Therapists In Litigation


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This is the PowerPoint that accompanies a full day CEU workshop I have done for psychological associations in New Hampshire, North Dakota, Vermont and Alaska

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  • Therapists In Litigation

    1. 1. Practical Risk Management: Court Related Issues, Ethics and Beyond Eric G. Mart, Ph.D., ABPP Highland Psychological Services
    2. 2. Vignette 1 – the Family therapist <ul><li>Example 1 </li></ul><ul><ul><li>Initial presentation of a 7 year old boy </li></ul></ul><ul><ul><li>She says </li></ul></ul><ul><ul><li>He says </li></ul></ul><ul><ul><li>They divorce and their lawyers say </li></ul></ul>
    3. 3. Vignette 1 – Ethical considerations <ul><li>Should the therapist release the records? </li></ul><ul><li>Should she write letters for either party? </li></ul><ul><li>What if the father’s lawyer want to depose her? What if mom’s lawyer doesn’t want any notes about the affair released? </li></ul><ul><li>How could any of these problems be “headed off”? </li></ul>
    4. 4. Vignette 2 – Marriage therapist <ul><li>Marriage therapy that ends in divorce </li></ul><ul><li>She says </li></ul><ul><li>He says </li></ul><ul><li>The case goes to court as a criminal matter and the wife wants the therapist to be there for moral support and to testify regarding her PTSD symptoms </li></ul>
    5. 5. Vignette 2 – Ethical considerations <ul><li>Should the therapist testify? </li></ul><ul><li>What might the opposing attorney query regarding the Borderline PD symptoms? </li></ul><ul><li>What if the husband’s attorney wants ALL of the records? </li></ul><ul><li>What about objectivity and ethics complaints? </li></ul><ul><li>How might one avoid this? </li></ul>
    6. 6. Vignette 3 – Recovered memories <ul><li>Presenting concerns </li></ul><ul><li>Guided imagery of vague memories </li></ul><ul><li>A recovered memory </li></ul>
    7. 7. Vignette 2 – Ethical considerations <ul><li>Abuse of a minor – file a report? </li></ul><ul><li>Parents do not believe their daughter, now what? </li></ul>
    8. 8. Vignette themes <ul><li>Confusion of role </li></ul><ul><li>Role boundaries </li></ul><ul><li>Lack of knowledge and consultation by the therapist </li></ul>
    9. 9. Role confusion <ul><li>Forensic evaluator vs. treating therapist </li></ul><ul><li>Fact vs. expert witness </li></ul><ul><li>Incompatibility of therapist and evaluator roles </li></ul><ul><li>Beware the stealth evaluation </li></ul>
    10. 10. Forensic evaluator vs. treating therapist <ul><li>FORENSIC EVALUATOR ROLE </li></ul><ul><ul><li>The client is the attorney and/or court </li></ul></ul><ul><ul><li>Therapist-patient privilege governs disclosure. </li></ul></ul><ul><ul><li>Attitude toward client is supportive, empathic and accepting </li></ul></ul><ul><ul><li>Competence is required in therapy techniques for treatment of client’s impairment </li></ul></ul><ul><li>THERAPIST ROLE </li></ul><ul><ul><li>The client is the patient/litigant </li></ul></ul><ul><ul><li>Attorney-client privilege governs disclosure until the evaluator becomes a witness. </li></ul></ul><ul><ul><li>Attitude toward subject is neutral, objective and detached </li></ul></ul><ul><ul><li>Competence is required in forensic evaluation techniques relevant to the legal claim; familiarity with the law is required as it applies to that issue </li></ul></ul>
    11. 11. Forensic evaluator vs. treating therapist <ul><li>Therapist Role </li></ul><ul><ul><li>Information is drawn mostly from the client with little external scrutiny </li></ul></ul><ul><ul><li>Therapy is mostly patient-structured, less structured than forensic assessment </li></ul></ul><ul><ul><li>Therapy is a helping process, rarely adversarial </li></ul></ul><ul><ul><li>Goal is to benefit the patient </li></ul></ul><ul><ul><li>Basis of therapy is the therapeutic alliance; critical and legally damaging judgments by the therapist could undermine the alliance </li></ul></ul><ul><li>FORENSIC EVALUATOR ROLE </li></ul><ul><ul><li>Litigant information is critically scrutinized and supplemented by collateral sources of information </li></ul></ul><ul><ul><li>Forensic assessment is evaluator structured, more structured than therapy </li></ul></ul><ul><ul><li>Forensic assessment is evaluative, probes for information the litigant prefers not to divulge </li></ul></ul><ul><ul><li>Goal is to assist the trier of fact (judge or jury) </li></ul></ul><ul><ul><li>Evaluative purpose of the forensic assessment is known in advance by the subject; critical judgments by the forensic examiner are less likely to cause lasting distress in the client </li></ul></ul>
    12. 12. Fact vs. expert witness <ul><li>Rule 701. Opinion Testimony by Lay Witnesses </li></ul><ul><ul><li>If the witness is not testifying as an expert, the witness' testimony in the form of opinions or inferences is limited to those opinions or inferences which are (a) rationally based on the perception of the witness, and (b) helpful to a clear understanding of the witness' testimony or the determination of a fact in issue, and (c) not based on scientific, technical, or other specialized knowledge within the scope of Rule 702 . </li></ul></ul><ul><li>Rule 702. Testimony by Experts </li></ul><ul><ul><li>If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the form of an opinion or otherwise, if (1) the testimony is based upon sufficient facts or data, (2) the testimony is the product of reliable principles and methods, and (3) the witness has applied the principles and methods reliably to the facts of the case. </li></ul></ul>
    13. 13. Fact vs. expert witness <ul><li>Evidentiary Standards </li></ul><ul><ul><li>Frye Standard </li></ul></ul><ul><ul><ul><li>Under Frye , the Court based the admissibility of testimony regarding novel scientific evidence on whether it has &quot;gained general acceptance in the particular field in which it belongs.&quot; The trial court's gatekeeper role in this respect is typically described as conservative, thus helping to keep pseudoscience out of the courtroom by deferring to those in the field . </li></ul></ul></ul><ul><ul><ul><li>North Dakota is a Frye State </li></ul></ul></ul>
    14. 14. Fact vs. expert witness <ul><li>Daubert Standard </li></ul><ul><ul><li>Relevancy-The relevancy of a testimony refers to whether or not the expert’s evidence “fits” the facts of the case. </li></ul></ul><ul><ul><li>Reliability </li></ul></ul><ul><ul><ul><li>Empirical testing: the theory or technique must be falsifiable , refutable, and testable. </li></ul></ul></ul><ul><ul><ul><li>Subjected to peer review and publication. </li></ul></ul></ul><ul><ul><ul><li>Known or potential error rate and the existence and maintenance of standards concerning its operation. </li></ul></ul></ul><ul><ul><ul><li>Whether the theory and technique is generally accepted by a relevant scientific community. </li></ul></ul></ul>
    15. 15. Beware the Stealth Evaluation <ul><li>Many types of court cases require testimony from an expert to establish the presence of an injury </li></ul><ul><ul><li>This should be done by a forensic experts who “ base the opinions contained in their recommendations, reports, and diagnostic or evaluative statements, including forensic testimony, on information and techniques sufficient to substantiate their findings. “ (2002 Code) </li></ul></ul><ul><li>The “Stealth Evaluation” </li></ul><ul><ul><li>Psychotherapy becomes a stealth evaluation when the therapist's impressions of the client's mental state and the proximate cause for these symptoms are presented in court as though they constituted a forensic evaluation. This type of testimony has a certain logic or face validity that can appeal to a jury, who may assume that the treating therapist knows the patient well and is in a position to understand the case. The difference between an evaluation and psychotherapy may be difficult to explain to a jury of laymen. </li></ul></ul>
    16. 16. Confusion of roles and role boundaries/Deficient knowledge and lack of consultation <ul><li>Clarify with all adult participants </li></ul><ul><ul><li>The purpose and nature of treatment </li></ul></ul><ul><ul><li>Who has requested the therapist’s services </li></ul></ul><ul><ul><li>Who will be paying the fees </li></ul></ul>
    17. 17. If court ordered, clarify <ul><li>The nature of the court order </li></ul><ul><li>Issues/goals identified by the court to be addressed in treatment </li></ul><ul><li>Any limitations imposed on treatment by the court </li></ul><ul><li>Any foreseeable limitations on therapist or client that may be imposed by the law or by specific court orders </li></ul>
    18. 18. If court ordered, clarify <ul><li>Relevant information about the issues needs to be presented to children (or persons with cognitive limitations) in a developmentally appropriate manner </li></ul><ul><li>If called to testify, therapist weights the potential impact on the client </li></ul><ul><li>Do not testify about the ultimate psycho-legal conclusions…that is the province of the forensic evaluator or the court </li></ul>
    19. 19. If court ordered, clarify <ul><li>No one can compel expert testimony </li></ul><ul><ul><li>If you do not have scientific evidence to support a hypothesis, do not give an opinion </li></ul></ul><ul><li>If you do not have sufficient data to offer an opinion ethically state </li></ul><ul><ul><li>“If I were to answer that question, I would be speculating, your honor.” </li></ul></ul>
    20. 20. APA ethics <ul><li>Release of records, revised 2002 </li></ul><ul><ul><li>HIPAA </li></ul></ul><ul><ul><li>Changed from earlier version of the code </li></ul></ul><ul><ul><li>Requirement for release only to trained professional removed </li></ul></ul><ul><li>Documentation </li></ul><ul><ul><li>APA </li></ul></ul><ul><ul><ul><li>enforceable </li></ul></ul></ul><ul><ul><ul><li>aspirational </li></ul></ul></ul>
    21. 21. Documentation <ul><li>Records should include </li></ul><ul><ul><li>First contact info and identification/cover sheet </li></ul></ul><ul><ul><li>Relevant history, risk factors, attempts to get previous records </li></ul></ul><ul><ul><li>Dates of services and fees </li></ul></ul><ul><ul><li>Diagnostic impressions, assessments, treatment plans, consults and progress notes </li></ul></ul><ul><ul><li>Notes on relevant phone calls </li></ul></ul><ul><ul><li>Info that you would want a new therapist to have if you retire/perish/become catatonic from burnout </li></ul></ul>
    22. 22. When an attorney calls for records <ul><li>Calmly respond </li></ul><ul><ul><li>Get releases from clients </li></ul></ul><ul><ul><li>You are entitled to a reasonable amount of time and reasonable copying fees </li></ul></ul><ul><ul><li>When in doubt, get you lawyer to clarify or attempt to quash subpoena </li></ul></ul>
    23. 23. Requests for written opinions <ul><li>Clarify your role: evaluator or therapist </li></ul><ul><li>If you don’t have a basis for an opinion, don’t give one </li></ul><ul><li>If there are several parties, be certain that everyone is on board with you writing such a letter </li></ul>
    24. 24. The Sheriff is in your waiting room <ul><li>Don’t panic </li></ul><ul><li>Don’t slip out the back, Jack </li></ul><ul><li>Make sure you have gotten good service </li></ul>
    25. 25. High Risk Clients <ul><li>Severe personality disorders </li></ul><ul><li>Risks for therapists </li></ul><ul><ul><li>Desire to rescue </li></ul></ul><ul><ul><li>Erosion of boundaries </li></ul></ul><ul><ul><li>Compromised therapist </li></ul></ul><ul><ul><li>The Board </li></ul></ul>
    26. 26. High Risk Clients <ul><li>Notes and documentation </li></ul><ul><ul><li>Focused and related to tx plan </li></ul></ul><ul><ul><li>Use of note checklists and computerized programs </li></ul></ul><ul><ul><li>“ Don’t write that down!” </li></ul></ul><ul><ul><li>Use of BSI, SCL-90, other forms of screening </li></ul></ul><ul><ul><li>The Therapy Planner Series-Jongsma et al </li></ul></ul>
    27. 27. High Risk Clients <ul><li>How and when to terminate </li></ul><ul><ul><li>Termination vs patient abandonment </li></ul></ul><ul><ul><li>Time limited therapy contracts </li></ul></ul><ul><ul><li>Document instances of therapy non-compliance </li></ul></ul><ul><ul><li>“If you don’t listen to me, you are firing me.” </li></ul></ul>
    28. 28. Ethical issues and technology <ul><li>Phone calls to your client </li></ul><ul><li>Fax machines </li></ul><ul><li>Cell phones </li></ul><ul><li>Computers </li></ul>
    29. 29. The Seven Deadly Sins <ul><li>From the movie “Serenity” </li></ul><ul><ul><li>The Operative : Do you know what your sin is? Capt. Malcolm Reynolds : Aw hell, I'm a fan of all seven... but right now, I'm gonna have to go with Wrath. </li></ul></ul>
    30. 30. Sin Number One-Ignorance of the APA Ethical Standards <ul><li>Competence-Provide services only when you are qualified to do so by virtue of education, training and/or experience. </li></ul><ul><li>Remember, in a forensic or any other setting the onus is on you to demonstrate your competence. </li></ul><ul><li>How competent is competent enough? </li></ul>
    31. 31. Sin Number One-Ignorance of the APA Ethical Standards <ul><li>You must actually know the APA Code-Not knowing, all by itself is unethical </li></ul><ul><li>Read the Code now and again </li></ul><ul><li>Also, there are good books with illustrative cases: </li></ul><ul><ul><li>Decoding the Ethics Code </li></ul></ul><ul><ul><li>Ethics in Plain English </li></ul></ul>
    32. 32. Sin Number One-Ignorance of the APA Ethical Standards <ul><li>Respect for people’s rights and dignity </li></ul><ul><ul><li>You must be aware that our judgments about people may be influenced by prejudices or ideologies. You have an obligation to limit the impact or else remove yourself if you can’t. (Examples: Corporal punishment, sexual behavior) </li></ul></ul>
    33. 33. Sin Number One-Ignorance of the APA Ethical Standards <ul><li>Bases for Scientific and Professional Judgments </li></ul><ul><ul><li>Psychologist’s work is based on scientifically and professionally derived knowledge of the discipline </li></ul></ul><ul><ul><li>You need to be able to support your conclusions </li></ul></ul><ul><ul><li>Clearly related to empirical data and professional literature </li></ul></ul>
    34. 34. Sin Two-Ignorance of the Code as Applied in Forensic Settings <ul><li>Everything in the rest of the standards goes double for forensic activities </li></ul><ul><li>“When assuming forensic roles, psychologists are or become reasonably familiar with the judicial or administrative rules governing their roles.” </li></ul>
    35. 35. Sin Two-Ignorance of the Code as Applied in Forensic Settings <ul><li>Except as noted in 9.01c, psychologists provide opinions of the psychological characteristics of individuals only after they have conducted an examination of the individuals adequate to support their statements or conclusions. </li></ul><ul><ul><li>Exceptions </li></ul></ul><ul><ul><ul><li>Limit and explain </li></ul></ul></ul><ul><ul><ul><li>An affirmative obligation </li></ul></ul></ul>
    36. 36. Sin Two-Ignorance of the Code as Applied in Forensic Settings <ul><li>While not put in these words, it is clearly implied that you should do the best job you can do within practical limits. </li></ul><ul><li>Don’t forget that the stakes are very high. </li></ul><ul><ul><li>The innocent can be wrongly punished </li></ul></ul><ul><ul><li>The guilty may walk free </li></ul></ul><ul><ul><li>A child may be sent back to his/her abuser </li></ul></ul><ul><ul><li>A parent may wrongly lose contact with their child </li></ul></ul><ul><li>You have tremendous informal authority </li></ul>
    37. 37. Sin Two-Ignorance of the Code as Applied in Forensic Settings <ul><li>You should use tests that have been designed for the task you are undertaking </li></ul><ul><li>You should use them the way they are supposed to be used </li></ul><ul><li>What would be an example of poor test selection? </li></ul><ul><li>What would be a common example of misuse of a particular test? </li></ul>
    38. 38. Sin Two-Ignorance of the Code as Applied in Forensic Settings <ul><li>Place minimal reliance on clinical judgment </li></ul><ul><ul><li>It is notoriously inaccurate </li></ul></ul><ul><ul><li>It can lower predictive validity </li></ul></ul><ul><ul><li>Your reasoning may be impenetrable to the court </li></ul></ul><ul><ul><li>How sure you are that you are right is not correlated with accuracy </li></ul></ul><ul><ul><li>It should be used to generate hypotheses-But why not use checklists and structured interviews? </li></ul></ul>
    39. 39. Sin Number Three-Ignorance of the Specialty Guidelines for Forensic Psychologists (SGFP) <ul><li>Forensic psychology refers to all professional practice by any psychologist working within any sub-discipline of psychology (e.g., clinical, developmental, social, cognitive) when the intended purpose of the service is to apply the scientific, technical, or specialized knowledge of psychology to the law and to use that knowledge to assist in solving legal, contractual, and administrative problems. </li></ul>
    40. 40. Sin Number Three-Ignorance of the SGFP <ul><li>If you engage in any of the aforementioned activities, you are in the forensic realm </li></ul><ul><li>When this happens, the SGFP kicks in </li></ul><ul><li>That means it is time to be more careful </li></ul><ul><li>Exceptions-If you are a therapist and you get dragged into court </li></ul>
    41. 41. Sin Number Three-Ignorance of the SGFP <ul><li>Requirement for accuracy, objectivity fairness and independence </li></ul><ul><li>Necessity of utilizing an hypothesis testing model </li></ul><ul><ul><li>Generating all reasonable hypotheses </li></ul></ul><ul><ul><li>Collecting data that supports or undermines hypotheses </li></ul></ul><ul><ul><li>Weighing the data impartially </li></ul></ul>
    42. 42. Sin Number Three-Ignorance of the SGFP <ul><li>To Diagnose or Not to Diagnose-That is the Question </li></ul><ul><ul><li>The draft SGFP suggests you consider the benefits and potential harm of applying a DSM-IV-TR diagnosis when providing testimony </li></ul></ul><ul><ul><li>The diagnosis tells the fact finder very little about actual functional capacity </li></ul></ul><ul><ul><li>The use of the diagnosis may be prejudicial </li></ul></ul>
    43. 43. Sin Number Four-Inappropriate Multiple Roles <ul><li>Probably the most common problem seen by boards of psychology </li></ul><ul><li>There is a percentage of practitioners that just don’t get this one </li></ul><ul><li>Particularly big problem where divorce/children involved </li></ul>
    44. 44. Sin Number Five-Avarice <ul><ul><li>There are many reasons we take cases that we should not </li></ul></ul><ul><ul><li>One of them (although we may be reluctant to admit it) is the bottom line </li></ul></ul><ul><ul><li>We don’t like to admit that unconscious influences play a part in our decision-making </li></ul></ul><ul><ul><li>Don’t forget that if you are in private practice, you are in large part a businessperson </li></ul></ul><ul><ul><li>If you don’t confront this basic reality, you will be blindsided by taking problematic cases </li></ul></ul>
    45. 45. Sin Number Six-Confirmatory Bias, Ideology and Agenda <ul><li>Confirmatory bias-a tendency to maintain beliefs in the face of counter evidence. People at psychologists tend to get stock on a way of looking at an issue and don’t change their minds in the face of contrary evidence. This leads to a tendency to “look for what should know and find what to look for.” </li></ul>
    46. 46. Sin Number Six-Confirmatory Bias, Ideology and Agenda <ul><li>Theoretical orientation can lead to confirmatory bias </li></ul><ul><ul><li>Freudians look for and find unconscious infantile sexual conflicts </li></ul></ul><ul><ul><li>Jungians look for and find nonintegrated archetypes </li></ul></ul><ul><ul><li>Adlerians look for and find strivings for superiority to compensate for feelings of inferiority </li></ul></ul><ul><ul><li>Sullivanians look for and find unhealthy interpersonal relations </li></ul></ul><ul><ul><li>Cognitive behavioral therapists look for and find irrational belief systems </li></ul></ul>
    47. 47. Sin Number Six-Confirmatory Bias, Ideology and Agenda <ul><li>Ziskin and Faust list a number of types of confirmatory bias: </li></ul><ul><ul><li>Favoring initial hypotheses </li></ul></ul><ul><ul><li>Double standards of evidence </li></ul></ul><ul><ul><li>Anchoring effects </li></ul></ul><ul><ul><li>Premature closure </li></ul></ul><ul><ul><li>Effects of confirmatory bias on data collection </li></ul></ul>
    48. 48. Sin Number Seven-Forgetting Who You Are and Where You Are <ul><li>Where You Are </li></ul><ul><ul><li>You are not in your consulting room </li></ul></ul><ul><ul><li>You are not in a clinic </li></ul></ul><ul><ul><li>You are playing the game on a ball field that belongs to lawyers and judges </li></ul></ul><ul><ul><li>The rules are very different </li></ul></ul><ul><ul><li>You need to conform to those rules </li></ul></ul>
    49. 49. Your day in court <ul><li>The emotional toll </li></ul><ul><li>Preparing </li></ul><ul><ul><li>Review your notes carefully </li></ul></ul><ul><ul><li>Do not revise or alter records </li></ul></ul><ul><ul><li>An expert opinion requires an expert’s fee </li></ul></ul><ul><ul><li>Have a current and accurate C.V. </li></ul></ul><ul><ul><li>Meet with the lawyer beforehand </li></ul></ul>
    50. 50. In Depositions <ul><li>I object! You may answer </li></ul><ul><li>Take your time </li></ul><ul><li>If you don’t understand, say so </li></ul><ul><li>Appropriately limit answers </li></ul><ul><li>“I don’t know” </li></ul><ul><li>Don’t try to be funny </li></ul>
    51. 51. Testifying <ul><li>Dress appropriately </li></ul><ul><li>Scope out the room, don’t wander </li></ul><ul><li>Heed the Duke of Wellington </li></ul><ul><li>Ask to clarify </li></ul>
    52. 52. Stupid lawyer tricks <ul><li>“How much are you paid for your opinion?” </li></ul><ul><li>“Were you lying then, or are you lying now?” </li></ul><ul><li>“How many left handed, red haired Estonian dyslexics with OCD have you treated?” </li></ul><ul><li>Erroneous recapitulation </li></ul><ul><li>“A simple yes or no will suffice.” </li></ul>