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Deconstructing Mental Health Assessment Reports


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This presentation is for lawyers who want to be better able to critically assess the reports of mental health professionals

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Deconstructing Mental Health Assessment Reports

  1. 1. Deconstructing Mental Health Assessment Reports: A Guide for Attorneys <ul><li>The Basics-Ethical Standards and Guidelines </li></ul><ul><ul><li>The Ethical Principles and Code of Conduct of the American Psychological Association are generally enforceable. </li></ul></ul><ul><ul><li>The Specialty Guidelines for Forensic Psychology (now in draft form) are aspirational. </li></ul></ul><ul><ul><li>“ Yar, they’re more like a set of guidelines” (The Pirate’s Code in Pirates of the Caribbean) </li></ul></ul>
  2. 2. Ethical Issues-Competence <ul><li>You have to be competent </li></ul><ul><ul><li>Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience. (APA 2.01) </li></ul></ul><ul><li>The onus is on the psychologist to show that he/she is competent </li></ul>
  3. 3. Competence <ul><li>Forensic practitioners adequately inform clients, examinees, judges, attorneys, parties, triers of fact, and other recipients of their services about relevant aspects of the nature and extent of their experience, training, credentials, and qualifications. (Sp. Guidelines 4.01) </li></ul>
  4. 4. Competence-Example <ul><li>It is not uncommon for MSWs, M.A. counselors (particularly in offender work) and psychiatrists to utilize tests and techniques about which they know little. </li></ul><ul><li>Use of MMPI-2, PAI, MCMI-III, ABEL narrative reports by people with little or no understanding of psychometrics. </li></ul>
  5. 5. Competence-Cross Exam Suggestions <ul><li>“What is meant by the reliability of a test?” </li></ul><ul><li>“Please name three forms of reliability” </li></ul><ul><li>“What is meant by validity?” </li></ul><ul><li>“What is criterion related validity?” </li></ul><ul><li>“What is incremental validity?” </li></ul>
  6. 6. Records and Court Related Assessment <ul><li>APA Code- 6.01 Documentation of Professional and Scientific Work and Maintenance of Records </li></ul><ul><ul><li>Records must be complete enough to allow the next professional to understand what was done. They should not be altered, redacted, erased or shredded. It is technically unethical for them to be illegible. </li></ul></ul><ul><li>Guidelines 13.01 Documentation and Compilation of Data Considered </li></ul><ul><ul><li>From the moment they reasonably know that the data and potential evidence derived from their services may be subject to discovery or relied upon by a trier of fact or other decision maker, forensic practitioners document all data they consider with enough detail and quality to allow for reasonable judicial scrutiny and adequate discovery by all parties. This documentation includes, but is not limited to, letters and consultations; notes, recordings, and transcriptions; assessment and test data, scoring reports, and interpretations; and all other records in any form or medium that were created or exchanged in connection with a matter. </li></ul></ul>
  7. 7. Tests <ul><li>APA 9.02- Use of Assessments (a) Psychologists administer, adapt, score, interpret, or use assessment techniques, interviews, tests, or instruments in a manner and for purposes that are appropriate in light of the research on or evidence of the usefulness and proper application of the techniques. </li></ul><ul><li>(b) Psychologists use assessment instruments whose validity and reliability have been established for use with members of the population tested. When such validity or reliability has not been established, psychologists describe the strengths and limitations of test results and interpretation </li></ul>
  8. 8. Tests <ul><li>9.08 Obsolete Tests and Outdated Test Results (a) Psychologists do not base their assessment or intervention decisions or recommendations on data or test results that are outdated for the current purpose. </li></ul><ul><li>(b) Psychologists do not base such decisions or recommendations on tests and measures that are obsolete and not useful for the current purpose. </li></ul><ul><li>Find out if the expert is using the most recent version of a test (WAIS-III vs. WAIS-R, MMPI-2 vs. MMPI etc.) </li></ul>
  9. 9. Have Another Expert Check the Scoring <ul><li>Numerical miscalculations are common and are simple to check. </li></ul><ul><li>You might want your expert to run the results through an interpretive program </li></ul>
  10. 10. Use of “Canned” Interpretive Reports <ul><li>Mental health professionals can hand score, use computerized profiles or obtain computerized narratives </li></ul><ul><li>Problems with the narratives: </li></ul><ul><ul><li>Where do they come from? </li></ul></ul><ul><ul><li>Are they based on empirical research? Clinical judgment? Some combination? </li></ul></ul><ul><li>Limited guarantee: The expert does not know these answers. </li></ul>
  11. 11. Canned Reports <ul><li>Most experienced experts don’t use narrative reports: </li></ul><ul><ul><li>They don’t want to be “locked in” to the interpretation </li></ul></ul><ul><ul><li>The reports are discoverable </li></ul></ul><ul><ul><li>Important note : Some experts will not print out the narrative and attempt to “hide the ball,” not offering them as part of discovery. Ask for them specifically. </li></ul></ul>
  12. 12. Use of Validity Scales and the Assessment of Malingering <ul><li>Clients can influence test results with their approach to the test </li></ul><ul><li>Other than honest responding, there are three basic response styles: </li></ul><ul><ul><li>Random </li></ul></ul><ul><ul><li>“Fake Good” </li></ul></ul><ul><ul><li>“Fake Bad” </li></ul></ul>
  13. 13. Response Style <ul><li>Random </li></ul><ul><ul><li>Seen with: </li></ul></ul><ul><ul><ul><li>People who are very disoriented or acutely psychotic </li></ul></ul></ul><ul><ul><ul><li>People who cannot read </li></ul></ul></ul><ul><ul><ul><li>People who are bored (mostly sullen adolescents) </li></ul></ul></ul><ul><ul><li>Detected by inconsistancy </li></ul></ul>
  14. 14. Response Style <ul><li>“Fake Bad,” Client exaggerates symptoms </li></ul><ul><ul><li>Seen with: </li></ul></ul><ul><ul><ul><li>Defendants who wish to appear NGRI or incompetent </li></ul></ul></ul><ul><ul><ul><li>Personal injury litigants </li></ul></ul></ul><ul><ul><li>Detected by ridiculously high levels of psychopathology, rare symptoms and unusual combinations of symptoms </li></ul></ul>
  15. 15. Response Style <ul><li>“Fake Good,” Client minimizes pathology </li></ul><ul><ul><li>Seen with: </li></ul></ul><ul><ul><ul><li>Custody litigants </li></ul></ul></ul><ul><ul><ul><li>Sexual offenders </li></ul></ul></ul><ul><ul><ul><li>Batterers </li></ul></ul></ul><ul><ul><li>Detected through denial of “normal” problems, over-endorsement of high moral standards </li></ul></ul>
  16. 16. Response Style <ul><li>All good assessments should have appropriate measures of response style </li></ul><ul><li>Many tests have no validity scales </li></ul><ul><li>Clinical assessment is helpful but not enough </li></ul><ul><li>Not all response style instruments are equal </li></ul>
  17. 17. Response Style <ul><li>“How did you assess the validity of this (test, interview, assessment)? </li></ul><ul><li>Did (particular test or technique) have validity scales? </li></ul><ul><li>Are there any indications of invalidity or (symptom exaggeration, minimization, malingering) in this assessment? </li></ul>
  18. 18. Projective vs. Objective Tests <ul><li>Projective Tests </li></ul><ul><ul><li>Ex: Rorschach (inkblot) Thematic Apperception Test, House-Tree-Person, Incomplete Sentences </li></ul></ul><ul><ul><li>Follow projective hypothesis-Client will “project” inner mental state onto ambiguous stimulus </li></ul></ul>
  19. 19. Objective Tests <ul><li>Have norms, scoring, and established reliability and validity. </li></ul><ul><li>Compare the client to a group of similar individuals. </li></ul><ul><li>Examples: MMPI-2, Wechsler Adult Intelligence Test, Child Abuse Potential Inventory </li></ul><ul><li>Often have validity scales (but not always) </li></ul><ul><li>Far less subjective. </li></ul>
  20. 20. Projective Tests <ul><li>With the exception of Exner Rorschach, these tests have no scoring, norms or validity scales. </li></ul><ul><li>They are highly subjective and have no established reliability or validity. </li></ul><ul><li>There is no established link between results of projectives and any psycho-legal issue </li></ul><ul><li>They are controversial in the professional community and probably would not pass Frye or Daubert . </li></ul>
  21. 21. Projective Tests <ul><li>Mental health professionals who use projectives in forensic matters may have other bad ideas. </li></ul><ul><li>They open themselves up to damaging cross-examination that undermines the things they did correctly. </li></ul><ul><li>“ Doctor, do you think it is appropriate to use a highly subjective test with no established reliability or validity when a man’s freedom is at stake?” </li></ul>
  22. 22. Characteristics of Good Forensic Assessments <ul><li>Should contain a formal mental status examination </li></ul><ul><li>Should attempt to corroborate all important information and not rely exclusively on self report </li></ul><ul><li>Should contain tests and techniques sufficient to answer the referral question </li></ul>
  23. 23. Characteristics of Good Forensic Assessments <ul><li>There should be a logical nexus between data relied on and conclusions reached (State of New Hampshire v. Cressy) </li></ul><ul><li>If the expert relied on “the totality of the data” you should be suspicious and make your questions more specific. </li></ul>
  24. 24. Characteristics of Bad Forensic Reports <ul><li>Make statements about characteristics of persons that have not been evaluated. </li></ul><ul><li>Conflate psychiatric diagnosis with functional assessment </li></ul><ul><li>Mix roles of therapist and forensic evaluator </li></ul>