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Psychiatry 72(4) Winter 2009
382
Intimate Partner Violence
Fussell et al.
Clinical Perception: A Study of Intimate Partner
Violence versus Methamphetamine Use as
Presenting Problems
Holly Fussell, Janice Haaken, Colleen S. Lewy, and Bentson H. McFarland, MD
This study draws on theory by Solomon Asch (1946, 1952) to examine how
presenting with intimate partner violence versus methamphetamine use shapes
characteristics of substance abuse assessment interviews. When responding to an
initial open-ended question from a substance abuse counselor, the methamphetamine user and intimate partner violence survivor may elicit very different reactions from the counselor. We predicted that these differing presenting problems
would initiate different trajectories for overall impression formation. To test this
hypothesis, 18 substance abuse practitioners interviewed one standardized patient (an actor portraying a substance abuse client) who alternated her presenting
problem between a) violence in a domestic setting and b) methamphetamine use.
The remainder of her story was identical for counselors in either presenting problem group. Results included differences between the two groups in median length
of the interviews and failure of both groups to explore domestic violence as a cooccurring problem. Clinical practices related to substance abuse counseling and
intimate partner violence are discussed in light of these findings.
Solomon Asch (1946, 1952) pioneered the study of impression formation-how discrete elements or variables shape
global assessments of others. Guided by
Gestalt theory, with its emphasis on how
the mind is organized to seek patterns and
to construct whole pictures out of disparate
elements, Asch initially demonstrated the
potency of first impressions in shaping subsequent perceptions. He later extended this
line of inquiry to include a focus on central
characteristics. Asch (1946) concluded that
“central characteristics, while imposing their
direction upon the total impression, were
themselves affected by the surrounding characteristics” (p. 62). He demonstrated how
the inclusion of items such as warm, cold, or
intelligent, for example, on a list of attributes
often shaped the subjects’ overall view of a
hypothetical person.
Holly Fusell, PhD, is affiliated with the Department of Public Health & Preventive Medicine, at Oregon Health
& Science University in Portland, Oregon. Janice Haaken, PhD, is with the Department of Psychology at Portland
State University. Colleen S. Lewy, PhD, is with the Department of Psychiatry at Oregon Health & Science University and Bentson H. McFarland, MD, PhD, is affiliated with both the Department of Public Health & Preventive
Medicine, at Oregon Health & Science University.
This research was supported by National Institute on Drug Abuse grant R03 DA 016958 entitled “Standardized
Patients as Drug Abuse Treatment Clients.” The authors also thank the standardized patient, Julie Starbird, and the
participating counselors.
Address correspondence to Holly E. Fussell, PhD, Department of Public Health & Preventive Medicine, Oregon
Health & Science University, 3181 SW Sam Jackson Park Rd., Mail Code CB-669, Portland, OR 97239-3098; Email: fussellh@ohsu.edu
Fussell et al.
Research demonstrates that first impressions influence how physicians assign
medical diagnoses as well as other areas of
clinical judgment (see Chapman, Bergus,
& Elstein, 1996; Chapman & Chapman,
1969; Chiaramonte & Friend, 2006; Curley, Young, Kingry, & Yates, 1988; Pain &
Sharpley, 1989).Most clinical interactions
occur, however, under confidential conditions, restricting opportunities for investigating these interactive processes. The use
of standardized patients in clinical training,
increasingly adopted to assess practitioner skills in eliciting clinical data (see Fussell, Kunkel, Lewy, McFarland & McCarty,
2008), has introduced a new lens for studying clinical interactions by “standardizing”
patient responses to specific questions or
lines of inquiry (Colliver & Swartz, 1997;
Swartz & Colliver, 1996). Standardized patients are actors trained to enact a particular
set of symptoms consistently across clinical
interactions with multiple practitioners, allowing for cross-clinician comparisons on
multiple pre-determined criteria (e.g., diagnosis). Colliver and Swartz (1997) found
that on an initial visit physicians are usually
unable to distinguish standardized patients
from “real” patients.
This paper reports on a study that
utilized a standardized patient to examine
how socially relevant presenting problems,
specifically intimate partner violence and
methamphetamine use, shape characteristics
of clinical interviews in the context of addictions treatment counseling. During assessment interviews drug and alcohol counselors
must obtain and integrate a wide range of
clinical data to diagnose the client and develop a treatment plan. Often the assessment
includes making recommendations that have
profound impacts on the life of the client, such
as court-mandated treatment or termination
of parental rights. This combined focus on
clinical intervention and social judgments
requires the addictions counselor to process
a complex array of social and clinical information. In carrying out the study reported
383
here, we sought to determine how varying
the opening lines of the script, with two differing presenting problem statements, would
shape subsequent clinical interactions.
Methamphetamine and Intimate
Partner Violence
Methamphetamine use and intimate
partner violence commonly co-occur (Cohen, Dickow, Horner, Zweben, Balabis, &
Vandersloot, 2003). However, even without methamphetamine use complicating the
picture, interpersonal violence alone has
been described as “one of the most critical
problems facing society” (Ammerman &
Hersen, 2000, p. xiii). Assistance for women, in particular those who are living with
intimate partner violence, has been described
as one of the most significant victories of
second-wave feminism (Haaken, Fussell
& Mankowski, 2007). Unlike with female
methamphetamine users, substantial public
effort has been placed on removing blame
and focusing on sympathetic efforts to assist females entrapped in violent domestic
settings. When responding to the question,
“What brings you in today?,” the methamphetamine user and the intimate partner violence survivor may elicit different reactions
from the counselor. We predicted that these
differing presenting problems would initiate
different trajectories for overall impression
formation.
Nonetheless, impression formation is
a dynamic process where other client characteristics and story elements also likely affect
interpretations of the presenting problem.
The challenge of untangling these interactive
effects and assessing their impacts in applied
settings is compounded by the enormous
variability in how clients present their problems and tell their stories. The standardized
patient procedure offers one methodological
strategy for reducing some of this variability.
384
Intimate Partner Violence
Research Question
The findings presented here are part of
a larger study that sought to test the authenticity of standardized patients as substance
abuse clients. The study consisted of creating four standardized patient scripts, recruiting and training the standardized patients,
recruiting addictions treatment clinicians,
conducting assessment interviews with standardized patients and clinicians, monitoring and assessing the standardized patients’
performances, and assessing key dimensions
of counselors’ performances (see Fussell,
Lewy, & McFarland, 2009). The standardized patient script and methods presented
here were designed specifically to investigate
the following research question: How do
presenting problems shape characteristics of
clinical interviews in the context of addictions treatment counseling? While this was
an open-ended study of how the presenting
problem shapes clinical impressions, we began with the prediction that responses to the
methamphetamine abuse story would elicit a
“colder” response and the domestic violence
story a “warmer” response, primarily because media representations of methamphetamine abusers, particularly women, have
been harsher and less sympathetic than those
of domestic violence survivors.
Methods
Quantitative and qualitative analyses
were conducted in order to gain a broad and
rich view of how substance abuse counselors,
in particular, develop perceptual frameworks
of a client based on two different presenting
problems in substance abuse assessment interviews. Individual substance abuse counselors saw one standardized patient and engaged in mock assessment interviews. The
standardized patient’s case included an indepth history sufficient for up to a one and a
half hour assessment interview.
Participants
The standardized patient was a professional actor recruited from the theater community in Portland, Oregon. The candidate
actor was screened for the ability to portray
affect and physical dispositions consistent
with presenting problems of substance abuse
clients. Training focused solely on script
memorization and delivery. The standardized patient was only told that she would be
rated for authenticity and that for another
aspect of the study she would alternate her
presenting problem. The recruitment of substance abuse practitioners to interview the
standardized patient occurred primarily in
the alcohol and drug counseling community
and through the inclusion of recruitment
materials at the 2005 Northwest Institute of
Addiction Studies conference in Portland.
Eighteen participants (72.2% female,
n = 13; Mean Age = 42, SD = 11.37) interviewed Debby, who was portrayed by one
female Caucasian actor. Counselor ethnicity
included ten Caucasians (55.6%), three African Americans (16.7%), two Asian/Pacific
Islanders (11.1%), one Hispanic (5.6%), one
“other” (5.6%) and one “multiple” (5.6%).
Highest level of education completed included some college (n = 2, 11.1%), associate’s degree (n = 5, 27.8%), bachelor’s degree
(n = 5, 27.8%), and master’s degree (n = 6,
33.3%). Three of the 18 participants had no
clinical experience other than their substance
abuse counselor training at the time of the
study.
Procedures
The standardized patient for this study
alternated her opening statement between a)
“Me and my husband have been fighting a lot
lately and this last time the police came and
they took my kids,” and b) “I’ve been having
some pretty bad problems with meth.” Alternating the standardized patient’s presenting problem between 18 counselors provided
Fussell et al.
•
•
•
•
•
•
385
Does this client have one or more problems with substances? Yes/No
If yes, what label(s)/diagnosis(es) would you use to describe the problem(s)?
Is the client suffering from one or more co-occurring problem(s)/disorder(s)? Yes/No? Label? Reason?
Client currently in physical danger? Yes/No
Given this client’s overall clinical picture, what are his/her barriers to recovery?
What is/are the treatment goal(s) for this client?
Figure 1. Post-Interview Questionnaire Topics
two data sets (intimate partner violence presenting problem, n = 9; methamphetamine
presenting problem, n = 9), allowing comparisons between two groups of counselors
on particular themes and descriptive characteristics of the interviews
After the opening statements, the standardized patient was instructed to respond
to probes based on the following scripted
story.
Debby Patterson is a 24-year-old unemployed woman who, along with her husband, Eric, was arrested one week ago
at their home after the police responded
to a domestic dispute. The police noted
dilapidated conditions (no telephone
or electricity) and a small amount of
methamphetamine. Debby’s children
were subsequently placed in protective
custody on grounds of neglect. Debby
knows she has a problem with methamphetamine and wants to quit but blames
the addiction on Eric. Debby’s husband
has increased physically and emotionally violent behavior toward Debby
over the past year and more so in the
last month. Debby’s story includes being
thrown to the floor and kicked in the
stomach within the past month. Eric is
still incarcerated at the time of the assessment interview with an unknown release
date. Debby has no social support. Her
children (Tyler, age 4, and Hope, age 2)
recently reported to Debby’s mother that
Debby and Eric “never pay attention” to
them, and this information along with
knowledge of Debby’s use of methamphetamine has caused Debby’s mother to
stop communicating with her. Debby’s
story includes acknowledging that Tyler
takes care of Hope most of the time,
including changing diapers, feeding, and
helping bathe, and that she has been
methamphetamine free for one week. She
does not know the current location of
her children. She has been mandated to a
substance abuse assessment interview.
All interviews took place in a private
room and were videotaped. Counselors were
instructed that they had up to one hour and
15 minutes to conduct a typical assessment
interview and that they would be asked to
offer a diagnosis as well as to respond to additional items assessing various aspects of the
client’s overall clinical picture, similar to a
real assessment interview. Diagnostic criteria
were left to the counselor’s discretion. Counselors were also told that the key purpose of
the interviews was to assess the authenticity
of the standardized patient.
Measures
Counselors completed a post-interview
questionnaire (see Figure 1 for questionnaire
topics reported on for this paper), and interview sessions were video- and audio-recorded.
Audio portions of the videotaped interviews were transcribed and sections identified where counselors offered impressions
to the standardized patient by a) summarizing their understanding of the situation, b)
speculating on what may have happened in
the past to cause the problem, c) making
predictive statements about the standardized
patient’s future, or d) asking a question that
carried an implicit interpretation or inference
(e.g., “so, you feel sad that you are not with
your kids?”).
386
Intimate Partner Violence
TABLE 1. Counselor Recognition of Intimate Partner Violence by Presenting Problem Group
Analytic Medium and Topic
*IPV Group
**Meth Group
N
9
9
Post-interview questionnaire: Acknowledged IPV as a cooccurring “problem” in diagnosis
0
0
Post-interview questionnaire: Responded affirmatively to question, “Is this patient currently in physical danger?”
0
2
14 of 28 total barriers
5 of 26 total barriers
1
0
Post-interview questionnaire: Listed the husband as an
open-ended response to “barrier to recovery.”
Interview transcriptions: Obtained information that Debby has
been physically assaulted and/or injured by her partner.
(issues of safety)
Note. *IPV = Intimate partner violence. **Meth = Methamphetamine.
Analyses
This study employed a three phase
analytic framework. While the sample size
does not allow for significance testing of
differences between groups, analyzing the
interviews through multiple methodological
approaches, including limited quantitative
analyses, provides a multi-layered description of outcomes and processes in the methamphetamine and intimate partner violence
presenting problem groups. Phase one included quantitative and qualitative analysis
of items on a post-interview questionnaire.
The questionnaire was designed to assess
both diagnostic outcomes of counselor/standardized patient interviews and the believability of the standardized patient (see Fussell, Lewy, & McFarland, 2009).
Phase two enlisted three mental health
practitioners to conduct blind ratings of the
post-interview questionnaires, each practitioner reading the documents as though they
were real-life case reports. The post-interview questionnaires elicited multiple openended responses from participating counselors beyond those specifically analyzed for
this study, including treatment plan priorities
and reasons for diagnostic responses. Practitioners were asked to rate counselor reactions to Debby as warm, cold, neutral, or
ambivalent. Although raters were considered
independent, inter-rater reliability was not
calculated as a measure of relevance to theoretical testing. This decision was due to two
factors: 1) Pre-existing definitions of warm,
cold, or ambivalent do not exist. Raters
were intentionally using an entirely subjective gauge for their decisions. 2) Each rater
was left to subjectively determine criteria for
definitions of warm versus cold. Therefore, it
was determined that overall number of warm
and cold ratings should dictate agreement or
disagreement with Asch’s (1946) theoretical
constructs.
Phase three involved accessing dominant themes and overarching story lines that
emerged in narrative transcriptions of nodal
points in the videotaped interactions between counselors and Debby. As opposed to
a coding system in which words and phrases
are examined individually based on one coding scheme, this study followed a narrative
analytic framework available in A Listening Guide (Gilligan, Spencer, Weinberg, &
Bertsch, 2003). This framework includes
analyzing narrative on multiple dimensions,
including a) the primary, overarching theme;
b) a closer examination of how the protagonist’s (Debby’s) story emerges differently in
respective presenting problem groups; and c)
how the former relate to the guiding research
question.
Fussell et al.
387
TABLE 2. Clinician Blind Ratings of Substance Abuse Counselor Impressions of Debby as Warm or Cold by
Presenting Problem Group
Rating
*IPV Group
**Meth Group
Total Ratings Across Groups
Warm
13 (68%)
6 (32%)
19
Warm/Neutral
2 (33%)
4 (67%)
6
Neutral
5 (50%)
5 (50%)
10
Ambivalent
6 (62%)
4 (38%)
10
0
1 (100%)
1
4
Ambivalent/Cold
Cold/Neutral
1 (25%)
3 (75%)
Cold
0
4 (100%)
4
Total
27
27
54
Note. *IPV = Intimate partner violence. **Meth = Methamphetamine
Results
Results provide insights on how counselors ascertain information about the standardized patient’s problems with intimate
partner violence across all three phases of
data analysis. Guiding theoretical premises
of this study included that the social saliency
of intimate partner violence should inform
the development of a different perceptual
trajectory for the intimate partner violence
group than the methamphetamine group. In
addition, issues of patient safety in situations
of intimate partner violence support understanding the more direct impact of the presenting problem on counselor diagnoses and
behavior. See Table 1 for ways counselors
ascertained and responded to the standardized patient’s scripted involvement in intimate partner violence by presenting problem
group. Notice that few counselors in either
group identified intimate partner violence.
Neither the intimate partner violence
nor the methamphetamine group emphasized or ascertained concerns over the standardized patient’s scripted experiences of
intimate partner violence with her husband.
However, systematic differences between the
two presenting problem groups did appear.
Table 2 reports on between-group differences
identified in clinicians’ blind ratings of substance abuse counselor responses to Debby
as warm or cold as derived by blind ratings
of the post-interview questionnaires.
Three clinicians were asked to act as
blind raters of post-interview questionnaires.
Instructions to clinicians included rating the
counselors’ interpretation of the client as
warm, cold, neutral, or ambivalent. Although
response options of warm, cold, neutral, and
ambivalent were provided a priori, as Table
2 illustrates, clinicians created categories due
to feeling the additional categories better reflected their actual judgment of the impression the substance abuse counselors had of
the standardized patient.
In addition to differences in warmer
and colder ratings of counselor perceptions
of Debby, substantial differences in duration
of interviews occurred as well (see Table 3
for interviews lengths by group).
Additional differences between presenting problem groups are found in the
numbers of questions or statements in the
interview transcriptions reflective of uncertainty for Debby’s future (i.e., “what if”
comments or questions). Counselors in the
intimate partner violence group overwhelmingly expressed less certainty about Debby’s
future than did the counselors for the methamphetamine group. The intimate partner
violence group transcripts included 36 comments or questions challenging Debby to
consider possibilities that could result in less
than ideal outcomes, with a particular em-
388
Intimate Partner Violence
TABLE 3. Interview Duration Data Points by Group
IPV* (median 40 minutes)
Meth** (median 18 minutes)
20
16
25
16
28
18
30
18
40
18
46
30
50
50
64
53
70
65
Note. *IPV = Intimate partner violence. **Meth = Methamphetamine.
phasis on her husband. Three of nine intimate partner violence group transcripts did
not include any “what if” questions or comments. Those three narratives were characterized by extreme and unrealistic optimism.
When Debby offered that problems
with methamphetamine brought her to the
session, counselors asked only seven “what
if” questions. For example, one counselor
asked, “If your husband comes back and
starts using again, is that a situation you can
feel comfortable with?” This closed-ended
question characterized many of the questions
in the transcripts from the methamphetamine
group. As opposed to open-ended questions,
such as the “what’s gonna happen?” query
in the intimate partner violence group, the
predominately closed-ended questions in
the methamphetamine group did not leave
room for further exploration of possible
problems. Table 4 provides additional differences between the intimate partner violence
and methamphetamine presenting problem
groups on responses to the post-interview
questionnaire.
One unanticipated overarching theme
emerged in the narrative analysis--a consistent emphasis on Debby’s maternal status
(a woman whose children had been forcibly
removed into protective custody). In particular, the transcripts from both presenting
problem groups included statements indicative of a strong desire by the counselors to
believe that Debby was a good mother in a
bad situation, despite direct statements that
she was not able to care for her children. For
example, Debby stated that four-year-old Tyler bathes and feeds his two-year-old sister;
that the children are sent to their room while
she and her husband stay high on methamphetamine for days at a time; that upon entry to the house, after neighbors called the
police over their fighting, the officers noted
dilapidated conditions, such as no electricity;
and that the children had reported to their
grandmother that she and Eric never pay attention to them. After learning of these circumstances, one counselor concluded the
topic of Debby’s relationship with her children by stating, “So, you would say, overall,
that they’re happy, pretty balanced kids.”
In focusing on Debby’s maternal status, including reshaping the story to conclude
that Debby is a good parent, the counselors
in both groups repeatedly suggested that
Debby’s ultimate goal was taking care of her
family. Although the standardized patient
was scripted to state that “she just wants her
kids back” in response to any questions of
motivation for sobriety, this aim of becoming a better parent was not scripted. Indeed,
the overemphasis on her desire to retrieve
her children was scripted as indicative of a
lack of motivation toward sobriety, given a
lack of insight into any other reason to avoid
methamphetamine.
Fussell et al.
389
TABLE 4. Differences Between Presenting Problem Groups on Responses to Items on the Post-Interview Questionnaire
*IPV Group
**Meth Group
100% ; 7 of 7 “yes” responses
50%; 4 of 8 “yes” responses
44%; 7 of 16 total reasons
11%; 2 of 16 total reasons
33%; 3 of 9 counselors
0%; 0 of 9 counselors
Questionnaire Topic
Mental health related co-occurring problem
Psychological reason for listed co-occurring problem
Mental health evaluation listed as a treatment goal
Note. *IPV = Intimate partner violence. **Meth = Methamphetamine
Discussion
These findings suggest differing
trends in substance abuse assessment interviews when the same standardized patient-“Debby”--equipped with one clinical story
presented with intimate partner violence versus problems with methamphetamine. Unexpectedly, however, findings also reveal an
overall paucity of clinical emphasis on the client’s involvement in a dangerous relationship
as well as her immediate safety. Regardless of
their presenting problem group, counselors
failed to obtain information on the severity
of the standardized patient’s situation. The
script required the standardized patient to
reveal further information upon counselor
probing. For the most part, this probing
did not occur. When clinical discussion did
turn to possibilities that Debby may be in a
violent relationship, the standardized patient
was to state initially that “I hit him too” and
that “he’s just been dealing with a lot lately.”
In all but one interview that broached this
topic, the counselors immediately changed
the subject. In addition, in both presenting
problem groups, an inordinate emphasis was
placed on the client’s maternal status, including over-confidence in the client as a “good”
mother in a bad situation, despite evidence
to the contrary.
None of the 18 counselors reported
intimate partner violence as a co-occurring
problem or disorder. Although the standardized patient’s script was identical for both
counseling groups, including level of intimate partner violence, the finding that no
counselors emphasized problems with vio-
lence is particular noteworthy given that nine
counselors heard Debby state that “Me and
my husband have been fighting a lot lately,
and this last time the police came and they
took my kids” as the presenting problem.
One potential explanation for the omission
concerns the post-interview questionnaire;
did the questionnaire afford counselors clear
opportunity for reporting intimate partner
violence as a co-occurring problem? Practitioners could have interpreted the question,
“if (the client is suffering from one or more
co-occurring problem(s)/disorder(s), what labels/diagnoses would you use to describe the
problem,” as inquiring specifically whether
the client had a mental health disorder. However, the term “co-occurring problem” was
intentionally inserted in this question in order to broaden response options. Also, and
crucially, only two of 18 counselors reported
that the client was in physical danger.
Duration of the intimate partner violence sessions was twice as long as that of
the methamphetamine group. Although a
plausible explanation for this time difference
could be that the intimate partner violence
group spent more time struggling with how
to deal with the topic of violence, this did
not occur. Rather, transcripts and responses
on the post-interview questionnaire pointed
to the interpersonal violence group shifting the emphasis away from violence and
toward explorations of psychological processes. Additionally, the methamphetamine
group transcripts included only seven “what
if” type inquiries, while the intimate partner
violence group included 36 such questions
and/or statements indicative of uncertainty
in the outcome of the client’s story. This
390
combination of findings suggests that the intimate partner violence presenting problem
elicited a more concerned response followed
by more detailed interviews. However, the
content analytic finding that only one of 18
counselors obtained information that the
standardized patient had been physically injured by her domestic partner reinforces concerns about omitting that critical component
of the standardized patient’s story.
Acknowledging a problem with methamphetamine, particularly as the patient’s
description of the presenting problem, could
lead counselors to believe that the standardized patient was highly motivated to change.
This belief could, in turn, have foreclosed
therapeutic exploration of other aspects of
the client’s story. This tendency toward clinical closure quite likely contributed to missing
the crucial intimate partner violence component of the client’s story and/or moving too
hastily to treatment issues.
The counselors’ emphasis on Debby’s
maternal status, to the point of all but ignoring information presented that countered the
idea that she was simply a “good mother in a
bad situation,” may register countertransference anxiety on the part of clinicians. This
redemptive script may operate as an unconscious effort to compensate for the historical tendency toward “mother-blaming” in
situations of domestic abuse. But clinicians
also may feel ill-equipped to explore the difficult terrain where problems of drug abuse
and intimate partner violence converge, and
where clinicians are caught between competing conventional discourses on women and
social problems.
The study included the prediction that
intimate partner violence would be interpreted more sympathetically than methamphetamine use, a premise tested directly through
external, blind ratings of post-interview
questionnaires. Clinicians were asked to include comments explaining the reasons for
their ratings. Interestingly, two of the blind
raters’ evaluations made use of Debby’s maternal status discrepantly in explaining criteria for warm versus cold perceptions. Com-
Intimate Partner Violence
ments from the first rater’s warm assessments
included items such as, “states positive traits
of client--honesty, determination, love for
her children, willing to follow directions …
despite low awareness of addiction clinician
perceives client ‘wants’ her kids … addresses
client’s self-esteem and self-confidence and
desires as clinician to support client’s goal
(to get kids back) ... points to children as
assets in recovery, client values kids.” This
clinician’s comments point to an emphasis
on substance abuse counselors ascertaining
Debby’s “love” for her children and the “value” she places on them as a sign of a warm
perception. The second clinician elaborated
on her rating criteria by stating that including getting kids back as a priority goal indicates a lack of attentiveness and depth of
exploration into Debby’s scenario--concepts
associated with a cold perception. Both clinicians viewed the children as indicative of
a warm perception if care was taken by the
substance abuse counselor to make use of
the information in a way consistent with developing what the third rater described as a
therapeutic alliance.
Due to the higher number of female
counselors (n = 13) than male (n = 5) that
participated in the study, one possible conclusion is that females tended toward warm
perceptions of the standardized patient and
males tended toward cold perceptions. However, closer analysis of which counselors
were rated as having warmer versus colder
perceptions of Debby shows that of the five
males only one received two “cold/neutral”
ratings. Of the remaining 13 ratings of the
five males, seven were interpreted as having a
warm perception of Debby and six as having
a neutral or ambivalent perception.
Although the numbers of questionnaires rated warm, cold, and so forth, were
similar, raters did not always agree on which
questionnaires fell into particular categories.
For example, one counselor was rated ambivalent, warm, and cold. Rather than lending
doubt to Asch’s (1946) theory, the discrepancies in ratings for counselors’ perceptions of
Debby actually substantiate the key premise
Fussell et al.
391
that even dynamic interactions between multiple characteristics of an individual demonstrate relatively predictable interpersonal
patterns in impression formation. Regardless
of individual criteria and subjectivity, aggregate outcomes nonetheless demonstrate more
warm perceptions related to a problem eliciting sympathy and more cold perceptions of a
problem eliciting distance.
Implications
Assisting patients with co-occurring
problems of intimate partner violence and
substance abuse is not limited to addictions
counseling. Possibilities for inadvertent and
inordinate attention to presenting problems
in clinical interviews exist across multiple
clinical domains. In conceptualizing interventions in intimate partner violence as a social priority, substance abuse treatment is an
opportune location for identifying the problem and providing information on assistance
and/or referrals. While reducing problems
specific to substance abuse remain the priority for counselors in the field, educating practitioners on how to broach intimate partner
violence could go some distance in attempts
to alleviate both problems.
This study began with the recognition that clinical exploration of interpersonal processes poses specific methodological challenges. Standardized patients address
some of these challenges by controlling for
the content of client responses to therapeutic inquiry. Use of standardized patients in
clinical settings has vastly increased over
the past decade as have studies investigating
their utility and limitations. The larger study
that provided the context for the findings
reported here offers preliminary evidence
that standardized patients can authentically
portray complex client cases, such as those
including intimate partner violence and substance abuse, supporting future use of standardized patient technology to understand
clinical processes with critical consequences
for individuals dealing with intimate partner
violence and substance abuse.
Findings from this study suggest that
practitioners from a range of counseling
fields may benefit from increased awareness
of how particular presenting problems influence clinical interaction. While this study
investigated intimate partner violence and
methamphetamine use specifically, what a
practitioner deems socially salient information and therefore unconsciously may allow
to sway a clinical interview toward particular outcomes undoubtedly varies. Awareness
of the possibility of trajectories for impression formation based on presenting problems could direct attention to the phenomenon and alleviate unintentional bias toward
particular diagnoses and treatments. Future
research might examine effects of identical,
similar, or related characteristics (e.g., gender, race, or ethnicity) in various clinical settings.
References
Ammerman, R. T., & Hersen, M. (Eds.). (2000).
Case Studies in Family Violence (2nd ed.). New
York: Kluwer Academic/Plenum.
Asch, S. E. (1946). Forming impressions of
personality. Journal of Abnormal & Social Psychology, 41, 258-290.
Asch, S. E. (1952). Social Psychology. Upper
Saddle River, NJ: Prentice-Hall.
Chapman, G. B., Bergus, G. R., & Elstein, A.
S. (1996). Order of information affects clinical judgment. Journal of Behavioral Decision
Making, 9(3), 201-211.
Chapman, L. J., & Chapman, J. P. (1969). Illusory correlation as an obstacle to the use of
valid psychodiagnostic signs. Journal of Abnormal Psychology, 74, 271-280.
392
Chiaramonte, G. R., & Friend, R. (2006).
Gender bias in CHD assessment: Patients’ gender and stress influence medical students’ and
residents’ diagnoses, referrals, and interpretation of cardiac symptoms. Health Psychology,
25(3), 255-266.
Cohen, J. B., Dickow, A., Horner, K., Zweben,
J. E., Balabis, J., & Vandersloot, D. (2003).
Abuse and violence history of men and women in treatment for methamphetamine dependence. American Journal on Addictions, 12(5),
377-385.
Colliver, J. A., & Swartz, M. H. (1997). Assessing clinical performance with standardized
patients. Journal of the American Medical Association, 278, 790-791.
Curley, S. P., Young, M. J., Kingry, M. J., &
Yates, J. F. (1988). Primacy effects in clinical
judgments of contingency. Medical Decision
Making, 8, 216-222.
Fussell, H., Kunkel, L., Lewy, C., McFarland,
B., & McCarty, D. (2008). Using a standardized patient walk-through to improve implementation of clinical trials. Journal of Substance Abuse Treatment, 35(4), 470-475.
Fussell, H., Lewy, C., & McFarland, B. (2009).
Evaluating and training substance abuse coun-
Intimate Partner Violence
selors: A pilot study assessing standardized
patients as authentic clients. Substance Abuse,
30(1), 47-60.
Gilligan, C., Spencer, R., Weinberg, K. M., &
Bertsch, T. (2003). On the Listening Guide:
A voice-centered relational method. In P. M.
Camic, J. E. Rhodes et al. (Eds.), Qualitative
Research in Psychology: Expanding Perspectives in Methodology and Design (pp. 157-172).
Washington, DC: American Psychological Association.
Haaken, J., Fussell, H., & Mankowski, E.
(2007). Bringing the Church to its knees: Evangelical Christianity, feminism and domestic
violence discourse. Psychotherapy and Politics
International, 5(2), 103-115.
Pain, M. D., & Sharpley, C. F. (1989). Varying the order in which positive and negative information is presented: Effects on counselors’
judgments of clients’ mental health. Journal of
Counseling Psychology, 36, 3-7.
Swartz, M. H., & Colliver, J. A. (1996). Using
standardized patients for assessing clinical performance: An overview. Mount Sinai Journal of
Medicine, 63, 241-249.
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