Conference brochure


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.




BIBLIOGRAPHY TO ACCOMPANY FORENSIC ASSESSMENT OF PSYCHOLOGICAL TRAUMA: COMMON PROCEDURAL AND ETHICAL ERRORS


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