FORENSIC ASSESSMENT OF PSYCHOLOGICAL
TRAUMA:  COMMON PROCEDURAL AND 
ETHICAL ERRORS




I.  WHAT IS PSYCHOLOGICAL TRAUMA?

     A.  PSYCHOLOGICAL AND BEHAVIORAL RESPONSES TO 
         AN EVENT



          (1)      Stressor - External Event

               (a)      with physical insult

               (b)      without physical insult

          (2)     Stress - Internal Response

               (a)     cognitive

               (b)     physiological

          (3)     Dose of Exposure

     B.  HISTORIC DEVELOPMENT



          (1)     Soldiers' Heart - American Civil War

          (2)     Railway Spine - England 1860's - 1910

          (3)     Shell Shock - WW I

          (4)     Combat Fatigue - WW II

          (5)     Coconut Grove Fire - Lindeman, 1944

          (6)     General Adaptation Syndrome - H. Selye, 1950

               (a)     alarm

               (b)     resistance

               (c)     exhaustion

          (7)     Post-Traumatic Stress Disorder - 1970's

     C.  EVOLUTION OF THE CONSTRUCT OF POST-TRAUMATIC

         STRESS DISORDER (PTSD)

    

          (1)     DSM (1952) - Gross Stress Reaction

          (2)     DSM - II (1968) - Adjustment Reaction

          (3)     DSM - III (1980) - PTSD

          (4)     DSM - IV (1994) - Modification of PTSD
                                         Criteria:

               (a)     criterion A

               (b)     criterion B

               (c)     criterion C

               (d)     criterion F

     D.  POTENTIAL ALTERNATIVES TO PTSD TO DESCRIBE
         RESPONSES

         TO PSYCHOLOGICAL TRAUMA



          (1)     Reliability of the PTSD Diagnosis

          (2)     Validity of PTSD

               (a)     even extreme stressors do not inevitably
                        induce PTSD in all persons

               (b)     not all persons are equally vulnerable
                        to PTSD

               (c)     constitutional factors

               (d)     different stressors may have common
                        expression

               (e)     pre- and post-event influences including
                        stressors and social support

               (f)     co-morbid disorders

               (g)     pre-event and symptoms disorders

          (3)     Complex vs. Simple Trauma

          (4)     Disorder of Extreme Stress Not Otherwise 
	           Specified

               (DESNOS)

          (5)     Acute Stress Disorder

          (6)     Adjustment Disorder

          (7)     Generalize Anxiety Disorder

          (8)     Dysthymic Disorder

          (9)     Major Depressive Disorder

          (10)    Panic Disorder

          (11)    Somatization Disorde

          (12)    Substance Abuse/Dependence Disorder

          (13)    Anti-Social Personality Disorder

          (14)    Bereavement 

          (15)    Dissociative Disorder

          (16)    Factitious Disorder

          (17)    Resilience 

          (18)    Malingering  

               (a)     context

               (b)     anti-social history

               (c)     litigation history

               (d)     pure malingering

               (e)     partial malingering

               (f)     false imputation


II.  THE GOAL OF A FORENSIC ASSESSMENT OF
PSYCHOLOGICAL TRAUMA IS TO PROVIDE THE FACT
FINDER (JUDGE OR JURY)WITH USEFUL, ACCURATE
AND RELIABLE CONCLUSIONS CONCERNING THE CAUSE(S), OUTCOME, FUTURE EFFECTS AND
PROGNOSIS OF A PSYCHOLOGICAL TRAUMA



     A.   FAULT



          (1)     Proximate Cause/Responsible Cause

          (2)     Foreseeability

          (3)     Natural and Probable Result

          (4)     Duty

          

     B.  HARM



          (1)     Impact of the Stressor

          (2)     Functioning Pre-Event

          (3)     Functioning Post-Event

          (4)     Anticipated Level of Functioning in the
                   Future

          (5)     Pre-Event Disorders

          (6)     Post-Event Disorders

          (7)     Co-Morbid Disorders

          (8)     Vulnerability

     C.  CAUSATION

          (1)     Due to an Action

          (2)     Due to Inaction

          (3)     Negligence

          (4)     A Departure from a Standard of Care

     D.  DAMAGES

          (1)     Expenses

          (2)     Lost and Future Wages

          (3)     Pain and Suffering

          (4)     Future Costs

          (5)     Punitive

     E.  PROGNOSIS

          (1)     How Traumatic was the Stressor?

          (2)     How Have Pre- and Post-Event Disorders
                     Affected Current Functioning?

          (3)     How Have Pre- and Post-Event Factors Affected
                     Functioning?

          (4)     What Effect on the Future Will Pre- and Post
                     Event Morbidity and Influences Have?

          (5)     What Progress Has the Patient Made to Date?

          (6)     Factors Affecting Treatment:

               (a)     economic

               (b)     motivational

               (c)     chronicity

               (d)     severity

          (7)     Pre-Event Functioning

          (8)     Post-Event Functioning

III.  ATTRIBUTES OF A COMPETENT FORENSIC    
ASSESSMENT OF PSYCHOLOGICAL TRAUMA



     A.  PROPER DISCLOSURE



          (1)     Purpose

          (2)     Who Retained the Examiner

          (3)     Is the Patient Represented by Counsel

          (4)     Disclosure of the Limits of Confidentiality

          (5)     Explanation of the Difference Between
                   Evaluation and Treatment

          (6)     The Importance of Candor

          (7)     Fee Discussion

          (8)     Description of Methods, Including Testing
      	           When Indicated

     B.  MULTIPLE SOURCES OF INFORMATION

     

          (1)     Records:

               (a)     school

               (b)     diaries

               (c)     medical

               (d)     police

               (e)     military

               (f)     therapy

               (g)     media accounts

          (2)     Testing as Indicated

          (3)     Collateral Contacts



     C.  ADEQUATE HISTORY



          (1)     Techniques:

               (a)     open-ended questions

               (b)     specifically-focused inquiry

               (c)     formal structured interviews

          (2)     Pre-Event, Including Major Stressors

          (3)     Post-Event, Including Major Stressors

          (4)     Event

     D.  ASSESSMENT OF CURRENT FUNCTIONING



          (1)     Social

          (2)     Vocational

          (3)     Recreational

          (4)     Medical

          (5)     Psychological

          (6)     Sexual

          (7)     Substance Use

          (8)     Resilience

          (9)     Support Systems/Social Relatedness

         (10)     Positive Coping Skills

         (11)     Symptoms Don't Necessarily Mean Impairment

         (12)     Memory and Reflection on the Trauma are not
                     Necessarily "Symptoms"

         (13)     Document the Decline, Impairment, or
                     Improvement in Specific Domains, Roles,
                     and Competencies

         (14)     Are There Secondary Effects - Especially
                     Vocational and Economic?

         (15)     Personality is Not Pathology

     E.  DIAGNOSIS

          (1)     Consider Alternatives to PTSD

          (2)     Beware of Over-Diagnosis of PTSD

          (3)     What was the Stressor(s), and How Severe was
                     it?

          (4)     Convenient Focus

          

     F.  PROGNOSIS



          (1)     Recommended Form(s) of Treatment

          (2)     Recommended Additional Diagnostic Studies

          (3)     Anticipated Duration and Frequency of
                     Treatment

          (4)     Projected Costs of Treatment and Diagnosis

          (5)     Predicted Outcome (by domain if indicated)



IV.  THE FIFTEEN MOST COMMON PROCEDURAL AND
ETHICAL ERRORS COMMITTED IN THE COURSE OF
ASSESSING

    PSYCHOLOGICAL TRAUMA



     A.  HINDSIGHT BIAS - Hindsight bias occurs when the
clinician has knowledge of a pre-assessment trauma(s), and
assumes that a subsequent symptom picture or diagnosis
necessarily follows.

     B.   THE AVAILABILITY HYPOTHESIS - The clinician
employs only data available to himself or herself in order
to account for the current level of functioning.  This
involves a failure to consider the impact of information
which may be essential but is not available.  It results
in an inappropriate effort to fit the "facts" to the
outcome.

     C.  CONFIRMATORY BIAS - Here, the clinician
systematically discounts information that may contradict
the "preferred" hypothesis.  The "preferred" hypothesis
oftentimes is the point of view preferred by the retaining
party.

     D.  IMPROPER USE OF EMPATHY IN A FORENSIC
EVALUATION - This occurs when techniques appropriate to a
supportive/psychodynamic treatment approach are
deceptively employed (often in concert with the creation
of a yes set and fixed questions) to develop a preferred
point of view from the patient.  Psychologists have an
obligation to conduct proper interviews no matter which
side retains them.

     E.  SYNDROME TESTIMONY - This error occurs when the
psychologist creates or misapplies information in order to
create a syndrome or improperly applies the facts of the
instant matter to an established syndrome.  Syndrome
testimony in general is difficult in that most syndromes
worthy of that designation will already have been
operationalized in DSM - IV.  The introduction of evidence
derived from conceptualizations commonly termed "rape
trauma" or "battered victim" can be more informative using 
psychological principles derived from social, clinical and
cognitive theory and the recognized disorders contained in
DSM -IV.

		F.  MISATTRIBUTION - In this instance, the
clinician erroneously attributes the cause of a set of
symptoms or a disorder to a trauma of insufficient
severity to cause the symptoms in question or to a trauma
which didn't cause the symptoms.

     

     G.  MISAPPLICATION OF CONCEPTUAL MODELS AND
SYMPTOM PATTERNS FROM THE RESEARCH CONCERNING SEXUAL
ASSAULT AND COMBAT TRAUMA - It is not yet possible to
post hoc determine the form of trauma experienced from the
presenting symptom picture.  Self-report, multi-source
assessment methods, and psychological testing are 
necessary to conduct a proper assessment.  The
misappropriation or misapplication from the clinical and
research literature concerning sexual assault or combat
trauma to the trauma at hand represents a significant
error in judgment.

     H.  FAILURE TO CONSIDER THE "EGGSHELL" STATUS OF
THE PLAINTIFF/PATIENT - Failure to recognize the
eggshell phenomenon can result in a false positive
diagnosis of trauma, or a false negative diagnosis. 
Recall that the law does not require a diagnosis of PTSD
to establish psychological harm.  The accurate diagnosis
of PTSD does not necessarily ensure that the Court will
recognize the presence of significant trauma.

     I.  INADEQUATE HISTORY - Inadequate histories
typically fail to adequately inquire about significant
pre-event traumas as well as significant post-event
traumas.

     J.  FAILURE TO CONSIDER MALINGERING/SECONDARY
GAIN - This is a common error of clinicians whose
predominant focus is treatment rather than forensic
assessment.  In any psychological/legal context,
malingering and secondary gain must be considered.  This
is true in both criminal and civil matters.

     K.  FAILURE TO CONSIDER AN ALTERNATIVE DIAGNOSIS
TO PTSD - A subsidiary problem under this category is the
mistaken assumption that PTSD (which is truly present) is
secondary to the event alleged or the event which has
prompted legal action.

     L.  OVER-DIAGNOSIS OF PTSD - A wide variety of
research investigating a variety of traumas indicate that
somewhere between 20 and 30% of people suffering
significant trauma can be diagnosed as suffering from PTSD
post-event one year post-event.  The actual meaning of
this statistic must be re-evaluated in light of the
addition of Criterion F that which demands that:  "the
disturbance causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning."

M.  POOR OR INADEQUATE DOCUMENTATION - This
occurs with alarming frequency.  Most common is the
absence of adequate notes requested of treatment
providers.  Recall the ethical standards demand an
adequate level of documentation whenever a forensic issue
is in process or can be realistically anticipated.

     N.  TREATMENT BIAS - This occurs when a treating
psychologist inappropriately agrees to provide expert
testimony from the perspective of a psychologist
conducting a forensic assessment.  Treatment bias can
obtain when a psychologist becomes over-invested in the
patient being evaluated and inappropriately provides
treatment to the patient.  Treatment can be provided only
in an emergency context in the course of a forensic
assessment.

     O.  IATROGENIC CREATION OF FALSE MEMORIES -
This occurs when the clinician inappropriately employs
therapeutic techniques such as hypnosis, dream analysis,
guided imagery, abreaction, etc. in the course of a
forensic assessment.

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