Behavioral observations - Scholing - 2019 - Article

This chapter provides an overview of the use of observation in clinical psychology. Observation in clinical psychology is defined as ‘perception, with the intention to draw conclusions’. This often refers to the client’s behavior. Observation has the goal to gather information about: the people with whom a person communicates directly or indirectly, relationships and situations in which a person is either involved or not, and the person himself. There is a distinction between everyday observation and professional observation. This chapter is only about professional observation. Within this type of observation, there is a distinction between unstandardized and standardized observation.

In the Netherlands, there are only a few methods available for standardized observation. It is often used in the health care sector for groups of clients for whom other test methods are less effective or unsuitable. For example, children, clients with mild intellectual disability (LVB), clients with autism, autism spectrum disorders, or other kinds of severe psychopathology such as psychosis or dementia.

The Dutch Committee on Tests and Testing (COTAN) makes a distinction between ‘rating scales’ and ‘observation scales’. A rating scale is defined as a ‘written behavioral examination that draws on psychological knowledge (evaluation). Sometimes, the client’s medical history, intake interview, and clinical interview form the element of the rating scale'. An observation scale is defined as ‘a written behavioral examination that draws on observations. The components are called subscales.’ In this chapter, the focus is only on observation scales.

What is the value of unstandardized observations?

Sometimes observations are carried out during an interview. An example of this is the mental status examination, which involves topics such as general impressions (eye contact, attitude), cognitive functions (awareness, attention, orientation), affective functions (mood and affect), cognative functions (psychomotor activity, motivation, and behavior) and personality.

However, this kind of observation is not standardized. Therefore, it is subject to different kinds of errors that disrupt the perception and information processing. Examples are the leniency effect (the tendency to rate friends and acquaintances more positively on certain traits), the halo effect (the tendency to examine all traits in the direction of a general impression), the logic error (the tendency to pass similar judgments on traits that seem to be logically linked although in reality the traits are detached from one another), the contrast error (the tendency to judge a certain trait in a person against that same trait in others), primacy and recency effects (the tendency to attach greater weight to the first, or, conversely, the last observation), and the tendency to mostly give average scores and to avoid making extreme judgments. These errors lead to wrong and distorted conclusions, and often the psychologists are not aware of these errors. Tversky and Kahneman have also discussed the human tendency to generate theories on the basis of inadequate data. These tendencies are called heuristics. So, heuristics are information processing strategies that people use to reduce complex assessment tasks to simpler operations. Two heuristics have a particularly strong effect on observation in the clinical context, namely availability and first impression. Availability refers to the immediate availability of memories. So, if a psychologist saw client A, who is suffering from Tourette syndrome, yesterday, he is more likely to recognize characteristics of this syndrome in client B than if he had seen client A years ago. First impression refers to people’s tendency to hold on to their first impression, even when there is additional information that contradicts this first impression.

Based on this information, it seems that unstandardized observations should be avoided.

What is the content of observations?

Selectivity

Nobody can perceive every little thing. Therefore it is best to carry the observation out in a framework of a particular question. This question then determines which behaviors are of interest. For example, if a child is suspected to have ADHD, it may be useful to observe the length of interrupted time he is able to spend on an activity in the classroom or to score him on the extent of movement.

Molar versus molecular

When it is decided on the content of the observation, a distinction will be made in the level at which the behavior is to be observed. This can be on a molar level, which means that larger units are rated (such as social skills), or on a molecular level, which refers to smaller, behavioral units (such as the extent to which a hand twitches, the duration of eye contact or speech, the number of times a person smiles).

What is the context in which observations are carried out?

Observations may be carried out in natural surroundings or in a standardized laboratory setting, or in a situation that is a combination of these two types. What can arise, is reactivity. This means that clients are aware of being observed, and they change their behavior (consciously or unconsciously) accordingly.

Observation in natural surroundings

An example of this type of observation is observing a child’s behavior at school or observing the interaction between parents and their children in the family home. The biggest problem in this kind of observation is the investment of time. There is also a lack of norms, because the client's surroundings are not comparable to other clients’.

Observation in simulated settings

An example of this type of observation is observing the behavior of a client with agoraphobia (a type of anxiety disorder in which you fear and avoid places or situations that might cause you to panic and make you feel trapped, helpless or embarrassed), who must carry out a number of predefined tasks on the street and in different stores. So, the surrounding is natural, but the client is given specific tasks, which makes this a structured observation.

Laboratory observation

An example of this type of observation is assessing a person’s social skills in a number of prescribed roles, which may or may not be carried out with the use of a video recording. An advantage of this type of observation is that the situation has a high degree of standardization, so the data of the client can be compared to data from other subjects. Another advantage is that the reliability and interrater reliability can be determined easily because different observers can assess the subject’s behavior independently of each other. However, there are also some disadvantages to laboratory observations. The first pertains to the validity. Research has shown that behavior observed in the laboratory cannot be generalized to behavior in everyday life. Also, behavior in the laboratory can be influenced by variations in instructions.

What are the different timescales in which observations are carried out?

Event sampling

This type of observation method is often chosen when the interest is in a specific behavior, and sometimes in the frequency of specific behavior. Then, the observation is carried out in the period in which the specific behavior occurs. For example, the times when a child complains about a stomach ache. Then, during these periods, questions such as: What exactly is the child saying and how do the parents or caretakers react to this? For this type of observation, it is important that the behavior is clearly defined so that it is clear when the observation should begin.

Time sampling

In this type of observation, the behavior is observed at regular intervals, regardless of the behavior at that time. This type is chosen when you want to get an impression of the variation in certain behavior. For example, when a client is suffering from depression, the nursing staff can record the client’s activity each hour to determine the level of activity.

Who carries out the observation?

Observations can be carried out by the client himself (self-observation), by an acquaintance or by a completely independent person.

Self-observation

This is a common method in behavioral therapy. The goal of it is to gain an impression of the nature of the problem behavior and the conditions under which it occurs. For example, one can record the frequency of social interactions, or the number of eating binges in a single day. It can be carried out at different times, depending on the nature of the behavior. It is mainly suitable for measuring the frequency and nature of the occurrence of behaviors that are not visible to others.

The validity of it is sufficient. However, reliability can be a problem, because of under- or overreporting.

Observation carried out by people close to the client

This type of observation is specifically used in the case of the problematic behavior of family members. When the client is a child, it can be a parent or a teacher who observes the child’s behavior. For example, how often does the child complain about stomach aches? The advantages and disadvantages of this method are comparable to that of self-observations.

How do standardized observations of specific phenomena take place?

Anxiety

Anxiety may manifest itself in three ways: the subjective experience of anxiety, outward observable behavior, and physiological reactions in response to a frightening situation (increased heart rate, blood pressure, muscle tension).

Standardized observations may be used to determine the form and the severity of the avoidance of a threatening situation, and the behavior of a client in an actual threatening situation.

Behavioral avoidance test

One method that is often used for avoidance behavior is the behavioral avoidance test (BAT). This is a diagnostic method that can be used for different anxiety complaints. This test consists of a list of situations in which the client has difficulties. Then, the client ranks these according to the perceived level of difficulty. In the second stage, the situations are read out one by one to the client, starting with the easiest. The client must then indicate for each of the situations whether he would be able to tolerate that particular situation.

Assessment of social skills and social anxiety

In the case of social anxiety, there are two important forms of behavior, namely the extent to which a client avoids certain situations and the quality of his social skills. The behavior of clients with social anxiety can be observed in structured and unstructured situations. An example of the first is the interview. An example of the second is that the subject is presented with descriptions of different social situations, in which he needs to report how he would react.

What are functional mental disorders?

People with brain disorders often show a visible change in behavior. There are four categories of disorders:

1. Cognitive disorders (attention, memory, language)
2. Emotional problems and personality changes (anxiety)
3. Sensomotor disorders and sensorimotor disorders (tremors, paralysis symptoms)
4. Psychosocial problems (loneliness, relationship problems)

Jennekens-Schinkel and De Haan came up with ten observational guidelines so that observation could be carried out in a standardized way, for example:

• Intelligence and alertness
• Outer appearance
• Way of doing things

What can be done in the case of elderly clients?

For elderly clients, there are a number of specific aspects that are important to determine. The first is the level of need and the presence of symptoms of dementia. The best scale to use in the case of elderly patients is the Behavioral Observation Scale for Intramural Psychogeriatrics (GIP). Other scales are the Behavioral Observation Sale for Geriatrics, the Behavioral Observation Scale for Intramural Psychogeriatrics, the Observation Scale for Psychogeriatrics, and the Rating Scale for Mental and Social Problems. 

What is Expressed Emotion?

Expressed Emotion (EE) refers to the degree of criticism and emotional over-involvement of a family member's attitude towards a client. In the case of psychotic clients, high EE predicts relapse. It can be determined in three ways, of which the best is the Camberwell Family Interview (CFI), which is a semi-structured interview that takes about 90 minutes. This interview is recorded and then scored on five aspects: warmth, positive remarks, criticism, hostility, and emotional involvement. 

What is the conclusion?

The authors conclude that proper behavioral observation can provide valuable information. However, in most clinics, the contact with clients is primarily based on non-standardized observation. As described, this kind of observation can lead to errors. Standardized observations are better to use. However, these instruments are often very time-consuming. This is probably the main reason for why these instruments are not implemented as much as we would like.