Making decisions one drink at a time and the "just one drink" effect: A fuzzy-trace theory model of harmful drinking

BACKGROUND

Understanding the decision factors that drive harmful alcohol use among young adults is of practical and theoretical importance. We apply fuzzy-trace theory (FTT) to investigate a potential danger that may arise from the arguably correct notion that a single drink carries no meaningful risk. Decisions that are mentally represented as one drink at a time could contribute to excessive drinking.

METHODS

College students (N = 351) made a series of decisions to take or decline eight hypothetical drinks presented one at a time. Outcome measures included each decision, recent alcohol consumption (weekly drinks, peak blood alcohol content, and binges), and alcohol-related harms (scores on the Brief Young Adult Alcohol Consequences Questionnaire and Alcohol Use Disorders Identification Test). Linear regression models predicted each outcome from sex, perceived risk of a single drink, perceived risk of heavy drinking, perceived consequences of drinking, and general health-related risk sensitivity.

RESULTS

Consistent with FTT, decisions to have a first drink and up to four additional drinks in short succession were each associated with lower perceived risk of one drink-a "just-one drink" effect-independent of perceived risks of heavy drinking, perceived consequences of drinking, and general risk sensitivity. Similarly, all measures of recent alcohol consumption and consequent harms were associated with perceived risk of one drink. Participants reporting "zero risk" of a single drink had worse outcomes on all measures than those reporting at least "low risk."

CONCLUSIONS

Results are consistent with the theoretically informed premise that consumption decisions are typically made one drink at a time rather than by deciding the total number of drinks to be consumed in a sitting. When decisions about alcohol use proceed one drink at a time, a perception of zero risk in a single drink may contribute to heavy drinking.

The power of meaningful numbers: Attorney guidance and jury deliberation improve the reliability and gist validity of damage awards

OBJECTIVE

A mock jury experiment tested the effects of attorney guidance and jury deliberation to mitigate the challenges that civil juries face in assessing damages.

HYPOTHESES

We hypothesized that two types of attorney guidance (per diem, per diem + lump sum), theoretically based in the Hans-Reyna model of jury decision making, would improve jury decision making compared with no guidance against five key benchmarks: injury assessment, validity, reliability, verbatim-gist coherence, and metacognitive experience. We expected that deliberation would increase reliability of, confidence in, and polarization of awards compared with predeliberation.

METHOD

Community members (N = 317; 61% women; 86.1% White; Mage = 48.68 years) deliberated in 54 mock juries. Participants watched a videotaped trial involving an automobile accident in which two plaintiffs sustained concussions (one mild and one severe). The plaintiffs' attorney's closing arguments varied attorney guidance (no guidance, per diem, per diem + lump sum). Mock jurors provided individual judgments before deliberating as a jury and reaching group verdicts and awards.

RESULTS

Juries performed well against benchmarks. Providing gist-based guidance with a meaningful award recommendation increased the validity of jurors' individual damage awards (η²p jurors = .03) and the reliability of jury damage awards (η²p jurors = .04; η²p jurors = .20); gist-based guidance without an award recommendation did not improve performance against benchmarks and increased perceptions of decision-making difficulty (η²p = .13). Deliberation increased reliability of (η²p = .17), confidence in (η²p = .02), and polarization of (d = 2.14) awards compared with predeliberation.

CONCLUSION

Juries performed well against objective benchmarks of performance (injury assessment, validity, reliability, and verbatim-gist coherence), and deliberation improved performance compared with predeliberation decisions. Jury decisions were further influenced by attorney closing arguments (the guidance manipulation), especially when the attorney requests a lump sum, which can serve as a powerful influence on jury awards, mainly by setting an upper limit. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Providing the Gist of Medical Expertise in the Context of Laws, Rules, and Guidelines: Fuzzy-Trace Theory's Alternative Approach to Improve Patient Communication

Current guidelines and regulatory frameworks create a dilemma that threatens the effectiveness of much needed communication between patients and medical providers: How can patients be presented with detailed facts without creating cognitive "overload"? We explain how this is a false dichotomy and illustrate, using three examples, how fuzzy-trace theory offers a third way of informing patients.

Giving information strategically and transparently: A pilot trial of the Oncolo-GIST intervention to promote patients' prognostic understanding

PURPOSE

Most patients with cancer lack the prognostic understanding necessary to make informed decisions. We tested the feasibility and acceptability of the Oncolo-GIST ("Giving Information Strategically and Transparently, GIST") intervention and explored its associations with patients' improved prognostic understanding.

METHODS

The Oncolo-GIST intervention distills prognostic discussions into easy-to-understand talking points. Patients with metastatic cancers that progressed on ≥1 line of chemotherapy and not expected to survive 12 months (n = 31) were recruited from October 2020 through November 2022. We compared patients who discussed their progressive scans with an oncologist trained in the GIST technique or not (i.e., usual care). A primary outcome was prognostic understanding (e.g., patients reporting a life-expectancy of months) assessed within a week of the scan discussion visit.

RESULTS

Oncologists (n = 4) appeared receptive to the Oncolo-GIST intervention and scored nearly perfectly on post-training tests of material mastery after a < 2-h tutorial. Post-scan discussion visit, 100% of patients who met with an Oncolo-GIST-trained clinician understood that their cancer was considered incurable (a 31% improvement from pre-visit) compared with 91% of patients meeting with usual care oncologists (an 18% improvement); 33% of patients who met with an Oncolo-GIST-trained oncologist understood that they likely had months, not years, compared to 18% in the usual care group. No statistically significant differences emerged for these changes, nor for therapeutic alliance, anxiety, or depression scores between groups.

CONCLUSION

Oncolo-GIST appears to be an easily learned approach to improve prognostic understanding that neither undermines therapeutic alliances nor increases patients' anxiety or depressive symptoms. Efficacy testing in a larger trial is warranted.

Critical tests of fuzzy trace theory in brain and behavior: uncertainty across time, probability, and development

Uncertainty permeates decisions from the trivial to the profound. Integrating brain and behavioral evidence, we discuss how probabilistic (varied outcomes) and temporal (delayed outcomes) uncertainty differ across age and individuals; how critical tests adjudicate between theories of uncertainty (prospect theory and fuzzy-trace theory); and how these mechanisms might be represented in the brain. The same categorical gist representations of gains and losses account for choices and eye-tracking data in both value-allocation (add money to gambles) and risky-choice tasks, disconfirming prospect theory and confirming predictions of fuzzy-trace theory. The analysis is extended to delay discounting and disambiguated choices, explaining hidden-zero effects that similarly turn on categorical distinctions between some gain and no gain, certain gain and uncertain gain, gain and loss, and now and later. Bold activation implicates dorsolateral prefrontal and posterior parietal cortices in gist strategies that are not just one tool in a grab-bag of cognitive options but rather are general strategies that systematically predict behaviors across many different tasks involving probabilistic and temporal uncertainty. High valuation (e.g., ventral striatum; ventromedial prefrontal cortex) and low executive control (e.g., lateral prefrontal cortex) contribute to risky and impatient choices, especially in youth. However, valuation in ventral striatum supports reward-maximizing and gist strategies in adulthood. Indeed, processing becomes less "rational" in the sense of maximizing gains and more noncompensatory (eye movements indicate fewer tradeoffs) as development progresses from adolescence to adulthood, as predicted. Implications for theoretically predicted "public-health paradoxes" are discussed, including gist versus verbatim thinking in drug experimentation and addiction.

Numeracy, gist, literal thinking and the value of nothing in decision making

The onus on the average person is greater than ever before to make sense of large amounts of readily accessible quantitative information, but the ability and confidence to do so are frequently lacking. Many people lack practical mathematical skills that are essential for evaluating risks, probabilities and numerical outcomes such as survival rates for medical treatments, income from retirement savings plans or monetary damages in civil trials. In this Review, we integrate research on objective and subjective numeracy, focusing on cognitive and metacognitive factors that distort human perceptions and foment systematic biases in judgement and decision making. Paradoxically, an important implication of this research is that a literal focus on objective numbers and mechanical number crunching is misguided. Numbers can be a matter of life and death but a person who uses rote strategies (verbatim representations) cannot take advantage of the information contained in the numbers because 'rote' strategies are, by definition, processing without meaning. Verbatim representations (verbatim is only surface form, not meaning) treat numbers as data as opposed to information. We highlight a contrasting approach of gist extraction: organizing numbers meaningfully, interpreting them qualitatively and making meaningful inferences about them. Efforts to improve numerical cognition and its practical applications can benefit from emphasizing the qualitative meaning of numbers in context - the gist - building on the strengths of humans as intuitive mathematicians. Thus, we conclude by reviewing evidence that gist training facilitates transfer to new contexts and, because it is more durable, longer-lasting improvements in decision making.

Social media: Why sharing interferes with telling true from false

Sharing on social media decreases true-false discrimination but focusing on accuracy helps people recognize what they already know. Process-oriented research offers hope in combatting misinformation.

Individual differences in numerical representations of risk in health decision making: A fuzzy-trace theory approach

Fuzzy-trace theory predicts that decisionmakers process numerical information about risk at multiple levels in parallel: the simplest level, nominal (categorical some-none) gist, and at more fine-grained levels, involving relative comparison (ordinal less-more gist) and exact quantities (verbatim representations). However, little is known about how individual differences in these numerical representations relate to judgments and decisions, especially involving health tradeoffs and relative risks. To investigate these differences, we administered measures of categorical and ordinal gist representations of number, objective numeracy, and intelligence in two studies (Ns = 978 and 956). In both studies, categorical and ordinal gist representations of number predicted risk judgments and decisions beyond objective numeracy and intelligence. Participants with higher scores in categorical gist were more likely to choose options to avoid cancer recurrence risks; those who were higher in ordinal gist of numbers were more likely to discriminate relative risk of skin cancer; and those with higher scores in objective numeracy were more likely to choose options that were numerically superior overall in terms of relative risk of skin cancer and of genetic risks of breast cancer (e.g., lower numerical probability of cancer). Results support parallel-processing models that assume multiple representations of numerical information about risk, which vary in precision, and illustrate how individual differences in numerical representations are relevant to tradeoffs and risk comparisons in health decisions. These representations cannot be reduced to one another and explain psychological variations in risk processing that go beyond low versus high levels of objective numeracy.

Understanding the landscape of web-based medical misinformation about vaccination

Given the high rates of vaccine hesitancy, web-based medical misinformation about vaccination is a serious issue. We sought to understand the nature of Google searches leading to medical misinformation about vaccination, and guided by fuzzy-trace theory, the characteristics of misinformation pages related to comprehension, inference-making, and medical decision-making. We collected data from web pages presenting vaccination information. We assessed whether web pages presented medical misinformation, had an overarching gist, used narrative, and employed emotional appeals. We used Search Engine Optimization tools to determine the number of backlinks from other web pages, monthly Google traffic, and Google Keywords. We used Coh-Metrix to measure readability and Gist Inference Scores (GIS). For medical misinformation web pages, Google traffic and backlinks were heavily skewed with means of 138.8 visitors/month and 805 backlinks per page. Medical misinformation pages were significantly more likely than other vaccine pages to have backlinks from other pages, and significantly less likely to receive at least one visitor from Google searches per month. The top Google searches leading to medical misinformation were "the truth about vaccinations," "dangers of vaccination," and "pro con vaccines." Most frequently, pages challenged vaccine safety, with 32.7% having an overarching gist, 7.7% presenting narratives, and 17.3% making emotional appeals. Emotional appeals were significantly more common with medical misinformation than other high-traffic vaccination pages. Misinformation pages had a mean readability grade level of 11.5, and a mean GIS of - 0.234. Low GIS scores are a likely barrier to understanding gist, and are the "Achilles' heel" of misinformation pages.

Adapting a Theoretically-Based intervention for underserved clinical populations at increased risk for hereditary Cancer: Lessons learned from the BRCA-Gist experience

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The use of GCT in underserved diverse populations is suboptimal.

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Translational genomics research has been conducted with mostly NHW.

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Adapting EBIs can enhance the reach of EBI to underserved diverse populations.

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This paper describes the adaptation BRCA Gist, for at-risk Blacks and Latinas.

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Findings illustrate the need to integrate fidelity and adaptation considerations.

Background

Minorities at increased risk for Hereditary Breast and Ovarian Cancer (HBOC) frequently have low awareness and use of genetic counseling and testing (GCT). Making sure that evidence-based interventions (EBIs) reach minorities is key to reduce disparities. BRCA-Gist is a theory-informed EBI that has been proven to be efficacious in mostly non-Hispanic White non-clinical populations. We conducted formative work to inform adaptations of BRCA-Gist for use in clinical settings with at-risk diverse women.

Methods

Genetic counselors (n = 20) were recruited nationally; at-risk Latinas and Blacks (n = 21) were recruited in Washington DC and Virginia. They completed the BRCA-Gist EBI between April 2018 – September 2019. Participants completed an acceptability scale and an interview to provide suggestions about implementation adaptations. T-tests for independent samples compared acceptability between at-risk women and genetic counselors. The Consensual Qualitative Research Framework was used to code adaptation suggestions. Suggested adaptations were discussed by a multidisciplinary team to integrate fidelity and adaptation considerations.

Results

At-risk women had a significantly higher acceptability (M = 4.17, SD = 0.47 vs. M = 3.24, SD = 0.64; p = 0.000; scale 1–5) and satisfaction scores (M = 8.3, SD = 1.3 vs. M = 4.2, SD = 2.0; p = 0.000; scale 1–10) than genetic counselors. Genetic counselors and at-risk women suggested contextual (e.g. format) and content (e.g. shortening) adaptations to enhance the fit of BRCA-Gist for diverse clinical populations.

Conclusions

Findings illustrate the process of integrating fidelity and adaptation considerations to ensure that EBIs retain their core components while enhancing the fit to minoritized clinical populations. Future studies will test the efficacy of the adapted BRCA-Gist in a Randomized Controlled Trial.

Supporting Health and Medical Decision Making: Findings and Insights from Fuzzy-Trace Theory

HIGHLIGHTS

Fuzzy-trace theory (FTT) supports practical approaches to improving health and medicine.FTT differs in important respects from other theories of decision making, which has implications for how to help patients, providers, and health communicators.Gist mental representations emphasize categorical distinctions, reflect understanding in context, and help cue values relevant to health and patient care.Understanding the science behind theory is crucial for evidence-based medicine.

The influence of verbatim versus gist formatting on younger and older adults' information acquisition and decision-making

Fuzzy-Trace Theory suggests that decision makers encode gist representations (bottom-line meaning) and verbatim representations (details) of information but rely more on gist, a tendency that increases with age. The present study examined implications for age differences in information seeking and decision-making by presenting gist and verbatim formatted choice scenarios. Participants comprised 68 younger and 66 older adults. Predecisional information seeking, indices of decision outcomes and recall, and relevant covariates were assessed. In line with theory, older adults self-reported and demonstrated stronger preferences for gist-based processing than younger adults did. Consistent with hypotheses, the total number of reviewed grid cells (including repeat views) was higher for gist than verbatim conditions, and this effect was stronger among older adults. Also, the proportion of unique cells reviewed and the accuracy of decision attribute recall were higher in the verbatim than gist condition and these effects were stronger among younger versus older adults. Further, gist formatting was associated with stronger use of option-wise information search, more value-concordant decisions (i.e., choices aligning with self-reported choice preferences), and decreased choice satisfaction, but these effects did not vary by age. Covariates, including information-processing preferences, partially accounted for these effects. Consistent with Fuzzy-Trace Theory, this suggests that information formatting and preferences modulate age differences in predecisional information acquisition: Depending on age, using either verbatim or gist formatting to communicate information can offer different benefits. Across age groups, however, gist formatting may facilitate value-concordant (and arguably higher-quality) decision-making. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Viruses, Vaccines, and COVID-19: Explaining and Improving Risky Decision-making

Risky decision-making lies at the center of the COVID-19 pandemic and will determine future viral outbreaks. Therefore, a critical evaluation of major explanations of such decision-making is of acute practical importance. We review the underlying mechanisms and predictions offered by expectancy-value and dual-process theories. We then highlight how fuzzy-trace theory builds on these approaches and provides further insight into how knowledge, emotions, values, and metacognitive inhibition influence risky decision-making through its unique mental representational architecture (i.e., parallel verbatim and gist representations of information). We discuss how social values relate to decision-making according to fuzzy-trace theory, including how categorical gist representations cue core values. Although gist often supports health-promoting behaviors such as vaccination, social distancing, and mask-wearing, why this is not always the case as with status-quo gist is explained, and suggestions are offered for how to overcome the "battle for the gist" as it plays out in social media.

Compliance with mass marketing solicitation: The role of verbatim and gist processing

INTRODUCTION

Mass marketing scams threaten financial and personal well-being. Grounded in fuzzy-trace theory, we examined whether verbatim and gist-based risk processing predicts susceptibility to scams and whether such processing can be altered.

METHODS

Seven hundred and one participants read a solicitation letter online and indicated willingness to call an "activation number" to claim an alleged $500,000 sweepstakes prize. Participants focused on the solicitation's verbatim details (hypothesized to increase risk-taking) or its broad gist (hypothesized to decrease risk-taking).

RESULTS

As expected, measures of verbatim-based processing positively predicted contact intentions, whereas measures of gist-based processing negatively predicted contact intentions. Contrary to hypotheses, experimental conditions did not influence intentions (43% across conditions). Contact intentions were associated with perceptions of low risk, high benefit, and the offer's apparent genuineness, as well as self-reported decision regret, subjective vulnerability to scams, and prior experience falling for scams.

CONCLUSIONS

Overall, message perceptions and prior susceptibility, rather than experimental manipulations, mattered in predicting scam susceptibility.

Development of the Oncolo-GIST ("Giving Information Strategically & Transparently") Intervention Manual for Oncologist Skills Training in Advanced Cancer Prognostic Information Communication

CONTEXT

Patient prognostic understanding is improved by oncologists' discussions of life expectancy. Most patients deem it important to discuss prognosis with their oncologists, but a minority of cancer patients within months of death report that they had such a discussion with their oncologist.

OBJECTIVES

To query stakeholders about their perspectives on the clinical approach and utility of an Oncolo-GIST manualized communication intervention, designed to enhance oncologists' ability to convey the gist of prognostic information simply, clearly, and effectively in the setting of progressing solid tumors and limited life expectancy.

METHODS

We obtained and analyzed feedback on the intervention from solid tumor oncology clinicians and bereaved family caregivers, soliciting opinions on the clinical approach taken in the videos, acceptability and likely impact of the instructions, and specific phrases recommended in the manual.

RESULTS

Twenty stakeholders (9 clinicians, 11 caregivers) participated. All agreed that oncologists should broach prognosis with patients, balancing honesty and sensitivity. Participants also advocated for oncologists to involve interprofessional team members (e.g., nurses, social workers) when serious mental health concerns arose. After the research team's discussion of the stakeholder feedback, the manual was modified to include or exclude preferred language and approaches.

CONCLUSION

The Oncolo-GIST intervention was characterized as simple and potentially effective at conveying prognoses to advanced cancer patients. Future research should determine if this approach to medical communication, which distills the essence of prognostic messages clearly and simply, is associated with improvements in patients' prognostic understanding.

Explaining risky choices with judgments: Framing, the zero effect, and the contextual relativity of gist

Contemporary theories of decision-making are compared with respect to their predictions about the judgments that are hypothesized to underlie risky choice framing effects. Specifically, we compare predictions of psychophysical models, such as prospect theory, to the cognitive representational approach of fuzzy-trace theory in which the presence or absence of zero is key to framing effects. Three experiments implemented a high-power design in which many framing problems were administered to participants, who rated the attractiveness of either the certain or risky options. Experiments also varied whether truncation manipulations were within-subjects or between-subjects and whether both options were present. Violations of both strong and weak rationality were clearly observed in attractiveness ratings of options. However, truncation effects showed that these violations were conditional on the form of the decision problem. Truncation effects that involved adding or subtracting zero-that should not matter in almost all decision theories-showed that such rationality violations were attenuated when zero was deleted, but were amplified when zero was emphasized, per predictions of fuzzy-trace theory. This is the first such demonstration using attractiveness ratings of certain and risky options. Ratings also revealed that framing effects are inherently comparative: The attractiveness of a given option is a function of zero versus nonzero contrasts both within and between options. Indeed, we observed a losing-nothing-is-better effect that violates attribute framing and prospect theory such that a probability of losing nothing was rated as substantially better than a probability of gaining nothing, in accord with fuzzy-trace theory. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A scientific theory of gist communication and misinformation resistance, with implications for health, education, and policy

A framework is presented for understanding how misinformation shapes decision-making, which has cognitive representations of gist at its core. I discuss how the framework goes beyond prior work, and how it can be implemented so that valid scientific messages are more likely to be effective, remembered, and shared through social media, while misinformation is resisted. The distinction between mental representations of the rote facts of a message-its verbatim representation-and its gist explains several paradoxes, including the frequent disconnect between knowing facts and, yet, making decisions that seem contrary to those facts. Decision makers can falsely remember the gist as seen or heard even when they remember verbatim facts. Indeed, misinformation can be more compelling than information when it provides an interpretation of reality that makes better sense than the facts. Consequently, for many issues, scientific information and misinformation are in a battle for the gist. A fuzzy-processing preference for simple gist explains expectations for antibiotics, the spread of misinformation about vaccination, and responses to messages about global warming, nuclear proliferation, and natural disasters. The gist, which reflects knowledge and experience, induces emotions and brings to mind social values. However, changing mental representations is not sufficient by itself; gist representations must be connected to values. The policy choice is not simply between constraining behavior or persuasion-there is another option. Science communication needs to shift from an emphasis on disseminating rote facts to achieving insight, retaining its integrity but without shying away from emotions and values.

To illuminate and motivate: A fuzzy-trace model of the spread of information online

We propose, and test, a model of online media platform users' decisions to act on, and share, received information. Specifically, we focus on how mental representations of message content drive its spread. Our model is based on Fuzzy-Trace Theory (FTT), a leading theory of decision under risk. Per FTT, online content is mentally represented in two ways: verbatim (objective, but decontextualized, facts), and gist (subjective, but meaningful, interpretation). Although encoded in parallel, gist tends to drive behaviors more strongly than verbatim representations for most individuals. Our model uses factors derived from FTT to make predictions regarding which content is more likely to be shared, namely: a) different levels of mental representation, b) the motivational content of a message, c) difficulty of information processing (e.g., the ease with which a given message may be comprehended and, therefore, its gist extracted), and d) social values.

Age Effects in Sequence-Construction for a Continuous Cognitive Task: Similar Sequence-Trends but Fewer Switch-Points

OBJECTIVES

Many real-life settings require decision makers to sort a predetermined set of outcomes or activities into a preferred sequence and people vary in whether they prefer to tackle the most challenging aspects first, leave them for the last, or intersperse them with less challenging outcomes. Prior research on age differences in sequence-preferences has focused on discrete and hypothetical events. The present study expands this work by examining sequence-preferences for a realistic, continuous, sustained, and cognitively challenging task.

METHODS

Participants (N = 121, aged 21-86) were asked to complete 10 min of a difficult cognitive task (2-back), 10 min of an easy cognitive task (1-back), and 10 min of rest over the course of a 30-min interval. They could complete the tasks in any order and switch tasks as often as they wished and they were rewarded for correct performance. Additional measures included affective and physiological responses, task accuracy, time-perspective, and demographics.

RESULTS

The majority of participants constructed sequences with decreasing task difficulty. Preferences for the general trend of the sequence were not significantly related to age, but the number of switches among the tasks decreased with age, and task-switching tended to incur greater accuracy decrements among older as compared to younger adults.

DISCUSSION

We address potential methodological concerns, discuss theoretical implications, and consider potential real-life applications.

Enhancing Patient Understanding of Medication Risks and Benefits

Objective

To evaluate the effectiveness of 2 interventions, including the DrugFactsBox format for presenting written medication information and the SMART (Strategic Memory Advanced Reasoning Training) program designed to enhance gist (i.e., “bottom‐line” meaning) reasoning ability.

Methods

We used a 2 × 2 factorial research design. A total of 286 patients with rheumatoid arthritis were randomly assigned to 1 of 4 groups, including DrugFactsBox with the SMART program, DrugFactsBox without the SMART program, other consumer medication information (CMI) with the SMART program, and other CMI without the SMART program. Data were collected via telephone interviews and online questionnaires at 4 time points, including baseline and 6‐week, 3‐month, and 6‐month time points following baseline. The primary outcome variable was informed decision‐making, which was defined as making a value‐consistent decision concerning use of disease‐modifying antirheumatic drugs based on adequate knowledge.

Results

We found no main effects for the 2 interventions, either alone or in combination. However, there was a significant interaction between assignment to the SMART/no SMART groups and informed decision‐making at baseline. Among participants in the SMART groups who did not meet the criteria for informed decision‐making at baseline, 42.5% met the criteria at the 6‐month follow‐up, compared to 23.6% of participants in the no SMART groups (mean difference 18.9 [95% confidence interval 5.6, 32.2]; P = 0.007). This difference was driven by increased knowledge in the SMART groups. Among participants who met the criteria for informed decision‐making at baseline, the difference between the SMART and no SMART groups was not statistically significant.

Conclusion

Participation in a theory‐driven program to enhance gist reasoning may have a beneficial effect on informed decision‐making among patients with inadequate knowledge concerning therapeutic options.

Of Viruses, Vaccines, and Variability: Qualitative Meaning Matters

Deaths from COVID-19 depend on millions of people understanding risk and translating this understanding into risk-reduction behaviors. Although numerical information about risk is helpful, numbers are surprisingly ambiguous, and there are predictable mismatches in risk perception between laypeople and experts. Hence, risk communication should convey the qualitative, contextualized meaning of risk.

Preferences for Temporal Sequences of Real Outcomes Differ Across Domains but do not Vary by Age

OBJECTIVES

People's preferences for temporal sequences of events have implications for life-long health and well-being. Prior research suggests that other aspects of intertemporal choice vary by age, but evidence for age differences in sequence-preferences is limited and inconclusive. In response, the present research examined age differences in sequence-preferences for real outcomes administered in a controlled laboratory setting.

METHODS

A pilot study examined sequence-preferences for aversive electrodermal shocks in 30 younger and 30 older adults. The main study examined sequence-preferences for electrodermal shocks, physical effort, and monetary gambles in an adult life-span sample (N = 120). It also examined emotional and physiological responses to sequences as well as underlying mechanisms including time perception and emotion-regulation.

RESULTS

There were no significant age differences in sequence-preferences in either of the studies, and there were no age differences in responses to sequences in the main study. Instead, there was a domain effect with participants preferring decreasing sequences for shocks and mixed sequences for effort and money.

DISCUSSION

After considering potential methodological limitations, theoretical contributions and implications for real-life decisions are discussed.

Palliative Chemotherapy or Radiation and Prognostic Understanding among Advanced Cancer Patients: The Role of Perceived Treatment Intent

Background: As patients' accurate understanding of their prognosis is essential for informed end-of-life planning, identifying associated factors is important. Objective: We examine if receiving palliative chemotherapy or radiation, and the perception of those treatments as curative or noncurative, is associated with prognostic understanding. Design: Cross-sectional analyses from a multisite, observational study. Setting/Subjects: Patients with advanced cancers refractory to at least one chemotherapy regimen (N = 334). Measurements: In structured interviews, patients reported whether they were receiving chemotherapy or radiation, and whether its intent was curative or not. Their responses were categorized into three groups: patients not receiving chemotherapy/radiation (no cancer treatment group); patients receiving chemotherapy/radiation and misperceiving it as curative (treatment misperception group); and patients receiving chemotherapy/radiation and accurately perceiving it as noncurative (accurate treatment perception group). Patients also reported on various aspects of their prognostic understanding (e.g., life expectancy). Results: Eighty-six percent of the sample was receiving chemotherapy or radiation; of those, 16.7% reported the purpose of treatment to be curative. The no-treatment group had higher prognostic understanding scores compared with the treatment misperception group (adjusted odds ratio [AOR] = 5.00, p < 0.001). However, the accurate treatment perception group had the highest prognostic understanding scores in comparison to the no-treatment group (AOR = 2.04, p < 0.05) and the treatment misperception group (AOR = 10.19, p < 0.001). Conclusions: Depending on patient perceptions of curative intent, receipt of palliative chemotherapy or radiation is associated with better or worse prognostic understanding. Research should examine if enhancing patients' understanding of treatment intent can improve accurate prognostic expectations.

Automatic Evaluation of Cancer Treatment Texts for Gist Inferences and Comprehension

Background. It is difficult to write about cancer for laypeople such that everyone understands. One common approach to readability is the Flesch-Kincaid Grade Level (FKGL). However, FKGL has been shown to be less effective than emerging discourse technologies in predicting readability. Objective. Guided by fuzzy-trace theory, we used the discourse technology Coh-Metrix to create a Gist Inference Score (GIS) and applied it to texts from the National Cancer Institute website written for patients and health care providers. We tested the prediction that patient cancer texts with higher GIS scores are likely to be better understood than others. Design. In study 1, all 244 cancer texts were systematically subjected to an automated Coh-Metrix analysis. In study 2, 9 of those patient texts (3 each at high, medium, and low GIS) were systematically converted to fill-the-blanks (Cloze) tests in which readers had to supply the missing words. Participants (162) received 3 texts, 1 at each GIS level. Measures. GIS was measured as the mean of 7 Coh-Metrix variables, and comprehension was measured through a Cloze procedure. Results. Although texts for patients scored lower on FKGL than those for providers, they also scored lower on GIS, suggesting difficulties for readers. In study 2, participants scored higher on the Cloze task for high GIS texts than for low- or medium-GIS texts. High-GIS texts seemed to better lend themselves to correct responses using different words. Limitations. GIS is limited to text and cannot assess inferences made from images. The systematic Cloze procedure worked well in aggregate but does not make fine-grained distinctions. Conclusions. GIS appears to be a useful, theoretically motivated supplement to FKGL for use in research and clinical practice.

Brain activation covaries with reported criminal behaviors when making risky choices: A fuzzy-trace theory approach

Criminal behavior has been associated with abnormal neural activity when people experience risks and rewards or exercise inhibition. However, neural substrates of mental representations that underlie criminal and noncriminal risk-taking in adulthood have received scant attention. We take a new approach, applying fuzzy-trace theory, to examine neural substrates of risk preferences and criminality. We extend ideas about gist (simple meaning) and verbatim (precise risk-reward tradeoffs) representations used to explain adolescent risk-taking to uncover neural correlates of developmentally inappropriate adult risk-taking. We tested predictions using a risky-choice framing task completed in the MRI scanner, and examined neural covariation with self-reported criminal and noncriminal risk-taking. As predicted, risk-taking was correlated with a behavioral pattern of risk preferences called "reverse framing" (preferring sure losses over a risky option and a risky option over sure gains, the opposite of typical framing biases) that has been linked to risky behavior in adolescents and is rarely observed in nondisordered adults. Experimental manipulations confirmed processing interpretations of typical framing (gist-based) and reverse-framing (verbatim-based) risk preferences. In the brain, covariation with criminal and noncriminal risk-taking was observed predominantly when subjects made reverse-framing choices. Noncriminal risk-taking behavior was associated with emotional reactivity (amygdala) and reward motivation (striatal) areas, whereas criminal behavior was associated with greater activation in temporal and parietal cortices, their junction, and insula. When subjects made more developmentally typical framing choices, reflecting nonpreferred gist processing, activation in dorsolateral prefrontal cortex covaried with criminal risk-taking, which may reflect cognitive effort to process gist while inhibiting preferred verbatim processing. (PsycINFO Database Record

Patients' and Clinicians' Perceptions of Antibiotic Prescribing for Upper Respiratory Infections in the Acute Care Setting

Reducing inappropriate prescribing is key to mitigating antibiotic resistance, particularly in acute care settings. Clinicians' prescribing decisions are influenced by their judgments and actual or perceived patient expectations. Fuzzy trace theory predicts that patients and clinicians base such decisions on categorical gist representations that reflect the bottom-line understanding of information about antibiotics. However, due to clinicians' specialized training, the categorical gists driving clinicians' and patients' decisions might differ, which could result in mismatched expectations and inefficiencies in targeting interventions. We surveyed clinicians and patients from 2 large urban academic hospital emergency departments (EDs) and a sample of nonpatient subjects regarding their gist representations of antibiotic decisions, as well as relevant knowledge and expectations. Results were analyzed using exploratory factor analysis (EFA) and multifactor regression. In total, 149 clinicians (47% female; 74% white), 519 online subjects (45% female; 78% white), and 225 ED patients (61% female; 56% black) completed the survey. While clinicians demonstrated greater knowledge of antibiotics and concern about side effects than patients, the predominant categorical gist for both patients and clinicians was "why not take a risk," which compares the status quo of remaining sick to the possibility of benefit from antibiotics. This gist also predicted expectations and prior prescribing in the nonpatient sample. Other representations reflected the gist that "germs are germs" conflating bacteria and viruses, as well as perceptions of side effects and efficacy. Although individually rational, reliance on the "why not take a risk" representation can lead to socially suboptimal results, including antibiotic resistance and individual patient harm due to adverse events. Changing this representation could alter clinicians' and patients' expectations, suggesting opportunities to reduce overprescribing.

Fuzzy-Trace Theory, False Memory, and the Law

Fuzzy-trace theory (FTT) provides well-researched scientific principles that explain worrisome forms of false memory in the law. False memories are of great legal concern because memory reports are frequently the evidence that determines guilt/innocence and are sometimes the only evidence that crimes have been committed. FTT’s principles reveal errors in commonsense theories that jurors use to judge the credibility of witnesses’ memory reports. This science versus commonsense disconnect is salient in cases involving child witnesses, eyewitness identifications, and confessions. The consequences of this disconnect for justice could be ameliorated by a simple change in federal rules of evidence.

Replication, Registration, and Scientific Creativity

The bureaucratization of psychological science exacts intellectual costs that go beyond the sheer amount of time that is drained away from creative scientific activity. Additional administrative hurdles are now being generated in an attempt to ensure the replicability of psychological effects. A cognitive analysis of those hurdles shows that impairment of scientific creativity is a foreseeable consequence, owing to their frequent verbatim-processing focus and the negative emotional context in which they are embedded. We consider whether it is possible to enhance replicability without increasing bureaucratic obstacles and to enhance scientific creativity in the presence of such obstacles.

A formal model of fuzzy-trace theory: Variations on framing effects and the Allais paradox

Fuzzy-trace theory assumes that decision-makers process qualitative "gist" representations and quantitative "verbatim" representations in parallel. We develop a lattice model of fuzzy-trace theory that explains both processes. Specifically, the model provides a novel formalization of how: 1) decision-makers encode multiple representations of options in parallel; 2) representations compete or combine so that choices often turn on the simplest representation of encoded gists; and 3) choices between representations are made based on positive vs. negative valences associated with social and moral principles stored in long-term memory (e.g., saving lives is good). The model integrates effects of individual differences in numeracy, metacognitive monitoring and editing, and sensation seeking. We conducted a systematic review of variations on framing effects and the Allais Paradox, both core phenomena of risky decision-making, and tested whether our model could predict observed choices: The model successfully predicted 82 out of 88 (93%) pairs of studies (comparing gain to loss conditions) demonstrating 16 variations on effects, theoretically critical manipulations that eliminate or exaggerate framing effects. When examining these conditions individually, the model successfully predicted 153 (90%) out of 170 eligible studies. Parameters of the model varied in theoretically meaningful ways with differences in numeracy, metacognitive monitoring, and sensation seeking, accounting for risk preferences at the group level. New experiments show similar results at the individual level. The model is also shown to be scientifically parsimonious using standard measures. Relations to current theories, such as Cumulative Prospect Theory, and potential extensions are discussed.

Effects of Probabilities, Adverse Outcomes, and Status Quo on Perceived Riskiness of Medications: Testing Explanatory Hypotheses Concerning Gist, Worry, and Numeracy

We tested predictions of fuzzy-trace theory that qualitative health status and gist representations (ordinal and categorical) of risks contribute to willingness to start medications, beyond effects of objective risk, emotion (worry), and numeracy. Adults in two experiments were given hypothetical scenarios based on actual medications, varying health status quo (acceptable or unacceptable), adverse event (pneumonia or cancer), and four levels of quantitative risk (from 1/100,000 to 1/100) between subjects. In both experiments, cancer and higher quantitative risk elicited greater worry and risk perceptions and reduced willingness to start a new medication. Willingness to start was also influenced by health status quo. After controlling for other variables, only status quo and gist representations consistently predicted willingness to start in both experiments. Results support an integrated approach to understanding and predicting perceptions of the risks of medications that encompasses numerical cognition, emotions (such as worry), and qualitative gist representations of medical information.

Developmental reversals in false memory: Development is complementary, not compensatory

We report the 1st example of a true complementarity effect in memory development-a situation in which memory for the same event simultaneously becomes more and less accurate between early childhood and adulthood. We investigated this paradoxical effect because fuzzy-trace theory predicts that it can occur in paradigms that produce developmental reversals in false memory, which are circumstances in which adults are more likely than children to remember new events as old. The complementarity prediction is this: If subjects separately judge whether those same events are new but similar to old ones, adults will be more accurate than children, even though adults are less accurate when they judge whether the items are old. We report 4 experiments in which children (6- and 10-year-olds), adolescents (14-year-olds), and adults encoded the modal developmental reversal materials: Deese-Roediger-McDermott lists. Then, they responded to memory tests on which half the subjects judged whether test items were old and half judged whether the same items were new-similar. The paradoxical complementarity effect was detected in all experiments: The tendency to falsely remember new-similar items as being old increased with development, but so did the tendency to correctly remember them as being new-similar. (PsycINFO Database Record

Limitations on the Ability to Negotiate Justice: Attorney Perspectives on Guilt, Innocence, and Legal Advice in the Current Plea System

In the American criminal justice system the vast majority of criminal convictions occur as the result of guilty pleas, often made as a result of plea bargains, rather than jury trials. The incentives offered in exchange for guilty pleas mean that both innocent and guilty defendants plead guilty. We investigate the role of attorneys in this context, through interviews with criminal defense attorneys. We examine defense attorney perspectives on the extent to which innocent defendants are (and should be) pleading guilty in the current legal framework and their views of their own role in this complex system. We also use a hypothetical case to probe the ways in which defense attorneys consider guilt or innocence when providing advice on pleas. Results indicate that attorney advice is influenced by guilt or innocence, but also that attorneys are limited in the extent to which they can negotiate justice for their clients in a system in which uncertainty and large discrepancies between outcomes of guilty pleas and conviction at trial can make it a sensible option to plead guilty even when innocent. Results also suggest conflicting opinions over the role of the attorney in the plea-bargaining process.

From meaning to money: Translating injury into dollars

Legal systems often require the translation of qualitative assessments into quantitative judgments, yet the qualitative-to-quantitative conversion is a challenging, understudied process. We conducted an experimental test of predictions from a new theory of juror damage award decision making, examining how 154 lay people engaged in the translation process in recommending money damages for pain and suffering in a personal injury tort case. The experiment varied the presence, size, and meaningfulness of an anchor number to determine how these factors influenced monetary award judgments, perceived difficulty, and subjective meaningfulness of awards. As predicted, variability in awards was high, with awards participants considered to be "medium" (rather than "low" or "high") having the most dispersion. The gist of awards as low, medium, or high fully mediated the relationship between perceived pain/suffering and award amount. Moreover, controlling for participants' perceptions of plaintiffs and defendants, as well as their desire to punish and to take economic losses into account, meaningful anchors predicted unique variance in award judgments: A meaningful large anchor number drove awards up and a meaningful small anchor drove them down, whereas meaningless large and small anchors did not differ significantly. Numeracy did not predict award magnitudes or variability, but surprisingly, more numerate participants reported that it was more difficult to pick an exact figure to compensate the plaintiff for pain and suffering. The results support predictions of the theory about qualitative gist and meaningful anchors, and suggest that we can assist jurors to arrive at damage awards by providing meaningful numbers. (PsycINFO Database Record

Complementarity in false memory illusions

For some years, the DRM illusion has been the most widely studied form of false memory. The consensus theoretical interpretation is that the illusion is a reality reversal, in which certain new words (critical distractors) are remembered as though they are old list words rather than as what they are-new words that are similar to old ones. This reality-reversal interpretation is supported by compelling lines of evidence, but prior experiments are limited by the fact that their memory tests only asked whether test items were old. We removed that limitation by also asking whether test items were new-similar. This more comprehensive methodology revealed that list words and critical distractors are remembered quite differently. Memory for list words is compensatory: They are remembered as old at high rates and remembered as new-similar at very low rates. In contrast, memory for critical distractors is complementary: They are remembered as both old and new-similar at high rates, which means that the DRM procedure induces a complementarity illusion rather than a reality reversal. The conjoint recognition model explains complementarity as a function of three retrieval processes (semantic familiarity, target recollection, and context recollection), and it predicts that complementarity can be driven up or down by varying the mix of those processes. Our experiments generated data on that prediction and introduced a convenient statistic, the complementarity ratio, which measures (a) the level of complementarity in memory performance and (b) whether its direction is reality-consistent or reality-reversed. (PsycINFO Database Record

Overdistribution illusions: Categorical judgments produce them, confidence ratings reduce them

Overdistribution is a form of memory distortion in which an event is remembered as belonging to too many episodic states, states that are logically or empirically incompatible with each other. We investigated a response formatting method of suppressing 2 basic types of overdistribution, disjunction and conjunction illusions, which parallel some classic illusions in the judgment and decision making literature. In this method, subjects respond to memory probes by rating their confidence that test cues belong to specific episodic states (e.g., presented on List 1, presented on List 2), rather than by making the usual categorical judgments about those states. The central prediction, which was derived from the task calibration principle of fuzzy-trace theory, was that confidence ratings should reduce overdistribution by diminishing subjects' reliance on noncompensatory gist memories. The data of 3 experiments agreed with that prediction. In Experiment 1, there were reliable disjunction illusions with categorical judgments but not with confidence ratings. In Experiment 2, both response formats produced reliable disjunction illusions, but those for confidence ratings were much smaller than those for categorical judgments. In Experiment 3, there were reliable conjunction illusions with categorical judgments but not with confidence ratings. Apropos of recent controversies over confidence-accuracy correlations in memory, such correlations were positive for hits, negative for correct rejections, and the 2 types of correlations were of equal magnitude. (PsycINFO Database Record

Dread sensitivity in decisions about real and imagined electrical shocks does not vary by age

Previous research has found age differences in intertemporal choices that involve trade-offs among events or outcomes that occur at different points in time, but these findings were mostly limited to hypothetical financial and consumer choices. We examined whether age effects extend to unpleasant physical experiences that elicit states of dread which lead participants to speed up the outcomes just to get them over with. We asked participants of different ages to choose among electrical shocks that varied in timing and intensity. We also assessed affective responses as a potential mechanism behind age effects and considered other potential covariates. In Study 1, the choice task involved real outcomes and the sample consisted of younger and older adults. In Study 2, the choice task was hypothetical and the sample was an adult life span sample. Across both studies, there was no evidence of age differences in the preferred timing of shocks. Instead, dread-sensitive choices were associated with higher conscientiousness. Age effects in dread-sensitive choices remained nonsignificant even after controlling for a range of age-associated covariates. We discuss possible explanations for the lack of age effects and consider implications for applied and clinical settings. (PsycINFO Database Record

Using fuzzy-trace theory to understand and improve health judgments, decisions, and behaviors: A literature review

OBJECTIVE

Fuzzy-trace theory is a dual-process model of memory, reasoning, judgment, and decision making that contrasts with traditional expectancy-value approaches. We review the literature applying fuzzy-trace theory to health with 3 aims: evaluating whether the theory's basic distinctions have been validated empirically in the domain of health; determining whether these distinctions are useful in assessing, explaining, and predicting health-related psychological processes; and determining whether the theory can be used to improve health judgments, decisions, or behaviors, especially compared to other approaches.

METHOD

We conducted a literature review using PubMed, PsycINFO, and Web of Science to identify empirical peer-reviewed papers that applied fuzzy-trace theory, or central constructs of the theory, to investigate health judgments, decisions, or behaviors.

RESULTS

Seventy nine studies (updated total is 94 studies; see Supplemental materials) were identified, over half published since 2012, spanning a wide variety of conditions and populations. Study findings supported the prediction that verbatim and gist representations are distinct constructs that can be retrieved independently using different cues. Although gist-based reasoning was usually associated with improved judgment and decision making, 4 sources of bias that can impair gist reasoning were identified. Finally, promising findings were reported from intervention studies that used fuzzy-trace theory to improve decision making and decrease unhealthy risk taking.

CONCLUSIONS

Despite large gaps in the literature, most studies supported all 3 aims. By focusing on basic psychological processes that underlie judgment and decision making, fuzzy-trace theory provides insights into how individuals make decisions involving health risks and suggests innovative intervention approaches to improve health outcomes. (PsycINFO Database Record

Development of a group and family-based cognitive behavioural therapy program for youth at risk for psychosis

OBJECTIVE

The onset of psychosis typically occurs during adolescence or early adulthood and can have a detrimental impact on social and cognitive development. Cognitive behavioural therapy (CBT) shows promise in reducing the risk of psychosis. Teaching families to apply CBT with their offspring may bolster therapeutic gains made in time-limited treatment. We developed a comprehensive group-and-family-based CBT (GF-CBT) program that aims to facilitate psychosocial recovery, decrease symptoms and prevent transition to psychosis in youth at risk. GF-CBT is grounded in ecological systems and cognitive theories, resilience models and research on information processing in delusions. The theoretical rationale and description of GF-CBT are presented together with a pilot study that evaluated the program's feasibility and explored participants' outcomes.

METHODS

Youth ages 16-21 at risk for psychosis and their families participated in an open trial with pre, post and 3-month follow-up assessments conducted by an independent evaluator. The Comprehensive Assessment of At-Risk Mental States was the primary clinical outcome measure.

RESULTS

All enrolled participants (n = 6) completed GF-CBT and all remitted from at-risk mental state (ARMS). As a group participants showed statistically significant decreases in attenuated psychotic symptoms, negative symptoms, depression, cognitive biases and improvements in functioning. Family members showed significant improvements in use of CBT skills, enhanced communication with their offspring, and greater confidence in their ability to help. Gains were maintained at follow-up.

CONCLUSIONS

GF-CBT may delay or prevent transition to psychosis in youth at risk, and potentially facilitate recovery from ARMS. More rigorous, controlled research is needed to further evaluate this program.