Postcards from the Id

Good Article Summarizing the Specialization of Forensic Psychology

While in the process of conducting a literature search for a possible area of research interest (yes, I am actually doing, and not just thinking about doing, research-related tasks!), I came across an article published in Volume 39 (2008) of Professional Psychology: Research and Practice (the link provides access to the abstract only).  The article is entitled, "Specialized Practice in Forensic Psychology: Opportunities and Obstacles," and was authored by Ira K. Packer, Ph.D.  I like the article very much as a basic descriptor of what forensic psychology is.

More specifically, the article simultaneously notes that there continues to be a wealth of opportunity for psychologists in the various sub-specialities of forensic psychology, due to a significant need for quality work in the area.  Packer cites various statistics about the numbers of requests for various types of psycho-legal evaluations, and he also provides definitions for terms associated with forensic work. 

In addition, the author provides brief summaries of the most important areas that a clinical psychologist must address if he or she is to engage in forensic-related work.  The article reviews various areas of specialized knowledge, such as developing a conceptualized understanding of the areas related to competency to stand trial, as well as the various measures that have been developed to assit in this type of assessment.  The differences in professional roles between the clinician and evaluator are discussed, as well as the particular issues associated with providing expert testimony.  The importance of developing knowledge of the dinstinctive research associated primarily with forensic work is also reviewed. 

The limited amount of available pre-doctoral, internship, and post-doctoral training in forensic psychology is addressed, and recommendations for supervision in forensic work are offered.  The article, by itself, does not provide in depth detail with respect to a number of these issues; however, it does provide a nice outline for those seeking a basic primer regarding the field of forensic psychology, and what is involved in developing an expertise within this specialization.  I'd recommend it to anyone who who like a summary of the field, as well as some citations related to the topics, to provide for further inquiry, if desired. 

Book Quote - The Amnestic Syndrome

" Global amnesia refers to a dense and circumscribed deficit in memory in the context of otherwise preserved intelligence.  It encompasses the acquisition of events and facts encountered postmorbidly (anterograde amnesia), as well as the retreival of information acquired premorbidly (retrograde amnesia).  Patients with amnesia are capable of holding a limited amount of information in mind for a very brief period of time, but with increased retention interval or increased interference, their recall and recognition of the information inevitably fails.  Anterograde amnesia is usually global, in that memory for all new information is affected - regardless of the nature of the information (i.e. verbal or nonverbal) or the modality in which it is presented (i.e. auditory or visual).  In most patients, anrerograde amnesia is associated with some degree of retrograde loss, although its extent is more variable.  The reverse, however, is not necessarily the case, as some patients have been described who demonstrate relatively focal retrograde amnesia in the absence of anterograde memory loss (Kapur, 1993; Kopelman, 2000)."

- From The Handbook of Memory Disorders, Chapter 7 (by Margaret O'Connor and Mieke Verfaellie)

I've had several cases recently in which some degree of memory impairment has been reported.  As a result, I've contined to focus on various aspects of memory impairment, which explains the recent posts on memory-related topics.  I thought this paragraph effectively described the issues associated with the two general types of amnesia: 1) Anterograde - from the point of onset, a person cannot form new memories, and; 2) Reterograde - a person cannot recall memories from a particular time period in the past, but is able to form new memories. 

With respect to anterograde amnesia, two movies that have portrayed this issue are: 1) 50 First Dates, in a lighthearted, comedic manner, and; 2) Memento, in a darker, film noir manner.  In each case, a head injury impairs the individual to the point where they can no longer form long-term memories; once time passes, or new information is presented (interference), the preceeeding stimuli is lost.  Memento is particularly effective in demonstrating the impact this sort of problem can have, utilizing a clever time-sequencing device to impart the memory problem onto the audience.  If one is interested in reading a fascinating portrayal of this type of problem, I highly recommend the chapter "The Last Hippie" from Oliver Sacks' An Anthropologist on Mars .

Retrograde amnesia has been shown in film as well.  In the case of a brain injury, Overboard with Goldie Hawn presents a woman who loses memory of her past after a fall and subsequent hit on the head.  More common in the movies (liely due to theatrical potential) is psychogenic retrograde amnesia (amnesia for past events for psychological, not medical, reasons).  In The prince of Tides, Nick Nolte works through a childhood trauma for which he cannot recall the event; many movies will portray memory loss of this type as a result of a traumatic event (including the comission of a crime), often using this set up as a plot device.

As time and interest permits, I'll keep posting stuff I think might be interesting!

New Study Bolsters Findings of Forensic Evaluators

This article reviews new research indicating forensic evaluators operate with a high degree of accuracy.  The research used a mathematical model to assess the findings of a group of forensic psychiatists, who offered opinions on 156 cases.  The researchers found the evaluators distinguished competent from incompetent defendants 29 out of 30 times.  From the article:

In an average of 29 out of every 30 cases, the psychiatrists could distinguish competent defendants from incompetent defendants. That’s a level of performance that exceeds standard diagnostic performance in other areas of medicine, such as spotting breast cancer in mammograms or using advanced imaging methods to detect Alzheimer’s disease.

What I also like about this research is the recognition of the difficulties in providing "Yes/No" responses, as psycho-legal issues generally require, when one is dealing with a particularly complicated case.  It is perfectly reasonable for two experts to examine the same data, yet ultimately arrive at different opinions, when the data is complex, scattered, etc.  There is not a single line separating competency versus incompetency to stand trial, or with other psycho-legal issues; there are cases where defendants fall somewhere in the middle.  As the article states:

“These results help us see how courtroom experts can be quite accurate in distinguishing competence from incompetence, but still reach different conclusions,” says Mossman of the study, which was published online in Law and Human Behavior, the journal of the American Psychology-Law Society. “It’s a matter of where experts draw the line on the issue of competence.”

Continues Mossman: “Experts may disagree with each other even though they are very good at making all the right distinctions. You’re apt to get disagreement when you ask experts for a ‘yes’ or ‘no’ answer, as the courts do, on issues that can have gray areas, like competence to stand trial.”

This is not to say there isn't the occasional individual who tends to find in one direction or the other more frequently, for whatever reason.  However, the notion that virtually all evaluators already have their minds made up is nonsense.  In addition, as the methods available to assess defendants continues to improve, it will become increasingly difficult to defend and outlying opinion.  Foresnic evaluations are far more data-driven than in the past, and more scientific in general; as a result, an opinion isn't worth much unless an expert can back it up on the stand.  A thorough evaluation, addressing the pertinent questions, explaining the findings in a way that makes sense to everyone in the courtroom, and being honest pretty much addresses these issues. 

Current Case Highlights The Differences Between Types of Forensic Evaluations

I just read this article, which indicates the judge has found the defendant competent to stand trial.  This case has reached national prominence; the defendant is accused of killing a beloved high school football coach in Iowa.

According to the article, there was no dispute between the various experts on the defendant's diagnosis: everyone agrees he suffers from paranoid schizophrenia.  However, the judge agreed with the prosecution expert that, due to a positive response to treatment with medication, the defendant meets the critieria to proceed.  From the article: 

The judge said Becker's paranoid schizophrenia is "undisputed" but that an increased dosage of an anti-psychotic medication, along with findings of the prosecution's psychiatrist, lead him to believe Becker can understand the trial proceedings.

"The evidence indicates that Mr. Becker has sufficient ability to recall events which will be pertinent to his defense," Carroll wrote in the order. That includes Becker's ability to recall June 24, when Thomas was shot to death in the high school weight room in front of more than 20 students.

"Becker was able to recall and relate those events in a 'precise, chronologic, detailed, coherent manner,'" the judge wrote.

Carroll also agreed with the prosecution psychiatrist's finding that Becker suffers from auditory hallucinations. The judge said that because the hallucinations do not involve the legal system, and because Becker didn't experience hallucinations during the psychiatrist's interview, they likely won't interfere with his ability to assist with his own defense.

The last paragraph is related to a significant point.  As I've noted in previous posts on the subject of competency to stand trial, the issue of competency is a functional analysis.  That is, an evaluator has to assess to what degree an individual is capable of completing certain tasks.  In the case of competency, the presence of a mental health disorder, even a significant one such as Schizophrenia, does not automatically preclude competency to stand trial.  An evaluator must assess the degree to which the symptoms associated with the disorder impact the abilities required to meet the threshold in question.  In this case, it appears as though all individuals agree not only on the diagnosis, but on a symptom that can significantly impair an individual (auditory hallucinations).  However, even with a symptom like this, an assessment must be made as to whether the presence of this individual's symptom experience would impact the criteria for competency.  In this case, it was determined the auditory hallucinations are not associated with a delusional belief system involveing the legal system; therefore, they do not impact the defendant's competency.

What this case may also highlight is the difference between various types of evaluations: in this case, competency to stand trial versus sanity at the time of the offense.  Often people will confuse the two, or believe there is no differnce: "How can he be competent now when he was so crazy then?  it's the same thing!"  No, it isn't, and this case seems to prove why in at least one way: medication.  An individual who engages in behaviors while experiencing the symptoms of a significant mental health problem may be taken into custody, where they then receive treatment, including medication.  If the individual responds to the treatment, they may present as a whole lot better than how they looked before their arrest.  It is certainly possible to be found competent to stand trial, but insane at the time of the offense, or vice versa.  I am certainly interested in seeing how this case plays out from this perspective, as more information is made known.

Forensic Psychology - The Issue of Free Will Versus Determinism

One of the “Bibles” of forensic psychology is Psychological Evaluations for the Courts, written by Gary Melton and others.  It is a extremely informative book that provides extensive examinations of most areas related to the practice of forensic psychology, and would likely be the primary book most people would recommend if “you only had one forensic psychology book to work from...” 

Most forensic practitioners will own this book as a reference, referring to specific sections as particular issues arise.  I am in the process, however, or reading the book (or at least the vast majority of it) in its entirety.  No, I’ve not gone crazy (I boarded that train a long time ago!); I’m actually taking the plunge in applying for ABPP certification.

That’s not what I want to post about right now, though (believe me, I’m sure there’ll be plenty of opportunities to write about that process!).  Instead, I thought I’d comment on a particular issue the book addresses in the first chapter, which I thought was interesting.  This chapter discusses the issues and difficulties inherent in the application of mental health knowledge to legal issues.  Some of this I briefly discussed here, in the context of competency evaluations; this chapter examines the issue more generally.

What I found interesting was the author’s discussion of free will versus determinism in this specific area.  The section opens: “Perhaps the most obvious philosophical difference between the law and the behavioral sciences is that the former is predicated on an assumption of free will whereas the sciences are generally solidly deterministic.”  It goes on to note that models of abnormal behavior have not provided a basis to differentiate between “caused” or “overborne” behavior from behavior that is the result of rational free will. As major models of behavior, the book first identifies behaviorism and psychoanalytic theory.  In these cases, there is no prevailing discussion for determining where influences of behavior end, and free will and choice begin.

The book does note that humanistic and existential schools of thought allow for free will, but perhaps too much in the other direction (i.e. no point of identifying when as person is irrational).  The final model discussed is the medical model, which often results in the concept of predisposition.  None of these models, generally speaking, provide a good fit for what the legal system is looking for, or how it views responsibility for actions.

A couple of quick observations at this point (this is a topic where 1,000 posts could be written, so I’ll stick to a few things that immediately came to mind).  First, this is nothing new - philosophers, scientists, legal experts, etc., have been debating this stuff since the dawn of civilization.  Over time, the pendulum has swung back and forth, both within the various disciplines, and with respect to various behaviors.  As science progresses, we understand more and more about certain aspects of behavior, but in most cases, what is “choice” and what is “beyond one’s control” is still an incredibly complex consideration.  This is particularly true when we consider that we haven’t even settled on the nature/nurture aspect of most behavioral issues, aside from understanding that most behaviors are the result of at least some of each.

I also find it interesting that the prevailing wisdom of the behavioral sciences is deterministic, since treatment providers are in the business of helping individuals facilitate change.  Yes, I could probably come up with a nice, long theoretical argument about how the process of therapy, and the facilitation of change/growth/insight, is still under the broader parameter of determinism, but I won’t.  First, because I don’t have time.  Second, because I do believe that the interplay of deterministic elements in our lives (e.g. our genes, environmental background, etc.) place limits and constraints on our options, I also believe that in most cases, individuals continue to exert some degree of choice within those parameters.  I have discussed this in posts regarding offender therapy, but I believe it applies more generally.

Lastly (for now), forensic evaluators are cut a significant break when it comes to this issue - we don’t have to deal with it (or at least, not very often).  This entire discussion is about broad theoretical considerations; forensic evaluators have very specific conditions to consider.  As the Melton chapter notes, our evaluations are often restricted to the impact upon free will and choice by such concepts as “severe mental disease or defect.”  While not a perfectly defined criteria, it frees us of having to expound upon the broader discussion.  For example, an individual’s background might have contributed to his current Antisocial personality Disorder, a somewhat deterministic conclusion.  However, the diagnosis itself does not rise to the level generally considered to be a “severe mental disease or defect;” therefore, unless there is some additional mental health issue present, the specific conclusion would be that the person’s competency is not impacted by his mental health issue.  The broader consideration is not applicable.

Interesting stuff, and not just from a forensic perspective.  I think I’d like to address this issue again soon, but this time from the context of a therapist - what is my role as a therapist, and how does that fit, as I see it, within the larger debate between free will and determinism.

The Minnesota Multiphasic Inventory - Second Edition - Restructured Format

I’ve finally had a chance to use the MMPI-2-RF on enough occasions to render a tentative verdict: it is as effective as the MMPI-2, and in some ways (primarily length), it’s better.  This may be serious “shoptalk” to those of you unfamiliar with psychological testing, but for those of us who use tests regularly, this “restructuring” is important, as the MMPI-2 may be the single most important psychological test (along with the WAIS) used today.  When there is a change to something as big as the MMPI-2, you’d better pay attention if you are in the business of evaluations.

Briefly, then, I’ll point out the main benefit to the restructured format - time.  Shortened by more than two hundred questions, the test doesn’t take nearly as long to administer.  This allows for the examinee to complete the test without the fatigue and boredom that often accompanies the completion of the longer test.  This translates into a test that received improved attention to the responses (at least in some cases), otherwise known as a more valid response (the test measured what it purported to measure).  Now, working in forensics, I don’t hold any illusions; I know most of my administrations will come back invalid, in my case due to an over-reporting of symptoms.  Even so, the shortened administration time is valuable, in that I can then work with the individual on other tasks with the freed up time. 

Another feature I like with this format is a increased focus on the somatic presentation of the examinee, including the validity of somatic complaints.  This is particularly helpful in a correctional setting, where many inmates pine for limited resources - accurate assessment of somatic concerns can help save money, as well as allow for resources to be directed to those most in need.  Other minor improvements, such as certain re-categorizations, are also beneficial.

Conversely, I've read some of the criticisms of the new structure (primarily the switch from the old clinical scales to the new RC scales - more shop talk), and while the concerns are reasonable (1) the new test focuses more on overt and/or different pathology than clinical/personality presentation, 2) though the new scales are "more pure" - no item overlap - this doesn't jive with clients, who often have multiple, overlapping problems, and 3) debates about the complexity of the new scales versus the old in assessing the subtleties such as defense mechanisms, etc.), I don't think they warrant too much worry, as least in my case (selfish me!).  For the time being, clinician's can use either test, and as long as both tests continue to receive ongoing examination and research, they should both be effective tools for assessment.

Now, the research will have to come out and  continue support the initial reports of the viability of the new instrument, above and beyond the initial efforts (which appear significant).  As the items are based on the items from the MMPI-2, this shouldn’t be much of a problem, but one needs to establish the validity and reliability anyway.  I recently read this article, published in Psychological Assessments (full text available by purchase only), which indicated the validity of the new L and K scales on the MMPI-2-RF are effective in sorting out under-reporting of symptoms (which is a necessary function in numerous contexts, including custody evaluations, assessment for need for treatment, etc.)  Obviously there is much more to the article than this, but that isn't the primary point of this post.  As the research on the various scales continues to come out, I’ll try to post links, if not summaries.

The Forensic Neuropsychology Casebook - Review of Chapter One

As I stated in my main review of this book,  I plan on providing briefer reviews with each individual chapter I find helpful, including all of the chapters related to criminal forensic psychology. However, today I will start with chapter one, which was written by Neil Pliskin and addresses a civil case related to an electrical injury.

I found this chapter interesting for two primary reasons: 1) I am unfamiliar with the literature related to the neuropsychological impact of electrical injuries, and 2) the jurisdiction in question was British rather than American. While the jurisdiction issue in this particular case is only interesting in the abstract (I don’t plan on having to testify under British rules anytime soon), the issues related to the electrical injury very well may be of practical use at some point.

Without too much detail, the case itself deals with the injuries suffered by a construction worker on a Caribbean island. The client was working on a job site for a steel construction company when a steel angle iron came into contact with an electrical power line that was supposed to have been shut down by the power company. Witnesses reported hearing an explosion, and seeing the client fall backward. He immediately stopped breathing, and his brother (also a coworker) provided CPR for approximately 15 minutes before paramedics were able to provide treatment via six defibrillations. He was transported first to a local hospital, then a hospital in Southern Florida where he remained for 18 days. In short, he required significant treatment for some period of time.

One interesting aspect about this particular chapter was that the evaluation required an assessment of the individual’s executive functioning (planning, goal setting, motivation, etc.) in addition to the usual areas of cognitive functioning. This required obtaining a detailed history of the client’s habits, experiences, and skills in these areas in addition to the usual testing. One point you will see me make again and again as I review the chapters of this book is the importance of obtaining relevant information outside of the formal testing session, whether through interviews, requests for information from previous treatment facilities, or observations of the individual outside of one’s office. In this particular case, what appeared to be extremely helpful were interviews with individuals who knew the client well both before and after the accident, and their descriptions of his behaviors relative to executive functioning. As an example, the individual profiled in the chapter demonstrated significant levels of initiative prior to his injury, including completing high school rolling, and starting his own business. Post-injury, the same individual displayed significant difficulty initiating any activity on his own. Interviews with his wife, brother, and friends helped the evaluator document this change.

The chapter also outlines some of the specific neurological difficulties that can result from electrical injuries. Without going into details, I found this interesting to the specificity of the injury.  serves as  an excellent reminder that different types of trauma experiences can have different types of neuropsychological (as well as psychological) impacts. The chapter identified one or two references for additional information specific to this particular type of injury, but the more important point is to consider the injuries in question during any evaluation.

One final point - know your jurisdiction! The rules regarding the evaluation, and how it fits in to the overall legal framework, will depend on what jurisdiction the case resides. In this chapter, the evaluation and fell under British law, which made in for some interesting reading. The more general point is that if you are conducting an evaluation, know whether you fall under federal or state law, and which state, as each one will have different criteria, definitions etc. The chapter provided detailed test data in the summary of the findings, which I always find interesting and helpful. Oh, one other thing - having to go and testify in the Caribbean wouldn’t be the worst thing in the world...

Book Review - The Forensic Neuropsychology Casebook

What a pleasure it has been reading The Forensic Neuropsychology Casebook. Edited by Robert Heilbronner, the book presents 17 chapters devoted to addressing different aspects of forensic neuropsychology cases, each written by a different author. The cases include various aspects of adult and child civil court issues, as well as for chapters addressing issues related to criminal court. In addition, there are three “Ask the Expert” dialogue chapters at the end of the book, addressing questions common to the practice of forensic psychology. The chapters are easy to read for anyone with even minimal experience in forensic psychology, chock full of interesting information/strategies/techniques for conducting comprehensive evaluations, and also provide an allowance for the authors to discuss her thinking process as they were completing the evaluations presented.

At first, I was slightly disappointed when the book arrived to note there were only for chapters addressing issues related to criminal forensic evaluations. I read those first, and found him to be both interesting and informative. I was planning at that point to move onto a different book, figuring the case presentations for civil law would not offer any information relevant to my area. I’m glad I did not listen to myself! I chose through the chapter addressing and assessment of traumatic brain injury and a Spanish-speaking client, and found a well filled information related to conducting such an evaluation, no matter that the case was civil in nature.

While I have not finished reading the book, I have read most of it, and I certainly comfortable wholeheartedly endorsing it. While anyone may find this book interesting, it may require at least some experienced intrinsic psychology to truly get anything meaningful out of it. Some of the very features I find so interesting, such as listings of test results that were administered during the evaluations, will likely be meaningless to individuals not familiar with that we some of these tests. In addition, certain terms such as ataxia, anoxic encephalopathy, etc. that are sprinkled throughout the book (this is after all a book dealing with individuals suffering from various organic brain disorders) may frustrate individuals not familiar with such terms. On the other hand, if you are a student, particularly an intern, this text would likely prove to be an excellent demonstration on conceptualizing cases, choosing assessment instruments, synthesizing assessment results, and other aspects related to conducting forensic evaluations. Thus far, every case presented as provided a comprehensive summary of testing results and history; this has made the experience even more informative.

In addition to recommending this book as a whole, I would like to provide a review of it chapter by chapter. While this may ultimately prove to be biting off more than I can chew, it certainly would be worthwhile to attempt. Keep an eye out, at the very least, for reviews of all four chapters related to criminal forensic evaluations, as well as at least a couple of the civil law chapters I found particularly helpful.

A Couple of Forensic Psychology Links

Hey folks, here is a short round-up of a few links to forensic psychology-related stuff:

1) Karen Franklin at In the News has this post about two cases, one in Texas, the other in front of the Supreme Court, that have significant ramifications for the issue of competency.  Not competency to stand trial, but the competency to represent oneself as one's own attorney, and the competency to be executed.  As I posted here, there are a number of different types of competency, including the three mentioned above.  However, the Supreme Court ruled in 1993, in Godinez vs. Moran, that the same level of competency applies, regardless of the issue.  For example, if you are competent to stand trial. you are also competent to make a decision about whether to represent yourself or not.  This is a hotly disputed issue, so the cases Dr. Franklin discusses have potentially huge ramifications for current and future cases involving competency.  If you are practicing criminal forensic psychology at all, a student in forensic psychology, or someone who's considering forensic psychology, check her post out, in order to get an idea about the types of issues forensic psychologists come up against.

2) Over at All About Forensic Psychology, there is a book review for a new book covering the insanity plea.  The book looks really interesting, as it examines 20 different cases that have helped to shape the current law regarding Not Guilty by Reason of Insanity (NGRI).  The book is entitled Insanity: Murder, Madness, and the Law , and it's authored by Charles Patrick Ewing.  I definitely plan on ordering this, so expect some sort of review in the future, though I promise no timetable!

3) Here is a fantastic summary of competency to stand trial, written by Ronald Roesch and Stephen Golding.  It was originally an article entitled "Competency to Stand Trial: Assessment and Treatment Issues," which was published in Applied and Preventive Psychology in 1993. If you are looking for a clear, succinct, and very informative overview of competency to stand trial, check it out.

With all the good stuff out there, I'm almost ashamed to stop at three links.  But, that will keep you busy until my next post.