Remembering what we know we don't know
as Budding Psychologists

George M. Slavich, Ph.D.
McLean Hospital/Harvard Medical School

The Clinical Psychologist

As budding psychologists, we are usually aware of what we know. Contained within this body of knowledge are details regarding our area of expertise, as well as information about the clinical and research skills that we possess. These facts, as Donald Rumsfeld might say, are the “known knowns”.

The opposite of known knowns, “unknown unknowns”, are the things that we don’t know we don’t know. This type of information is especially abundant, but by definition unknowable, when we meet a patient for the first time or when we begin a new research project. Unknown unknowns, one might say, are the things that futures are made of; they are the facts that we (hopefully) come to know as we progress with a psychotherapy patient or with our program of research.

Known knows and unknown unknowns are fascinating, but this column is about “known unknowns”, or the things that we know we don’t know. Despite its novel-sounding name, known unknowns are nothing new. In fact, it was this type of information that Nisbett and Wilson (1977) highlighted in their classic article, “Telling more than we can know: Verbal reports on mental processes”. At the heart of their thesis was the argument that people often have little insight into their own cognitive processes, and that our judgments of cause and effect are frequently based more on our a priori hypotheses than on true introspection into our mental machinery. By virtue of their account, the authors made the previously unknown known and in doing so taught us that we generally do not know much about the cognitive processes that underlie our judgments and behaviors… even though we might think we do.

The purpose of the present article is not to recap Nisbett and Wilson (1977), but to briefly describe how remembering what we know we don’t know might be useful to us as budding psychologists. Two brief stories help illustrate this point.

First is the story about the superstar fifth-year graduate student who a friend of mine once interviewed for a clinical internship position. As my friend tells the story, everything was going well for the first half of the interview. My friend tends to ask difficult questions, but as she recalls, the interviewee fielded them with ease. The interviewee even managed to cite text directly from a hospital brochure as a means of conveying his interest in the position.

The catch to this story is that the interview eventually broke down when my friend asked the interviewee to describe how his research on emotion regulation might inform the development of an empirically-supported treatment for adolescents with bulimia nervosa. At this point, the interviewee could have acknowledged that the relation between emotion regulation and bulimia would be important to investigate in the future, or something along those lines, but instead he opted to answer the question -- a question for which he did not really have an answer. In this moment, it would have been useful and quite appropriate for him to remember that he knew he did not know the answer.

The second story is thematically similar to the first, but with greater potential repercussions for not remembering the known unknowns. At the center of this story was a patient suffering from a severe bout of depression. He was admitted to an inpatient hospital program where I once worked and, after a two-week stay, the treatment team was still questioning his ability to keep himself safe. The nurse, citing her personal experience with depressed patients in the past, felt that he would not attempt suicide if released, but the psychiatrist, citing personal communication with the patient, disagreed.

One thing we know we don’t know is the future, and in such situations, especially those involving patients, our success as clinicians is influenced greatly by the heuristics that we employ to make decisions. So, who made the better decision? The nurse’s judgment appears to be sound at first, but in this example she is likely employing the “representativeness heuristic” (Kahneman & Tversky, 1973), where the probability that a particular individual is an actively suicidal patient, for example, is estimated by comparing information from that patient with the contents of a stereotype for suicidal patients. This comparison is entirely valid, but it ignores data that is likely to be more pertinent to a true probability judgment, such as the patient’s personal history, including his frequency of past suicidal attempts. These latter data, of course, were unknown to the nurse because she had not directly questioned the patient.

One take-home message from these two stories is that there are many benefits to remembering what we know we don’t know. Although this is especially true for budding psychologists, I think the message remains relevant throughout the professional lifespan. After all, the pressure to know does not subside over time; if anything, it grows stronger as our expertise and responsibilities increase.

The silver lining in this tale is that, when correctly identified, situations involving known unknowns represent excellent opportunities to learn. In the case of the superstar interviewee, for example, remembering the unknown could have ignited an interesting discussion from which promising research ideas regarding emotion regulation in bulimia could have arisen; and with the depressed patient, remembering the unknown could have prompted a more comprehensive assessment of the patient by the treatment team. Both of these events occurred against a backdrop of pressure to pretend to know the unknown, but in such instances, remembering what we know we don’t know may be even more important. It is only after remembering these instances, after all, that we attempt to find the relevant answers.

References
Kahneman, D., & Tversky, A. (1973). On the psychology of prediction. Psychological Review, 80, 237-251.

Nisbett, R. E., & Wilson, T. D. (1977). Telling more than we can know: Verbal reports on mental processes. Psychological Review, 84, 231-259.

George M. Slavich, Ph.D. :: Cousins Center for Psychoneuroimmunology
UCLA Medical Center Plaza 300, Rm 3156 :: Los Angeles, CA 90095-7076
+1 310-825-2576 :: gslavich at mednet.ucla.edu