PROBLEM DEFINITION IN MARITAL

AND FAMILY THERAPY:

A QUALITATIVE STUDY
Peter J. Jankowski
David C. Ivey

ABSTRACT: This paper describes findings from a grounded theory

study on the process of constructing problem definitions by marital and
family therapists. Coding of the observations and interviews resulted
in two meta-problem definition processes. In the first meta-process
clinicians kept their definitions internal to themselves during the therapy session. In contrast, the second meta-definition process involved
clinicians bringing forth their internal problem definitions and incorporating them into the therapeutic conversation. Implications for existing
conceptualizations and marital and family therapy practice and supervision are discussed, as well as suggestions for further consideration.
KEY WORDS: problem definition; clinical judgment; qualitative research, marital and
family therapy.

There is recognition among research-practitioners that the advancement of marriage and family therapy (MFT) as a viable treatment
option in the larger health care system rests upon research-practitioners ability to provide consumers with descriptions of the clinical
processes of MFT and evidence of the effectiveness of MFT (Sprenkle &
Bailey, 1995; Pinsof & Wynne, 1995). Since many marital and family
therapists (MFTs) have been reluctant to conduct research on the process of their clinical work (Pinsof & Wynne, 1995), there is a significant
knowledge gap concerning the processes of clinician practices in the
MFT literature. Without the model-building potential of process rePeter J. Jankowski, PhD, is Assistant Professor, Department of Psychology, Judson
College, Elgin, IL, 60123 (e-mail: pjankowski@judson-il.edu). David C. Ivey, PhD, is
Associate Professor, Marriage and Family Therapy Program, Texas Tech University,
Lubbock, TX, 79409-1162. Reprint requests should be sent to Peter J. Jankowski, Ph.D.
Contemporary Family Therapy 23(4), December 2001 2001 Human Sciences Press, Inc.

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search, as well as the detailed descriptions of clinician processes in

their natural context, the field risks becoming an unviable treatment
option (Greenberg, Heatherington, & Friedlander, 1996). Beyond the
discipline of MFT, researcher-practitioners frequently examine the
area of clinical judgment as a means of determining the effectiveness
of psychotherapy (Falvey, 1992). Following the lead of researchers outside of MFT, we argue that understanding the processes of clinical
judgment needs to be an essential component of the efforts being made
to advance the practice of MFT as a viable treatment option.
This paper reviews the literature on existing conceptualizations
of clinical judgment and describes the results of a qualitative study on
clinical judgment. In doing so, this paper offers an alternative conceptualization of clinical judgment that considers contextual and therapistclient interaction factors. The alternative conceptualization is more
compatible with the systemic and contextual orientation of MFT and
has implications for existing conceptualizations of clinical judgment
and the practice and training of MFTs. The discussion section contains
a critique of the extant literature and a description of three possible
applications to MFT practice and training.

LITERATURE REVIEW
The origin of the systematic study of clinical judgment can be
attributed to Meehls (1954, 1957) comparisons of subjective cognition
(clinical judgment) with objective statistical processes (actuarial judgment). The first subsequent decade of research was concerned with the
processes of prediction and diagnosis. Research results have consistently supported the superiority of actuarial judgment over clinical
judgment in terms of predictive and diagnostic accuracy (Goldberg,
1968; Goldberg & Werts, 1966; Meehl, 1954, 1957; Sawyer, 1966). Research during this period also demonstrated that the subjective judgment of clinicians was no better than that of secretaries (Goldberg,
1959), and that trained clinicians performed only slightly better than
chance and no better than untrained persons in terms of diagnostic
accuracy (Oskamp, 1965).
Despite the fact that research and discussion comparing actuarial
and clinical judgment persists to the present (e.g., Dawes, Faust, &
Meehl, 1989; Garb, 1994; Gardner, Lidz, Mulvey, & Shaw, 1996a,
1996b), another focus emerged during the second decade of research.
Research shifted from simply conducting outcome comparisons to at-

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tempts at understanding how clinicians gather and integrate information (Falvey, 1992). With the emergence of the information-processing
model as the predominant means of conceptualizing clinical judgment
(Falvey, 1992), researchers focused on identifying heuristics and biases
assumed to cause the consistent finding that clinicians make inaccurate
and inferior judgments.
The information-processing model rests on mechanistic philosophical assumptions and does not adequately describe the judgment process
of clinicians (Ivey, Scheel, & Jankowski, 1999; Miller, 1993). The mechanistic orientation of the information-processing model can be seen in
its focus on the internal judgment processes of the clinician to the
neglect of the influence of context and therapist-client interaction (Holt,
1986, 1988; Sarbin, 1986). Another one of the mechanistic assumptions
of the information-processing framework is linear causality. The model
assumes a linear flow of information from the environment and subscribes to the idea that knowledge is a product of sequential processing
(Ivey et al., 1999). Finally, the model also assumes an objective external
reality and that data collection and analysis processes which are free
of error can obtain an exact mental representation of that reality (Ivey
et al., 1999; Mahoney, 1988).
Although efforts have been made to enhance the conceptualization
such that information-processors are seen as active seekers, creators
and users of information (Turk, Salovey, & Prentice, 1988, p. 1), clinical
judgment remains a linear, outside-in process. Furthermore, despite
attempts to conceptualize therapist-client interaction in the judgment
process (Turk et al., 1988), the attempt rests on the notions of transference and counter-transference that rely on the mechanistic assumptions of the objectivity and separation of the observer from the observed.
The term transference, for example, refers to the clients projection of
significant others onto the objectively neutral clinician (Turk et al.,
1988, p. 8).
Mechanistic philosophical assumptions are also evident in the clinical judgment process conceptualized by researchers within the traditional approach. The scientific model of interviewing is believed to
be more immune from error than other models of clinical judgment
(Strohmer, Shivey, & Chiodo, 1990). According to the scientific model
of interviewing, the clinician observes the client, makes inferences
concerning the clients current status and related causal factors, and
then develops a testable hypothesis about the client. The clinician
proceeds to test the hypothesis against additional independent observations of the client and the process continues until the clinician has

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developed an accurate hypothetical model of the client (Strohmer et

al., 1990, p. 465). Finally, the hypothetical model serves as the basis
for decisions to be made regarding treatment and intervention. Some
of the mechanistic assumptions which can be found in the model include
the foundational assumption that the clinician is an objective outside
observer, as well as the assumptions that the clinician is in a hierarchical position of expertise for developing inferences, and that adherence
to the scientific method of hypothesis construction and testing enables
the clinician to obtain accurate diagnoses of the client.

Clinical Judgment Within MFT

While clinical judgment continues to gain attention in mental health
disciplines beyond MFT, a discussion of clinical judgment within MFT
for the most part is absent, apart from a very few researchers who have
attempted to study the topic or related issues (e.g., Hecker, Trepper,
Wetchler, & Fontaine, 1995; Ivey, 1995, 1996; Leslie & Clossick, 1996;
McCollum & Russell, 1992; Zygmond & Denton, 1988). One explanation
for the dearth of research attention centers on the fact that MFT is
based primarily in a contextual worldview sensitive to the dynamic
and reciprocal processes of systems. As a consequence, the existing
clinical judgment literature is largely incompatible with the contextual
and systemic orientation of MFT.
The existing MFT research has focused on the negative effects of
therapist factors on clinician perception, prognostic predictions, diagnosis,
and decision-making. Therapist factors found to result in deficient judgments include beliefs about the consequences of maternal employment,
and personal family history (Ivey, 1995; 1996); and values about sex
outside of marriage, and gender stereotypes concerning sexual activities,
sex, and religiosity (Hecker et al., 1995). Furthermore, Zygmond and
Denton (1988) found that the gender of the therapist influenced which
client characteristics were used to formulate therapeutic prognoses (p.
269). Leslie and Clossick (1996) found that therapists who received training in gender issues did not differ from those who did not receive training
in terms of the level of sexism in their clinical decision-making processes,
unless the gender training was conducted from a feminist perspective.
Finally, in contrast to the negative findings above, McCollum and Russell
(1992) surveyed family therapists and found no evidence of motherblaming on the part of the therapists in their processes of diagnosis.
The concern with the influence of gender on clinician judgments
(Hecker et al., 1995; Ivey, 1995, 1996; Leslie & Clossick; 1996; McCol-

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lum & Russell, 1992; Zygmond & Denton, 1988) can be seen as an
attempt at considering the influence of the larger social context on
clinician and client. Furthermore, the concern with the influence of
family history (Ivey, 1995, 1996) also reflects a consideration of context
on clinician judgment. Thus, MFT research on clinical judgment is an
advancement of the extant literature and its neglect of context on
clinician processes. However, there remains a neglect of therapist-client
interaction factors and a need to clarify and expand the conceptualization of contextual factors on clinical judgment. Furthermore, mechanistic assumptions are inherent within the conceptualization of clinical
judgment. Mechanistic assumptions remain such as a focus on clinician
bias and a concern with the inaccuracy and deficiency of clinician judgments. In addition, there is an absence of research that offers descriptions of the actual processes of clinician judgment.
In an effort to redress the lack of process research on clinical
judgment and to forward the development of models that more fully
consider context and therapist-client interaction, we examined one of
the principle aspects of clinical judgment, problem definition, and employed qualitative methods sensitive to a systemic and contextual perspective. Problem definition refers to the clinicians assessment at any
point during a session of the clients needs based on the perceived
causes, precipitants, and/or maintaining influences of the clients experience. As such, a problem definition is an answer a clinician constructs
to the question what will be the focus of clinical attention? or how
can I be helpful to this client? Thus, a problem definition helps guide
the direction for therapy. The chief purpose of our study was to describe
the processes by which problem definition occurs in marital and family
therapy, thereby advancing existing conceptualizations. The fundamental research question that guided the project was: How do marriage and family therapists arrive at a problem definition(s) in the first
session of therapy?

METHOD
We used a grounded theory approach (Charmaz, 1983; Glaser &
Strauss, 1967; Strauss & Corbin, 1990; Turner, 1981) because we were
generating a tentative theory in an area where there has been an
absence of systematic study (Rafuls & Moon, 1996). Furthermore,
grounded theory methods are appropriate for research questions that
are process oriented (Rafuls & Moon, 1996).

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Sampling and Selection

Theoretical sampling occurred as the study progressed with an
awareness of and openness to the saturation of categories (Charmaz,
1983). Saturation refers to the point in the data collection and analysis
process in which incidents of a particular category become repetitive
and further data does not elaborate upon the understanding of the
category (Charmaz, 1983). Saturation of categories was obtained with
10 participants.
The 10 participants consisted of clinicians with training in marriage and family therapy. Four male and six female clinicians with at
least 500 hours of direct client contact each, and a minimum of 250
hours of relational experience, comprised the sample. Participants were
from two community mental health agencies, a primary care setting,
and a university-based clinic. The theoretical orientations of the clinicians were diverse. Three of the clinicians indicated that psychodynamic therapy was their orientation and one selected MRI brief
therapy. The remaining six therapists indicated an integrative approach selecting more than one model with five of the six having solution-focused therapy as the primary thread of their orientation.

Data Collection
Data collection and analysis proceeded simultaneously (Charmaz,
1983). We obtained multiple sources of data through the use of observation of face-to-face interaction and semi-structured interviews (Turner,
1981). The use of multiple sources of data collection was a means of
enhancing the validity of the study (Maxwell, 1996).
We gathered observational data using a peripheral membership
role (Adler & Adler, 1994). Clients were informed that a doctoral student was observing the session from behind the one-way mirror and
given opportunity to meet the researcher. The focus of the observation
was on therapist-client interaction and the problem definition process
of the therapist. For observations that did not involve the use of a oneway mirror, observation took place with the researcher in the role of
a silent observer during the therapy session.
The data collection process proceeded through three phases. Initial
observations of therapy sessions were descriptive, unfocused, and general (Adler & Adler, 1994), and consisted of simply writing down the
therapists questions and comments, particularly those comments that
indicated that the therapist was answering the question what will be

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the focus of clinical attention? The second phase of the observation

process involved focusing more clearly on the key process being studied
(Adler & Adler, 1994). For example, the types of questions asked and
comments made indicated a particular focus and direction of the therapist that were reflective of the emerging categories of problem definition
construction. Finally, the elements of the problem definition process
and the relationship between those elements were clarified (Adler &
Adler, 1994). For example, clinicians that kept their judgments internal
tended to ask different questions and be more directive with clients.
The observations also provided a context for the semi-structured
interview that followed (Adler & Adler, 1994). Some questions were
constructed while observing the session so that they could be asked
immediately following the observation as a part of the interview. The
questions focused on the problem definition process observed during
the session and were designed to elicit information about the factors and
processes utilized by the clinician in formulating the problem definition.
For example, you mentioned near the end of the session something
about assessment versus treatment for her. Were you thinking about
this session as a kind of formal assessment phase or period? . . . And
what were you specifically assessing? or you mentioned treating alcoholism as a disease . . . what made you say that?
The semi-structured in-depth interviews ranged from one to two
hours in length. The interviews were audio-taped and transcribed verbatim (Glaser & Strauss, 1967; Strauss & Corbin, 1990). Seeking examples, and asking open-ended questions about the therapy experience
assured that the interview had a storied nature (Mishler, 1986, cited
in Ellis, 1994). Thus, while questions constructed during the observation were asked, questions that emerged out of the researchers curiosity during the interview were also asked. For example, and that kind
of idea, how did you arrive at thattaking care of herself as an important thing for her? or you mentioned training a little bit ago. Did you
have specific moments in the session when you thought of previous
training experiences?

Data Analysis
Data analysis of the field notes and transcriptions followed Charmazs (1983) interpretation and application of Glaser and Strauss
(1967) data analysis procedures. Initial coding consisted of searching
the data, attaching labels to lines or paragraphs of the data, and describing the data at a concrete level (Charmaz, 1983; Turner, 1981). This

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process involved comparing pieces of data with each other for similarities and differences.
Focused coding, in contrast to initial coding, moved the coding
process to a conceptual level. Initial codes became a part of a category
that was abstract enough to subsume it as well as other initial codes.
For example, the statement by the therapist well, I think the fact that
its a hard referral because its coming from the police station was
initially coded as recognizing the source of the referral to indicate
the therapists awareness and use of this fact in the problem definition
construction process. This code was later subsumed under the larger
category of contextual factors, as were initial codes such as recognition of the referral incident and recognition of the larger system
within which the client was embedded.
Finally, writing memos occurred throughout data collection (Charmaz, 1983). The practice of writing memos was used to describe the
categories, and explain how they were or were not related to each other.
Validity was also monitored through the memo writing process by
consistently juxtaposing new understandings of the phenomenon derived from the data with pre-existing understandings of the phenomenon (Chenail & Maione, 1997). The self-reflexive process of juxtaposing
understandings assured that the data was not being conformed to fit
a pre-existing framework, thereby increasing the validity of the study.
After writing the memos, and rather than sorting the memos, categories
were diagrammed in an attempt to pictorially describe the relationship
between categories. The last phase of the data analysis process involved
writing memos that described the relationships between categories
revealed through the process of diagramming. The descriptions contained in this paper first appeared in the form of hand-written memos
that were later compiled and refined.

FINDINGS
Coding of the observations and interviews resulted in the construction of two meta problem definition processes that occurred during the
therapy sessions. The term meta-process is used because as individual
judgment processes were being coded and described it became apparent
that they could be conceptualized as fitting into larger categories. The
larger categories varied by factors used in the judgment formation
process. For example, some of the individual problem definitions were
constructed using therapist-specific and contextual factors; others were

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constructed using therapist-specific, contextual, and therapist-client

interaction factors; and yet others were constructed using therapist
specific and interactional factors. Finally, these three categories could
be conceptualized as fitting within two larger categories varying by
whether or not the clinician made overt his or her problem definition
construction process.
What follows are descriptions of the two meta problem definition
processes using representative examples of each meta process. The
first meta-process that emerged from coding of the data was a process
in which the clinicians definitions remained internal. In contrast, the
second meta-process created during the coding of the data involved
clinicians making overt their internal problem definitions and incorporating that process into the therapeutic conversation.
The label therapist-specific factors refers to aspects of the clinicians worldview. The composite category of therapist-specific factors
drawn from all individual examples of problem definition processes
consisted of the following elements: fundamental assumptions about
therapy and people held by the clinicians, preconceived ideas the clinicians had about the client(s) or situation before interacting with clients,
a prior knowledge base that the clinician carried with him or her which
was learned through training and educational experiences, therapists
perceptions of their professional role, and the clinicians perception of
the nature of the referral.
The category of therapist-client interaction factors reflects what
became a part of the clinicians problem definition process as a result
of interacting with the client. It should be noted that the label does
not refer to the conversational process of asking questions and making
statements by the clinician and the responses from clients. The conversational process is depicted with distinct arrows on the diagrams that
follow. The incidents that comprised the composite category of interactional factors drawn from all the individual examples of problem definition processes included: the clinicians own experiences lens, which
referred to personal experiences which were brought forth during the
session; previous experiences the clinician had with other clients; the
clinicians perceptions of the reason for coming to therapy; the therapists concerns about clients perceptions of him or her as the therapist;
reading clients reactions to questions, comments, and the interaction
between self and client; observing clients behaviors; observing clients
interact with each other; the therapists self-perceptions and experience
of self; the therapists emotional experience during the session; the
therapists own professional growth issues; personalizing of clients

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experiences; the therapists desires for change and to be helpful; finding

parallels in popular media or works of literature; and the therapeutic
contract.
The composite category of contextual factorsonce again drawn
from all the individual examples of problem definitionprocesses included the following elements: larger systems or contexts in which the
therapy took place such as the legal system, community mental health
agencies, and hospitals; the physical location of the therapy session;
the aesthetics of the physical location; the actual referral incident; the
referral process; the referral source; and the expectations for therapy
that came with the referral.

Description of the Internal Problem Definition Process

Figure 1 is a diagram of a problem definition process that symbolizes and is representative of an internal definition process. As such,
the process is representative across the host of internal definitions that
occurred throughout the study. Figure 1 consists of a clinicians problem
definition that a client was scared or just kind of back. In other words,

FIGURE 1
Diagram of the Scared Problem Definition Process.

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PETER J. JANKOWSKI AND DAVID C. IVEY

the clinician was answering the question: what will be the focus of
clinical attention? An element of the category of therapist-specific
factors that influenced the problem definition process was the clinicians preconceived notion of how a ten-year-old boy would act. When
the boys behavior was contrary to the clinicians expectation, the clinician got the impression that this client was wondering, whats going
on? or what is this place? Another element of the clinicians worldview that influenced the definition process was the assumption that
feeling safe is an important aspect of therapy. This assumption
stemmed from the clinicians experiences with others that led the clinician to feel safe, and to open up and become less defensive.
Part of the clinicians impression, that this client was holding
back and frightened by the experience of therapy, came from the interactional factors of observing facial expressions and behaviors. For example the statement, he was more quiet and he just kept his jacket on
and just kind of like sitting back in his seat. An additional interactional
element that influenced this particular problem definition was the
clinicians remembrance of previous clinical experiences. Because of
the clinicians previous experiences with police referrals, the clinician
was able to draw upon previous clients experiences of the referral
process and infer some things about this clients behavior.
The context of the therapy also played a role in the clinicians
problem definition process. The clinician was aware of the clients embeddedness within other systems. The clinician knew that there were
problems in the way the referrals were handled which potentially could
lead to feelings of fear and holding back on the part of clients. The
referral process created some of the context within which the therapy
occurred. Thus, the clinicians worldview, the context of the therapy,
and interactional factors led the clinician to determine that this client
was frightened.

Interview Excerpt
Therapist:

I got the impression that he was really, I dont know if

it was scared or just kind of back and not really sure what
this place was and it just seemed more than shy, just like
Im here, why am I here kind of thing? . . .
Interviewer: Were you picking up on something in particular do you
think that gave you that impression that he was like
what is this place?
Therapist: Well, just from, just from the very beginning when I went

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out to give mom the paperwork and introduced myself

and I shook moms hand and then his hand and introduced
who I was. But, just the look on his face, kind of like who
is this woman that is shaking my hand and then in the
beginning when he was more quiet and he just kept his
jacket on and just kind of like sitting back in his seat, he
didnt seem really comfortable like a 10 year-old would
normally be and how I pictured, could have been you
know of course theres always just different personalities,
but even you had said he came in and asked the date or
whatever, thats different from my impression of seeming
more OK whats going on?
Interviewer: Anything else you might have been thinking about or
aware of that made you think that you need to make him
feel more at ease?
Therapist: Well, I think the fact that its a hard referral because
its coming from the police station and they just call over
or say you need to go there and theres nothing behind
it except you just got into trouble so you need to go here
. . . so with those referrals I think I feel a little more like
I want to join with them even more so to keep them
invested.
Interviewer: Where is that coming from for you? What gave you the
impression that these police department referrals are
more difficult?
Therapist: Oh, because Im the one who gets the referrals from the
police station when kids are stealing and stuff and theres
not a clear set up between us and the police station about
how that referral system works. Sometimes Ive called
and had to say we got this referral from the police station and parents havent been aware of that and then it
becomes awkward and so Im telling them for the first
time . . .
Interviewer: A couple of things based on what you just said, you mentioned earlier about making this a safe place for them,
why is that idea important to you? . . .
Therapist: Its almost like from my past experiences with other clients, that just seeing how when they first came in they
were very skeptical and even just assume I was the system and looking at how that relationship is developed
and once they felt that I was safe and differed from them,
then there was change that happened or what we talked
about in therapy felt more productive in change but I

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dont know if thats the only thing, I know thats important

in my own life.

Description of the Conversational Problem Definition Process

In this section, we highlight an example that illustrates the conversational problem definition process. As such, the process is representative across the host of conversational definitions studied. The fundamental distinction between internal and conversational problem
definition processes was the clinicians overtness about his or her formulations during the session and incorporating those problem definitions into the therapeutic conversation; hence the term conversational
judgment process. Figure 2 portrays a traumatic problem definition
process in which the clinician was able to make overt some impressions
about the clients experience. Similar to the internal problem definition
process described earlier, the categories of therapist-specific factors,
context, and interactional factors were a part of the problem definition
process. However, it was the reflecting of the clinicians internal constructions into the conversation and allowing for the clients to use the
ideas in any way they chose that distinguished the conversational from
the internal problem definition process.
The traumatic problem definition contained the category of therapist-specific factors with the element of preconceived ideas. In fact, the
clinician was aware of the influence of preconceived ideas obtained
from information given by the intake worker at the mental health
center. The clinician had the preconceived idea that this (therapy) was
going to be somewhat difficult for them.
Connected to the element of preconceived ideas, was the contextual
factor of the clinicians awareness of the influence of the larger system
on the clients. The clinicians previous experience of working in this
particular mental health system allowed the clinician to be aware of
the impact this larger system had on prior referral processes. The
clinician knew that the larger system had a way of implying to clients
that something was wrong or abnormal with them. Thus, the clinician
knew that the mental health system was simply another source of
messages in the clients lives telling them theyre not behaving normally.
The clinician incorporated the internal problem definition process
into the therapeutic conversation. In this case, the clinician incorporated the impression that something traumatic did indeed happen to
this family. Furthermore, the clinician thought of the term post-trau-

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matic stress as a way of making sense of the familys experience. The

clinician then made overt the thought of post-traumatic stress. Simply
making the internal process overt was not the only distinguishing
feature of a conversational problem definition process. There was also
a respect for the clients own determination of whether or not the
clinicians problem definition was helpful. For example, the clinician
stated and if they had some words or labels or a syndrome to put on
that (their experience), that may or may not be something that they
could use as a normal sort of reaction.
The clients were able to respond to the clinicians making overt
the impressions of post-traumatic stress and the statement that their
experience was indeed traumatic, similar to Vietnam veterans. In this
case, the clients found the problem definition helpful. The clinician
utilized the interactional factor of observing client behavior to determine the helpfulness of the impression. The clinician stated and unless
I misread their reaction to that, when I alluded to the Vietnamese
thing they both nodded their heads, and said oh yea. I think there
was value in introducing that.
Additional interactional elements in this example included: previ-

FIGURE 2
Diagram of the Traumatic Problem Definition Process.

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PETER J. JANKOWSKI AND DAVID C. IVEY

ous experiences with other clients and situations; the therapists experience during the session; the therapists perceptions of the referral incident; and reading the clients reactions. Each of these incidents was
found in examples of internal definition processes. However, the main
distinction between internal and conversational problem definition processes was not the elements comprising the categories but the clinicians
making overt their impressions during the session and their attitude
of respect that gave value to the clients ability to determine the helpfulness of a particular problem definition.

Interview Excerpt
Interviewer: I remember you used the word normalizing, . . . and I
was wondering if you could just tell me a little bit about
why you thought it was important to try to help them
feel normal?
Therapist: A couple of things, first of all, I had this feeling that it
was difficult for them to come to the community mental
health system. I think there were some vibes or stigma
about being perceived as being crazy. Ive run into that
with other families, and I think my impression was that
there was some feeling about that. The intake worker
even mentioned that the daughter didnt want to do this,
because she didnt want her friends to know. So I had a
preconceived idea that this was going to be somewhat
difficult for them, or they werent sure, so I think one
layer of the normal piece was the external system, about
that. I think that was evidence early on to me that a lot
of other people had been telling them theyre not behaving
normally, just to go back to work, go back to school,
pretend like nothing happened in your life. It seemed
important for someone to say something traumatic happened in your life here, and youre having realistic responses to it.
Interviewer: One of the other things that stood out was, you used the
phrase PTS, can you tell me a little bit about what made
you use those initials?
Therapist: To be something of the expert, to provide some sort of
explanation or maybe some of my own need to feel like
if I can offer some information to help normalize. My main
goal in this session was to normalize their experiences.
I feel like I did a number of things that were pointed in
that direction and if they had some words or labels or a

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syndrome to put on that, that may or may not be something that they could use as a normal sort of reaction.
And I think unless I misread their reaction to that, when
I alluded to the Vietnamese thing they both nodded their
heads, and said Oh yea. I think there was some value
in introducing that, Im not sure if I would want to stay
there very long, but that was one of my educational tidbits.

SUMMARY
The process of formulating a problem definition involved, in varying combinations: (1) the clinician comparing and contrasting pre-existing knowledge with information obtained from the clients during the
session; (2) using an understanding of how larger contextual factors
affected his or her and the clients experience during the session; and
(3) an awareness of the experiences resulting from interaction with the
client during the session, and determining how those fit with previous
experiences with other clients.
Clinicians engaged in two meta-level problem definition processes.
The distinction between the internal and conversational problem definition processes was that clinicians who engaged in a conversational
problem definition process: (1) made overt their internal problem definition process and incorporated those formulations into the therapeutic
conversation; and (2) relied upon client input about the helpfulness of
an emerging problem definition.

DISCUSSION
Prior to this study, descriptions of the actual judgment processes
of clinicians evidently did not exist. The representative descriptions
provided in this study make concrete what, until now have been only
abstract, theoretical and hypothetical descriptions of clinicians judgment processes. The findings from this study have implications for the
existing mechanistic conceptualizations of clinical judgment within the
traditional and MFT literature, as well as the practice and training of
MFTs.
The findings of this study fundamentally influence the reliance on
the information-processing model of clinical judgment. As mentioned

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earlier, the information-processing model assumes an outside-in, linear flow of information, as well as a conceptualization of judgments
constructed solely within the mind of the clinician, thereby neglecting
contextual and interactional factors. The descriptions of the judgment
processes showed that formulations often involved interactional and
contextual factors. The interactional and contextual factors indicated
that clinicians used more than verbal information obtained from the
client alone. Clinicians judgment formation processes were more dynamic and cyclical than the linear process of the information-processing
model.
It may be that judgments only involving therapist-specific factors,
as conceptualized in this study, would be consistent with an information-processing model. However, none of the clinicians relied solely on
the category of therapist-specific factors when constructing a problem
definition. Clinicians utilized contextual and/or interactional factors
when forming their judgments, thus clinical judgment cannot be seen
as stemming entirely from the mind of the individual clinician. In fact
as shown in the conversational problem definition process, judgments
were often created between clinician and client.
One final implication for existing conceptualizations of clinical
judgment involves the move away from a research focus on outcome
to a process research approach. Traditionally, both without and within
MFT, researchers have focused on identifying errors or pathologies
within clinicians judgment processes and/or the accuracy of their judgment as compared to some objective standard. Since the informationprocessing model assumes the clinician is inherently limited and deficient and in need of adhering to a particular procedure to avoid error,
it makes sense that existing research has focused on pathology. This
study focused more on the process of arriving at particular judgments,
and did not contain an evaluative component as to the rightness or
wrongness of the judgments. The avoidance of a focus on outcome
allows the descriptions of internal and conversational problem definitions to simply be descriptions of different ways of formulating judgments. It was not the intent of this study to state that one mode of
judgment construction is superior to another.

IMPLICATIONS FOR MFT PRACTICE AND TRAINING

There are three implications for MFT practice and training based
on the findings from this study. First, many of the participants made

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comments following the research interview about how helpful it was to

answer the questions and reflect on the therapy session. The interview
enabled clinicians to make sense of their experience of the session,
evaluate their therapy, and clarify their personal theories of therapy.
The qualitative research interview has implications for the way in
which the supervisor relates to the supervisee and conducts supervision
sessions. Guided curiosity which is at the heart of the research interview results in a questioning process that promotes self-understanding
in the interviewee (Weber, 1986, cited in Ellis, 1994), helps him or
her find his or her own voice, feel heard, and worthwhile (Heath,
1993), and provides an opportunity for sense-making of personal experiences (Mishler, 1986, cited in Ellis, 1994). Supervision done from a
stance of a qualitative research interview has the potential to promote
similar beneficial experiences in the supervisee. Likewise, supervisees
can be encouraged to practice therapy from a qualitative research positioning.
Second, clinicians were consistently drawing upon personal life
experiences, as well as prior clinical and supervision experiences to
inform their problem definitions. While beginning therapists may not
have as much clinical and supervisory experiences to draw upon in
their clinical work, beginning therapists do have life experiences that
they can be encouraged to draw upon to make sense of clinical situations. Thus, one of the implications for training is that each supervisee
has knowledge and expertise that he or she can be encouraged to draw
upon and utilize in therapy sessions.
Third, while clinicians differed in their degree of awareness of the
different elements comprising the category of conversational processes
when forming and reflecting on their problem definitions, each clinician
experienced some aspect of the process between self and client;
whether it was an emotional reaction, attending to client interaction,
or an awareness of previous experiences. Some clinicians were readily
aware during the therapy session and others became aware while reflecting on the session during the research interview. Thus, a goal of
supervision informed by this study consists of assisting supervisees to
become aware of and utilize the relational process between self and
client to inform their clinical work. Supervisees can be encouraged to
reflect the interactional factors into their therapeutic conversations,
similar to the way that the clinicians who engaged in a conversational
problem definition process reflected emerging judgments into the therapeutic conversation.

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FUTURE CONSIDERATIONS
A number of other areas for further study emerged from the coding
process. Further study is needed when it comes to trying to establish
relationships between factors that may influence the ways in which
clinicians formulate problem definitions. Factors that need to be explored include the level of clinician development and how that influences the process of definition construction, as well as specific client
and clinician assumptions about change, people and the world and
how those assumptions influence problem definition processes. Further
exploration of contextual factors such as the location of therapy, the
referral incident and process, and the role larger systems such as
schools, courts, and churches play in problem definition formation processes could also inform existing understandings of clinical judgment.
Finally, examination of the outcomes of various processes including
clients experience of the differing processes could also inform therapy
practice and supervision, particularly if certain processes are found to
be associated with more positive clinical outcomes.

CONCLUSION
By offering a more contextually oriented conceptualization of clinical judgment, it is our hope that marriage and family therapists find
clinical judgment more compatible with their fundamental systemic
orientation. We hope marriage and family therapists will further explore how clinical judgments evolve and influence the clinical endeavor.
The extant literature based on prior empirical studies neglects the
influence of interactional factors on the clinical judgment process. In
addition, conceptual models that currently exist do not capture the
complexity of clinicians problem definition processes. Based on the
findings of this study, clinical judgment is a complex process of makingsense of and utilizing therapist-specific, contextual, and interactional
factors. Thus, there is an evident need to develop theories that consider
the complexity of clinical judgment and it is our hope that we have
initiated progress in that direction.

REFERENCES
Adler, P.A., & Adler, P. (1994). Observational techniques. In N.K. Denzin, & Y.S.
Lincoln (Eds.), Handbook of qualitative research (pp. 377392). Thousand Oaks, CA: Sage.

438
CONTEMPORARY FAMILY THERAPY

Charmaz, K. (1983). The grounded theory method: An explication and interpretation.

In R. Emerson (Ed.), Contemporary field research (pp. 109126). Boston, MA: Little,
Brown.
Chenail, R. J., & Maione, P. (1997). Sensemaking in clinical qualitative research.
The Qualitative Report, 3, 17. Accessed June 2, 1997. http://www.nova.edu/ssss/QR/
QR3-1/sense.html.
Dawes, R. M., Faust, D., & Meehl, P. E. (1989). Clinical versus actuarial judgment.
Science, 243, 16681674.
Ellis, J. (1994). Narrative inquiry with children: A generative form of preservice
teacher research. International Journal of Qualitative Studies in Education, 7, 367380.
Falvey, J. E. (1992). Science or serendipity? What we know about clinical judgment
in mental health. Journal of Mental Health Counseling, 14, 458470.
Garb, H. N. (1994). Toward a second generation of statistical prediction rules in
psychodiagnosis and personality assessment. Computers in Human Behavior, 10, 377
394.
Gardner, W., Lidz, C. W., Mulvey, E. P., & Shaw, E. C. (1996a). Clinical versus
actuarial predictions of violence in patients with mental illnesses. Journal of Consulting
and Clinical Psychology, 64, 602609.
Gardner, W., Lidz, C. W., Mulvey, E. P., & Shaw, E. C. (1996b). Comparison of
actuarial methods for identifying repetitively violent patients with mental illness. Law
and Human Behavior, 20, 3548.
Glaser, B.G., & Strauss, A.L. (1967). The discovery of grounded theory: Strategies
for qualitative research. New York: Aldine de Gruyter.
Goldberg, L. (1959). The effectiveness of clinicians judgments: The diagnosis of
organic brain damage from the Bender-Gestalt test. Journal of Consulting Psychology,
23, 2533.
Goldberg, L. (1968). Simple models or simple processes? Some research on clinical
judgments. American Psychologist, 23, 483496.
Goldberg, L., & Werts, C. (1966). The reliability of clinicians judgments: A multitraitmultimethod approach. Journal of Consulting Psychology, 30, 199206.
Greenberg, L.S., Heatherington, L., & Friedlander, M.L. (1996). The events-based
approach to couple and family therapy research. In D.H. Sprenkle & S.M. Moon (Eds.),
Research methods in family therapy (pp. 411428). New York: Guilford.
Heath, A. (1993). Reading signs. In A. H. Rambo, A. Heath, & R. J. Chenail, Practicing
therapy: Exercises for growing therapists (pp. 89152). New York: Norton.
Hecker, L. L., Trepper, T. S., Wetchler, J. L., & Fontaine, K. L. (1995). The influence
of therapist values, religiosity, and gender in the initial assessment of sexual addiction
by family therapists. The American Journal of Family Therapy, 23, 261272.
Holt, R. R. (1986). Clinical and statistical prediction: A retrospective and would-be
integrative perspective. Journal of Personality Assessment, 50, 376386.
Holt, R. R. (1988). Judgment, inference, and reasoning in clinical perspective. In
D. C. Turk, & P. Salovey (Eds.), Reasoning, inference, and judgment in clinical psychology
(pp. 233250). New York: The Free Press.
Ivey, D. C. (1995). Family history, parenting attitudes, gender roles, and clinician
perceptions of family and family member functioning: Factors related to gender inequitable practice. The American Journal of Family Therapy, 23, 213226.
Ivey, D. C. (1996). Family history and gender roles: Critical factors in practitioners
views of family interactions. Contemporary Family Therapy, 18, 425445.
Ivey, D. C., Scheel, M. J., & Jankowski, P. J. (1999). A contextual perspective of
clinical judgment in couples and family therapy: Is the bridge too far? Journal of Family
Therapy, 21, 339359.
Leslie, L. A., & Clossick, M. L. (1996). Sexism in family therapy: Does training in
gender make a difference? Journal of Marital and Family Therapy, 22, 253269.
Mahoney, M. J. (1988). Rationalism and constructivism in clinical judgment. In

439
PETER J. JANKOWSKI AND DAVID C. IVEY

D. C. Turk, & P. Salovey (Eds.), Reasoning, inference, and judgment in clinical psychology
(pp. 155181). New York: The Free Press.
Maxwell, J.A. (1996). Qualitative research design: An interactive approach. Thousand
Oaks, CA: Sage.
McCollum, E. E., & Russell, C. S. (1992). Mother-blaming in family therapy: An
empirical investigation. The American Journal of Family Therapy, 20, 7176.
Meehl, P. E. (1954). Clinical versus statistical prediction: A theoretical analysis and
a review of the evidence. Minneapolis: University of Minnesota Press.
Meehl, P. E. (1957). When shall we use our heads instead of the formula? Journal
of Counseling Psychology, 4, 268273.
Miller, P. H. (1993). Theories of developmental psychology. New York: W. H. Freeman
and Company.
Mishler, E. G. (1986). The analysis of interview-narratives. In T. R. Sarbin (Ed.),
Narrative psychology: The storied nature of human conduct (pp. 233255). New York:
Praeger.
Oskamp, S. (1965). Overconfidence in case-study judgments. Journal of Consulting
Psychology, 29, 261265.
Pinsof, W.M., & Wynne, L.C. (1995). The effectiveness and efficacy of marital and
family therapy: Introduction to the special issue. Journal of Marital and Family Therapy,
21, 341343.
Rafuls, S.E., & Moon, S.M. (1996). Grounded theory methodology in family therapy
research. In D.H. Sprenkle, & S.M. Moon (Eds.), Research methods in family therapy
(pp. 6480). New York: Guilford Press.
Sarbin, T. (1986). Prediction and clinical inference: Forty years later. Journal of
Personality Assessment, 50, 362369.
Sawyer, J. (1966). Measurement and prediction, clinical and statistical. Psychological
Bulletin, 66, 178200.
Sprenkle, D.H., & Bailey, C.E. (1995). Editors introduction. Journal of Marital and
Family Therapy, 21, 339340.
Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory
procedures and techniques. Newbury Park, CA: Sage.
Strohmer, D. C., Shivy, V. A., & Chiodo, A. L. (1990). Information processing strategies in counselor hypothesis testing: The role of selective memory and expectancy. Journal
of Counseling Psychology, 37, 465472.
Turk, D. C., Salovey, P., & Prentice, D. A. (1988). Psychotherapy: An informationprocessing perspective. In D. C. Turk & P. Salovey (Eds.), Reasoning, inference, and
judgment in clinical psychology (pp. 114). New York: The Free Press.
Turner, B.A. (1981). Some practical aspects of qualitative data analysis: One way
of organizing the cognitive processes associated with the generation of grounded theory.
Quality and Quantity, 15, 225247.
Weber, S. J. (1986). The nature of interviewing. Phenomenology and Pedagogy, 45,
6572.
Zygmond, M. J., & Denton, W. (1988). Gender bias in marital therapy: A multidimensional scaling analysis. The American Journal of Family Therapy, 16, 262272.