METHODS OF IMPROVING INTERPRETATION AND JUDGMENT

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Clinical Psychology (PSY401)

LESSON 24

METHODS OF IMPROVING INTERPRETATION AND JUDGMENT

There are variety of factors that can reduce the efficiency and validity of clinical predictions and

interpretation. One cannot presume to lay down a series of prescriptions that will lead inevitably to perfect

performance. Let us, however, call attention to several factors that are important to keep in mind as one

move from data to interpretation to prediction. Although the performance of clinicians has not been

good, there are ways of making improvements (Faust, 1986; Garb, 1998).

INFORMATION PROCESSING

As clinicians process assessment information, they are often bombarded with tremendous amounts of

data. In many instances, this information can be difficult to integrate because of its volume and complexity.

Clinicians must guard against the tendency to oversimplify. It is easy for them to overreact to a few

"eye-catching" bits o f information and to ignore other data that do not fit_ i n t o the picture they are

trying to paint. Whether the pressure comes from an overload of information or from a need to be

consistent in inferences about the patient, clinicians must be able to tolerate the ambiguity and com-

plexity that arise from patients who are inherently complex.

THE READING-IN SYNDROME

Clinicians sometimes tend to over interpret. They often inject meaning into remarks and actions that are

best regarded as less than deeply meaningful. Because clinicians are set to make such observations, they

can easily react to minimal cues as evidence of psychopathology. What is really amazing is that the

world gets along with 'so many "sick" people out there. It is so easy to emphasize the negative rather

than the positive that clinicians can readily make dire predictions or interpretation` that fail to take

the person's assets into account. Garb (1998) points out that clinicians who do evaluate clients'

strengths and assets in addition to assessing pathology and dysfunction are less likely to pronounce

clients as maladjusted or impaired.

VALIDATION AND RECORDS

Too often, clinicians make interpretations or predictions without following them up. if clinicians fail to

record interpretations and predictions, it becomes too easy to remember only the correct ones. Taking

pains to compare the clinician's view with that of professional colleagues, relatives, or others who know

the patient can also help to refine interpretive skills.

VAGUE REPORTS, CONCEPTS, AND CRITERIA

One of the most pervasive obstacles to valid clinical judgment is the tendency to use vague concepts and

poorly defined criteria. This process; of course culminates in psychological reports that are equally vague.

Under these conditions, it can be very difficult to determine whether clinicians' predictions and

judgments were correct (which may be why some of them use such shadowy terminology!). To combat

this problem, Garb (1998) recommends that clinicians use structured rating scales, objective personality

tests, and behavioral assessment methods to form their clinical judgment and predictions.

THE EFFECTS OF PREDICTION

Sometimes predictions turn out to be in error not because they were based on faulty inferences but

because the predictions themselves influenced the behavioral situation. For example, a prediction that a

patient would have difficulty adjusting at home after release from the hospital may have been correct.

However, the Patient's relatives may have accepted the prediction as a challenge and therefore provided

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an environment that was more conducive to the patient's a d j u s t m e n t than it would have been in the

absence of the prediction Thus; the very act of having made a judgment may serve to alter the clinician's

own behavior or that of others.

PREDICTION TO UNKNOWN SITUATIONS

Clinical inferences and predictions are likely to be in error when clinicians are not clear about the

situations to which they are predicting. Inferring aggression from the TAT is one thing; relating it to

specific situations is another. Furthermore, no matter how careful and correct clinicians are, an

extraneous event can negate an otherwise perfectly valid prediction. Take the following example from

the OSS assessment program:

One high-ranking OSS officer while operating abroad, received a letter from a friend of

his in America informing him that his-wife had run off with the local garage man,

leaving no message or address. As a result the officer's morale, which had formerly been

high, dropped to zero. The assessment staff could predict that a small percentage of men

would have to cope with a profoundly depressing or disquieting event of this sort, but,

again, it was not possible to guess which of the assesses would be thus afflicted.

Co mmon sense should suggest that to accurately predict a person's behavior, the clinician must

consider the environment in which that behavior will take place this is also a tenet of behavioral

assessment. However, clinicians are frequently asked to make predictions based on only imprecise and

vague information regarding the situation in which their patient will be living or working.

In a hospital setting, a clinician may be requested to provide a prerelease workup on a given psychiatric

patient. But the information available to the clinician will too often cover only general background,

with supplementary descriptions of individual differences. Investigators such as Chase (1975),

Ekehammar (1974), Megargee (1970), Mischel (1968), and Moos (1975) all agree that such data are

subject to a ceiling effect that will allow correlations of no better than .30 to .40 between the data and

subsequent behavior. To say the least, correlation of that magnitude leaves a great deal to be desired.

Therefore, personality data alone are likely to be insufficient in many prediction situations.

FALLACIOUS PREDICTION PRINCIPLES

In some instances, intuitive predictions can lead clinicians into error because they ignore the logic of

statistical prediction. Intuitive predictions often ignore base rates, fail to consider regression effects, and

assume that highly correlated predictors will yield higher validity (Garb, 1998; Kahneman & Tversky,

1973). For example, suppose that a clinician is assessing a patient by collecting samples of behavior in a

variety of situations. Even though observations reveal an extremely aggressive person, the clinician

should not be surprised to learn that eventually the person behaves in a non aggressive fashion.

R e g r e s s i o n c o n c ep t s sh o u l d l e ad o n e t o e x p e c t that exceptionally tall parents will have a

shorter child that brilliant students sometimes do poorly, and so on.

In addition, clinicians' own confidence can sometimes be misleading. For example, Kahneman and

Tversky (1973) showed that individuals are more confident when they are predicting from correlated tests.

More specifically, although clinicians are often more confident of their inferences when they stem from

a combination of the Rorschach, the TAT, and the MMPI rather than from a single test, tit. Golden (1964) could

find no evidence to support this confidence. The reliability and validity of clinical interpretations did not

increase as a function of increasing amounts of test data. One should always seek to corroborate one's

inferences, but it would be a mistake to believe that the validity of inferences is inevitably correlated with

the size of the test battery.

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THE INFLUENCE OF STEREOTYPED BELIEFS

Sometimes clinicians seem to interpret data in terms of stereotyped beliefs (Chapman & Chapman,

1967). For example, Golding and Rorer (1972) found that certain clinicians believed that anal responses

on the Rorschach indicated homosexuality; and they w-ere extremely resistant to changing their

preconceptions even in the face of intensive training to the contrary. Such research is a reminder that

clinicians must constantly be on guard against any tendency to believe that certain diagnostic signs

are inevitably valid indicators of certain characteristics.

Another example comes from a survey of the effects of clients' socioeconomic status on clinicians'

judgments (Sutton & Kessler, 1986). A sample of 242 respondents read case histories identical in all

respects except that the client was placed in different socioeconomic classes. When t h e cl i en t was

described as an unemp l oy ed welfare recipient with a seventh-grade education, clinicians predicted

a poorer prognosis and were less likely to recommend insight therapy.

"WHY I DO NOT ATTEND CASE CONFERENCES"

In an engaging paper, Meehl (1977) lists a variety of reasons why he gave up attending case conferences.

He catalogs a number of fallacies that often surface at such meetings. Most of them are entirely

relevant to the interpretive process generally. The following synopsis of a few of Meehl's examples

provides something of their general flavor:

· Sick-sick fallacy: the tendency to perceive people very unlike ourselves as being sick. There is a

tendency to interpret behavior very unlike our own as maladjusted, and it is easier to see pathology

in such clients.

· Me-too fallacy: denying the diagnostic significance of an event in the patient's life because it has

also happened to us. Some of us are narcissistic or defensive enough to believe we are paragons of

mental health. Therefore, the more our patients are like ourselves; the less likely we are to detect

problems.

· Uncle George's pancakes fallacy: "There is nothing wrong with that; my Uncle George did not

like to throw away leftover pancakes either." This is perhaps an extension of the previous fallacy.

Things that we do (and by extension, things that those close to us do) could not be maladjusted;

therefore, those like us cannot be maladjusted either.

· Multiple Napoleons fallacy: There was only one Napoleon, despite how strongly a psychotic

patient may feel that he or she is also Napoleon. An objection to interpreting such a patient's belief as

pathological is buttressed by the remark, "Well, it may not be real to us, but it's real to him (or her)!"

Further, "Everything is real to the person doing the perceiving. In fact, our percepts are our reality." If

this argument were invoked consistently, nothing could possibly be pathological. Even the patient with

paranoid schizophrenia who believes aliens are living in his nasal passages would be normal since; after

all, this is reality for him.

· Understanding it makes it normal fallacy: the idea that understanding a patient's beliefs or

behaviors strips them of their significance. This trap is very easy for clinicians to fall into. Even the

most deviant and curious behavior can somehow begin to seem acceptable once we convince

ourselves that we know the reasons for its occurrence. This may not be unlike the reasoning of

those who excuse the criminal's behavior because they understand the motives and poor child-

hood experiences involved.

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CONCLUSION

There are number of recommendations to improve the reliability and validity of clinical judgment.

1) Consider all available information and do not ignore inconsistent data.

2) Consider clients' or patients' strengths and assets as well as pathology and dysfunction.

3) Documents all predictions, try to evaluate their accuracy, and use this information as feedback.

4) Use only structured interviews, structured ratting scales, objective personality tests, and

behavioral assessment methods to gather data.

5) Consider the client's situation and environment before making predictions.

6) Consider base rates and regression effects.

7) Do not let one's level of confidence influence prediction.

8) Be ware of and guard against stereotyped beliefs and illusory correlation.

THE CLINICAL REPORT WRITING: AN EFFECTIVE CLINICAL REPORT

COMMUNICATION: THE CLINICAL REPORT

After the clinician has completed the interview, administered the tests, and read the case history. The

tests have been scored, and hypotheses and impressions have been developed. The time has come to

write the report. This is the communication phase of the assessment process.

Appelbaum (1970) has characterized the role of the assessor as sociologist, politician, diplomat, group

dynamicist, salesperson, artist, and yes, even psychologist. As a sociologist, the assessor must assay the

local mores to aid in the acceptance of the report and to direct the report to those most likely to

implement it. In some instances, this may mean interacting directly with hospital personnel to

convince them of the validity of the report and to encourage them to act on it. These interactions may

involve ward attendants, nurses, psychiatrists, and others. Such persuasion may at times seem more

suitable for a politician or a diplomat than for a clinician.

One should not accept the role of clinical huckster. However, there are certainly times when reports

will have to serve the function of convincing reluctant others. Not everyone is willing to regard the

clinician as a purveyor of wisdom and unadulterated truth. Ideally, of course, the evidence for

clinicians' conclusions and the tightness of their arguments will be reasons enough for accepting their

descriptions and recommendations.

There is no single "best format" for a report. The nature of the referral, the audience to which the

report is directed, the kinds of assessment procedures used, and the theoretical persuasion of the clinician

are just a few of the considerations that may affect the presentation of a clinical report. What one says to

a psychiatrist is likely to be couched in language different from that directed to a school official. The

feedback provided to the parents of a mentally retarded child must be presented differently from the

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feedback given to a professional colleague. Given below is a sample outline of a psychological test report

(Beutler, 1995).

1. Identifying question

a. Name of patient

b. Sex

c. Age

d. Ethnicity / Class

e. Date of evaluation

Referring clinician

2. Referral question

3. Assessment procedures

4. Background

a. Information relevant to clarifying the referral question.

b. A statement of the probable reliabailty/validty of conclusion.

5. Summary of impressions and findings

a. Cognitive level

Patient's intellectual and cognitive functioning (ideation, intelligence, memory,

perception)

Degree (amount of impairment) compared to premorbid level.

Probable cause of impairment.

b. Affective and mood levels

Mood, affect at present---compare with premorbid levels.

Degree of disturbance (mild, moderate, sever).

Chronic versus acute nature of disturbance.

Lability--how well can the person modulate, control affects with his/her

cognitive resources?

c. Interpersonal-intrapersonal level

Primary interpersonal and interpersonal conflicts and their significance.

Interpersonal and intrapersonal coping strategies.

Formulation of personality.

6. Diagnostic-interpersonal levels

a. Series of impressions about cognitive and affective functioning, or

b. The most probable diagnosis.

7. Recommendations

a. Assessment of risk, need for confinement, medication.

b. Duration, modality, frequency of treatment.

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THE REFERRAL SOURCE

The major responsibility of the report is to address the referral question. The test report should carefully

and explicitly answer the questions that prompted the assessment in the first place. If the referral

questions cannot be answered or if they are somehow inappropriate, this should be stated in the report

and the reasons given for this judgment. In some (perhaps most) instances, contradictions will be

inherent in the assessment data. Although the clinician must make every effort to resolve such

contradictions and present a unified view of the patient, there are instances in which such resolution

is not possible. In those instances, the contradictions should be described. Distortion in the service of

consistency is not a desirable alternative.

There are often secondary readers of clinical reports for example, although the primary report may

be sent to the referring person (a psychiatrist, another clinician, or an agency), a secondary reader

may be an agency administrator, ad program evaluator, or a research psychologist. In specific

circumstances it may be necessary or even desirable to prepare a special report for such people. In any

event, a clinical report does not always serve an exclusively clinical or direct helping function. It can also

be useful in assisting an agency to evaluate the effect of its programs. It can likewise be useful from the

standpoint of psychological research. Information in clinical reports can often be helpful in validating tests

or the interpretations and predictions made from tests. Such data can sometimes provide a baseline against

which to compare subsequent change in the patient as a function of various forms of intervention.

AIDS TO COMMUNICATION

The function of a report is communication. The following are some suggestions for enhancing that

function.

Language

One should not resort to jargon or to a boring and detailed test-by-test account of patient responses. Again,

it is important to recall the nature of the referral source. In general, it is probably best to write in a style

and language that can be understood by the intelligent layperson. Of course, what is jargon or excessively

technical is partly in the eye of the beholder. A considerable amount of technical language can be

tolerated in a report sent to professional colleagues whom one knows. On the other hand, technical jargon

has no place in a report that is going to a parent. The terms interest scatter and Erlebnistypus may be

all right for another clinician, but they should not appear in a report sent to a junior high school counselor.

Individualized Reports

We know the importance of avoiding the Barnum effect (a term applied in case where statements that appears to

be valid self-descriptions in actually characterize almost everybody).The distinctive (be it current

characteristics, development, or learning history) is preferred over the general. To say "Jack is insecure"

hardly distinguishes him from 90% of all psychotherapy patients. To say that Jack's insecurity stems from

a history of living with several different relatives as a child and that it will become particularly acute

Whenever he must make a decision that will make him away (even temporally) from the home-is

considerably more meaningful. In this case, a general characteristic has been distinctly qualified by both

antecedent and subsequent conditions.

The Level of Detail

The question often arises as to how detailed a report ought to be. Again, the answer depends largely

on the audience. In general, however, it seems desirable to include a mix of abstract generalities, specific

behavioral illustrations, and some testing detail. For example, in reporting depressive tendencies, a few

illustrations of the test responses that led to the inference would be in order. A few of the relevant

behavioral observations that were made during testing could also be quite helpful. A certain amount of

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detail can give readers the feeling that they can evaluate the clinician's conclusions and interpretations.

The exclusive use of abstract generalities places the reader at the mercy of the author's inferential

processes.

CONCLUSION

The clinical report serves as the major form of communication to convey the findings from a clinician's

assessment and evaluation. The report should address the referral questions, using language that is

tailored to the person or persons who will be reading the report. Finally, the report should contain

information that is detailed and specific to the client and should avoid vague, Barnum like statements.

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