SMH) posits that somatic states develop and guide advantageous decision making by "marking" disadvantageous options (i.e., arousal increases when poor options are considered). This assumption was tested using the standard Iowa Gambling Task (IGT) in which participants win/lose money by selecting among four decks of cards, and an alternative version, identical in both structure and payoffs, but with the aim changed to lose as much money as possible. This "lose" version of the IGT reverses which decks are advantageous/disadvantageous; and so reverses which decks should be marked by somatic responses - which we assessed via skin conductance (SC). Participants learned to pick advantageously in the original (Win) IGT and in the (new) Lose IGT. Using multilevel regression, some variability in anticipatory SC across blocks was found but no consistent effect of anticipatory SC on disadvantageous deck selections. Thus, while we successfully developed a new way to test the central claims of the SMH, we did not find consistent support for the SMH.

Understanding Children's Heart Surgery Data: A Cross-Disciplinary Approach to Codevelop a Website.

Risk-adjusted survival statistics after children's heart surgery are published annually in the United Kingdom. Interpreting these statistics is difficult, and better resources about how to interpret survival data are needed. Here we describe how a multidisciplinary team of mathematicians, psychologists, and a charity worked with parents of heart surgery children and other users to codevelop online resources to present survival outcomes. Early and ongoing involvement of users was crucial and considerably changed the content, scope, and look of the website, and the formal psychology experiments provided deeper insight. The website http://childrensheartsurgery.info/ was launched in June 2016 to very positive reviews.

Assessing the likelihood of an important clinical outcome: new insights from a comparison of clinical and actuarial judgment.

PURPOSE: To assess and rank the performance of different methods of predicting the probability of death following a specified surgical procedure. METHOD: Actuarial estimates of the probability of early mortality for 40 patients were derived from 2 sources: a large published surgical series and a smaller series from the center where surgery was performed. Surgeons and cardiologists also provided probability estimates for these patients. RESULTS: Estimates derived from the published literature were too optimistic and did not differentiate between patients more, or less, likely to die (i.e., failed to discriminate). Doctors' judgments were unbiased but failed to discriminate. Local actuarial estimates (influenced by only 1 or 2 variables) were unbiased, did discriminate, but exhibited more random variation. CONCLUSIONS: The preferred source of estimates depends upon which aspect of accuracy is of greatest importance. Differences in patient selection and error in the identification of risk factors mean that published results will not always appropriately predict surgical risk at other institutions. Risk stratification may be more robust when based on a small set of cross-validated predictors rather than a larger set of predictors that includes some whose reliability has not been confirmed.

Evaluating three criteria for establishing cue-search hierarchies in inferential judgment.

The authors identify and provide an integration of 3 criteria for establishing cue-search hierarchies in inferential judgment. Cues can be ranked by information value according to expected information gain (Bayesian criterion), cue-outcome correlation (correlational criterion), or ecological validity (accuracy criterion). All criteria significantly predicted information acquisition behavior; however, in 3 experiments, the most successful predictor was the correlational criterion (followed by the Bayesian). Although participants showed sensitivity to task constraints, searching for less information when it was more expensive (Experiment 1) and when under time constraints (Experiment 2), concomitant changes in the relative frequency of acquisition of cues with different information values were not observed. A rational analysis illustrates why such changes in the frequency of acquisition would be beneficial, and reasons for the failure to observe such behavior are discussed.