John Monahan

Bio: John Monahan is an academic researcher from University of Virginia. The author has contributed to research in topics: Poison control & Risk assessment. The author has an hindex of 72, co-authored 313 publications receiving 21833 citations. Previous affiliations of John Monahan include University of California, San Francisco & City University of New York.

License as Leverage: Mandating Treatment for Professionals

Abstract: Mandating professionals with mental disorder to adhere to psychological or psychiatric treatment in order to maintain their professional license frequently occurs and is rarely controversial. We survey current practices in using a professional license as “leverage” to assure adherence to treatment, and compare mandated treatment for professionals with other, more controversial forms of mandated treatment. Our analysis raises two questions. First, if the same level of high quality treatment now available to licensed professionals with mental or addictive disorders were made readily available to others with these disorders, would the positive outcomes experienced by the former also be experienced by the latter? Second, if the same intensive level of monitoring were applied to others as is now applied to licensed professionals, would rates of treatment adherence between the two groups tend to converge?

Statistical Literacy A Prerequisite for Evidence-Based Medicine

Abstract: Currently in the United States a prostate cancer drug is being touted in a novel way: The primary benefit of the drug is claimed to be not that it reduces the risk of the disease, but rather that it reduces the risk of being treated for the disease. ‘‘Men are getting screened, discovering that they have cancers that may or may not be dangerous, and opting for treatments that can leave them impotent or incontinent . . . Preventing the cancer can prevent treatments that can be debilitating, even if the cancers were never lethal to start with’’ (Kolata, 2008, p. A1). Such is the state of doctor–patient communication: Most doctors and virtually all patients are unschooled in how meaningfully to compare the risks of foregoing versus undergoing treatment, and the patient’s frantic desire to ‘‘do something, now’’ often trumps the doctor’s ancient commitment to ‘‘first, do no harm.’’ The problem that Gigerenzer, Gaissmaier, Kurz-Milcke, Schwartz, and Woloshin address in this exemplar of interdisciplinary and international collaboration could hardly be more pressing. Marshalling one study after another, they demonstrate that, across widely varying samples of health professionals, patients, and policymakers, in all countries studied, statistical illiteracy reigns supreme—often with catastrophic consequences for individual and public health. The media function as enablers of this problem. For example, while the author of the newspaper article quoted in the previous paragraph showed unusual journalistic insight by noting the irony of inoculating people against treatment rather than against disease, she still expressed the benefit of the drug in terms of relative risk reduction (‘‘dropping the incidence [of prostate cancer] by 30 percent’’; Kolata, 2008, p. A1) rather than in the muchless-dramatic terms of absolute risk reduction recommended in these pages. Clearer risk communication would go far in helping patients make informed and intelligent trade-offs between the costs and the benefits of various medical interventions, including the nonintervention of ‘‘let’s wait and see.’’ Innumeracy, as this monograph makes abundantly clear, is an enormous societal problem. Even if statistical literacy could be achieved by following the sensible and feasible recommendations of Gigerenzer and his colleagues, however, the issue of what people take to be credible ‘‘evidence’’ in evidence-based medicine and public health would remain. And part of the problem may have less to do with differences in numeracy than with differences in values. Here, the concept of ‘‘cultural cognition’’ (Kahan & Braman, 2006) may have a valuable explanatory role to play. Cultural cognition refers to a series of social and psychological mechanisms that induce individuals to conform their factual beliefs about contested practices—including contested medical practices—to their cultural evaluations of the activities that these practices promote or discourage. As a result of such processes, people with different cultural worldviews may form different empirical beliefs about which practices ameliorate medical problems and which ones compound them. Consider the heated debate over the mandatory vaccination of school-age girls for the human papillomavirus (HPV). Some see this policy as essential to the health of young women, among whom exposure to HPV, the primary cause of cervical cancer, is widely prevalent. Others take the position that the HPV vaccine will give teenage girls a false sense of immunity that will lead to their engaging in unprotected sex and thus increase their risk of contracting HIV-AIDS. Cultural cognition theory predicts that the latter position will be more common among individualists— who are likely to view it as displacing private healthcare decision making—than among communitarians; and more common among hierarchs—who are likely to understand it as evincing tolerance for the denigration of traditional sexual mores—than among egalitarians. This prediction has been borne out by recent large-scale survey and experimental research (Kahan, Braman, Slovic, Gastil, & Cohen, 2007). Distressingly, the provision of empirical information on vaccinating against HPV serves only to make cultural disparities in risk–benefit perceptions more pronounced. Whether the transparent communication of health information advocated by Gigerenzer and his colleagues can attenuate the effects of cultural predisposition on people’s receptivity to new empirical evidence remains for research to determine. The implications of the findings reported in this monograph go far beyond the doctor–patient relationship. Statistical illiteracy is endemic in courtrooms as well as in consultation rooms. The late U.S. Supreme Court Justice Lewis Powell was merely more honest than most of his colleagues when he stated—in regard to PSYCHOLOGICAL SCIENCE IN THE PUBLIC INTEREST

Risk and resources: A qualitative perspective on low-level sentencing in Virginia.

Abstract: Virginia's sentencing guidelines include alternative sanctions based on the use of a quantitative instrument called the Nonviolent Risk Assessment (NVRA) that identifies individuals convicted of drug and property crimes that are considered to be at lower risk of recidivism. Although nondispositive, the NVRA affords judges the discretion to grant alternative sentences to eligible low-risk defendants. In this study, we explore how judges make use of the NVRA instrument when sentencing individuals convicted of low-level drug and property crimes. Through semistructured interviews (N = 24) and inductive thematic analysis, the research team identified contextual factors that influence the use of the NVRA results, including: the availability of alternative programs in a community, the role of court actors, particularly prosecutors, in shaping the sentencing outcomes, as well as an individual judge's willingness to defer to or reject negotiated plea agreements offered by the prosecutor. Our research shows that while some judges are aware of and embrace the benefits of the instrument, others lack knowledge altogether of its function and empirical basis. We identified seven themes that account for variation in how actuarial risk is utilized in the sentencing process. Our findings provide insight into the practical challenges of using risk-based assessment as a tool for the sentencing of low-level convictions. As more states adopt risk-based approaches to sentencing, studying Virginia, which has gone farther than other states in legislating this strategy, becomes increasingly important.

License as Leverage: Mandating Treatment for Professionals

Abstract: Mandating professionals with mental disorder to adhere to psychological or psychiatric treatment in order to maintain their professional license frequently occurs and is rarely controversial. We survey current practices in using a professional license as "leverage" to assure adherence to treatment, and compare mandated treatment for professionals with other, more controversial forms of mandated treatment. Our analysis raises two questions. First, if the same level of high quality treatment now available to licensed professionals with mental or addictive disorders were made readily available to others with these disorders, would the positive outcomes experienced by the former also be experienced by the latter? Second, if the same intensive level of monitoring were applied to others as is now applied to licensed professionals, would rates of treatment adherence between the two groups tend to converge?

Heuristics and Biases: The Psychology of Intuitive Judgment

Abstract: A review is presented of the book “Heuristics and Biases: The Psychology of Intuitive Judgment,” edited by Thomas Gilovich, Dale Griffin, and Daniel Kahneman.

Individual differences in reasoning: Implications for the rationality debate?

Abstract: Much research in the last two decades has demon- strated that human responses deviate from the performance deemed normative according to various models of decision mak- ing and rational judgment (e.g., the basic axioms of utility theory). This gap between the normative and the descriptive can be inter- preted as indicating systematic irrationalities in human cognition. However, four alternative interpretations preserve the assumption that human behavior and cognition is largely rational. These posit that the gap is due to (1) performance errors, (2) computational limitations, (3) the wrong norm being applied by the experi- menter, and (4) a different construal of the task by the subject. In the debates about the viability of these alternative explanations, attention has been focused too narrowly on the modal response. In a series of experiments involving most of the classic tasks in the heuristics and biases literature, we have examined the implica- tions of individual differences in performance for each of the four explanations of the normative/descriptive gap. Performance er- rors are a minor factor in the gap; computational limitations un- derlie non-normative responding on several tasks, particularly those that involve some type of cognitive decontextualization. Un- expected patterns of covariance can suggest when the wrong norm is being applied to a task or when an alternative construal of the task should be considered appropriate.

Peer relations and later personal adjustment: Are low-accepted children at risk?

Abstract: In this review, we examine the oft-made claim that peer-relationship difficulties in childhood predict serious adjustment problems in later life. The article begins with a framework for conceptualizing and assessing children's peer difficulties and with a discussion of conceptual and methodological issues in longitudinal risk research. Following this, three indexes of problematic peer relationships (acceptance, aggressiveness, and shyness/withdrawal) are evaluated as predictors of three later outcomes (dropping out of school, criminality, and psychcpathology). The relation between peer difficulties and later maladjustment is examined in terms of both the consistency and strength of prediction. A review and analysis of the literature indicates general support for the hypothesis that children with poor peer adjustment are at risk for later life difficulties. Support is clearest for the outcomes of dropping out and criminality. It is also clearest for low acceptance and aggressiveness as predictors, whereas a link between shyness/withdrawal and later maladjustment has not yet been adequately tested. The article concludes with a critical discussion of the implicit models that have guided past research in this area and a set of recommendations for the next generation of research on the risk

Risk As Analysis and Risk As Feelings: Some Thoughts About Affect, Reason, Risk, and Rationality

Abstract: Modern theories in cognitive psychology and neuroscience indicate that there are two fundamental ways in which human beings comprehend risk. The analytic system uses algorithms and normative rules, such as probability calculus, formal logic, and risk assessment. It is relatively slow, effortful, and requires conscious control. The experiential system is intuitive, fast, mostly automatic, and not very accessible to conscious awareness. The experiential system enabled human beings to survive during their long period of evolution and remains today the most natural and most common way to respond to risk. It relies on images and associations, linked by experience to emotion and affect (a feeling that something is good or bad). This system represents risk as a feeling that tells us whether it's safe to walk down this dark street or drink this strange-smelling water. Proponents of formal risk analysis tend to view affective responses to risk as irrational. Current wisdom disputes this view. The rational and the experiential systems operate in parallel and each seems to depend on the other for guidance. Studies have demonstrated that analytic reasoning cannot be effective unless it is guided by emotion and affect. Rational decision making requires proper integration of both modes of thought. Both systems have their advantages, biases, and limitations. Now that we are beginning to understand the complex interplay between emotion and reason that is essential to rational behavior, the challenge before us is to think creatively about what this means for managing risk. On the one hand, how do we apply reason to temper the strong emotions engendered by some risk events? On the other hand, how do we infuse needed "doses of feeling" into circumstances where lack of experience may otherwise leave us too "coldly rational"? This article addresses these important questions.