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

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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

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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

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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

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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

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T-Score

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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

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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