ASAPIL Conferences & Presentations

Second ASAPIL Meeting

August 2015 - Toronto, Canada

THE SECOND ASAPIL PRACTICE AND RESEARCH CONFERENCE:
NEW DIRECTIONS FOR OUTSTANDING ISSUES

***FREE Registration - NOW CLOSED***

Registration Deadline: August 4, 2015 (Tues)

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Date: August 7, 2015 (Friday)
Time: Full Day; 8am-5pm (EDT)
(Note: $25 USD Food Charge Applies for Full Day)
Location: York University Osgoode Professional Development
1 Dundas Street West Suite 2602, Toronto, ON M5G 1Z3



Research Conference Abstracts

PANEL 1 (MORNING)

FORENSIC PSYCHOLOGICAL EVALUATIONS FOR PERSONAL INJURY: RESEARCH, THEORY, PRACTICE, AND STANDARDS

"Introduction to Legal and Clinical Issues"

Eric Y. Drogin, J.D., Ph.D., ABPP

Personal injury matters present ample opportunity for employing the unique contributions of forensic psychologists. Tort cases are civil matters in which some individual or group had a duty, breached that duty, did so in a fashion that resulted in harm, and was ultimately determined to have a sufficiently causal role in the harm in question. Of central importance is the forensic psychologist’s recognition that mental pain and suffering are multidimensional experiences that may result from a diverse array of potential influences. The assessment of malingering is a key factor in these evaluations, further complicated by the limits of clinical judgment alone in detecting malingering. Evaluators will be expected to utilize a biopsychosocial model that benefits from standardized interview procedures, standardized tests, and reference to collateral sources. As in other areas of forensic practice, personal injury evaluators are obligated to adhere diligently to ethical canons, standards of practice, and legal regulations.


"Psychological Theories and Principles"

Thomas J. Guilmette, Ph.D., ABPP

The etiology of psychological injuries and harm emerging after a traumatic event, even without the prospect of litigation, is often multifactorial and the result of a complex interaction of pre-injury, peri-injury, and post-injury factors, some of which are psychological and personality related, biological, and socially mediated (e.g., biopsychosocial and diathesis-stress models). The most common psychological injuries encountered in personal injury litigation are those associated with emotional distress/mental disorders such as depression, anxiety, or posttraumatic stress disorder (PTSD), cognitive impairments following traumatic brain injury (TBI), particularly from mild TBI or concussion, and pain and suffering as evidenced most often in chronic pain syndromes or other medical symptoms. The complex interaction of biological, psychological, and psychosocial factors that may influence a personal injury litigant’s symptom presentation and maintenance must also include consideration of the potential for the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives.


"From Research to Practice"

Lisa Drago Piechowski, Ph.D., ABPP

Identifying relevant forensic issues is the first step in personal injury evaluations. Considering legal definitions in light of research-based psychological knowledge, the forensic issues can be broken down into three questions or tasks for the forensic mental health expert to address: (1) What mental health disorders are present? (2) What legally relevant functional abilities were affected by the traumatic event? (3) What is the nature and strength of any causal connection between the allegedly traumatic events and the resultant functional abilities of the plaintiff? A personal injury evaluation expands upon and translates this information into data about functional capacity, by identifying the functional capacity that is directly relevant to the legal question, explaining the relationship between diagnosis and functional capacity, and not substituting diagnosis for an analysis of functional capacity. Despite significant conceptual and empirical advances in recent decades, there remains considerable inconsistency in the quality of forensic assessment practice.


"From Practice to Standards"

Leigh D. Hagan, Ph.D., ABPP

Contemporary practice parameters obligate forensic psychologists to adhere diligently to ethical canons, standards of practice, and regulations when practicing in personal injury matters. As guests in the house of law, forensic psychologists must also familiarize themselves with the legal requirements relevant to the preparation and presentation of their findings and opinions. Psychologists who fail to comport adequately with ethical principles, practice standards, regulatory requirements and legal construction put their efforts in some peril and risk substantially undermining the interests of those they serve. The American Psychological Association’s Ethical Principles and Code of Conduct (2002) addresses conflicts between law and ethics, bases for scientific and professional judgment, disclosures of confidential information, documentation of professional work, bases for and interpretation of assessment data, and informed consent. The profession also offers additional sources of guidance with respect to record keeping, test user qualifications, testing standards, and special ethical considerations for the forensic practitioner.


"Legal Standards: The International Perspective"

John R. Williams, LL.B. (Wales), LL.B. (Cantab)

It is illuminating for forensic psychologists to consider not only the legal standards that address personal injury evaluations in their own home jurisdictions, but also those legal standards that may be obtain in other states, provinces, or countries. Comparative legal analysis not only sharpens our insight into critical aspects of the laws that govern our own primary practices, but also may serve as the gateway for opportunities to serve as forensic psychological experts, consultants, or teachers in other diverse locations. Core tort elements of duty, breach, harm, and causality are essentially consistent across jurisdictions, but the ways in which these elements are defined, established, implemented, and regarded will vary in a number of interesting and impactful ways, depending upon the particular practice location in question. The comparative influence of case law, statutes, regulations, and local custom is also going to be observed and construed differently as a function of geography.


"Practice Standards: The International Perspective"

Carol Spaderna, LL.B.

The fashion in which forensic psychologists are expected to conduct themselves was once the function of local practice standards that were rarely considered outside the personal injury evaluator’s specifically defined professional community. The recent tendency, however, has been for international, national, regional, and local guild entities to research, analyze, adapt, and incorporate key aspects of external codes and guidelines into their own ethical schemes. One representative example has been the decision of the British Psychological Society to pattern its own professional strictures and encouragements after those espoused by the Canadian Psychological Association—rejecting, as a consequence, the American Psychological Association’s explicit linkage of legal and psychological issues in the latter’s attempt to fashion precise responses to each of a number of potentially problematic ethical conflicts. Mastering practice standards from foreign jurisdictions lends much to the effective implementation of one’s own indigenous guidance and also may also potentiate employment opportunities abroad.


PANEL 2 (AFTERNOON)

PSYCHOLOGICAL INJURY AND LAW: PRACTICING IN THE TRENCHES

"PTSD Biomarkers as Evidence in Court"

Larry Cohen, J.D., Ph.D.

Biomarkers hold out hope in the legal community for a more definitive diagnosis of psychological disorders like Posttraumatic Stress Disorder than presently is available with diagnoses based on subjective criteria, and especially criteria based on the client’s self-report. Experts relying for their opinions on proposed biomarkers can anticipate admissibility challenges that will focus on the methodological validity, reliability, sensitivity and specificity of these measures. The ways in which courts have dealt with challenges to opinion testimony relying on biomarkers in other substantive contexts suggest a protocol that should be useful to experts and lawyers alike, whether in seeking to admit or challenging the admissibility of biomarkers of PTSD and like psychological disorders, and whether the admissibility standard involves Daubert, Frye or hybrid factors.


"Psychological Safety for Regulated Practices: Suggestions for Psychologists"

Robert H. Woody, Ph.D., ScD, J.D.

The societal evolution of health care has led to an unprecedented degree of governmental regulation, which has stripped away the authority of members of mental health care professions to define, monitor, and control relevant ethics, standards, and laws. The shift to governmental monitoring imposes conditions of practitioners that can have deleterious effects, such as (but not limited to) psychological injury. From the perspective of a defense attorney for mental heath practitioners, this presentation provides anecdotal (i.e., evidence-based) information to reveal adverse conditions and offers suggestions that will help the practitioner create a healthful shield.


"The Role of Suggestibility in Personal Injury Claims"

I. Bruce Frumkin, Ph.D., ABPP

This presentation will discuss the individual differences approach in suggestibility and how that relates to psychological evaluations in intentional torts and negligence cases. Oftentimes an admission of guilt or acknowledgment of wrongdoing is given great weight by the trier of fact. Yet certain individuals, based on individual psychological vulnerabilities and the interrogation or interviewing tactics used, are at greater risk of giving false or partially false confessions. This talk will discuss assessment methods used to determine vulnerabilities to false statements including the use of the Gudjonsson Suggestibility Scale. Also discussed are interrogation tactics used by law enforcement or security personnel, types of false confessions, research in the area of interrogative suggestibility, and relevant case.


"Perceived Injustice Contributes to Poor Rehabilitation Outcomes in Individuals who have Sustained Whiplash Injuries"

Michael Sullivan, Ph.D.

The experience of unnecessary suffering as a result of another’s actions, or the experience of irreparable losses are likely to give rise to perceptions of injustice. Until recently, little systematic research had been conducted on the effects of perceptions of injustice on recovery outcomes following injury. It is now becoming clear that justice-related appraisals can have a dramatic impact on the physical and emotional consequences of injury. High levels of perceived injustice have been associated with more severe pain, more severe emotional distress, and more pronounced disability. Research has also pointed to multiple sources of a client’s perceptions of injustice including, the person responsible for the accident, the insurance representative, as well as the health care provider. This presentation will summarize what is currently known about the relation between perceived injustice and recovery outcomes. The presentation will also address the processes by which perceptions of injustice might contribute to adverse health and mental health outcomes consequent to injury. Implications for intervention will be discussed.


"Assessing High Achievers in Medicolegal Contexts: Challenges and Solutions"

Izabela Z. Schultz, Ph.D., R. Psych.

High achievers, including individuals of above average intelligence, entrepreneurs, business leaders, artists and performers are a challenge in neuropsychological, psychological and vocational assessments in personal injury and workers’ compensation contexts. It is difficult to prove their losses because of the low ceiling and scope of neuropsychological tests, their use of sophisticated compensatory strategies in testing, and significant brain reserves. This presentation will provide a critical review of psychometric, clinical and vocational capacity determination challenges in these assessments, while offering recommendations for vocational experts working with high functioning clients. A novel research-based neuropsychological, psychological and psycho-vocational assessment model developed for business leaders and entrepreneurs with acquired brain injuries and Posttraumatic Stress Disorder will be discussed with the audience. The objectives are: (1) Increased understanding of psychometric, clinical and vocational capacity determination challenges in assessment of high achievers; (2) Ability to identify clinical scenarios involving high achievers in which special multimethod assessment approaches apply; and (3) Learning to integrate neuropsychological and psychological evidence from multiple sources to determine vocational losses of high functioning people.


"Resourcefulness for Recovery Inventory –Research Edition (RRI-RE): Diagnostic and Therapeutic Considerations"

Marek J. Celinski, Ph.D. [co-authors: Rashit Tukaev, MD & Ewa W. Ruzyczka, Ph.D.]

We have developed a rehabilitation planning and progress monitoring instrument that fills the gap in the assessment and treatment of traumatized patients with physical and psychological injuries. The instrument includes subscales such as: having control versus being controlled, having positive ideations versus negative, positive emotions versus negative, integration versus disintegration, and acceptance versus non-acceptance. We present data obtained from administration of the scale in three countries to different groups of subjects: in Canada – it was administered to about 500 victims of MVA and industrial accidents, and to refugees who were frequently psycho-traumatized in the country of origin; in Russian Federation, the scale was administered pre-and post treatment to 55 patients suffering with psychosomatic and anxiety disorders; and in Poland it was given to 660 nursing students to represent the “control” sample. Convergent validity was established. In conclusion, assessment of both pathology and resourcefulness is the optimal way of planning therapy and to increase probability of positive outcome.


"PTSD-SUDs Comorbidities in the Context of Psychological Injury and Law"

Gerald Young, Ph.D., C.Psych.

PTSD and SUDs are both common psychological problems and they are frequently comorbid. However, there is little longitudinal research that can disentangle their temporal relationship towards determining the mechanisms in their comorbidity. Furthermore, the extant research does not consider possible confounds to diagnosis that are relevant to the area of psychological injury and law, such as exclusion of cases of malingering after appropriate assessment and testing. This paper reviews the literature on the question of comorbidity of PTSD and SUDs towards establishing preliminary conclusions that could serve directions for needed research in the area, and with potential application to individual assessment and court purposes. There are four major models in how PTSD and SUDs relate -- self-medication, high risk, susceptibility, and shared vulnerability. Recent research is examining the different models in these regards with respect to individual differences in negative emotionality/ constraint, emotional/ dysregulation, and patterns in PTSD’s different clusters. Overall, the self-medication model is supported, but not exclusively.


Presenter Bio's

Marek J. Celinski, Ph.D.

Marek J. Celinksi is a registered psychologist in the Province of Ontario (Registration Number 1276). Since 1979, he is one of the directors of the Canadian Academy of Psychologists in Disability Assessment. He has been working as a rehabilitation psychologist and a provider of neuropsychological services since 1977 both in private practice focusing on rehabilitation and assessment of head injury and in worker compensation. He has presented at national and international conferences, and published more than 50 papers and book chapters and is the co-editor of a four book series on Resilience and Resourcefulness and Individual and Mass Trauma already published by Nova Science Publishers. He has published or am working on a number of clinical and rehabilitation tests (co-authored or alone) including: Rehabilitation Survey of Problems and Coping (Multi-Health System of Toronto); Resourcefulness for Recovery Inventory - Research Edition; Resilience to Trauma Scale – Research Edition; Psychoassistant/ Concentration and Remote Memory Test - Research Edition; and Social Intelligence Test – R (all published by Cognisyst of Durham, N.C.).

Larry Cohen, J.D., Ph.D.

Larry J. Cohen is a certified specialist in injury and wrongful death litigation who has focused in his more than twenty nine years of law practice on serious medical injury and emotional damages cases, including especially brain injury claims. He received his J.D. from Northwestern University in 1985, and has been admitted to practice in Arizona since 1985. Dr. Cohen also has a Master’s degree and a Ph.D. from Syracuse University and has participated in a post-doctoral program in clinical neuropsychology. He was for many years a member of the adjunct faculty at the Sandra Day O’Connor College of Law at Arizona State University where he regularly taught courses in professional responsibility, pretrial practice and professional liability, and currently teaches as a member of the adjunct faculty at Norwich University. He has received awards such as from the State Bar of Arizona for contributions in continuing legal education. He was recognized by the National Association of Distinguished Counsel as among the top one percent of lawyers in the United States.

Eric Y. Drogin, J.D., Ph.D., ABPP

Eric Y. Drogin is a board-certified forensic psychologist and attorney on the faculties of the Harvard Medical School and the Harvard Law School Trial Advocacy Workshops. He has served in such roles as President of the American Board of Forensic Psychology, Chair of the American Psychological Association’s Committee on Professional Practice and Standards, Chair of the American Psychological Association’s Committee on Legal Issues, and Chair of the American Bar Association’s Section of Science and Technology Law.

I. Bruce Frumkin, Ph.D., ABPP

Dr. Bruce Frumkin holds a Diplomate in Forensic Psychology from the American Board of Professional Psychology. He has performed more than 700 suggestibility-related evaluations, testified more than 150 times in this area, and has several dozen publications related to disputed confessions. He has developed U.S. data to be used in conjunction with the premier suggestibility test, the Gudjonsson Suggestibility Scale.

Thomas J. Guilmette, Ph.D., ABPP

Thomas J. Guilmette is a board-certified neuropsychologist on the faculties of Providence College and the Warren Alpert Medical School of Brown University. He has served in such roles as Director of Neuropsychology for the Southern New England Rehabilitation Center, Director of Neuropsychology for the Rhode Island Hospital, Clinical Director of Neuropsychology for the Vanderbilt Rehabilitation Center, and Chief of the Psychology Service for the William Keller Army Hospital of the United States Military Academy at West Point.

Leigh D. Hagan, Ph.D., ABPP

Leigh D. Hagan is a board-certified forensic psychologist on the faculty of the Eastern Virginia Medical School. He has served in such roles as Director of Psychology Training for the Richmond Veterans Administration Medical Center, Psychology Director of the Middle Georgia Pain Clinic, Psychology Consultant to the John Randolph Work Evaluation Center, Psychology Consultant to the Tennessee Bar Association, Medical Consultant to Disability Determination Services, and Fellow of the American Academy of Forensic Psychology.

Lisa Drago Piechowski, Ph.D., ABPP

Lisa Drago Piechowski is a board-certified forensic psychologist on the faculty of the American School of Professional Psychology. She has served in such roles as President-Elect of the American Board of Forensic Psychology, Chair of the American Psychological Association’s Committee on Professional Practice and Standards, Co-Chair of the American Psychological Association’s Committee on Legal Issues, and recipient of the 2014 Outstanding Achievement Award from the Association for Scientific Advancement in Psychological Injury and Law.

Izabela Z. Schultz, Ph.D., R. Psych.

Dr. Izabela Schultz is a neuropsychologist, clinical psychologist and vocational expert. She is doubly certified with both the American Board of Professional Psychology and the American Board of Vocational Experts. She is a Professor of Rehabilitation Psychology at the University of British Columbia and a director of graduate program in Vocational Rehabilitation Counselling. Dr. Schultz presented and published extensively, nationally and internationally on prediction of disability, early rehabilitation and vocational intervention, and on medico-legal, psychological and vocational aspects of disability, especially in nonvisible disabilities, including mental disorders, brain injury and pain. She was a recent recipient of the American Psychological Association’s Award for Distinguished Contributions to Disability Issues in Psychology. She co-edits Springer Handbook Series on Health, Work and Disability.

Carol Spaderna, LL.B.

Carol Spaderna is a British law graduate currently completing her Ph.D. studies in Psychology at Aberystwyth University. She has served as Co-Chair of the American Bar Association’s Committee on Behavioral and Neuroscience Law and as a member of the American Bar Association’s Committees on Scientific Evidence and on the Rights & Responsibilities of Scientists, having recently presented her latest research findings at the British Psychological Society Annual Conference and at the 34th International Congress of Law & Mental Health.

Michael Sullivan, Ph.D.

Dr. Michael Sullivan is currently Professor of Psychology, Medicine and Neurology at McGill University. He has lectured nationally and internationally on the social and behavioral determinants of pain-related disability. He is known primarily for his research on the psychosocial determinants of delayed recovery following debilitating injury. Dr. Sullivan has published over 160 scientific papers, 15 chapters, and 5 books. He currently holds a Canada Research Chair in Behavioral Health. In 2011, Dr. Sullivan received the Canadian Psychological Association Award for Distinguished Contributions to Psychology as a Profession.

John R. Williams, LL.B. (Wales), LL.B. (Cantab)

John R. Williams is a Barrister-at-Law and Head of the Department of Law and Criminology at Aberystwyth University. He has served in such roles as Legislative Advisor to the National Assembly for Wales, Advisor to the Older People’s Commissioner for Wales, Advisor on Ethics to the British Psychological Society, Trustee and Director of the Age UK and Age Scotland Charities, International Editor for the Journal of Psychiatry and Law, and Member of the United Nations Expert Group Meeting on the Human Rights of Older Persons.

Robert H. Woody, Ph.D., ScD, J.D.

Robert H. Woody is a Professor of Psychology at the University of Nebraska Omaha (UNO), and an attorney (admitted to practice in Nebraska, Florida, and Michigan) representing mental health practitioners in licensing and malpractice complaint cases. He holds a Bachelor of Music Education and Specialist in Education (psychology) degree from Western Michigan University. He has earned a Master of Arts and Doctor of Philosophy degrees from Michigan State University, a Doctor of Science degree (health services administration and research) from the University of Pittsburgh, and a Juris Doctor degree from Creighton University. He is a graduate of the Pat Thomas Law Enforcement Academy (Tallahassee). He has authored/edited 38 books and several hundred articles for professional publications. Prior to coming to UNO, Dr. Woody was on the faculties at the State University of New York at Buffalo, the University of Maryland, the Grand Valley State University, and the Ohio University.

Gerald Young, Ph.D., C. Psych.

Gerald Young, Ph.D., C. Psych., is an Associate Professor in the Department of Psychology at Glendon College, York University, Toronto, Canada. In addition, he is a practicing psychologist. He is the sole author or senior editor/ co-author of seven books, including on malingering (Malingering, Feigning, and Response Bias in Psychiatric/ Psychological Injury - Implications for Practice and Court published by Springer SBM, New York, 2014). For the area of psychological injury and law, he is the first to have organized (a) a scientific association [www.asapil.net], (b) an academic journal [Psychological Injury and Law [PIL, springer.com], and (c) he has written integrative books on the topic (including in 2006, 2007). His other areas of research include child development (Development and Causality: Neo-Piagetian Perspectives, Springer, 2011) and the DSM-5 (he co-edited two PIL special issues on the topic, in 2010 and 2013). His most recent book is on causality and etiology in psychology and psychopathology (Springer SBM, 2016).


First ASAPIL Annual Meeting

August 2009 - Toronto Canada

Click here for the Workshop Vignettes

Research Conference Abstracts

Robert J. Barth, Ph.D.

The American Medical Association’s Guides Library, as it Pertains to “Psychological Injury”, and to “Trauma and Its Psychological Impacts”

The Guides library represents the American Medical Association’s attempt to create state of the art protocols for impairment evaluation, causation analysis, and return to work planning. This library involves multiple publications, including: Guides to the Evaluation of Permanent Impairment; Guides to the Evaluation of Disease and Injury Causation; A Physician’s Guide to Return to Work; The Guides Newsletter; The Guides Casebook; and Disability Evaluation.

The impairment evaluation components of this library are the most widely used basis for adjudicating claims of impairment in the USA and Canada. They are used in occupational injury systems, federal systems, automobile casualty systems, and personal injury systems. For example, they have been formally adopted into the regulations of 38 state workers compensation systems in the USA.

This presentation will discuss how each portion of the Guides library addresses all of the key words listed below. That list of key words was based on the major areas of the new journal “Psychological Injury and Law”, as listed in the announcement for this conference. The presentation will also address the components of the Library, give an update on the corrections that have just been issued for the impairment Guides, address reaction to the Library, address the continuing evolution of the Library, and address shortcomings that need to be addressed (for example, recent research will be reviewed which provides indications of how chronic pain claims should be addressed in future editions of the impairment Guides). The presentation will also review available information in regard to how the library components are created. This will be an introductory discussion to the Library, a critique of its shortcomings, and an effort to prompt responses which can lead to improvement in future editions.


Daniel Bruns, Psy.D., Pamela A. Warren, Ph.D.

Medical Guidelines, Law, and The Biopsychosocial Paradigm

1. Chronic Pain, Guidelines, and the Biopsychosocial Paradigm

2. Chronic Pain, Guidelines, and Supporting Research

Chronic Pain, Guidelines, and the Biopsychosocial Paradigm. In recent years, professional organizations have developed practice guidelines as a means to provide a standardization of care within a profession as well as synthesizing research with clinical practice. The underlying premise was to clarify the appropriate treatment process and improve treatment outcome. Additionally, the insurance industry, most notably Medicare, made far-reaching changes in how the industry defined “usual and standard care” as well as appropriate charges paid for specific professional services.

Chronic Pain is recognized to be a complex biopsychosocial concern requiring a multidisciplinary approach for treatment. A discussion of three chronic pain treatment guidelines, those of the American College of Occupational and Environmental Medicine Practice Guidelines, the Work Loss Data Institute’s Official Disability Guidelines, and the State of Colorado will be presented. This discussion will include an overview of the science behind these guidelines, and the evidence-based medicine methodology used to develop them.

Chronic Pain, Guidelines, and Supporting Research. As these guidelines have now been formally mandated by some State and governmental agencies, there are broad implications for the professions of Psychology, Medicine, and the Law. The use of such guidelines isn’t as simple as deciding which particular set to employ. Rather, the rigor of the science behind the development of guidelines is a critical issue in the future treatment of clinical concerns, as well as in the courts when the practice guidelines, once mandated, are legally challenged.


Angela M. Carter, Ph.D., Tharshini Chandra, B.Sc., Richard. Holden, Ph.D.

The use of forensic tests for the assessment of psychological symptom magnification in worker’s compensation-seeking head injury claimants

A proportion of mild traumatic brain injury (mTBI) patients report persistent symptoms post-injury, despite meta-analytic literature suggesting that symptoms should largely be resolved within three months of the injury. One commonly considered etiology for these persistent symptoms is intentional symptom magnification or fabrication (i.e., malingering). Although there is now substantial sophistication in the field of neuropsychology in the detection of malingering of cognitive dysfunction, there is more uncertainty when the complaints are psycho-emotional/psychological in nature. Apart from the lengthy Minnesota Multiphasic Personality Inventory - 2 (MMPI-2), neuropsychologists often rely on psychological symptom tests without validity indices (or with rudimentary or insensitive indices). The purpose of the present research was to validate the use of some psychological malingering measures within an mTBI population, borrowing the techniques commonly used by our forensic psychology colleagues. The current research examined the validity of the Structured Inventory of Malingered Symptomatology (SIMS) and the Malingering Probability Scale (MPS) in a sample of Worker’s compensations claimants with a high rate of persistent symptoms following mTBI. Comparisons were made with more widely validated tests, such as the MMPI-2 and a variety of cognitive Symptom Validity Tests. Results provide preliminary support for the utility of these tests in populations of mTBI Worker’s compensation claimants.


Marek Celinski, PhD., Lyle Allen, M.A.

Cross-validation of Psycho Assistant, a Novel Symptom Validity Measure

This investigation concerns cross-validation of a novel two-part computerized SVT called Psycho Assistant (PA), with the first part requiring mere confirmation of recognition of presumably over-learned stimuli. The authors posit that such tasks are even easier than the learning and recognition memory tasks in most SVTs. The Objects portion (PAO) includes three remote memory recognition subtests using over-learned stimuli (“Objects”; pictures of famous people, maps and monuments). Following the first subtest, corrective learning and retesting is performed under standard and then purportedly difficult conditions using visual distortion and distracting, random feedback. The optional Shapes (PAS) portion consists of two forced-choice attention / concentration recognition memory subtests utilizing geometric shapes stimuli.

Methods: Samples were drawn from 294 Canadian disability patients undergoing compensation-related evaluations. Genuine and Exaggerating subgroups were defined using CARB, TOMM, and/or a combination of well-validated embedded neuropsychological malingering measures, with binary logistic regression used to predict membership.

Results: Analyses using PAO performance variables correctly classified 90% of patients passing versus failing both TOMM subtests (N=56) with 83% sensitivity at the 95% specificity level. Shapes variables produced 92% overall agreement with 85% sensitivity and 97% specificity, while all variables provided 93% accuracy with 87.5% sensitivity and 97% specificity. Genuine (N=22) and Exaggerating (N=16) subgroups defined by three or more SVT or embedded markers were classified 100% using all PA Object and Shape variables.

Conclusion: Psycho Assistant is a promising novel SVT. Although sensitivity will decline with lower base rates of exaggeration, specificity is expected to remain robust in culturally appropriate populations.


Eric Y. Drogin, J.D., Ph.D.

Michael S. Finch, J.D., S.J.D.

John R. Williams, LL.B., LL.B.

Alan D. Gold, B.Sc., LL.B.

Evidence Law Roundtable:

Evidence Law, Admissibility, and Psychological Injury: International Perspectives

This keynote speaker discussion roundtable addresses the admissibility of evidence of psychological injury as it has evolved in three related international jurisdictions: Canada, the United States, and the United Kingdom. Although each of these legal traditions is linked by common antecedents, the ways in which each jurisdiction has subsequently chosen to address the issue of psychological injury reflects a distinct national character and unique developments in evidentiary jurisprudence.

Speakers will present a brief overview of each jurisdiction’s current and historical approach to the admissibility of evidence of psychological injury, with reference to key cases, specifically elucidated criteria, and reflection on the corresponding state of—and legal regard for—the forensic psychological profession’s own scientific, practice, and ethical posture. Speakers will then review three separate vignettes that raise differing admissibility issues, commenting in each case on the likely outcome in their respective jurisdictions.

The first vignette will involve a novel theory of psychological injury; the second will involve a dispute within the field on the reliability and validity of a psychological instrument; and the third vignette will involve questions of the knowledge, skill, training, education, and experience of the expert witness in question. The review of each vignette will be moderated in a fashion that encourages audience participation in the form of subsequent commentary as well as questions posed to the panelists.

This roundtable will conclude with summaries delivered by each panelist that address (1) differences and similarities in the different approaches to admissibility issues; (2) what forensic psychologists can do to increase the likelihood of admissibility; and (3) implications of the preceding discussion for the future of admissibility of evidence of psychological injury.


Melanie P. Duckworth, Ph.D., Tony Iezzi, Ph.D.

The Fake Bad Scale: Malingering, Overreporting, or Accurate Reflection of Symptoms

It is commonly believed that litigation can lead to an overreporting of symptoms, resistance of symptom resolution, and a focus on disability. The Fake Bad Scale (FBS) is a 43-tem scale that was specifically designed to assess for malingering and overreporting of symptoms in the litigation context (Lees-Haley, English, & Glenn, 1991). The FBS literature has focused particularly on identifying groups that score high and low on the FBS, but clinical differences between these two-group distinctions have remained ignored.

In a convenience sample of 292 litigating chronic pain patients injured in a motor vehicle collision (MVC), a cut-off score of 29 on the FSB was used to form high FBS and low FBS groups. These groups were compared on the following variables: 1) clinical features at the time of MVC and at the time of psycholegal assessment; 2) pre-collision background characteristics; 3) psychological distress (MMPI-2); 4) pain severity and impairment (Multidimensional Pain Inventory); 5) quality of life (Sickness Impact Profile); 6) pain-coping style (Coping Strategies Questionnaire); and 7) health attitudes. No significant differences between the 2 groups on pre-collision variables (e.g., prior physical/sexual abuse and prior MVC and WSIB involvement). The larger proportion of the high FBS group reported neck pain than the low FBS group. Multivariate analyses indicated that the high FBS group experienced more psychological distress, more pain severity and impairment, poorer quality of life, and tended to use more maladaptive coping strategies. Of note, 66% of the high FBS group was likely to be classified as totally disabled compared to 21% of the low FBS group.

Although the current analyses do not rule out the possibility of overreporting or malingering among patients in the high FBS group, the results do indicate significantly higher reports of psychological distress, higher reports of pain and impairment, and poorer pain coping among patients in the high FBS group.


Jeffrey S. Kreutzer, Ph.D., Juan Carlos Arango, Ph.D.

1. Return to work after brain injury. (Dr. Arango)

2. Using research to develop empirically based life care plans. (Dr. Kreutzer)

3. Neuropsychological assessment, cultural sensitivity, and serving the needs of persons from minority groups. (Dr. Arango) 4. How to sleep well at night: Expert witness nightmares and how to avoid them. (Dr. Kreutzer)

Return to work after brain injury. Research indicates high unemployment rates after traumatic brain injury with especially low employment rates for people who were not working before their injury. Participants will learn about research on employment rates after brain injury and prognostic factors. The role of neuropsychological assessment in vocational assessment and rehabilitation will be discussed. Discussion will also focus on vocational rehabilitation strategies and their efficacy. A special emphasis will be placed on describing specialized assessment and intervention techniques for persons with injury who are minority group members.

Using research to develop empirically based life care plans. Rehabilitation professionals are often asked to evaluate patients and identify their long terms needs relating to independent living, transportation, financial management, and other daily living skills. Some have questioned the validity of life care plans. This presentation will describe research on long-term outcomes after brain injury and describe how research results can guide the development of valid long-term care plans.

Neuropsychological assessment, cultural sensitivity, and serving the needs of persons from minority groups. Research on outcomes after brain injury has suggested that persons from minority groups are more likely to have negative outcomes after brain injury. Concerns have been raised about the validity of traditional neuropsychological assessment techniques for persons in minority groups. This presentation will provide information about the unique qualities of persons from minority groups and how their status affects outcomes. Practical information will be provided regarding adaptation of neuropsychological measures and the selection of special methods for persons depending on need. Approaches to specialized test interpretation and treatment planning will also be discussed in detail.

How to Sleep Well at Night: Expert witness nightmares and how to avoid them. Sometimes intentionally, and sometimes not, psychologists often work with attorney to prepare and present cases for courtroom trial. Litigation is an adversarial process that creates stress for psychologists as well as their clients. This presentation will outline a series of challenges and errors often made by psychologists involved in litigation. Emphasis will be placed on describing and suggesting practical strategies to help professionals become more aware of their roles and responsibilities, thereby being more prepared for litigation and more effective as experts. Specifically, consequent to attending this presentation, participants will be able to serve more effectively as courtroom experts, identify situations that commonly jeopardize credibility, and describe effective damage control techniques.


Andrew W. Meisler, Ph.D.

If It’s Not PTSD or Depression, Is It Still Emotional Injury? Issues of Diagnosis and Causation in Personal Injury

Emotional sequelae following tortious action most often take the form of anxiety and depressive reactions. Hence, diagnoses of anxiety disorders (PTSD in particular) and depressive disorders are the most common in personal injury and workers compensation cases involving emotional distress claims. PTSD is especially common – and favored – because of the implicit causal connection between the event and the “resultant” condition. Indeed, many writers have suggested that the diagnosis of PTSD is overused and often misused in this context, and experts involved in forensic evaluation see this frequently in their work.

In contrast, other psychiatric diagnoses with less obvious external “causation” are rarely claimed in such cases. These include Schizophrenia and other psychotic disorders, Bipolar Disorder, and Obsessive-Compulsive Disorder. A recent Medline literature search yielded no references describing such reactions – or claimed reactions – in personal injury or work-related injury cases.

The present paper addresses issues of causation in personal injury, first by providing a research overview and update of findings pertinent to the diathesis-stress model of mental illness. The paper then reviews evidence on biologic and environmental factors in the etiology of different disorder types, including PTSD, depression, and psychosis. An empirically based model of causation is proposed that accounts for the contribution of multiple factors, and helps to reconcile differences between scientific findings on causation and legal definitions of “proximate cause.” Development of a new model for evaluating causation in personal injury is particular relevant in light of a burgeoning research literature on the importance of genetic and biologic vulnerability, as well as prior trauma, in the etiology of PTSD. Case material is presented that (1) illustrates complexity inherent in determining causation in cases of claimed emotional injury, and (2) challenges conventional notions of causation across a spectrum of psychiatric disorders. The evidence suggests that, although non-traditional “emotional injury conditions” may be deemed compensable under certain circumstances, a more rigorous approach should be taken to determining – and not assuming – causation in all cases involving emotional injury claims, including those involving the more traditional depressive and posttraumatic stress reactions.

The presentation will be rooted firmly in the empirical literature, with case material mainly for illustrative purposes and as a bridge from the scientific literature to the clinical/forensic work.


Rickey Miller, Ph.D.

Psycholegal Assessments of Personal Injury: The Scientifically Informed Approach

The unique value of an objective psycholegal assessment of personal injury derives from its scientifically informed approach. This paper aims to help both psychologists and lawyers better understand variables that can compromise objectivity in psycholegal assessments. Strategies for ensuring an unbiased assessment process and analysis of the data obtained with a special emphasis on the assessor-patient relationship will be discussed. In psycholegal assessments, assessors can easily be influenced by the overt and/or covert pressures exerted by the referral source to arrive at conclusions that help build a case. An adversarial relationship can develop between the assessor and the patient in assessments that are initiated by the insurer. Similarly, bias reflected by an uncritical acceptance of the assessment data can compromise objectivity in assessments that are initiated by the patient’s lawyer. In either case, a confirmatory bias may occur in which the assessor consciously and/or unconsciously gathers and interprets data that confirm a preconceived conclusion rather than giving equal weight to data and interpretations that do not. This paper focuses on strategies for identifying and avoiding bias. Issues to be discussed with case examples include: (1) strategies for establishing rapport while maintaining objectivity; (2) ensnarement of patients; how assessors can consciously and/or unconsciously set patients up to fail various tests; and (3) the unbiased and scientifically informed analysis of data obtained from tests including those assessing malingering. Rather than focusing on assessment findings alone, it is crucial for both psychologists and lawyers to analyze assessment methodology and to be aware of possible confounding variables. It is only by analyzing assessment data in a scientifically rigorous manner that the validity of the data can be appraised.


J. Douglas Salmon, Jr., Ph.D., Jacques Gouws, Ph.D.

A practical biopsychosocial model of impairment and occupational disability determination: Ontario motor vehicle accident jurisdiction

This paper will present a practical holistic model of impairment and occupational disability determination with respect to common “own occupation” and “any occupation” definitions. The model considers physical, emotional and cognitive impairments in unison, and draws upon case law support for empirically based functional assessment of secondary cognitive symptoms arising from psychological conditions including chronic pain disorder. Primarily in the context of Ontario motor vehicle accident jurisdiction, case law is presented to demonstrate how triers of fact have: addressed occupational disability in the context of chronic pain; and, interpreted the “own occupation” and “any occupation” definitions by considering the concepts of “work as an integrated whole”, competitive productivity, demonstrated job performance vs. employment, work adaptation relative to impairment stability, and, "suitable work", retraining considerations, “self-employment” and remuneration/socio-economic status in consideration of “any occupation”. A critical evaluation of computerized transferable skills analysis (TSAs) in the occupational disability context shall also be presented. By contrast, support is offered for the notion that (neuro)psychovocational assessment (and situational work assessments) should play a key role in “own occupation” disability determination even when specific vocational rehabilitation/retraining recommendations are not requested in the disability evaluation (e.g. insurer disability examination).


Izabela Z. Schultz, Ph.D.

Vocational impact of psychological impairment: Predicting psychological disability from assessment data

Psychological assessments in medico-legal contexts have both implicit and explicit goals. Often, an implicit goal is determining the impact of psychological impairment on work function and vocational capacity. The psychologist’s opinion is then utilized by vocational experts and forensic economists to determine loss of earning capacity. However, despite significant advances in the science of prediction of disability, using multivariate psychosocial data, no guidelines have been developed for psychologists attempting to translate impairment into disability.

The objective of this presentation is to bridge the chasm between the science of occupational disability prediction and the practice of psychological prognostication in forensic assessment and to facilitate articulation of best practices in this complex and emerging field. The more evidence-informed psychological and vocational prognoses are the more precise and less vulnerable psychological expert testimony in the court will be.

The presentation will address key conceptual and methodological issues, controversies and clinical solutions in the field of predicting psychological disability, focusing on:

1. Conceptual models of occupational disability and return to work: how they inform research and practice of disability determination

2. The relationship between psychological impairment and occupational disability: a cross-diagnostic multifactorial approach

3. Translating the science of prediction of disability into practice of clinical and occupational prognostication

4. Methodological complexities and pitfalls in disability determination in psychological and neuropsychological disorders: brain injury, chronic pain, depression and PTSD

5. The International Classification of Functioning (ICF) Model of Disability (WHO, 2001) and AMA Guides' (2007) approaches to disability determination in psychological injury

6. Decision-making tree in assessing impact of psychological impairment on occupational disability

7. Maximizing reliability, validity and fairness of disability determination: best clinical and forensic practices

8. Anticipated research and clinical advances: where are we headed?

Case examples and audience interaction on issues of interest will be interwoven into the presentation.


Jaye L. Wald, Ph.D., Steven Taylor, Ph.D

Work Impairment and Disability in Posttraumatic Stress Disorder: An Empirical and Conceptual Synthesis

Work impairment and disability are common outcomes of posttraumatic stress disorder (PTSD), as reflected by significant rates of sickness absence, delayed or failure to return to work (RTW) post-trauma, and impaired work performance. Within the psychological injury field, the issue of work impairment and disability in PTSD often arises in workers’ compensation, disability insurance, and other civil litigation. In this context, clinical and forensic practitioners are faced with the formidable challenge of rendering expert opinion on the degree, causation, and prognosis of work impairment and disability in persons with PTSD based upon on a limited scientific literature. The relationship between PTSD and work disability is not well understood, and the longitudinal course, prognosis, and determinants of this disease outcome are largely unknown. Although PTSD and its severity are risk factors of work disability, studies also considerable variation in work disability outcomes, which suggests that other factors also play an important role. Knowledge of the longitudinal course and risk factors of work disability is necessary for developing empirically-based conceptual and prediction models of work disability, which currently do not exist. This information is also needed for developing work disability assessment tools and interventions to improve the evaluation and remediation of this psychological injury. To promote knowledge and understanding of this important critical practice issue, there are three aims of this paper. The first aim is to review the limited available scientific literature on work impairment and disability in PTSD. The second aim is to present a preliminary biopsychosocial conceptual model of work impairment and disability in PTSD, which provides a framework for disability evaluation and management. The last part of the paper offers recommendations for psychological injury research and practice based upon this empirical and conceptual synthesis.


Gerald Young, Ph.D.

Causes in the construction of causal law: A psycho-ecological model

The article presents an integrated psycho-ecological model of the construction of law, with implications for practice in law and psychology. The model is based on a series of concentric circles, each representing a layer of influence on the construction of law. The circle furthest removed from the center represents the influence of culture, society and industry, in particular, and the circle at the center of the circle represents the case at hand, for example, about individual complainant or mass action. The basic terms in relation to cause need clarification and also work is needed to disambiguate the concepts involved. After dealing with these issues, the article examines science and psychology. Is the scientific evidence presented by the expert sufficiently reliable and valid to meet admissibility standards of good compared to poor or junk science? Is the research undertaken for court or presented to court biased, with factors hidden, such as links to industry. Are individual evaluations conducted with biased science serving to justify partial conclusions? The dangers of powerful influences on the construction of law are highlighted, for example, related to the individual complainant malingering and the insurance industry protecting its financial interests at the expense of genuinely injured patients.

ASAPIL 2009 - Workshop Vignettes

To: ASAPIL/ PIL senior board members

From: Gerald Young, President, ASAPIL; Editor in Chief, Psychological Injury and Law, PIL, and Izabela Schultz, Section Head, PIL, Disability/ Work

Glendon College, York University, Toronto, and University of British Columbia, Vancouver

Date: August 24, 2008 [revised February 2, 2009]

Re: Workshop Objectives, Learning Outcomes and Measures, and Vignettes for the Conference: “Trauma and Psychological Injury: Practice, Legal and Ethical Issues”

Abstract. Psychologists need continuing education in areas pertinent to their practice. The area of psychological injury and law presents issues and conundrums that need careful ongoing evaluation for appropriate clinical practice, adherence to ethical standards, and functioning in the legal context. In this article, we prepared a series of vignettes that illustrate these difficulties in the practice, clinical, legal, and ethical spheres related to the area of psychological injury and law. The vignettes, together with accompanying commentaries, are meant for use in workshops, and they aim to educate, stimulate, and provoke. Furthermore, this article has been written as an interactive one with readers, in that we seek commentaries from readers both for purposes of publication and use in workshops.

The editorial board of the journal, Psychological Injury and Law (PIL), and its parent society, the Association for Scientific Advancement in Psychological Injury and Law (ASAPIL), invite commentary to the vignettes presented in this article from everyone interested in this area of study and clinical practice. The article is meant to be interactive, and we actively solicit reader comments. The vignettes have been written for the purposes of a continuing education workshop that the journal and association board is organizing (to be held at the annual convention of the American Psychological Association, August, 2009, in Toronto, Canada; consult www.asapil.org). Specifically, the workshop deals with trauma and psychological injuries deriving from events which are actionable in law. The vignettes are meant to educate, stimulate, and provoke.

The vignettes address conceptual, practice, clinical, legal, and ethical issues and conundrums in each of the major sections of the area of psychological injury and law. These areas concern law (e.g., on evidence and admissibility), forensic psychology, disability and work, the three major types of psychological injury including chronic pain; posttraumatic stress disorder (PTSD) and distress; traumatic brain injury (TBI); and assessment and malingering. In addition, we cover the topic of causation and causality.

The vignettes follow the same structure to some extent. Usually, there is a narrative that accompanies it, and several scenarios are offered for the reader to consider. Often, we tried to mask the best options from our perspective, but sometimes, this was difficult to accomplish. Moreover, what we may consider to be the best choice may present difficulties that we had not anticipated. This is another reason why we are actively soliciting reader feedback.

With your consent, these commentaries on the vignettes that you submit to us will form a major component of the workshop material that we are organizing. Moreover, we will publish the best ones in the journal under your name, after vetting by independent review.

Aside from the vignettes, the following presents the full scope of material for the workshop that the board is organizing. We provide the educational objectives of the workshop, its specific learning objectives, and the particular learning outcomes that we expect.

Psychological injuries concern conditions that occur subsequent to negligent events, such as accidents and other trauma (Schultz and Brady 2003; Schultz and Gatchel 2008; Young et al. 2006; Young and Shore 2007; Young 2008a). They include emotional, neuropsychological, and pain-related sequelae of events at claim. This area of practice and research requires an integrative approach, combining the biopsychosocial and forensic models, in particular (Schultz and Brady 2003; Schultz 2008; Schultz and Stewart 2008; Young 2008b, c).

After referral, the psychologist needs to evaluate the presenting complaints of clients in a comprehensive, impartial manner. Tests that are reliable and valid for the purpose of the assessment are used to supplement other multiple sources of data (interviews; clinical, educational, and work documentation; behavioral observation, collateral data, and so on). The psychologist arrives at conclusions about whether there are relevant diagnoses, impairments, and associated functional impacts, prognosis, and the need for intervention. An important issue to consider is causality—to what extent has the event at claim contributed materially to the presenting complaints and impairments? Usually, in contrast to typical conceptions of legal causality, the concept of psychological causality is multifactorial (Schultz 2003; Young 2007, 2008d). Therefore, the assessing psychologist becomes involved in disentangling the multiple determinants of psychological impairments, including those preexisting and concurrent to the event at claim.

Threats to assessment validity include malingering, symptom exaggeration, symptom minimization, denial, and other response biases. As well, the psychologist has to monitor his or her own biases and learn how to avoid the adversarial pitfalls that mark the field. Evidence law concerns the thresholds of admissibility to court and challenges to the evidence, which in the present field relates to whether the evidence proffered to court is scientifically informed, reaching standards of good science or whether it is based on poor or junk science. The workshop presentations deal with these legal issues as well.

To stimulate the discussion, we offer some of our own commentary to the vignettes written for the presentations. We emphasize that appropriate practice in the field of psychological injury and law requires not only working within the scope of professional regulations, standards, and guidelines but also with specified knowledge of the area that the vignettes address. However, we refrain from commenting on the vignettes themselves, as we look forward to contributions from readers.

A. EDUCATIONAL OBJECTIVES OF THE WORKSHOP

1. (Law) To be able to identify relevant evidence law and legal procedures in cases of psychological injury, and how to avoid some of the pitfalls in the area.

2. (Forensic Psychology) To be able to apply knowledge of the crucial components of a scientifically-informed, comprehensive impartial assessment in cases of psychological injury, meeting all relevant professional, ethical, and legal standards and guidelines.

3. (Disability/ Work) To be able to determine the relationship between psychological impairment and disability, assess readiness to return to work, and facilitate sustained employment in psychological injury cases.

4. (Chronic Pain) To be able to recognize when pain has become chronic, and how to treat such cases by matching treatment to individual in chronic pain clinics, while being aware of client effort and attempt to mitigate loss.

5. (PTSD/ Distress) To be able to evaluate whether a client meets DSM-IV (DSM-IV-TR; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiatric Association, 2000) criteria of PTSD, while analyzing cases in terms of some of the difficulties in the area, such as whether the disorder is being diagnosed too frequently, whether its entry traumatic stressor criterion is appropriate, and whether its criteria reflect the scientific literature.

6. (TBI) To be able to discern the differences between mild, moderate, and severe traumatic brain injury after an event at claim, and to be able to describe the different explanations of how a mild TBI can produce persistent postconcussive sequelae, and how the court deals with such claims.

7. (Assessment/ Malingering) To be able to analyze some different types of reliability and validity, as well as sensitivity and specificity, and to be able to determine whether several often-used scales/ tests of symptom exaggeration and malingering in the area of psychological injury possess acceptable psychometric properties along these lines.

(8.) (Models/ Causality) To acquire the skill of applying the biopsychosocial model to cases at hand, while integrating forensic and related factors. To improve skill in evaluating causality in cases of psychological injury and law.

B. LEARNING OBJECTIVES OF THE WORKSHOP

1. Law.

(a) To be able to distinguish the components of the Supreme Court decision Daubert (1993) and its progeny. (b) To be able to explain the legal decision procedures and players, along with their roles, in cases of psychological injury. (c) To be able to apply learned knowledge of the role of the expert witness in court in cases of psychological injury, and to be able to avoid the dangers in not knowing or not adhering to them, thereby being capable of better meeting admissibility challenges against allowing proffered evidence into court.

2. Forensic Psychology.

(a) To be able to outline the major components of a comprehensive assessment in the area of psychological injury and law, from interview, to collateral information, to prior records, to assessment instruments. (b) To be able to appraise the major biases that can influence assessments in the areas of psychological injury, including in its relationship to the law, and how to avoid them. (c) To be able to summarize the relevant aspects of the forensic psychology guidelines and other relevant professional and ethical guidelines applicable to cases of psychological injury and law.

3. Disability/Work.

(a) To be able to list the complex relationships among impairment, disability and return to work in psychological injury, and list critical factors in how to assess readiness to return to work. (b) To be able to dictate clinical and occupational best practices that promote safe and sustained return to work in psychological injuries, focusing on job accommodation and the occupational impact of psychological injuries. (c) To be able to identify barriers to return to work in psychological injuries and factors in predicting disability.

4. Chronic Pain.

(a) To be able to critically examine the components of chronic pain, and how the definition differs in the DSM and in practice. (b) To be able to determine whether there are types of pain patients, individual differences that matter, and interventions that match the differences. (c) With cases of chronic pain, to be able to monitor treatment efficacy for clients that may be in litigation, because of the legal need for clients to mitigate loss; e.g., to be able to monitor when the readiness for treatment is lacking, treatment adherence slackens, or effort may not be fully forthcoming or is otherwise compromised.

5. PTSD/ Distress.

(a) By examining different client symptom presentations after an event at claim, to be able to distinguish absent, subsyndromal, and full-blown PTSD. (b) To be able to arrive at an opinion as to whether the traumatic stressor criterion is valid or should be changed in the DSM-V. (c) To be able to judge whether the existing categorization of PTSD symptoms into three major clusters reflects the scientific literature, and whether the scientific literature even agrees that PTSD should be a separate diagnosis.

6. Traumatic Brain Injury.

(a) To be able to name the critical variables used in evaluating the distinctions between mild, moderate, and severe traumatic brain injury. (b) To be able to critically read portions of neuropsychological reports referring to mild traumatic brain injury, persistent postconcussive syndrome or postconcussional disorder, and understand possible biological and psychosocial contributions to their etiology. (c) To be able to analyze whether the reports had involved symptom validity, or effort testing, and whether the current controversy in court about whether these instruments should be considered as admissible is valid.

7. Assessment/Malingering.

(a) To be able to examine a test manual and know whether critical psychometric properties are mentioned to determine the test’s appropriateness for cases of psychological injury. (b) To be able to list the most common psychological instruments used in the area of assessment of psychological injury, especially for PTSD and for personality assessment, including some of their strengths and limitations. (c) At a level appropriate for court purposes, to be able to decide and justify which of the tests or scales used in the detection of response bias, including of malingering, should be used in cases of psychological injury and, in interpreting their results on tests of symptom validity, to be able to identify all relevant factors, including those that do and others that do not point to malingering, or that that may otherwise affect results.

(8). Models/ Causality.

(a) To be able to determine whether, or to what degree, a psychologist is working from an integrated biopsychosocial and forensic perspective in a case of psychological injury. (b) To be able to pinpoint whether a psychologist has considered all pre-event, event-related, post-event, and extraneous factors in arriving at conclusions about causality. (c) To be able to decide whether a particular case is one without significant pre-existing psychological vulnerabilities or whether it is a “thin” skull one, or a “crumbling” skull one, even to the point of explaining (almost) all of a complainant’s post-event psychological symptoms, rendering the event at claim without sufficient material cause to be actionable. That is, to be able to discern how event-related factors interact with pre-existing, post-event, and concurrent factors [both unrelated to the event at claim and related to it], and what is the relative contribution of these various factors in causality determinations.

C. ASSESSMENT OF LEARNING OUTCOMES

1. Law

Based on the contents of the workshop, I am able to:

(a) List the four main components of the Supreme Court decision Daubert (1993) and list its progeny. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(b) Describe some key legal decision procedures and players, along with their roles, in cases of psychological injury. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(c) Identify critical ways that expert witnesses can encounter difficulties in court in cases of psychological injury, and how to circumvent them. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

2. Forensic Psychology

Based on the contents of the workshop, I am able to:

(a) Outline the major components of a comprehensive assessment in the area of psychological injury and law, from interview, to collateral information, to prior records, to assessment instruments. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(b) List the major biases that can influence assessments in psychological injury and law. I learned how to avoid them. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(c) Summarize relevant aspects of forensic and other professional and ethical guidelines applicable to cases of psychological injury and law. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

3. Disability and Work

Based on the contents of the workshop, I am able to:

(a) Indicate how impairment differs from disability and what factors affect this relationship and the readiness to return to work. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(b) Identify clinical and occupational best practices that promote safe and sustained return to work in psychological injuries, focusing on job accommodation and the occupational impact of psychological injuries. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(c) Utilize knowledge of barriers to return to work in psychological injuries and factors in predicting disability. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

4. Chronic Pain

Based on the contents of the workshop, I am able to:

(a) Critically examine the components of chronic pain, and how the definition differs in the DSM and in practice. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(b) To decide which type of individual differences matter in chronic pain, and whether treatments should match the differences. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(c) To attempt to monitor treatment efficacy in cases that may be in litigation for psychological injury due to the event at claim because of the legal need for clients to mitigate loss. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

5. PTSD/ Distress

Based on the contents of the workshop, I am able to:

(a) To distinguish absent, subsyndromal, and full blown PTSD, based on client presenting symptoms. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(b) To discuss with sufficient background whether the traumatic stressor criterion is valid or should be changed in the DSM-V. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(c) To decide for myself whether PTSD symptoms should be grouped into three major clusters and even whether the notion that PTSD is a valid diagnosis reflects the scientific literature. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

6. Traumatic Brain Injury

Based on the contents of the workshop, I am able to:

(a) Name the critical variables used in evaluating the distinctions between mild, moderate, and serious traumatic brain injury. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(b) Decipher those portions of neuropsychological reports referring to persistent postconcussive syndrome or postconcussional disorder, and understand possible biological and psychosocial contributions to their etiology. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(c) Read the reports to see if they had involved symptom validity, or forced choice testing, and decide whether such instruments are better than other stand-alone or embedded scales in testing for response bias. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

7. Assessment/ Malingering

Based on the contents of the workshop, I am able to:

(a) Examine a test manual for critical psychometric properties that indicate a test’s appropriateness for cases of psychological injury. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(b) List the most common psychological instruments used in the area of assessment of psychological injury, especially for PTSD and for personality assessment. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(c) At a level appropriate for court purposes, decide which of the tests or scales used in the detection of response bias, including of malingering, should be used in cases of psychological injury. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(8.) Models/ Causality

Based on the contents of the workshop, I am able to:

(a) Value an integrated biopsychosocial and forensic perspective in a case of psychological injury. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(b) Consider pre-event, event-related, post-event, and extraneous factors in arriving at conclusions about causality in cases of psychological injury. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

(c) Decide whether a particular case involves sufficient material cause to be actionable. [Strongly Agree = 5 4 3 2 1 = Strongly disagree]

D. VIGNETTES AND ISSUES

Law

Vignette

A psychologist in a small town receives a referral from an attorney for conducting a psycholegal assessment for an MVA victim who has experienced two years of chronic pain and depression subsequent to the accident. Despite some training in his internship placements, he has never had a case like this and has never testified in a case that went to court. He does not know state evidence law pertaining to admissibility. Although familiar with tort actions, he has never heard of the terms “psychological injury,” “evidence law,” “claimant,” “event at claim,” etc., and is barely familiar with the requirements to be accepted as an “expert witness” by the court.

Possible Responses

1. The psychologist refuses the referral.

2. The psychologist asks the attorney how to proceed with the assessment.

3. The psychologist seeks a senior colleague for advice, who decides to supervise, if not lead in the assessment. They consult the state laws relevant to evidence law, determining whether it is Daubert-based (1993), Frye-based (1923), or different. They learn as they go along.

4. The psychologist accepts the referral, but purchases several good new books in the field and reads some relevant chapters before proceeding.

5. The psychologist passes on the referral to a senior colleague well-trained in the area. She is familiar with how to conduct assessments for MVA victims that meet professional, ethical, and legal guidelines. She is familiar with the state laws with respect to admissibility and challenges, which happen to be Daubert-based. She knows that her testimony must be scientifically-informed. It must be consistent with a state-of-the-art knowledge of the literature and based on a comprehensive, impartial assessment, which includes using the most reliable and valid instruments pertaining to the referral question. She is aware of cross-examination techniques that opposing attorneys may use. She is confident that she can undertake the assessment and do well in court. She subscribes to the best journals in the area (such as Psychological Injury and Law) and understands that psychological injury refers to difficulties such as chronic pain, PTSD, and TBI that may arise due to events at claim. She reads the best books in the area, and knows that she may be asked to bring in the sources at the base of her professional opinions expressed in assessment and testimony. She is aware that the primary Daubert factors in evidence law help screen improper, poor, or suspect science. The potential factors include using scientific methods in testimony that can be proven falsifiable, that have been the subject of peer-review, that have a known error rate, and/or that are commonly accepted (the Frye standard). At the same time, she is aware of the decisions that have followed Daubert, the problems with the criteria, and related psycholegal issues. She knows the steps and reasons for the legal proceedings in such cases. The court would likely accept her as an “expert witness” for cases of psychological injury that fit her education and training.

6. Relative to the ideal psychologist described in the prior paragraph, the psychologist has some familiarity with the issues, does not brush up, and decides to muddle through. Although to a limited degree, he has done mostly defense work.. He has criticized most plaintiff reports on MVA victims that he has had to review. He has a reputation of being somewhat biased toward the insurance industry. He may use tests that are not the most reliable or valid, because they allow him to arrive at the conclusions in his assessments and testimony that he prefers. He decides not to let this one referral from the plaintiff side jeopardize his good standing among defense attorneys and the insurance industry. [Of course, in this example, one could have equally described a psychologist biased toward plaintiffs.]

Some of the errors that the psychologist just described makes in his procedures and assessment as he proceeds include the following: (a) He phones the attorney, asking what is her position about the case and does she have good evidence. (b) He examines the documentation sent to him, and the contents of the data that he gathered in interview and on testing, ignoring evidence against his pre-conceived hypothesis that the client must be malingering. (c) He had used psychological tests that have not passed previous admissibility challenges in court, because of their likely biased nature. (d) In writing his report, he refers to outdated literature that supports his point of view, ignoring recent, more balanced literature. (e) Before submitting his report, without giving his conclusions, he asks for full payment. (f) Later, in court, he denies that he spoke to the lawyer about the case.

Information toward (a) Educational objectives, (b) Learning objectives in measurable terms, and (c) Learning assessment outcomes

This presentation will enable attendees to identify what are relevant federal and state laws related to admissibility of evidence. In particular, the attendee will distinguish details of the requirements of Daubert (1993) and its progeny about proffering evidence. In the end, judges serve as gatekeepers of what is considered admissible to court, and vet testimony for its probative value relative to its prejudicial one. Triers of fact (judge or jury) decide upon the ultimate issue in a case at hand, but mental health professionals can provide valid and valuable evidence (considered “reliable” and “relevant” evidence, respectively, in legal terms) in this regard. At the same time, the multiple errors that they can commit, as shown in the examples provided, can jeopardize not only the case at hand but, also, their careers.

Another objective is to have attendees understand the steps in the legal process and adjudications involved, and the key players and their roles. Attendees will be able to distinguish what are the main differences between the law and psychology in the area of psychological injuries. They will learn explicitly the differences in the professional and ethical obligations of attorneys and psychologists. Ultimately, all psychologists working in the area of psychological injury must know exactly how to function well enough in the adversarial legal system without compromising their integrity and ethical and professional standing.

Forensic Psychology

Vignette

A psychologist receives a referral for a disability assessment, but the referral source can only pay her half of what she is used to receiving in payment. She has some room in her workload, so she takes the case. However, she decides to cut corners. Moreover, she does mostly plaintiff work, and the referral is for the defense. (a) Therefore, she decides beforehand that she does not have to look at all the psychological insurance or independent examinations that have been conducted, so as not to take the chance of arriving at a conclusion favorable to the defense and having the word get around, thereby alienating her usual referral sources. (b) She conducts a quick interview of the individual, without obtaining collateral information from the spouse, or about the workplace regarding functional requirements in the individual’s job, because she is determined to find for the plaintiff and does not want any information to jeopardize her already partly-formed conclusions. (c) She gives the individual simple screening tests instead of diagnostic psychological instruments that test for response validity, style, and bias, including over- or underreporting of symptoms and malingering, in order to avoid obtaining evidence of lack of forthright attitude to the assessment. (d) The psychologist knows from her past experience that any signs of symptom exaggeration by the individual could be interpreted as a cry for help rather than anything like conscious exaggeration for monetary gain or malingering. The psychologist learns later on that the forensic guidelines in place in the profession are being revised and tightened. She worries about the consequences once the quality of her report becomes known in court.

Of course, the type of bias being described can apply in reverse, and the psychologist can become an advocate for one side or another. For example, a psychologist working for the defense receives a referral and proceeds in his usual manner. (a) Already in explaining matters to the complainant, he adopts a sarcastic attitude about her pain behavior, which only tightens her up more, adding to his impression that she is exaggerating, if not malingering. (b) He asks questions of her in a cursory manner with a preset, brief schedule, that ignores many of the issues facing her, for example, how difficult it is for her to work at her job because of the specific nature of her pain, and he ignores the effect of pain on her personal life. (c) He uses psychological tests that have not been standardized separately for gender effects, because they would compensate for the fact that the individual is female. (d) He gives a battery of tests that include many about symptom validity, effort, and malingering in the hope of getting at least some evidence of some exaggeration or invalid effort, which he would consider enough to label the individual as a malinger. He is cross-examined on how his methodology contravenes aspects of the forensic guidelines.

Information toward (a) Educational objectives, (b) Learning objectives in measurable terms, and (c) Learning assessment outcomes

This presentation will guide attendees through the procedural and attitudinal requirements needed to conduct comprehensive, impartial assessments, the cornerstone of meeting professional, ethical, and legal requirements in the field. The psychologist must gather all the evidence needed to arrive at scientifically-informed conclusions. Therefore, the psychologist strives to get all relevant documentation, and analyze it impartially. She/he interviews the individual with an open attitude, allowing the person to express her or his story. The psychologist carefully evaluates mental status and nonverbal behavior, as well, for example, if there is seemingly exaggerated pain behavior, and notes discrepancies and inconsistencies, if any, with the verbal report provided, and the existing records. All necessary collateral information gathering and interviewing is conducted, for example, with respect to any military record, from spouses, about work, and by getting records from physicians. The psychologist chooses the most appropriate tests for the referral question, selecting those with the best psychometric properties for the purpose of the assessment. Using a multitrait-multimethod format, these tests address both client symptoms and client validity, from variable effort, through symptom exaggeration, to indicators of malingering. The psychologist is aware of all biases that have been described in the literature and that he or she may consciously or unconsciously entertain, taking steps to eliminate their impact in the assessment undertaken and the subsequent testimony in court. Indeed, the psychologist keeps up to date in all relevant scientific fields related to her practice in psychological injury and law and with respect to all relevant professional, ethical, and legal guidelines.

Disability, Work

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A psychologist retained by the plaintiff’s lawyer receives a referral to assess an individual who was denied long-term disability benefits three years prior by his insurance company. A two-inch thick record binder and a series of surveillance videotapes completed by the insurance company have been provided before the assessment. The surveillance tapes are the key pieces of evidence purportedly showing that the individual is capable of doing more than he claims. The individual is a 48-year-old male immigrant with limited English, a wife and three children aged 14 to 24. He was previously employed for 25 years as a worker at the factory. He fell off a ladder (12’) at home three years prior and hit his head, neck and back. There might have been a brief loss of consciousness but the evidence was unclear and there was no diagnosis of concussion. The man developed chronic pain, cognitive problems, depression and anxiety. There are no records attesting to any previous mental health history, although he had a history of occupational asthma. The videotapes were taken over 16 months, on six different dates. The shortest of them is 6 minutes, the longest is one hour; the total duration of tapes was two hours. They show the individual in the following situations: (1) driving a child to school; (2) mowing the lawn and gardening on a sunny day with his wife helping, without any apparent restrictions (two clips); in one of the clips the man is seen through the window lying down after mowing; (3) walking in the rain with a female (4) peeking through the window and having a conversation on the phone, smiling briefly when talking and then lying on the bed covering himself with a sheet (5) walking up the front stairs of a large building with another person.

The opinions on this man’s impairment and disability are polarized:

(1) His general practitioner, two treating psychiatrists, one treating psychologist, and one assessing psychiatrist diagnosed him with Major Depressive Disorder with Psychotic Features, Generalized Anxiety Disorder, Movement Disorder (the man developed jerking body movements) and Chronic Pain (back and neck);

(2) One physiatrist, one orthopedic surgeon, two psychiatrists (including one who actually examined the individual in person) and one psychologist, working for the defense, viewed the videotapes and concluded that the man’s behavior was incompatible with pain, depression, anxiety and movement disorder and rendered him able to return to work. Because he did not, disability benefits were terminated.

The plaintiff’s psychologist assessed the man with the interpreter, conducted three collateral interviews, reviewed his medical and work records and viewed the videotapes. She discovered that the man was taking 19 different medications, including Gabapentin and Tylenol # 3. The man presented as severely depressed, crying, with his body jerking during the most emotionally difficult points of the interview, and slumped in the chair. Three family members reported that the man spends about 80% of his waking hours in his bedroom, mostly in bed. The man stated that his deceased relatives are calling him to join them in heaven and he fears being killed by the insurance company. When people gather around his house or ring the bell, he thinks that these people will kill him on behalf of the insurance company.

The psychologist for the plaintiff renders an opinion that the man is not able to work, contrary to the opinions of the defense experts.

Information toward (a) Educational objectives, (b) Learning objectives in measurable terms, and (c) Learning assessment outcomes

This presentation will guide participants through the conceptual and methodological demands of assessment of the impact of psychological impairment on work capacity in a personal injury context, using the best practices learned in the workshop. The complex case with polarized opinions regarding disability will likely stimulate discussion on the following topics:

(1) How to perform functionally-oriented psychological assessment in personal injury;

(2) The relationship between diagnostic and functional assessment;

(3) The role of context in making a determination of impact of impairment on function;

(4) Whether videotaped surveillance tapes can be used in psychological injury assessments to determine function and on some of the methodological and ethical issues associated with this use;

(5) How cultural/language and symptom validity factors may complicate functional determinations;

(6) How to predict disability based on identifiable psychosocial risk factors;

(7) When and how to determine readiness to return to work, and to activate employment-related function;

(8) Debiasing of disability determinations through the use of complex constructs of relationships among diagnosis, impairment, disability and RTW.

Chronic Pain

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A psychologist working in a multidisciplinary pain center encounters a range of patients with chronic pain, including those who appear poorly motivated to recover and return to work. The referring insurance companies often want these patients identified by the center. He knows that the DSM-IV defines chronic pain with a series of criteria that he has long ignored because of their lack of utility and validity and the attachment to antiquated mind-body dualism. For him, chronic pain is considered a persistent, pervasive experience that has lasted at least 3 months, and comes to dominate the life of the individual. It moves from the acute stage partly because of the complicating emotional reactions that accompany it. He knows, for example, that depression involves some of the pain centers in the brain as does pain. Some of the predictors of the development of chronic pain are quite psychological in nature, such as catastrophizing, or thinking the worst. Surprisingly, there is little evidence that the severity of the original tissue damage correlates with the subsequent development of chronic pain. The idea that there is a pain-prone personality has also been refuted, but the research shows that the key predictors of pain disability are psychosocial. The psychologist thus treats each person as an individual, and arrives at individually-tailored interventions for them. However, one of the factors that he realizes may be at play is the extent of effort expended by the patients to improve their condition, the degree of compliance with treatment, their motivation to recover, and their readiness to return to work. He wonders to what extent these issues reflect either secondary or even primary gain factors in some cases, and he attempts to monitor them. Also, he is aware that patients have a legal obligation to attempt to mitigate their losses. He knows that he will have to testify, if the cases go to court, about the efficacy of his treatment and the effort and motivation of his patients.

The psychologist has several choices to pursue:

1. He decides to ignore the insurance company pressures to identify those with poor effort to recover by relying on his past clinical experience and his judgment. He believes that all people are good by nature, feels empathy towards pain sufferers, and wishes to focus solely on the application of cognitive-behavioral treatment to the best of his ability, which is bound to help most of his patients. He offers vague statements on effort and motivation to return work in his reports and asks the insurance companies for more treatment funding in those cases that patients fail to improve.

2. He decides to make a referral to a colleague who runs a successful medico-legal practice to help the insurance companies with answers to their questions. He believes that forensic and treatment roles are completely incompatible and refuses to provide the insurance companies with any answers, even if he has them, in order to avoid any undue harm to the patients and not to compromise his rapport with them.

3. He decides to review the test validity indicators from his recent rehabilitation-oriented assessment of the patients, together with the patients’ attendance and participation data in his center and provide the answers to the insurance companies’ inquiry about their motivation to return to work. He is aware of the fact that the insurance companies pay for treatment and his center needs to be accountable. Otherwise, he continues focusing on treatment, although he is less invested in those patients who fail to improve as expected.

4. He decides to read more on the topic, and investigates several promising psychological tests that he can use to help him understand motivational and coping issues in pain disability. He uses the results of these new tests to help answer insurance company questions. In order to avoid bias, the psychologist refuses to acknowledge the data provided by the insurance companies and rejects any data that may be labeled as “subjective”.

5. The psychologist recognizes that questions about effort and motivation to return to work in chronic pain cases are not only forensic but also clinical questions. He reads the literature and finds out that psychological readiness to return to work in musculoskeletal pain is linked to expectations of recovery, perception of disability, and probability of return to work. However, there are very few well-validated instruments in the field. Before deciding on the assessment instruments that could help answer some of the insurance companies’ questions, he selects constructs linked to readiness and motivation that he wants to measure. He consults the literature widely and checks with well-respected colleagues who practice in the field. He selects instruments that have been empirically found to predict disability and are established in clinical practice. He checks if the norms include chronic pain patients with sociodemographic characteristics similar to his patients. He reviews primary, secondary, and tertiary gains and losses clinically identifiable in his cases.

Finally, the psychologist decides to write a report that is rehabilitation-oriented for each of his patients and uses some of the new constructs and appropriate ways of measuring them. He carefully balances gains and losses evident in the patients because of their chronic pain. He links the newly identified psychosocial factors to matching treatment approaches. He puts a caution in his reports that they are intended for clinical rather than medico-legal purposes. He refuses to supply a list of patients who have demonstrated poor effort to the insurance companies even though the companies pay for treatment.

6. After a year of being under pressure by the insurance companies, the psychologist complains to the management of the pain center, cites ethical concerns, and asks for being excused from addressing motivational and other contentious issues in his reports. He tells his patients about his ethical conflict. Because the management does nothing about it, he quits his job.

Information toward (a) Educational objectives, (b) Learning objectives in measurable terms, and (c) Learning assessment outcomes

This presentation will emphasize that chronic pain development is a dynamic, time-based process and it can be responsive to intervention at its various stages.. There are medicolegal-forensic issues to consider which apply to all cases of psychological injury. Increasingly, we are learning about the physiology of pain, and its central influences. Melzack and Katz (2006) developed the gate control theory of pain, which allowed for a psychological contribution to pain, and others have emphasized its biopsychosocial determinants or its result from a diatheses, or psychological vulnerability, interacting with stress. Franche and Krause (XXXX) developed a conceptual model of return to work in musculoskeletal pain. A number of psychosocial instruments empirically validated to identify individuals at high risk of disability were developed, including Linton’s, Gatchel’s and Schultz’s questionnaires (XXXX, XXXX, XXXX, respectively). Psychosocial predictors of recovery and coping in chronic pain have been widely researched. Primary, secondary, and tertiary gains and losses that need to be accounted for in assessments of pain have been conceptualized and their measurements advanced (Polatin & Gatchel, XXXX). Psychologists have a valuable role in assessing and treating chronic pain patients, but they need to be aware of the insurance-forensic context. Undue pressures may be placed on treating psychologists not only from insurers and other third party payors but also from the parties in the litigation process.

Posttraumatic Stress Disorder/ Distress

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A client, performing administrative duties on a war-zone military base, had been involved in a horrendous incoming mortar incident in which she was seriously injured physically and she had feared for her life. She had many signs of peritraumatic stress and dissociation. Her heart rate continued to beat quickly once she arrived at the hospital. The hospital procedures themselves became an additional source of flashbacks. She felt time slow down during the incident, and she felt as if she was experiencing it again with each flashback. After she was out of the hospital and back to duty, she was so jumpy in her jeep even though she was avoiding dangerous roadways. She felt an increasing distance from her colleagues despite their support, and sank deeper into a general anxiety and feeling of helplessness. She could not sleep well because of nightmares. She could not concentrate well at work, as she was extremely tired and her mind wandered off constantly. Back home, she was referred to a psychologist for assessment and treatment of PTSD. The psychologist found it difficult to get treatment authorized and the client found it difficult to get benefits. [The example could apply to any type of serious injury due to a traumatic event, such as a motor vehicle accident.]

The psychologist also received a referral for an individual claiming to have developed PTSD as a result of a minor incident of harassment at work. Her attorney had made the referral, after he convinced her that she had the same type of PTSD as for more serious incidents. He coached her on the symptoms, in case she “forgot” them, and they became more intense for her. By the time she was assessed, she had every cardinal symptom of PTSD, and this was evident upon examination of all sources of information. The client was even coached on the psychological tests, and she knew how to answer the ones administered to her in order to increase her chances of being diagnosed with PTSD. The psychologist disagreed that the entry criterion about having experienced a traumatic stressor that had been horrific and had induced a fear for life had been satisfied. However, he gave the client the diagnosis of PTSD, because, after all, PTSD was now being diagnosed simply because an individual had been close to a very traumatic event without having been involved. He understood that the diagnosis had become a growth industry, and should not be given, but the data indicated that the client had the disorder, so he could not conclude that she was not experiencing it, and he diagnosed her with PTSD. After the diagnosis was given, the attorney sued the harassing party. Eventually, the client obtained a lucrative settlement.

Another client who was referred to the psychologist manifested many of the symptoms of PTSD after her motor vehicle collision, but few that concerned hyperarousal. The client demonstrated distress at reminders, avoidance and phobic behavior, and numbing, but could still sleep adequately, concentrate at work, not be jumpy in the car, and so on. The psychologist diagnosed subsyndromal PTSD, and expected a better rate of recovery, because she was using evidence-based treatment procedures, such as exposure and systematic desensitization. However, she was perplexed when recovery was slow. Finally, she realized that a subsyndromal syndrome for PTSD might be just as debilitating as a full-blown diagnosis and that she had been neglecting the treatment of the client’s comorbid pain. She adjusted her formulation and treatment plan. However, despite some success, the client’s symptoms persisted and they resisted treatment for quite a while.

Information toward (a) Educational objectives, (b) Learning objectives in measurable terms, and (c) Learning assessment outcomes

This presentation will help attendees be able to diagnose PTSD. What is the traumatic stressor entry criterion? How does this make PTSD different from other disorders in the DSM ? How has this criterion evolved over successive versions of the DSM? Is it responsible for the growth industry in the diagnosis of PTSD and increased tort action related to PTSD? Should the committee working on revising the DSM change the traumatic stressor criterion in the DSM-V, in order to reduce the legal abuses? However, if they do, for events at claim that are actionable, will individuals with a legitimate psychological injury be denied their rightful access to psychotherapy and to financial compensation? What are the major symptom clusters in PTSD? Does conceptualization and factor analytic research support the division of the symptoms in these clusters? In fact, it has been argued that PTSD reflects an extreme pre-existing negative emotionality, or that in all cases one will find pre-existing factors that potentiate it or even explain it in full, such as child abuse. Some have argued that there is never a valid reason to pursue cases of psychological damages for monetary because there is never a valid diagnosis of PTSD that is possible wit respect to a traumatic event at claim.

Traumatic Brain Injury

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A neuropsychologist receives a referral for a case of closed head injury after a traumatic injury; the athlete had been complaining of his symptoms for many months, despite assurances given to him that he should be ready to return to his team after a few weeks. The athlete has a history of concussions, but has recovered each time, albeit at a slower rate with successive injuries. This time, the recovery has not been complete, and the athlete is complaining of continuing nausea, dizziness, headaches, ringing in the ears, a lack of smell, nonrestorative sleep, fatigue, sadness, apathy, social withdrawal, irritability, forgetfulness, inability to pay attention, lack of capacity to multitask, stumbling on words, poor planning, lack of impulse control, and slower speed, in general, both motorically and in thinking. The psychologist reviews the records of the injury, and determines there had been a brief period of unconsciousness, with a bit of poor recall of events just after the injury and afterwards. The Glasgow Coma Scale score remained at 14 or 15 out of 15 throughout the post-injury evaluation period. The most striking finding after the injury was a lack of consecutive memory that lasted for hours, as the athlete was dazed and in shock. The scan results were not clear, and a second set had been ordered. The neuropsychologist suspected a complex interaction of factors at play in the perpetuation of the symptoms, but he was not ready to rule out persistent pathophysiological effects until all of the medical and neuropsychological test results were available to him. He checked for different grades of mild traumatic brain injury, but ruled out a more moderate TBI, although he was not quite sure how to evaluate the cumulative effects of the recurrent head trauma. In the end, he diagnosed persistent postconcussive syndrome. An insurer examination argued that the syndrome is best accounted for by psychological factors alone, and therefore, with appropriate treatment, it should go into remission. The neuropsychologist maintained his professional opinion that the treatment would be long and arduous, and even if no pathophysiological effects were found, cognitive rehabilitation would be necessary and could help.

In his assessment, he knows that he had used several forced choice tests that had ruled out symptom exaggeration or other response biases, including possible malingering. Nevertheless, other insurance and defense neuropsychologists had used other instruments and determined that the patient had been exaggerating greatly and perhaps even malingering. The neuropsychologist became uncertain of the opinion he had rendered, and decides to compare the instruments that he had used with those of the other psychologists. He reads extensively on their scientific test reliability, validity, sensitivity, and specificity. He explores better the known base rates and error rates pertaining to the injury in question and the tests used. He appreciates better the arguments made by the other psychologists, but is not sure to what degree they alter his opinion. He knows that if he is ever called to court he will be asked questions about the scientific literature, which is voluminous and contentious. He asks experienced colleagues for their advice. He formulates his revised conclusions, after having weighed the nomothetic scientific evidence on the instruments that he and the others used and the idiographic evidence collected in the assessment. He is prepared for any future testimony and cross-examination

Information toward (a) Educational objectives, (b) Learning objectives in measurable terms, and (c) Learning assessment outcomes

The area of neuropsychology is one of the most contentious in the field of psychological injury and law. On the one hand, a traumatic brain injury can lead to pathophysiological effects, and because these are physical sequelae, the court may be more sympathetic to awarding monetary damages. Moreover, this is reinforced because cognitive activities are involved. The research is showing that, except for a miserable minority, the effects of mild TBI dissipate. Moreover, the degree to which there are documented and reliable pathophysiological effects in these clients is subject to fierce debate. Therefore, these clients are accused of having their symptoms persist for reasons that are non-organic, that relate to hope for primary or secondary gain, or that otherwise reflect a lack of material cause for the event at claim. Even in cases of moderate to serious TBI, motivations related to full or partial malingering may be raised, depending on the outcome of the assessment. Neuropsychologists use extensive psychological testing in their assessments, measuring basic intellectual and cognitive skills, but also personality, emotional, and related variables. Importantly, they examine complainant effort with forced choice, or symptom validity tests. Criteria for definite, probable, and possible malingering have been formulated based on the results of such testing, but researchers have queried the degree of certainty of such conclusions based on these tests, and in court the tests are being challenged for their admissibility, or the extent to which they reach acceptable standards of good science compared to poor science.

Assessment/Malingering

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A psychologist tries to teach a graduate student the appropriate concepts related to test construction, as he supervises her in her work. He explains to her and has her read about (a) the different types of reliability, or consistency (e.g., test-retest and interrater agreement) and validity, or accuracy, and (b) how tests can have better or worse hit rates of the condition at issue, both positive and negative (concerning the concepts of sensitivity and specificity), as well as (c) other relevant psychometric properties. She studies hard in her courses and passes her exams, both at school and for registration purposes. Once in private practice, she buys the tests on which she had been trained, but finds it difficult to evaluate new ones on the market that claim to measure constructs of interest to her, in her work in the area of psychological injury. She visits her ex-supervisor, and they read together the test manuals of concern to her. His experience helps her elucidate a better understanding of the issues. It reminds her of when she had learned statistics, but really did not understand it until she did her thesis research and had to apply statistics to the data collected. She vows to keep up to date in the literature on testing, attend educational workshops, consult with colleagues, join list serves, and so on, and perhaps participate in research projects on psychological tests used in cases of psychological injury. As her career develops, she becomes part of a research team investigating a new test on malingering. She and the team find it difficult to conceptualize the issues, construct an adequate research design, and interpret the data once gathered. However, the team persists and she becomes comfortable with the results of the project and psychometric properties of the test. She cannot anticipate the firestorm that greets publication of the test, given the adversarial nature of the field. The opponents of the test raise the issue that malingering is a legal rather than psychological construct and what the new test attempts to measure is symptom validity and/or exaggeration of complaints. The critics say that the intentionality aspect of malingering could never be proven in testing. The psychologist and the team stick to their guns, the publisher runs an excellent marketing campaign, and the test gains wider use and encourages further research.

Information toward (a) Educational objectives, (b) Learning objectives in measurable terms, and (c) Learning assessment outcomes

Psychologists working in the field of psychological injury need expert knowledge of test construction, in general, and the psychometric properties of the tests that they use, in particular. They need to be aware of the most widely used tests, the alternatives, and justify the choices of tests that they use in light of the scientific evidence. The assessment of malingering-related constructs such as symptom validity, effort, exaggeration or illness behavior is especially contentious, and psychologists need to know of the ways that it can be detected. Most important, tests provide but one source of information leading to conclusions about symptom validity and risk for malingering. Second, even if a test reveals scores that indicate possible malingering, the assessor should not automatically conclude that malingering is present without considering all possible explanations and ruling out all competing hypotheses. Third, malingering/exaggeration can be indicated by different types of tests, from stand-alone, to embedded, to forced choice, or symptom validity tests. Some of the best tests to use in the area include the MMPI-2 (Butcher et al., 2001), the SIRS (Rogers et al. 1992), and the TOMM (Tombaugh, 1996). The use of multi-method assessment and not relying on the test scores alone in arriving at conclusions are important considerations.

Models/ Causality

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A psychologist working in a medical setting encounters a case of chronic pain deriving from a work accident, where the family physician and treating specialists consider that the pain is “all in the head” of the individual. Adhering to the medical model, they do not recognize psychosocial influences on pain, and argue that they tried everything so that there must be psychological overlay involved. The individual feels poorly understood, rejected, and believes that he is being blamed for something that was no fault of his own. He is left to his devices, as his pain persists but his benefits have been denied because of the doctors’ reports. He attends a series of medical and physical examinations, and each one acts to increase his pain through the stresses involved, the lack of sleep and headaches that they induce, as well as the resultant fatigue. Each doctor concludes that pre-existing soft tissue injuries can account for the persistence of the pain as predisposing factors. An effect of the work injury as a precipitating cause of the ongoing pain experience is denied, and the only exacerbatory, maintaining factors admitted relate to the individual’s “hysterical personality.” Ultimately, the individual attempts suicide because of the mounting sense of hopelessness and loss.

The psychologist gets another referral where a minor work injury has purportedly led to severe chronic pain. The person had been diagnosed with an anti-social personality before the accident, and had a history of pain complaints leading to long periods off work. The person also had a history of manic-depression, but medications had it somewhat under control at the time of the injury. After the accident, it manifested in its usual extreme form, and the worker cited this as another of his losses due to the event at claim.

The psychologist conducts a comprehensive, impartial assessment in both cases. For the first case, he attributes causality for the disorders and disability in question to the event at issue, and, for the second, no material cause is ascribed to the injury for subsequent psychological presentation.

Information toward (a) Educational objectives, (b) Learning objectives in measurable terms, and (c) Learning assessment outcomes

Psychological injury is multifactorial, both in the sense of being biopsychosocial and in the sense of having to consider pre-event, event-related, post-event, and unrelated factors. Also, the terminology in the field can be difficult to grasp, including legal versus psychological causality, the “but for” and material contributions tests, “thin” and “crumbling” skulls, impairment versus disability, and prediction versus prognosis. Another issue related to terminology in the area of psychological injury and law is that he same or similar terms may mean different things in different professional fields, or a term in one field may not have an equivalent in another. An important example concerns the psychological term “validity”, the equivalent of which legally is “reliability,” a term that has a very different meaning in psychology. The attendees will be able to recognize the difficulties in translating terms across different professions and fields of inquiry.

Key Terms Related to Causality and Causation

Key Terms Related to Causality and Causation in Law

Term Meaning (simplified)

Concurrent Joint

Contributing Secondary

Immediate Most recent

Intervening Added

Joint Multiple

Material Part of joint

Proximate Dominant (Direct)

Remote Initial, too far removed

Superseding Replacing dominant

Key Terms Related to Causality and Causation in Medicine

Component Part of multiple

Exacerbation Worsening

Exciting Direct

Immediate Beginning, Initial

Predisposing Susceptible

Primary Principle

Remote Predisposing, Secondary

Secondary Not principle

Ultimate Remote

Key Terms Related to Causality and Causation in Psychology

Catalytic Facilitative

Latent Delayed

Maintaining Current, Perpetuating

Mediating Intervening

Multiple Multifactorial

Original Remote, Initial

Remote Initial

Triggering Immediate, Precipitating

Conclusions

Working in the area of psychological injury and law is rewarding yet challenging. There are complex and ever emerging conceptual, methodological, and practical issues and conundrums that require specified knowledge and considered reflection. In these workshop vignettes, we have attempted to educate, stimulate, and provoke the reader about the challenges in working in the field and the requirements needed to work effectively in it.

There are fundamental axes that govern clinical practice in the area of psychological injury and law. They relate to (a) its underlying science, (b) the complexities of working in the legal arena, and (c) adopting integrative models that cohere psychology and law.

1. The field of psychological injury and law is founded on rigorous scientific and ethical standards. Psychologists need to present evidence to court and related venues that is scientifically informed.

2. They should be aware of the adversarial nature of the field and remain impartial in formulating conclusions about the individuals that they assess when proffering evidence to court or related venues.

3. The general theoretical approach in the field is integrative involving the biopsychosocial and the forensic psychological perspectives. The mind and body form an integrated matrix that can help explain psychological injuries and resulting impairments, inabilities to function, and disabilities. At the same time, there are legal and related considerations that impact the individual. Psychological assessors need to be aware of complications such as (a) possible motivational factors in clinical presentation, for example, primary, secondary, and tertiary gains and losses, (b) symptom invalidity, including considerations of malingering, and (c) effects of the stress of the insurance and legal process on the individual.

This being said, assessors need to be aware of legitimate psychological concerns, such as (a) factors related to behavior, affect, cognition, and life destabilization after an injury at claim, and (b) psychological issues related to coping, resiliency, and vulnerability.

How can science help the PIL psychologist address the impact of legitimate psychological injuries? First, it allows the practitioner to understand client presentation and to rule out or disentangle the role of complicating factors. Second, it helps the practitioner to address the long term impacts on the client. For example, psychologists working in the area of psychological injury and law need to aware of and apply the emerging body of knowledge in the area of prognosis and prediction of disability and return to work that goes above and beyond mere clinical judgment. Therefore, workers in the field should remain grounded in the integrated biopsychosocial and forensic evidence-informed perspective.

Similarly, in terms of the therapeutic approach used in the field, best practice and provision of quality service demands require use of evidence-informed practice (treatment and intervention, in general) that, nevertheless, respects individual and cultural variations, values, and preferences. Patients with psychological injuries require cognitive-behavioral intervention procedures that may incorporate interpersonal, narrative, and systems work, for example, with relevant accommodations for age, gender, culture, minority status, and disability status.

Is the science in the area sufficiently advanced to meet

acceptable criteria of reliability and validity, for example, for court and related purposes? In general, the field is acquiring a rapidly expanding conceptual, empirical, and practical base supported by good science. However, as with any applied research in psychology, there are limits to the research that can be undertaken. Moreover, there are complications in the research that reside in its adversarial nature. For example, there are research limitations inherent in working with small sample sizes, frequently encountered in clinical studies, including in studies of client-treatment matching. Also, the research in the area is marked by frequent absence of populations with disability, for example, in treatment trials leading to the development of evidence-supported treatments.

Another research limitation in the field lies in the divide between psychologists working primarily for the plaintiff and those working primarily for the defense, which affects not only practice but also research initiatives in the field. This divide, which PIL attempts to balance and bridge, makes some of the evidentiary basis in the field fragmented and needlessly contentious. The fragmentation adversely affects practice in the field, where scientific accuracy is most important.

Thus, it is important for workshops in the area of psychological injury and law, such as the one for which this article was written, to advance knowledge of good scientific research and clinical evidentiary bases. Moreover, workshop attendees should learn to separate good research and clinical practice approaches from insufficiently adequate ones. Workshops having goals such as these will facilitate a scientific approach to assessment and intervention in the psychological injury field.

We emphasize that working in the field of psychological injury and law is not just for forensic psychologists to practice. Many psychologists receive referrals for pain patients, survivors of accidents who have signs of PTSD, those who have sustained concussions or mild TBI, and other conditions. These types of psychological injury, which are often complex and confounded by a variety of factors, require psychologists to have sufficient knowledge in order to handle well the cases involved, especially in terms of assessment and intervention. By attending a workshop on the topic, psychologists will be able to improve the quality of service that they provide. In addition, these types of injuries constitute cases that lead to court action, especially in the potentially contentious medicolegal environment.

Our position is that many psychologists who are not forensic psychologists may benefit from the type of workshop that we are preparing. It will solidify their knowledge base and facilitate better quality work in the area, while preparing them for scrutiny by forensic and other psychologists and possible call to court. Even if they do not see themselves as working in the forensic field, in many cases, the court may be involved. Moreover, the workshop being planned will deal with appropriate ways of handling other aspects of these complex cases, including their daunting ethical dilemmas. These issues in such cases range from record keeping, to dealing with third party payors, to treatment. Therefore, the planned workshop will be beneficial to many practitioners for reasons beyond the legal and forensic matters raised.

Psychologists working with cases of psychological injury require not only adherence to the scope of general professional regulations, standards, and guidelines but also possession of specified knowledge such as that underscored by the vignettes presented in the present article. We look forward to your commentaries both for publication purposes for use in our workshops. This article is an interactive one inviting response by readers, and reader commentary will be considered its most important contribution.

Aside from addressing the specific issues that the vignettes are meant to underscore, the reader should consider general ethical, clinical, practice, and legal considerations applicable to any type of client, not just those with psychological injury, that have not been emphasized in the article. Examples are provided. For any of the vignettes, what are the effects of a client being female compared to male? Are there effects of belonging to a particular minority, culture, or language group on how the vignettes should be approached? Would answers provided in response to the vignettes vary in terms of different developmental levels for clients, such as adolescence or the elderly time period, or the presence of a disability status? What if there conflicts of interest, for example, knowing the client beforehand in a small rural town? What if work cannot be accommodated because of real world issues such as employer prejudice against injured workers, or what if a school refuses to provide to a student the resources needed to accommodate a return to school because of recession-induced budget cuts? What if an attorney takes a case without ever having had a personal injury case? What if the judicial system is so overwhelmed that a case drags on for years and the client is denied services and deteriorates to the point of suicide for not receiving serviced later deemed necessary? By adding variations to the vignettes in these regards, and in responding to them with the types of concerns being mentioned, future workshop attendees will profit from the effort of readers who respond to our call for their interactive contributions.

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Announcements!

Announcement #1: Hardcopies of PIL are now available free to members! Fees for 2017 remain the same at $100 (USD) for Full Status Member. Please see our Membership Fee page for more details.

Announcement #2: Dr. Gerald Young completed a FREE online educational workshop on Psychological Injury and Law. Please see our Continuing Education page for details and links to the videos.

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