mental health overview certification in medico-legal expertise · alternate-form reliability inter...
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Mental Health OverviewCertification in Medico-Legal Expertise
Dr. Jeremy Frank, C.Psych.,C-CAT(MB)Consulting Clinical And Rehabilitation Psychologist
Director, Dr. Jeremy Frank and Associates, Program Chair___________
Dr. Konstantine K. Zakzanis, C.Psych.,C-CAT(MB) ProfessorDepartment of Psychology | University of Toronto Scarborough
Consulting Neuropsychologist | PsychologistProgram Chair
what is mental illness?
….Digit Span….
what is mental illness in the medial legal context?
statistical infrequency
violation of norms
personal distress
impairment or disability
unexpectedness
what is mental illness?
statistical infrequency
what is mental illness?
violation of norms
A behavior that defies or goes against social norms; it either threatens or makes anxious those observing it
https://www.youtube.com/watch?v=Vwh0lBPHg9o
what is mental illness?
personal suffering
a behavior that creates personal suffering, distress, or torment in the individual
what is mental illness?
impairment or disability •Disability may be defined as an alteration of an individual’s capacity to meet personal, social, or occupational demands, because of an impairment.
•Disability refers to an activity or tasks the individual cannot accomplish
•A disability arises out of the interaction between impairment and external requirements, especially those of a persons’ occupation
•Disability may be though of as the gap between what a person can do and what the person needs or wants to do.
•An “impaired” individual is not necessarily “disabled”
•An individual who is able to meet life’s demands is not disabled, even if a medical examination discloses an impairment.
•If an impaired individual is not able to accomplish a specific task or activity despite accommodation, or if no accommodation exists that will enable completion of the task, then that individual is both handicapped and disabled.
what is mental illness?
unexpectedness
a surprising or out of proportion response to environmental stressors
in search of madness:Is It Evidence Based Opinion or Mere Fairytale?
• In Search of Madness: and we are not referring to patient psychopathology but that of “mad expert opinion”
• The Crystal Ball Approach to Assessment
• Evidence Based Psychological Assessment
• Survey of Psychopathology
• Qualifications of an Expert and Medical Legal Guidelines
• Misinterpretive Pitfalls and How to Spot a Not so Expert Expert
in search of madness:Is It Evidence Based Opinion or Mere Fairytale?
• The Crystal Ball Approach to Assessment
the crystal ball approach
the crystal ball approach
in search of madness:Is It Evidence Based Opinion or Mere Fairytale?
• Evidence Based Psychological Assessment
evidence based examination of mental illness?
evidence based
examinationof mental
illness?
evidence basedexamination
of mental illness?
evidence based examination of mental illness?
DO YOU HAVE:• superhuman strength?• superhuman speed?• superhuman vision (including X-ray,
microscopic, telescopic, and infrared?• superhuman hearing?• heat vision?• flight?• super breath (also freeze breath)
MULTI-KRYPTON PSYCHOMETRIC INVENTORY OF SUPERHEROISM
neuro|psychological tests
standardization
Responses of person being assessed are compared to test norms that have been established
test norms
The test is administered to many people and the responses are analyzed to establish how a group of people tend to respond
Provides a comparison context which is used to interpret an individual’s score
how to standardize a score
Example: A patient scores 9/50 on a depression inventory. Are they depressed?
How would we answer this question?
how to standardize a score
Example: A patient scores 9/50 on a depression inventory. Are they depressed?
We first need to compare this score to the normative sample
25 5037120
N=1000 Mean (X) = 25Standard Deviation (SD) = 10Patient’s measurement value (x) = 9
standardized scores
Example: A patient scores 9/30 on a depression inventory. Are they depressed?
interpreting scores
What are some issues that can arise when trying to interpret standardized scores?
selecting appropriate normative data
Selecting the normative dataset should be done a priori
Large samples are ideal (at least n=200)
Date of norming (usually have a lifespan of 15-20 years)
2 schools of thought when selecting norms:
1. Norms should be as representative of the general population as possible
2. Norms should represent the specific subgroup to which the individuals belongs
selecting appropriate normative data
1. Stratified General Population Norms
When you are interested in comparing an individual to everyone of the same age
2. Demographically corrected norms (within-group norms)
When you’re interested in comparing an individual’s score to a group of people of the same age, gender, education, handedness, ethnic group, geographic location, etc.
reliability and validity in assessment
Reliability
Test-retest reliability
Alternate-form reliability
Inter rater reliability
Validity
Content validity
Criterion validity
Construct validity
reliability
reliability
Refers to consistency of measurement
Two components of reliability:
▪ Sensitivity: agreement regarding the presence of a particular diagnosis
▪ Specificity: agreement concerning the absence of a particular diagnosis
Reliability is measured by correlation (how closely two variables are related; the stronger the correlation the better the reliability
reliability
inter-rater reliability
validity
Validity
Central question to validity:
▪ Does a measure fulfill its intended purpose?
Validity is related to reliability:
▪ Unreliable measures will not have good validity
DO YOUR MEASURES HAVE ESTABLISHED RELIABILITY AND VALIDITY TO MEET VARIOUS STANDARDS (e.g., Daubert; Mohan)?
validity
construct validity
evidence based assessment of mental health
The psychological examination
Background Data Behavioural Observations
Quantitative Data Qualitative Data
The Personality Assessment Inventory▪ The Personality Assessment Inventory (PAI) is a 344 item self-report
questionnaire that attempts to understand an individual’s personality traits and characteristics.
▪ Renders diagnostic considerations based on the DSM-IV.
▪ Diagnostic considerations involve Axis I and Axis II disorders
▪ Provides clinical and validity scales
▪ Has screening measure to make assessment more efficient, 22 items vs. 344 items
T-Score
30
40
50
60
70
80
90
100
110
T-Score
30
40
50
60
70
80
90
100
110
Scale ICN INF NIM PIM SOM ANX ARD DEP MAN PAR SCZ BOR ANT ALC DRG AGG SUI STR NON RXR DOM WRM
Raw 7 4 1 14 10 25 18 20 16 20 18 21 12 3 6 12 3 3 3 20 18 23
T 55 55 47 48 49 58 48 56 42 52 55 53 49 47 54 47 49 44 45 63 45 49
% 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
ICN
INF
NIM
PIM
SOM
ANX
ARD
DEP
MAN
PAR
SCZ
BOR
ANT
ALC
DRG
AGG
SUI
STRNON
RXR
DOM
WRM
T-Score
30
40
50
60
70
80
90
100
110
T-Score
30
40
50
60
70
80
90
100
110
Scale ICN INF NIM PIM SOM ANX ARD DEP MAN PAR SCZ BOR ANT ALC DRG AGG SUI STR NON RXR DOM WRM
Raw 12 7 15 12 45 47 50 43 43 39 37 38 29 3 12 17 5 20 6 9 23 23
T 70 67 99 43 84 79 86 80 72 74 80 70 67 47 66 53 54 82 53 40 54 49
% 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
ICN
INF
NIM
PIM
SOM
ANX
ARD
DEP
MAN
PAR
SCZ
BOR ANT
ALC
DRG
AGGSUI
STR
NON
RXR
DOM
WRM
T-Score
30
40
50
60
70
80
90
100
110
T-Score
30
40
50
60
70
80
90
100
110
Scale ICN INF NIM PIM SOM ANX ARD DEP MAN PAR SCZ BOR ANT ALC DRG AGG SUI STR NON RXR DOM WRM
Raw 10 2 2 16 26 32 29 45 27 12 22 18 3 0 6 8 2 9 4 13 20 21
T 64 47 51 52 65 65 61 83 54 43 60 50 39 41 54 42 47 57 48 48 49 46
% 90 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 75 88 100 100 100 100
ICN
INF
NIMPIM
SOM
ANX
ARD
DEP
MAN
PAR
SCZ
BOR
ANT
ALC
DRG
AGG
SUI
STR
NON RXR
DOM
WRM
evidence based assessment of mental health
Remember:Is it all about statistical infrequency?
▪ violation of norms
▪ personal distress
▪ impairment or disability
▪ unexpectedness
cultural diversity and assessment
Cultural bias in assessment▪ What is the appropriate culture?
•The Clients?•Country of Origin?•Canadian Culture?
▪ What is the Referral Question?
Strategies for avoiding cultural bias in assessmentLanguage and bias
•Assess language skills•Are there tests in their language (is it recognized?!?)•Translators?
evidence based assessment of mental health
Breadth, severity and veracity
evidence based assessment of mental health
Is clinical judgement sufficient?
how do we know if its malingering?symptom validity indexes
T-Score
30
40
50
60
70
80
90
100
110
T-Score
30
40
50
60
70
80
90
100
110
Scale ICN INF NIM PIM SOM ANX ARD DEP MAN PAR SCZ BOR ANT ALC DRG AGG SUI STR NON RXR DOM WRM
Raw 12 7 15 12 45 47 50 43 43 39 37 38 29 3 12 17 5 20 6 9 23 23
T 70 67 99 43 84 79 86 80 72 74 80 70 67 47 66 53 54 82 53 40 54 49
% 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
ICN
INF
NIM
PIM
SOM
ANX
ARD
DEP
MAN
PAR
SCZ
BOR ANT
ALC
DRG
AGGSUI
STR
NON
RXR
DOM
WRM
how do we know if its malingering?symptom validity measures
how do we know if its malingering?embedded validity measures
how do we know if its malingering?performance validity measures
is it always malingering?
malingering?
malingering?
Is it malingering?
Non Credible Test Results
MalingeringFactitious | Conversion Disorder
Exaggeration Poor EffortBonefide Impairment
non credible test findings| malingering
non credible test findings conversion disorders (FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER in DSM 5)
https://www.youtube.com/watch?v=V8ITCYijzYo
non credible test findings | exaggeration
non credible test findings |poor effort
non credible test findings |bonefide impairment
in search of madness:Is It Evidence Based Opinion or Mere Fairytale?
• Survey of Psychopathology
survey of psychopathology
survey of psychopathology
survey of psychopathology
Risk factors
Factors that interact to put people at greater risk of– or make them more vulnerable to– developing disorders
Protective factors
Factors that if present, can help protect individuals from developing disorders
Resilience
The ability to bounce back in the face of adversity
survey of psychopathology
survey of psychopathology
Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
American Psychiatric Association
survey of psychopathology
DSM-5 Definition of Mental Disorder
“A syndrome characterized by clinically significant disturbance in individuals cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. Mental disorders are usually associate with significant distress or disability in social, occupational or other important activities.”
Controversy?
https://www.youtube.com/watch?v=-AMvrcBvYWk
DSM-5 Definition of Mental Disorder
Excludes
an expectable and culturally sanctioned response to a particular event-Can you think of an example???
deviant behavior (e.g., political, religious, or sexual)
conflicts that are primarily between the individual and society (unless the deviance or conflict is a symptom of a dysfunction in the individual)- Can you think of an example????
anxiety disorders
Phobia
Panic Disorder
Generalized Anxiety Disorder
phobias
Phobia
Disrupting, fear-mediated avoidance
Out of proportion to the danger actually posed
Recognized by the sufferer as groundless
What is the difference between fear and phobia?
○ http://www.youtube.com/watch?v=4tEIh_fJ_9g
phobias- two types
Specific phobia
Unwarranted fears caused by the presence or anticipation of a specific object or situation
Social phobia
Persistent, irrational fear linked to the presence of other people
▪ Generalized (earlier age onset, more severe) or specific (e.g., public speaking)
therapies for phobias
Behavioral approaches:
Virtual reality
Systematic desensitization
Flooding
virtual Reality
my vignette
Flooding…..
panic disorder
Panic disorder
Sudden, inexplicable attack of symptoms▪ Laboured breathing, heart palpitations, nausea, chest pain, feelings of
choking and smothering, dizziness, sweating, trembling, feelings of impending doom
Depersonalization
Derealization
Cued vs. uncued panic attacks
http://www.youtube.com/watch?v=_qo4uPxhUzU
Agoraphobia
generalized anxiety disorder
Generalized anxiety disorder (GAD)
Chronic, uncontrollable worry about all manner of things
obsessive-compulsive disorder (OCD)
Obsessions
Intrusive and recurring thoughts, images, and impulses
Compulsions
Repetitive behaviour or mental act that the person feels driven to perform to reduce the distress caused by obsessions
posttraumatic stress disorder (PTSD)
Posttraumatic stress disorder (PTSD)
Extreme responses to a severe stressor
Re-experiencing the traumatic event such as….
Avoidance of stimuli associated with the event or numbing of responsiveness
Symptoms of increased arousal
Acute stress disorder
Stressor causes significant impairment in social or occupational functioning for less than one month
therapies for anxiety disorders
therapies for anxiety disorders
therapies for anxiety disorders
somatoform disorders
Somatic Symptom disorders
Bodily symptoms that suggest a physical defect or dysfunction, but no physiological basis can be found
somatoform disorders
somatoform disorders
Conversion disorder
Sensory or motor symptoms without any physiological cause
Now called Functional Neurological Symptom Disorder
therapies for somatoform disorders
Addressing secondary gain / iatrogenic disability
Addressing underlying anxiety and depression
Cognitive behavioral approach
Validating that the pain is real, and not just in the patient’s head
Relaxation training
Rewarding the person for behaving in ways inconsistent with the pain
major depressive disorder
Diagnosis of depression (DSM-5 requires the presence of 5 of the following symptoms for ate least 2 weeks; either depressed mood or loss of interest and pleasure must be one of the 5 symptoms)
Major depression
Sad, depression mood, most of the day, nearly every day
Loss of interest and pleasure in usual activities
Difficulties in sleeping (insomnia); not falling asleep initially, not returning to sleep after awakening in the middle of the night or early morning awakenings; in some patients, a desire to sleep a great deal of the time
major depressive disorder
Major depression (con’t)Shift in activity level, becoming either lethargic (psychomotor retardation) or agitatedPoor appetite and weight loss, or increased appetite and weight gainLoss of energy, great fatigueNegative self-concept, self-reproach and self-blame, feelings of worthlessness and guiltComplaints or evidence of difficulty in concentrating, such as slowed thinking or indecisivenessRecurrent thoughts of death or suicide
bipolar disorder
Diagnosis of bipolar disorder
Bipolar I disorder
Increase in activity level at work, socially, or sexually
Unusual talkativeness, rapid speech
Flight of ideas or subjective impression that thoughts are racing
Less than the usual amount of sleep needed
bipolar disorder
Bipolar I disorder (con’t)
Inflated self-esteem and belief that one has special talents, powers, and abilities
Distractibility and attention easily diverted
Excessive involvement in pleasurable activities that are likely to have undesirable consequences, such as reckless spending
heterogeneity within the categories
Mixed episodes
Hypomania (Bipolar II)
Mood specifiers
Psychotic features
Seasonal
chronic mood disorders
Cyclothymic disorder
Frequent periods of depressed mood and hypomania
Dysthymic disorder
Chronically depressed
Double depression
therapies for mood disorders
Psychological therapies
Cognitive and behaviour therapies
▪ Beck’s cognitive therapy
• Cognitive biases
o Arbitrary inference
o Selective abstraction
o Overgeneralization
o Magnification and minimization
biological therapies
Drug therapy
Depression
▪ Tricyclics
▪ Selective serotonin re-uptake inhibitors (SSRIs)
▪ Monoamine oxidase (MAO) inhibitors
Bipolar disorder
▪ Lithium carbonate
eating disorders
Anorexia nervosa
Refusal to maintain a normal body weight
Intense fear of gaining weight
▪ Fear is not reduced by weight loss
Distorted sense of body shape,
self-esteem is linked to weight and shape
Amenorrhea in females
▪ Restricting subtype
▪ Binge eating/purging subtype
eating disorders
Bulimia nervosa
Recurrent episodes of binge eating
Recurrent compensatory behaviors to prevent weight gain (e.g., vomiting)
Body shape and weight are extremely important for self-evaluation○ Purging subtype
○ Nonpurging subtype
Binge eating disorder
Binge eating without compensating
http://www.youtube.com/watch?v=HYfaZV7_fRQ
eating disorder comorbidity
Depression
Anxiety
Substance use and abuse
Personality disorders
treatment of eating disorders
Biological treatments
Medications
Hospitalization
Psychological treatment of Eating Disorders
Motivational enhancement
Cognitive behavioural therapy
Family lunch sessions
schizophrenia
Schizophrenia
Psychotic disorder characterized by major disturbances in thought, emotion, and behaviour
Disordered thinking in which ideas are not logically related, faulty perception and attention, flat or inappropriate affect, and bizarre disturbances in motor activity
clinical symptoms of schizophrenia
Positive symptoms
Excesses or distortions
Disorganized speech (thought disorder)
▪ Incoherence
▪ Loose associations
Delusions
Hallucinations
hallucinations and delusions
A day in the life…
http://www.youtube.com/watch?v=LWYwckFrksg
clinical symptoms of schizophrenia
Negative symptoms
Behavioural deficits
Avolition
Alogia
Anhedonia
Flat affect
Asociality
schizophrenia: Its diagnosis
DSM-IV-TR requires at least six months of disturbance for the diagnosis.The six month period must include at least one month of the active phase, which is defined by the presence of at least two of the following:
Delusions, hallucination, disorganized speech, grossly disorganized or catatonic behavior and negative symptoms (only one of these symptoms is required if the delusions are bizarre or if the hallucinations consist of voices commenting or arguing). The remaining time required within the minimum six months can be either a prodromal (Before the active phase) or a residual (after the active phase) period. Problems during the prodromal and residual phases include social withdrawal, impaired role functioning, blunted or inappropriate affect, lack of initiative, vague and circumstantial speech, impairment in hygiene and grooming, odd beliefs or magical thinking, and unusual perceptual experiences.
Schizophreniform Disorder: the symptoms are the same as those of schizophrenia but last only from one to six months
Brief Psychotic Disorder: lasts from one day to one month.
biological treatment
Drug Therapies
Phenothiazine: Chlorpromazine (Thorazine)
Butyrophenones: Haloperidol (Haldol)
Thioxanthene: Thiothixene (Navane)
Tricyclic dibenzodiazepine: Clozapine (Clozaril)
Thienbenzodiazepine: Olanzapine (Zyprexa)
Benzisoxazole: Risperidone (Risperdal)
substance dependence
Symptoms of substance DEPENDENCE
Tolerance
Withdrawal
Person uses more of substance or uses it for a longer time than intended
Person recognizes excessive use of substance
Much of the person’s time is spent trying to obtain substance or recover from its effects
Substance use continues despite problems
Person gives up or cuts back participating in many activities because of substance
substance abuse
Symptoms of substance ABUSE
Failure to fulfill major obligations
Exposure to physical dangers
Legal problems
Persistent social or interpersonal problems
personality disorders
Personality disorders
Heterogeneous group of disorders
Longstanding, pervasive, and inflexible patterns of behaviour and inner experience
Deviate from the expectations of a person’s culture
Impair social and occupational functioning
odd | eccentric cluster
Paranoid personality disorder (PPD)
Suspicious of others
Schizoid personality disorder
Does not desire or enjoy social relationships▪ https://www.youtube.com/watch?v=hEBwjvU-XZk
Schizotypal personality disorder
Odd beliefs or magical thinking▪ The difference between Schizoid and Schizotypal PDs
▪ https://www.youtube.com/watch?v=dukG2IyzKdY
dramatic | erratic cluster
Borderline personality disorder
Impulsivity and instability in relationships, mood and self-image
https://www.youtube.com/watch?v=xdPuSnP8YY8
dramatic | erratic cluster
Histrionic personality disorder
Overly dramatic and attention-seeking
▪ https://www.youtube.com/watch?v=u_q5Met1rVA
Narcissistic personality disorder (NPD)
▪ Grandiose view of one’s own uniqueness and abilities
▪ http://www.youtube.com/watch?v=f9jRDHGabp8
dramatic | erratic cluster
Antisocial personality disorder
Presence of conduct disorder before age 15
Continuation into adulthood
Emphasis is on behavior
anxiety | fearful cluster
Avoidant personality disorder
Sensitive to possibility of criticism, rejection, or disapproval
Reluctant to enter into relationships unless they are sure they will be liked
Dependent personality disorder
Lack of self-confidence and sense of autonomy
anxiety | fearful cluster
Obsessive-compulsive personality disorder
Perfectionist
Preoccupied with details, rules, schedules
neurocognitive disorders
neurocognitive disorders
neurocognitive disorders
degenerative disorders
Differential Diagnosis of Dementia
https://www.youtube.com/watch?v=IuIqVrCAZcU
Gradual deterioration of intellectual abilities
Step wise vs. slowly progressive
Impairment in social and occupational functioning
Each dementia syndrome has a unique cognitive signature
A diagnosis of dementia is clinical.
Only at autopsy can it be definitive
degenerative disorders
Cortical Dementia Dementia of the Alzheimer’s type Fronto-temporal dementia
▪ FTD and its variants▪ Primary Progressive Aphasia▪ Semantic Dementia
Subcortical Dementia Progressive supranuclear palsy Huntington's disease Parkinson’s disease Multiple sclerosis
care pathway for psychological disorders
• Recovery is highly idiopathic
• There is no accurate tool to identify injured persons who may not recovery, but prognosis may be less optimal for,o Those with high levels of pain after a collision
o Those with poor expectation of recovery
o Those with a pre-existing history of psychological disorder prone to “declare” an “excuse for all of life’s problems”
• During initial stage of recovery, the patient may benefit most from education, advice, reassurance and evidence based psychological clinical care (e.g., CBT).
survey of psychopathology: conclusions
Importance of differential diagnosis, forming and testing hypotheses
Be thorough—don’t make assumptions
It might walk like a duck, and quack like a duck, but it can be a turkey
More than one disorder is common
Draw knowledge from various levels to make good diagnoses
in search of madness:Is It Evidence Based Opinion or Mere Fairytale?
• Qualifications of an Expert and Medical Legal Guidelines
Some Key Points from the OPA-CAPDA Guidelines for Best Practices in Insurance Examinations
Introduction to the Guidelines and why they are relevant for all assessors
Some of the following slides include quotes taken directly from these guidelines
In Pursuit of Impartiality, Comprehensiveness and Accuracy
Executive summaries – your responsibilities
Staying within your area of competence – different standard for your College vs Medical legal expectations
One must decline assessment referrals that are outside of your area of expertise/competence.
On the use of professional interpreters
On Choosing Appropriate Measures
Language and cultural factors and the use of self-report measures
It’s more about whether a test is used appropriately rather than whether it’s an appropriate test
Relationship between measures and what you are trying to understand
Proper qualifications for use of measures
Can I use the ______ test?
Practical considerations
Your College?
The test publishers who sell them to you
▪ The test publishers rely on the test authors to determine the qualification “level” and given that the authors are most familiar with the ins and outs of the test, the ethical assessor will give great deference to the test publisher’s (or author’s) guidelines.
The courts
Inappropriate test usage - examples
Inappropriate use of test can easily lead to harm!
Test names and test scores are very often misleading
“The Beck Inventories were in the severe range but the claimant exhibited on mild to moderate depression at interview – this is inconsistent.”
“The SIMS score was above the cut-off as per the manual, so the individual is likely overreporting.”
“Performance on the Rey-15 was good so the individual is credible.”
“Scored high on Schizophrenia on the MMPI-2 and PAI and as such likely has schizophrenia”
Usage of test publisher computerized protocols
Reliance on out of date test manuals without knowing latest research and being able to evaluate this research within the context of the population the examinee belongs to
PAR Inc and Qualification Levels
https://www.parinc.com/Support/Qualification-Levels
4 Tiers of qualification: A, S, B, and C.
Tests are categorized under one of three tiers and can only be purchased by someone with the appropriate tier level qualification
Qualification Level A
Can purchase only level A products
No special qualifications are required, although the range of products eligible for purchase is limited.
Qualification Level S
Can purchase level A and S products
“A degree, certificate, or license to practice in a health care profession or occupation, including (but not limited to) the following: medicine, neurology, nursing, occupational therapy and other allied health care professions, physician's assistants, psychiatry, social work; plus appropriate training and experience in the ethical administration, scoring, and interpretation of clinical behavioral assessment instruments.”
Qualification Level B
Can purchase Level A, S and B level products
A degree from an accredited 4-year college or university in psychology, counseling, speech-language pathology, or a closely related field plus satisfactory completion of coursework in test interpretation, psychometrics and measurement theory, educational statistics, or a closely related area; or license or certification from an agency that requires appropriate training and experience in the ethical and competent use of psychological tests.
Qualification Level C
Can purchase all products
“All qualifications for level B plus an advanced professional degree that provides appropriate training in the administration and interpretation of psychological tests, or license or certification from an agency that requires appropriate training and experience in the ethical and competent use of psychological tests.”
In the context of medical-legal work
Assessors who use psychometric tests should:
1. have post-graduate knowledge of statistics, psychometric theory,
and research design so that they understand the strengths and limitations of different psychometric measures
2. also have training, supervision and experience in integrating test data with other sources of information, accounting for consistencies and inconsistencies.
3. have a thorough understanding of the evidence based literature in regard to the psychometric properties, strengths and limitations of the specific tests being used.
If you use tests…
You may receive requests to release a claimant’s clinical file or test data. These requests may raise questions regarding integrity of data sources (copyright protection) and privacy. Assessors should consider these issues and determine how they will handle various situations. In order to protect test integrity and security, when responding to requests made with proper consent for test data, it is understood that it is professionally correct to provide test materials, scores and profile sheets only to other qualified users. On the other hand, assessors should release only test responses but not questions, scores, profile sheets and other test material to those who are not qualified to use a test.
Disclaimers
When conducting an IE, assessors are strongly encouraged to use evidence-based methods and to clearly articulate strengths, limitations and appropriateness of any measures used as part of the evaluation. Consideration should be given to the unique factors affecting the individual being assessed, including cultural, linguistic, demographic, psychosocial and situational factors relevant to the evaluation context. Assessors should indicate if the patient falls outside the normative sample for the test in terms of age, language, culture, education or if the test is being utilized for a purpose for which there is incomplete empirical support.
It is incumbent on the assessor to provide a rationale for nonstandard administrations and how this may or may not affect the conclusions.
Issues with Addendums
If you are asked for an addendum to address follow up questions you must indicate that your opinions are based on their findings at the time of the in person assessment.
Consent issues and addendums – how to protect yourself so you can answer new questions in the future
On “Vulnerability” and the ethical duty of assessors
Given that the principal goal of an ML assessment is to offer an objective and impartial/unbiased opinion, we cannot allow the concept of “greatest responsibility to the more vulnerable client” to taint the impartial nature of the opinion. Quite simply, the assessor must strive to offer an objective and unbiased opinion and to accurately document assessment findings and to formulate opinions based on the entirety of the data set.
This being said, the concept of “greatest responsibility to the more vulnerable client” is critical in ensuring that the ML assessor carry out the examination, interpret the results, and formulate the conclusions in a manner that is respectful and clinically sound in the context of the individual claimant.
More on Vulnerability
It is also critical for the assessor to consider the potential vulnerability of the claimant when making other decisions that are unrelated to the assessment findings and opinions. For instance, the assessor might recognize that the claimant’s mental (or physical, for physical assessors) health status is such that they should not be assessed on the scheduled date and might choose to terminate the assessment early even though the insurer would prefer for the assessment to be completed. In this situation, the assessor is placing the more vulnerable client’s mental health needs above those of the insurer. In another example, the assessor might determine that the claimant is suicidal and might engage in crisis intervention/suicide risk protocols, once again at the expense of timely completion of the assessment.
Essential vs Important information
Our opinions are dependent on the information available at the time of our examinations. We must distinguish between essential versus important information for completing assessments. If essential information is not available, we may not be able to provide an opinion.
On the use of validity measures
The assessor should try to contextualize validity test scores with other sources of information and a determination of over-reporting, exaggerating, feigning, or malingering of symptoms should be offered thoughtfully, based on sound assessment methodology and in consideration of other possible explanations. The assessor must be cautious in attributing causation and motivation to failed validity scores.
Overreporting is not a yes or no construct
It’s a continuum!
It is important that the assessor appreciate the reality that individuals who present with significant distortion could still potentially be legitimately impaired to some degree. The examinee may be experiencing significant psychological symptoms AND be engaging in a significant degree of exaggeration/fabrication.
Given that the assessor will have to provide a summary opinion on a balance ofprobabilities as to whether the claimant is eligible for a benefit (e.g., approval oftreatment, income replacement benefits, etc.), it is incumbent upon the assessor to rely on all sources of information and to offer a fair and balanced opinion. A review of the medical file for instance can often provide valuable information that can help to contextualize assessment findings and that may influence the assessors’ opinion.
Surveillance and consent
You should consider having your consent process include a statement that video surveillance material could be provided for review at the time of the assessment or at a later date and that this material may be considered. However, we caution that at least one regulatory body (College of Psychologists of Ontario) has suggested [see Bulletin 24.3] that the IE Psychologist should provide the examinee with an opportunity to review the surveillance with the psychologist and to explain or contextualize what is on camera if it shapes their opinion. The same processes may berelevant when the insurer asks the IE to consider other materials they have gathered through investigation such as the claimant’s social media profile.
Mental Health and Legal Tests
Material contribution vs But For
Tort threshold
Disability related issues
Diagnosis is not disability! What impairment results from the diagnostic formulation that in turn leads to disability? The diagnosis needs to match the disability given the real world demands (e.g., essential tasks of a job)
final take home pointshow to identify ”madness” in an “expert report
While medico legal experts are free to evaluate a common body of evidence and come up with differing opinions, they are certainly not free to come up with their own facts, nor disregard with no explanation those facts that are contrary to their final opinions, especially if their final opinion is purported to have been formed following the analysis of all available evidence rather than preceding the evidence. Such is the difference between science, opinion based on examinable and quantifiable facts, and faith, belief in things unseen, intangible, and that which is ultimately unproveable.
final take home pointshow to identify “madness” in “expert” reports
rely only on evidence based examination findings
that can objectively substantiate the breadth, severity and veracity ofimpairment
an evidence based examination will employ formal validity testing; in itsabsence, such can only be attributed to bias or ignorance
know the research literature
know your base rates and expected long term outcomes based on researchevidence and consider those factors (grounded in research) that predict afavorable or poor long term prognosis