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Held (2006a; 2006b) has critiqued my position (Miller, 2004; Miller, 2006a) that the centrality of suffering to clinical practice in psychology makes moral concerns also inherent in, and central to, clinical judgment and practice. Held does not deny the importance of basic human suffering or moral concerns to the clinical situation. Instead, she denies the claim that the objective elements of a clinical situation are inextricably entwined with moral issues. Held defends the position that there is an objective component to clinical practice that can be separated from moral concerns by distinguishing between moral and ethical values, and separating the means from the ends of psychotherapy. Her defense of the existence of causal mechanisms in clinical problems and interventions is dependent on the position that reasons are causes, and her view that the clinical generalizations from a case study database are causal claims. In response, I distinguish between the bare-bones factual account of a personA¢Â€Â™s behavior that is objective but clinically impoverished, and a full scale clinical judgment imbued with moral import. The game of chess is examined as an example of a reason-governed interpersonal practice in which reasons for acting can be distinguished from causes of behavior.

Round 4B: How Real Is Clinical Wisdom? A Further Reply to Held