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Learning Resources

Required Readings

Bartol, C. R., & Bartol, A. (2017). Criminal behavior: A psychological approach (11th ed.). Upper Saddle River, NJ: Pearson Prentice Hall
Chapter 7, “Psychopathy” (pp. 178-210)

Heilbrun, K., Marczyk, G. R., & DeMatteo, D. (2002). Forensic mental health assessment: A casebook. New York, NY: Oxford University Press.

Chapter 5, “Case 1: Competence to Be Sentenced” (pp. 85–95)

Required Media

Laureate Education (Producer). (2014c). Psychopathy [Video file]. Retrieved from https://class.waldenu.edu
Dr. Scott Duncan discusses psychopathy and how it relates to the study of criminal behavior. Consider how the measurement of psychopathy originated and the characteristics measured.

Note:  The approximate length of this media piece is 16 minutes.

Accessible player –Downloads–Download Video w/CCDownload AudioDownload Transcript

Assignment: Characteristics of Psychopaths

In this week’s Discussion, you considered the complexity of psychopathy. Despite uncertainty about how to define and classify psychopathy, there are firm characteristics that are associated with psychopaths. In your resources this week, you are introduced to the work of Robert Hare, one of the foremost psychopathy experts. Among other things, Hare created a way to measure criminal psychopathy. His tool for measurement, the Psychopathy Checklist–Revised (PCL-R), is a list of characteristics consistently associated with psychopaths that may be useful in identifying and evaluating characteristics of psychopaths. Widely used to classify psychopaths in the criminal justice system, the PCL-R is not a perfect instrument and is not the only instrument of measure for psychopathy. It is, however, a means to discover patterns of features associated with psychopaths.

For this Assignment, review the psychopathic behaviors identified by Hare and Cleckley on page 174 of the course text, and consider the characteristics of psychopaths. Then, review the forensic report case study of D.V. in Chapter 5 of Forensic Mental Health Assessment: A Casebook, focusing on the criminal behavior and personality traits present in the case. Reflect on whether the personality traits indicate that the individual in the case study is a psychopath, as well as the degree to which psychopathy fully accounts for his behavior.

Assignment (1–2 pages):

  • Briefly describe the criminal behavior in the case study.
  • Explain whether or not the individual in the case study exhibits the characteristics of a psychopath, and why or why not.
  • Based on the information in the case study and this week’s other resources, explain at least oneconclusion you might draw about the nature of psychopathic behavior.

Support your Assignment with specific references to all resources used in its preparation. You are asked to provide a reference list only for those resources not included in the resources for this course.

By Day 7

Chapter 5

Competence to Be Sentenced

This chapter concerns competence for sentencing. This is a relatively rare issue for forensic clinicians, so there is only one case included. The principle applied to this case involves the use of psychological testing when appropriate to assess response style. A particular kind of malingering—the feigning of cognitive deficits—is discussed in the teaching point.

Case 1

Principle: Use testing when indicated in assessing response style

This principle addresses the value of using psychological and specialized testing to assess response style in FMHA. Response style is an important consideration in FMHA; it refers to the exaggeration, minimization, or accurate reporting of symptoms of mental or emotional disorder. When an individual exaggerates (or even fabricates) symptoms, or when symptoms that are genuinely experi- enced are minimized or denied, then self-report is less useful and must be deemphasized accordingly. The assessment of response style in FMHA is par- ticularly important because of the incentives that exist in forensic contexts and the perception by judges and attorneys that self-reported information may, therefore, be inaccurate.

Rogers (1984, 1997) has described response style as having four distinct forms: (1) Reliable/Honest, in which a genuine attempt is made to be accurate, and factual inaccuracies result from poor understanding or misperception; (2) Malingering, involving a conscious fabrication or gross exaggeration of psycho- logical and/or physical symptoms, understandable in light of the individual’s circumstances and not attributable merely to the desire to assume the patient role, as in factitious disorder; (3) Defensive, in which there is a conscious denial or gross minimization of psychological and/or physical symptoms, as distin- guished from ego defenses, which involve intrapsychic processes that distort perception; and (4) Irrelevant, involving the failure to become engaged in the evaluation, with responses not necessarily relevant to questions and sometimes

85 Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-01-18 11:26:33.

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86 • Forensic Mental Health Assessment

made randomly. These four distinct styles provide a useful framework for eval- uating response style.

Response style can be assessed through the use of some traditional psycho- logical tests and interviews, as well as by specialized measures that have been specifically designed and developed for this purpose. It is important to note that relatively few psychological tests include any measure of response style, despite the importance of self-report in such tests, and the related assumption that the individual being tested is not deliberately distorting his or her own experience. This was discussed in a recent chapter (Greene, 1997) on the use of several multiscale personality inventories, such as the Minnesota Multiphasic Personality Inventory, 2nd edition (MMPI-2) and the Millon Clinical Multi- axial Inventory-III (Millon, 1994), in assessing malingering and defensiveness. In addition, Rogers (1997) discussed the use of the Structured Interview of Reported Symptoms (SIRS) and its application to malingering. In discussing such tests, it is important to consider both the consistency and accuracy of responding, which encompass underreporting and overreporting. We will de- scribe evidence on item response consistency and the accuracy of responding for the MMPI-2, the MCMI-III, and the SIRS.

Greene (1997) noted that response consistency on the MMPI-2 is assessed through visual inspection for obvious patterns (e.g., TFTFTF, TTFTTF) and by observing the elevation of the F scale. In addition, response inconsistency on the MMPI-2 can be detected through an examination of the Variable Response Inconsistency Scale (VRIN) and the True Response Inconsistency Scale (TRIN), although additional research is needed to provide information regarding the optimal cutoff score for VRIN. With respect to the accuracy of item endorse- ment, the MMPI-2 contains several scales that are relevant to underreporting or overendorsement of psychopathological symptoms. The results of several recent studies, in which participants were provided with detailed information on the nature of the psychopathology to be faked, suggest that the MMPI-2 validity scales are reasonably effective in distinguishing genuine mental disor- ders characterized by severe psychopathology, such as schizophrenia, from simulated disorders (Rogers, Bagby, & Chakraborty, 1993). Other research, however, suggests that the MMPI-2 validity scales are less effective in distin- guishing between genuine but less severe disorders and faking (Lamb, Berry, Wetter, & Baer, 1994; Wetter, Baer, Berry, Robinson, & Sumpter, 1993).

Greene (1997) noted that response consistency on the MCMI-III is as- sessed through a 3-item Validity Index that contains nonbizarre items endorsed by less than 0.01% of individuals from clinical populations. The endorsement of one such item suggests caution in the interpretation of the results, while the endorsement of two items indicates an invalid profile (Millon, 1994). The MCMI-III contains a validity scale that is useful in detecting the accuracy of item endorsement. Specifically, the Debasement Scale (Scale Z) of the MCMI- III has been shown to identify college students who were instructed to malinger on the MCMI-II (Bagby, Gillis, Toner, & Goldberg, 1991).

Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-01-18 11:26:33.

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Competence to Be Sentenced • 87

The SIRS (Rogers, 1992), a 172-item structured interview with eight pri- mary scales, was developed specifically for assessing the feigning of psychopath- ology. Research with the SIRS suggests that it is effective in discriminating between feigners and genuine patients (Rogers, 1997). The SIRS is limited, however, by its inability to detect a malingerer who falsely reports a single symptom and fails to respond meaningfully to a number of questions. In addi- tion, the SIRS provides limited information regarding the “partial malingerer”— the individual who experiences genuine symptoms but who also selectively reports, exaggerates, or fabricates some symptoms depending on the circum- stances.

This principle appears to be well supported on ethical, empirical, and stan- dard of practice dimensions. It is important, however, that forensic prac- titioners select the few tests that meet the appropriate criteria for relevance and empirical support. Toward this end, Heilbrun (1992) offered guidelines that include the explicit assessment of response style through the use of tests, such as the MMPI-2, that have demonstrated empirical support for this appli- cation. There are also several interview strategies that can help the forensic prac- titioner in assessing response style. For example, asking specific and detailed questions, recording the responses, and asking the questions again later in the evaluation can help the forensic practitioner to assess consistency. Finally, when assessing an individual’s response style, it is important for the forensic prac- titioner to employ multiple measures. The use of multiple measures, such as psychological tests, structured interviews, and collateral information, provides additional support for conclusions regarding the individual’s response style.

The present report illustrates the application of this principle in the con- text of a court-ordered evaluation of competence to enter a plea and to be sentenced. Because the referral question involved the cognitive capacity of the defendant to understand his current situation, the evaluator was concerned with obtaining an accurate representation of the defendant’s cognitive func- tioning. Therefore, an accurate assessment of the defendant’s response style was necessary. Because the evaluator was skeptical about the accuracy of the self-reported psychopathological symptoms, he addressed the possibility of the defendant’s malingering.

The determination of malingering was made through the use of interview strategies and psychological testing. As part of the evaluation, the defendant was administered several psychological tests, such as the SIRS and the MMPI- 2, that have demonstrated empirical support in detecting malingering. This selection of tests is consistent with the guidelines offered by Heilbrun (1992) regarding the assessment of response style by using tests with empirical support for that purpose. Because the evaluator suspected that the defendant was ma- lingering, the defendant was administered psychological tests on three occa- sions in an effort to assess consistency of responding.

The results of the first administration of the SIRS suggested that the defen- dant was misrepresenting himself as mentally ill; his responses were consistent

Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-01-18 11:26:33.

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88 • Forensic Mental Health Assessment

with those of someone intending to feign a psychotic disorder. Specifically, he endorsed an excessively high number of unusual symptom combinations. Be- cause the defendant was exaggerating his psychopathological symptoms, his response style would be characterized as malingering (Rogers, 1984, 1997). The defendant scored in the “Definitely Malingering” range on one scale, and in the “Probably Malingering” range on four others. After the evaluator spoke with the defendant regarding the possibility that the defendant was feigning mental illness, the defendant was readministered the SIRS. The results indi- cated that the defendant substantially modified his report of psychopathologi- cal symptoms. On the second administration, the defendant scored in the “Probably Malingering” range on only two scales. As such, the SIRS provided one effective means of assessing malingering in this case.

The defendant was also administered the MMPI-2. He consistently en- dorsed items reflecting psychopathology, with the number of items endorsed far exceeding the number of items usually endorsed by patients. The MMPI-2 VRIN, TRIN, and F scales reflected scores consistent with a pattern of respond- ing often seen in individuals trying to feign mental disorder. When the MMPI- 2 was readministered, the defendant’s response style would be classified as irrelevant (Rogers, 1984, 1997).

Based on the results of the psychological testing, the evaluator concluded that the defendant presented with a malingering response style. By using psy- chological tests with demonstrated empirical support for the evaluation of re- sponse style, the evaluator was able to more accurately assess the defendant’s response style. The defendant’s pattern of responding on the SIRS and MMPI- 2 was consistent with the performance of individuals who are attempting to feign mental illness by exaggerating psychopathological symptoms. The evalua- tor concluded that the defendant was malingering psychopathology, motivated by his expectation that a diagnosis of schizophrenia might contribute to a re- duced sentence. Based on the results of the evaluation, which included a thor- ough assessment of the defendant’s response style, the evaluator concluded that the defendant was competent to proceed with the plea agreement and subsequent sentencing.

FORENSIC REPORT1 Prisoners by the U.S. District Court for the West- ern District of Missouri pursuant to Title 18, U.S. Code, Section 4241 and 4247(b). According toDates of Evaluation: July 29 to August 30, 1999

Date of Report: August 30, 1999 the documents provided by the U.S. Attorney as- signed to the case, DV was charged with Posses- sion of a Firearm by a Convicted Felon.

REFERRAL The referring Court directed that a mental

health professional at the Medical Center exam-DV is a 36-year-old, single Black male who was referred to the U.S. Medical Center for Federal ine DV and provide an opinion regarding his

Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-01-18 11:26:33.

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Competence to Be Sentenced • 89

5. DV Proffer, undated.competency to enter a plea and to be sentenced. 6. Indictment, United States District CourtPrior to beginning the initial interview, DV was for the Western District of Missouri,informed that the usual psychotherapist/patient dated March 31, 1998.relationship did not exist and that the informa-

7. Report of Investigation, dated Februarytion obtained from the evaluation was not confi- 12, 1998.

dential. He was also informed that a report would 8. Springfield Police Department Statement be prepared and submitted to the referring Court Form, dated January 27, 1998. and then be distributed to both the defense and 9. Offense-Incident Report, Springfield Po- prosecuting attorneys. DV acknowledged and ap- lice Department, dated January 27, peared to understand these conditions and was 1998.

10. Complaint/Arrest Affidavit, undated.periodically reminded of the conditions as the evaluation progressed.

DEFENDANT’S PERSONAL HISTORY SOURCES OF INFORMATION

DV’s personal history was obtained through self- This evaluation was conducted in the Mental report and review of criminal investigative mate- Health Evaluation Unit of the U.S. Medical Cen- rials. ter for Federal Prisoners. During his stay at the DV stated that he lived at home with his facility, DV was regularly observed by clinical mother, father, and two brothers until the age of and correctional staff. He participated in addi- 8, when his mother was killed in a car accident. tional clinical interviews with the undersigned DV stated that after his mother’s death, he began evaluators. Additionally, the medical staff com- living with an aunt, who raised him until he left pleted a routine physical examination of DV. home at the age of 14. He stated that when he Other sources of information included psycholog- was 14 years old he moved to Missouri, where he ical testing, including: initially lived with his older brother.

According to DV, he attended school through1. Validity Indicator Profile the eighth grade. He stated that he was expelled2. Rey 15-Item Memory Test from school after the eighth grade, partly because3. Rey Auditory Verbal Learning Test of his poor attendance and partly because of his4. Dot Counting Test involvement in two fights. He reported repeating5. Rey Word Recognition Test

6. Test of Nonverbal Intelligence-2 the eighth grade once due to his poor attendance. 7. Structured Interview of Reported Symp- DV stated that his grades were mostly Bs, Cs, and toms Ds. He described school as being difficult for him

8. Minnesota Multiphasic Personality Inven- because he never had any family support. He tory-2 stated that after his mother died, nobody really

9. Shipley Institute of Living Scale cared whether he went to school. He denied ever attending special education classes or being diag-Documents reviewed included prior medical nosed with a learning disability.records, and criminal investigative materials, in- DV stated that he began smoking marijuana ascluding:

a teenager and has continued to use it throughout 1. Order for Psychiatric Examination of De- adulthood. He reported that prior to his arrest, fendant, United States District Court for he used marijuana on a daily basis. He stated that the Western District of Missouri, dated he drinks alcohol much less frequently, primarily July 14, 1999. on the weekends or when it was available. He

2. United States Government Memoran- stated that selling illicit drugs has been his pri-dum dated May 5, 1999. mary source of income through the years.3. United States Government Memoran- DV stated that he has two sons. He reporteddum dated May 4, 1999.

having a close relationship with his 10-year-old4. Plea Agreement, United States District son, who lives in another state. He reported hav-Court for the Western District of Mis-

souri, dated April 26, 1999. ing little to no contact with his 13-year-old son,

Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-01-18 11:26:33.

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90 • Forensic Mental Health Assessment

who lives in yet another state. He reported a se- During formal interviews, DV was initially uncooperative with the evaluators. He was non-ries of brief relationships with women, never hav-

ing sustained a relationship for longer than 6 disclosing and pretended not to understand what was asked of him. He was strongly encouraged tomonths.

DV stated that he has been arrested at least cooperate with the evaluation. After a period of observation and initial psychological testing, we20 times throughout adolescence and adulthood.

He has been incarcerated in state prisons twice, explained to him that his report of experiencing auditory hallucinations was unlikely to be true.both for felony convictions. According to DV,

the only previous mental health treatment he has We informed him that we did not believe he had any mental disorder. DV ostensibly changed hisreceived was during his incarceration in a state

prison. He stated that he had been experiencing attitude and agreed to cooperate with us. He told us that he was not mentally ill, but he seemed tonervousness, tremors, and what he referred to as

“depression.” This “condition” was reportedly want to continue to present himself as somewhat impaired. He also agreed to recomplete some oftreated with antipsychotic medication for a pe-

riod of 6 months. His reports of past mental the psychological testing that had previously been administered to him. Because his performance onhealth symptoms were vague, and he indicated

that he has never sought mental health treatment tests in the second administration did not sub- stantially improve, we met with him again andwhen out of prison. reemphasized the importance of answering test items truthfully and to the best of his ability. He insisted that he had done his best. We took the

HOSPITAL COURSE position that perhaps he had not understood the directions for the testing and reexplained how toDV was admitted to the Mental Health Evalua-

tion Unit on July 29, 1999. On admission, he was complete the tests. He was then tested a third time and improved substantially.housed in a locked ward, as is standard policy.

Initially, DV was cooperative but guarded. He gave a vague and unconvincing report of hearing voices and stated that he experienced difficulty sleeping.

MENTAL STATUS AT He reported receiving treatment in the past with

THE PRESENT TIME antidepressant medication for “depression.” On arrival at the Medical Center, DV was re- DV was alert and oriented to person, place, time,

and situation. His speech was clear and coherent,ceiving thioridazine (an antipsychotic medica- tion, 200 mg at bedtime). This medication had although low in volume and slowly delivered.

Psychomotor movements were slow. There wasrecently been prescribed in the county jail based on a brief interview, and was discontinued by the staff no evidence of thought disorder. His thinking was

linear, relevant, coherent, and organized, andpsychiatrist after the initial interview. He received diphenhydramine (50 mg at bedtime, as needed) showed no evidence of delusional content. DV’s

mood was euthymic. He displayed a limitedthroughout the study period to help him sleep. By August 5, DV had displayed no evidence range of emotional expression. He demonstrated

no apparent psychosis. He denied any current sui-of problems from the discontinuation of medica- tion. He was cooperative, and he was deemed cidal or homicidal ideation or intent. suitable for transfer to an unlocked unit. He was allowed to go unescorted throughout the institu- tion to various activities. He managed his daily

PSYCHOLOGICAL TEST RESULTS routine in the institution with full capacity to care for himself. Hygiene and personal grooming DV was administered psychological testing on

three separate occasions. Initial test results clearlywere satisfactory. DV interacted appropriately with staff members and other inmates. He inter- revealed that DV intended to represent himself

as mentally ill and confused. He was presentedmittently complained of difficulty sleeping. No disturbance in appetite was noted. with our conclusion that he had been feigning

Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-01-18 11:26:33.

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Competence to Be Sentenced • 91

mental illness. He claimed he had not and agreed When these measures were readministered in the second testing session, they continued to indicateto be retested with some of the tests. His perfor-

mance on the second attempt did not suggest ac- that he was only providing token effort to respond correctly, and tests of cognitive ability were nottive feigning, but he did not appear engaged in

giving an accurate portrayal of his abilities. After administered. In the third testing session, he re- sponded with much greater effort. Repeat adminis-further counseling, he was readministered two

tests, which he appeared to complete in a cooper- tration of tests of cognitive ability indicated he had at least Low Average ability in nonverbal reasoning,ative fashion.

DV’s responses on a structured interview of word knowledge, and verbal comprehension.7

symptoms of mental illness were consistent with those of someone intending to feign psychotic mental illness. He endorsed an excessively high

DIAGNOSTIC FORMULATION number of unusual symptom combinations. He tended to report that he had experienced almost DV does not manifest a mental disorder. Over

the period of this evaluation, DV’s behavior wasany type of unusual psychotic experience with a high degree of impairment.2 When this test was observed on a daily basis. He demonstrated excel-

lent hygiene and organization in daily behavior,readministered, he substantially modified his re- port of problems but still endorsed an unusually but he appeared to make an attempt to malinger

mental illness. He actively reported to nursinglarge number of psychological problems with sig- nificant levels of impairment. This pattern of re- and correctional staff that he was hearing voices.

He acted confused when they questioned himsponding was not as clearly similar to that of indi- viduals who malinger mental disorder.3 about his complaints. When evaluated by the ex-

aminers in formal interviews, however, theseOn a self-report inventory of personality char- acteristics, DV’s responses were consistent and complaints appeared feigned.

His initial performance on psychological testsreflected a good comprehension of the test items. He consistently endorsed items obviously related was consistent with that of individuals who feign

mental illness. In addition to exaggerating com-to psychopathology. He endorsed a significant number of items infrequently endorsed by chronic monly experienced symptoms of mental illness,

DV reported experiencing an abundance of unbe-mental health patients. Additionally, the number of mental health symptoms he endorsed far ex- lievable and unlikely symptoms. Not only was his

test performance unbelievable it was also inconsis-ceeded the number of items typically endorsed by mental health patients.4 This pattern of respond- tent with his daily behavior. When he was told that

his presentation was not believable, he prompt-ing is typically seen among individuals who wish to feign mental disorder. When this test was read- ly ceased portraying himself as mentally ill.

Although DV stopped actively feigning men-ministered, his responses appeared to be irrele- vant to content and too inconsistent to interpret. tal illness, and in fact told us that he was not

mentally ill, he nevertheless continued to under-It was likely that he responded without paying close attention to the test statements.5 represent his cognitive abilities on psychological

tests. As we continued to emphasize the need toDV’s performance on several tests of memory was also consistent with that of someone who is cooperate with testing, he gradually became more

cooperative, and his performance improved. Hisfeigning cognitive impairment. For example, he presented with a greater ability to recall words for gradual improvement supports the conclusion

that it was his approach to evaluation rather thanmemory than to recognize them. This finding is typically restricted to individuals who are feigning genuine deficits that was responsible for his ini-

tially poor performance on tests of memory andmemory impairment.6

His first efforts on tests of cognitive ability re- cognition. DV reported receiving antipsychotic medica-sulted in estimate of ability in the range of Mild

Mental Retardation. Measures of motivation and tion while incarcerated in a state prison. He stated that he was treated for what he referred toeffort, however, indicated that he was motivated

to respond incorrectly or to give minimal effort. as depression, but it is unlikely that he has ever

Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-01-18 11:26:33.

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92 • Forensic Mental Health Assessment

experienced a clinical depression. DV’s report of agreement. He accurately and completely related the circumstances of the offense to which he haspast symptoms of depression and psychosis was

vague and unconvincing. Based on a brief inter- pled guilty. He fully described the process of making a plea. DV knew he has the choice toview, he recently received a diagnosis of schizo-

phrenia in the county jail. This conclusion was stand trial, and he believes that entering a plea provides a better outcome. He knew that the cur-probably the result of undetected malingering.

DV appears to have been malingering in a rent adjudication constitutes his third felony con- viction, and he knew the sentencing mandates as-halfhearted fashion. He was apparently aware

that his recent diagnosis of schizophrenia might sociated with a third felony conviction. That is, DV was aware that he could have received a verycontribute toward a reduced sentence, even be-

yond the reduction gained in his plea agreement. lengthy sentence for his third conviction and knew his plea carried the probability of a rela-When faced with the prospect of having us report

to the court that he was malingering, however, tively short sentence. He knew that his plea agree- ment called for his full cooperation in the resolu-he clearly changed his report of confusion and

psychotic experience. He claimed he had no tion of his case. When we indicated that we thought he was not cooperating with the evalua-mental disorder and eventually chose to reveal his

true abilities on psychological testing. He is not tion sought by the court by actively misrepresent- ing his true mental state, he became very con-currently malingering.

DV does not manifest a mental disorder. He cerned and substantially modified what he told us about his mental state. His thinking evidenced nodoes manifest a personality style and behavior

pattern that is characterized by antipathy toward irrational reasoning or delusional content. His conduct throughout the course of his hospitaliza-authority and violation of social norms and laws.

He is persistently irresponsible in relationships tion, especially in interview with us, demonstrated that he is quite capable of communicating effec-and personal commitments. He has abused mari-

juana throughout his adolescence and adulthood. tively with his attorney. He knew that the sen- tence he was anticipating was based on an agree-His personality style does not generally constitute

a mental illness. ment with the prosecutor, was not binding on the court, and was intended to punish him for his be- havior. He expressed confidence in his attorneyDIAGNOSES and related several instances of cooperation with

According to the criteria set forth in the Diagnos- his attorney in reaching the plea agreement. tic and Statistical Manual of Mental Disorders, Based on these considerations, it is our opin- Fourth Edition (American Psychiatric Associa- ion that DV is competent to proceed with his tion, 1994), DV is diagnosed as follows: case. He is aware of the nature and potential con-

sequences of the charge against him and he is able Axis I: Malingering (resolved) to properly assist his attorney in this matter. He

Cannabis abuse has a rational and factual appreciation of the cir- Axis II: Antisocial personality disorder cumstances relating to his potential sentence. He

does not manifest a mental disorder that wouldAxis III: None interfere with these abilities.

OPINION CONCERNING Comment The determination of malingering in

COMPETENCY TO PROCEED this case was initiated by a skepticism about symptoms reported by the defendant. His reportDV was aware of the terms and conditions of his

plea agreement. He recognized the consequences of depression was inconsistent with the applica- tion of antipsychotic medications. It is not un-of a guilty plea and was able to articulate rational

and coherent reasons for entering such a plea. He usual, however, for individuals with psychosis to sometimes misunderstand or underreport priordemonstrated an awareness of the potential bene-

fits of accepting a plea agreement, as well as the psychotic episodes, misrepresenting them as “de- pression” or “nervous breakdowns.” In the case ofpossible consequences of violating te terms of the

Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-01-18 11:26:33.

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Competence to Be Sentenced • 93

DV, when asked to describe his episode of de- to claim that he had not been faking, did not have a mental disorder, and had responded truthfullypression, he reported that he had heard voices,

and he reported nothing more. We chose not to to testing. When he was retested, he did not per- form well, continuing to report some problemsquestion the examinee about a list of possible ex-

periences, preferring instead to ask open-ended on the SIRS and responding randomly on the MMPI-2. He made only a token effort to performquestions and evaluating the completeness of his

response. Because of our advantage of inpatient well on the VIP. Given the importance of his cog- nitive capacity to know what was happening inevaluation, with individuals under constant ob-

servation, we can safely observe individuals over his case, we were most concerned with obtaining a valid representation of his thinking skills. DVtime without medication to see if they demon-

strate a coherence of symptomatology that would was no longer actively feigning a psychotic disor- der, but he was unwilling to reveal his true cogni-suggest a mental disorder. DV demonstrated

symptoms of mental disorder only in conversa- tive abilities. Our strategy was to reapproach him for testing, allowing him to “save face.” We sug-tions with direct care staff and not in interactions

with other defendants or with secondary adminis- gested the possibility that we had not given clear instructions on how to complete the test and re-trative staff.

Initial psychological testing was quite helpful explained them in excessive detail. With this ba- sis for explaining his previous poor performance,to direct our attention to the likelihood he was

faking a mental disorder. Engaging DV in an open he was free to respond correctly, and did so. discussion of what was happening was more dif- ficult. Based on the SIRS, MMPI-2, and VIP re-

Karin Towers, J.D., M.A. sults, we were rather confident that DV was mis-

Psychology Intern representing his true mental state. When we told him that we did not believe he had a mental dis- Richard Frederick, Ph.D.

Diplomate in Forensic Psychology, ABPPorder and was faking symptoms, his response was

Teaching point: How do you assess feigned cognitive deficits?

Consistent with Heilbrun’s (1992) exhortation to use tests with demonstrated empirical support for identification of invalid response styles, Van Gorp and colleagues (1999) found that tests that specifically assess malingering classified invalid response styles more accurately than some recommended posttest anal- yses of standard neuropsychological procedures. When cognitive impairment is potentially at issue in a forensic examination, I routinely have examinees com- plete a number of procedures and tests that specifically assess the reliability of their presentation. I follow Rogers’s (1997) guidance to gather convincing evi- dence of malingering and to understand the motives of the test taker before concluding that malingering exists. Convincing evidence of malingering in- cludes instances of improbability in testing and clinical presentation. Examiners should look at all the evidence, including clinical presentation, test findings, the case history, and potential gain for misrepresentation of abilities, to make sense of all the information.

Courts are often interested in the capacity of criminal defendants to rea- son, attend, concentrate, track proceedings, and remember salient details. Courts, compensation boards, and juries must determine whether civil plain-

Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-01-18 11:26:33.

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94 • Forensic Mental Health Assessment

tiffs have suffered compensable impairment in functional cognitive capacities, intellect, or memory ability. Psychologists and neuropsychologists have devel- oped a number of tests to identify impairments in these capacities but rela- tively few evaluate response style. The VIP is the only commercially available test that has been developed and validated to directly evaluate the believability of presentation of ability in reasoning, intellect, and word knowledge (Freder- ick & Crosby, 2000). Some other tests and procedures have been reported for this purpose but are not routinely available or well validated.

By contrast, there are a number of procedures available to assess memory impairment. The Portland Digit Recognition Test (PDRT; Binder, 1990) and the Test of Memory Malingering (TOMM; Tombaugh, 1997) have a extensive literature establishing their validity. The TOMM, in particular, has identified performance characteristics for a number of clinical conditions involving brain impairment (e.g., Ress, Tombaugh, Gansler, & Moczynski, 1998). Currently, the primary strategy of identifying suspicious performance for these tests is to identify the range of errors that are likely for individuals with genuine memory impairment and to establish that as the lower boundary of acceptable perfor- mance. The PDRT requires a relatively long time (up to an hour) to present 5-digit strings for memorization and recognition, but the TOMM can be ad- ministered much more quickly, in as little as 5 to 10 minutes. It uses simple line drawings. Some of the drawbacks of the PDRT have been eliminated with the development of the Victoria Symptom Validity Test (VSVT; Slick, Hopp, Strauss, & Thompson, 1997), a test that administers 5-digit strings for memori- zation and recognition by computer. The VSVT provides a useful analysis of errors and response time. The manual is quite helpful in interpreting the mean- ing of recognition errors.

I like to use a number of procedures developed by Andre Rey, a neuropsy- chologist in Geneva from the 1930s to the 1960s. These include the Word Recognition Test (WRT), the Auditory Verbal Learning Test (AVLT), and the 15-item Rey Memory Test (RMT, known by a number of slightly dissimilar names). Rey’s procedures are not well established as malingering detection techniques, although they have received more examination on malingering de- tection than any other technique in the professional literature. The Rey tech- niques were primarily introduced to the United States through Lezak’s 1983 book on neuropsychological assessment. When read in the original French, however, it appears that Lezak did not accurately report Rey’s test procedures and instructional sets, or fully communicate Rey’s approach to malingering detection. Rey (1958) clearly stated that his techniques were merely “signs” and cautioned against overinterpretation, noting that the presence of a single positive sign should not cause the evaluator to reach a conclusion of malinger- ing. These techniques and their various instructional sets have been described (Frederick, 1997), and the applicable literature reviewed (Frederick, Crosby, & Wynkoop, 2000).

The Rey 15-Item Memory Test (RMT) presents 15 items on a sheet of paper for visual memorization. Failure to reproduce nine items is generally

Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-01-18 11:26:33.

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Competence to Be Sentenced • 95

considered predictive of malingering, unless severe impairment is present or possible. Frederick (2000a) demonstrated that the RMT is especially useful in criminal forensic evaluations (which are not primarily neuropsychological) in identifying malingering. Greiffenstein, Baker, and Gola (1996) examined a number of methods of evaluating memory complaints. They found that com- paring performance on Rey’s recognition and recall memory techniques was useful in identifying malingered memory impairment. Given that recognition memory should be much stronger than recall memory, performances in which recall appears stronger than recognition require close scrutiny (see also Freder- ick, 2000b).

It is possible to evaluate complaints of amnesia by developing a recognition test that is individually tailored to the information the patient claims not to know (Frederick, Carter, & Powel, 1995; Frederick & Denney, 1998). I have found that such assessment of claimed amnesia has much greater sensitivity than indirect assessment by available malingering tests.

Making sense of the presentation means integrating information from his- tory, testing, clinical presentation, and the incentive for malingering to form hypotheses about the patient. In evaluating evidence relevant to these hypoth- eses, it is sometimes useful to confront the patient with concerns that their testing performance does not reflect their best abilities and to ask to retest them. In the example we presented, there was clear evidence that we could not trust results of the first testing, nor could we support hypotheses that con- sidered the results of this testing to be accurate.

Notes

1. Identifying information about this individual, including initials, certain demo- graphic information, some case characteristics, and the referring court have all been disguised to protect his identity.

2. On the first administration of the SIRS he scored “Definitely Malingering” in the Severity category, and “Probably Malingering” in the Blatant, Subtle, Selectivity, and Symptom Combination categories.

3. On the second administration of the SIRS, he scored “Probably Malingering” in the Subtle and Severity categories.

4. On the MMPI-2 first administration, VRIN = 6, F = 37, Fb = 22, and F(p) = 8. 5. On the second administration of the MMPI-2, VRIN = 10, F = 28, Fb = 13,

*F − Fb* = 15, F(p) = 3. 6. He recalled six words on the Rey AVLT first trial. On the Rey WRT, he cor-

rectly recognized five words and misrecognized five words. On the Rey 15-item test, he reproduced six items correctly. One row of the two reproduced was a combination of sticks and a circle.

7. On the first administration of the VIP, his performance were classified as “irrele- vant,” with a total score of 55/100 on the nonverbal subtest and 39/78 on the verbal subtest. On the second administration of the VIP, his performances were classified as “careless,” with a total score of 54/100 on the nonverbal subtest and 49/78 on the verbal subtest. For the third testing session, only the nonverbal subtest was administered. His performance was classified as “compliant,” with a total score of 74/100.

Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-01-18 11:26:33.

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