Forensic Mental Health Evaluations Research Articles

Persecution as stigma-driven trauma: Social determinants, stigma, and violence in asylum seekers in the United States

ObjectiveExisting literature documents high rates of experienced violence in asylum seekers. Despite this high prevalence, experiences of traumatic stress are neither necessary nor sufficient grounds for claiming asylum, without documented experiences of persecution. The aim of the current study is to better understand the role of co-occurring pre-migratory social determinants, stigma, and trauma on the experiences of persecution among asylum seekers in the United States. MethodWe conducted a retrospective file review of legal declarations submitted by 25 asylum seekers who participated in forensic mental health evaluations at a pro-bono asylum clinic. We coded de-identified data for co-occurring events of trauma, social determinants of health, and components of “discrimination” from the legal definition of persecution - conceptualizing persecution as stigma-driven infliction of violence. Data was analyzed using a tiered deductive and inductive reflexive thematic analysis. ResultsFindings suggest pre-migratory social determinants included demographics, neighborhood, economic, environmental, and social and cultural level disparities across various grounds for seeking asylum, and experiences of stigma were associated with the specific acts of violence and harm. ConclusionsOur findings - specific to asylum seekers who have obtained legal representation and completed applications for asylum in the United States - describe the co-occurrence of social determinants, stigma and traumatic experiences among asylum seekers. To our knowledge, this study is the first of its kind to bridge the existing legal framework of asylum to a psychological construct incorporating trauma, stigma, and social determinants of health, lending support for the conceptualization of persecution as stigma-driven trauma.

How online data informs forensic mental health evaluations of sexual behavior: An overview.

The Internet plays a pervasive role in modern life including the expression of human sexuality and sexual offending. A range of online sexual activities may be of interest in forensic mental health evaluations (FMHE), including those which are clearly illegal or those which are legal but functionally problematic. Online sexual offenses will clearly prompt forensic evaluators to consider the role of the Internet in these offending behaviors. The Internet may also be relevant in forensic evaluations of contact sexual offending including informing on history of mixed or cross-over offending, and Internet-facilitated contact offenses. A review of Internet-data may span several online domains, many of which provide the user with substantial anonymity and would likely not be available to the evaluator unless provided through the process of discovery. Early guidelines for the review of Internet-data in FMHEs have been proposed and support the Internet as a useful source of collateral data in the conduct of forensic evaluations of sexual behavior.

Widening the net: Use of social media data in personal injury and disability evaluations.

A central tenet of forensic mental health assessment is the use of multiple sources of data. Traditionally, these sources have included clinical interviews with and observations of the examinee, written records review, psychological test data, and interviews with collateral sources. Data from social media and social networking sites (SNS) is now widely used in civil litigation. However, existing professional practice standards and guidelines do not specifically address the use of SNS data. This leaves forensic mental health evaluators with little guidance as to why, when and how to incorporate SNS data into their evaluations. We review the extant literature on the use of SNS and other social media data in personal injury and disability cases, including legal, ethical, and practical considerations, with the goal of providing forensic mental health practitioners with a framework for making decisions about when and how to incorporate these data into their evaluations and opinions. We advocate caution in conducting independent searches of social media and the Internet, and in making inferences about internal states based on SNS postings. To illustrate these points, we include a case study.

Forensic Mental Health Evaluators' Unprocessed Emotions as an Often-Overlooked Form of Bias.

There has been robust interest in the influence of cognitive and implicit biases that can hamper a forensic mental health evaluator's ability to provide objective opinion evidence. By contrast, literature exploring the biasing effects of the examiner's unacknowledged and unprocessed emotions has been scanty. Borrowing from concepts originating from psychodynamic treatment literature, this article explores how a forensic mental health evaluator's emotional and transferential reactions can affect the assessment process and formulation of findings. We make the case that forensic mental health evaluators are not impervious to their own mental health concerns, including vicarious trauma. We ultimately argue for a cultural shift in forensic practice that acknowledges the unavoidable existence and influence of a forensic evaluator's human emotions, personal reactions, and conflicts, so that strategies can be developed for compassionate but careful management in training programs, supervision, and beyond. We suggest that self-reflection, sometimes with the aid of consultation and psychotherapeutic support, is not only important for clinical trainees but also could serve forensic practitioners throughout their careers, especially during challenging junctures in their personal and professional lives.

Field Reliability of Forensic Mental Health Evaluations of Offenders for Post-Prison Civil Commitment

ABSTRACT This study examined the field reliability of forensic mental health examiners’ opinions in pre-parole evaluations. The California Offenders with Mental Health Disorders (OMD) statute allows for the post-incarceration commitment to a state hospital for treatment as a condition of parole. Reliability is critical in these evaluations because the triers of fact rely on them for their determinations. We expect to find variability among opinions, not only on the final opinions but also on each criterion. We compared three expert opinions on 98 cases to determine the level of interrater agreement. Agreement rates varied by agency, evaluator, and the forensic question posed. We found higher reliability for criteria that were more reliant on past factors and lower reliability for those criteria based on factors present at the time of the assessment. Imprecisely defined legal constructs, unknown individual evaluator characteristics, contextual factors, and passage of time between the evaluations impede reliability.

Developing consensus for culturally informed forensic mental health assessment: Experts' opinions on best practices.

Individuals with minoritized identities are overrepresented in legal system contexts; thus, forensic mental health professionals conduct evaluations of examinees with a diversity of identities. Professional and ethical guidelines direct that these evaluations be completed in a culturally informed manner, yet many professionals still identify a need for specific guidance on how to do so. In the present study, we sought to establish consensus regarding best practices in incorporating culture into forensic mental health evaluations. Given the exploratory nature of this research, no formal hypotheses were tested. We expected that participants would concur that some practices are important to completing culturally informed forensic evaluations. We recruited two samples. Nine people with joint expertise in cultural considerations and forensic evaluations participated in a Delphi-type poll. More than half reported a minoritized racial/ethnic identity, and all identified as a man (56%) or woman (44%). Experts were surveyed regarding importance (two rounds) and relevance (one round) of recommended practices. They contributed seven additional relevant practices. Twenty-one board-certified forensic psychologists completed a one-time survey of their perceptions of best practices. These psychologists primarily identified as White (90%), and most did not identify as Hispanic or Latine (80%). They all identified as men (45%) or women (55%). This sample was asked to rate the importance of a list of practices refined during the Delphi-type poll. The majority of practices were considered important or very important by experts and board-certified psychologists. Consensus is most clear for 28 practices with means, medians, and modes all in the "important" to "very important" range at all time points. There is wide agreement on the importance of particular methods for incorporating cultural considerations in each phase of the forensic evaluation process. Forensic psychologists can use this information to self-evaluate and improve their practice and to inform training. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Examiners' perceptions of forensic mental health assessments conducted via videoconferencing.

The COVID-19 pandemic led to an acceleration in the adoption of videoconferencing (VC) for conducting forensic mental health evaluations (forensic mental health assessments [FMHA]). Two years into the COVID-19 pandemic, we administered a survey to 71 Minnesota-licensed forensic evaluators. Approximately two-thirds (65.7%) had started using VC for FMHA only after the pandemic, though a combined 84.5% reported performing FMHA via VC frequently at present. A striking 43.7% of respondents preferred VC for FMHA over in-person evaluation, and another 22.5% expressed no preference between modalities. Further, nearly 70% of respondents denied there were any populations for which they would never use VC to complete an FMHA. We conclude that the widespread adoption of VC for FMHA with the advent of the COVID-19 pandemic has induced a lasting change in the practice of FMHA. We postulate that with further advancements in technology and the development of testing instruments that can be administered online, the use of VC for FMHA will become standard practice.

Forensic Mental Health Assessment as a Critical Intercept for Enhancing Mental Health Care.

Rates of psychiatric diagnosis, medical morbidity, and suicide risk are notably high among incarcerated individuals. However, engaging these individuals in community-based health care settings can be a challenge. Among justice-involved individuals who do access services, community-based health care settings may lack available resources to effectively conduct comprehensive assessments that inform evidence-based conceptualization. We propose forensic mental health assessment (FMHA) as a critical opportunity to enhance service delivery for this at-risk population. In particular, within the scope of their role, forensic mental health evaluators are able to conduct a comprehensive review of records across health (eg, inpatient and outpatient health care settings), social (eg, homeless shelter), and correctional (eg, jail or prison) settings. Moreover, FMHA often includes specialized batteries that are able to assess and differentially diagnose myriad clinical presentations that may have overlapping symptomatology. We present 2 case vignettes to illustrate the utility of FMHA for enhancing service delivery. Finally, we conclude by noting challenges to integrating FMHA into conceptualization and necessary next steps in research and programing.

Using a Mobile App to Identify Base Rates and Monitor Bias in Forensic Evaluation

ABSTRACT The potential for bias in forensic mental health evaluations can threaten the objectivity of psycholegal opinions. To date, individual evaluators have few mechanisms to identify bias in their own work. The present study examines the use of a recently developed iPhone App designed for this purpose. Evaluators from 18 states used this platform to enter information related to their forensic evaluations, allowing them to receive real-time data about the rates of their opinions across a variety of variables. This study discusses results from 831 evaluations entered into the app and outlines the benefits of using handheld technology in practice. Some variables appeared to influence forensic outcomes (such as the payment of a fee to an evaluator), while others did not (such as defendant ethnicity and race). Analyses also revealed a 49.6% base rate of incompetency to stand trial opinions across all competency evaluations entered into the app.

Immigration Judges' Perceptionsof Telephonic and In-Person Forensic Mental Health Evaluations.

Clinicians affiliated with medical human rights programs throughout the United States perform forensic evaluations of asylum seekers. Much of the best practice literature reflects the perspectives of clinicians and attorneys, rather than the viewpoints of immigration judges who incorporate forensic reports into their decision-making. The purpose of this study was to assess former immigration judges' perspectives on forensic mental health evaluations of asylum seekers. We examined the factors that immigration judges use to assess the affidavits resulting from mental health evaluations and explored their attitudes toward telehealth evaluations. We conducted semistructured interviews in April and May 2020 with nine former judges and systematically analyzed them using consensual qualitative research methodology. Our findings were grouped in five domains: general preferences for affidavits; roles of affidavits in current legal climate; appraisal and comparison of sample affidavits; attitudes toward telephonic evaluations; and recommendations for telephonic evaluations. Forensic evaluators should consider the practice recommendations of judges, both for telephonic and in-person evaluations, which can bolster the usefulness of their evaluations in the adjudication process. To our knowledge, this is the first published study to incorporate immigration judges' perceptions of forensic mental health evaluations, and the first to assess judges' attitudes toward telephonic evaluations.

The Personality Assessment Inventory in U.S. Case Law: A Survey and Examination of Relevance to Legal Proceedings

The Personality Assessment Inventory (PAI), a popular measure of personality, psychopathology, and interpersonal functioning, has demonstrated utility to address various psycholegal questions. This case law review examines a large sample of randomly selected published U.S. case law decisions to ascertain how the PAI has been applied and considered by legal decision makers. The review indicates the instrument is popular in criminal and civil legal settings, particularly in preadjudication forensic mental health evaluations (e.g., competency to proceed) and cases considering social security disability benefits. Forensic evaluators and legal actors primarily consider the results of the PAI as indicators of examinee impression management, psychopathology, and interpersonal functioning, although this varied by psycholegal context. The admissibility of the instrument was rarely challenged, although some challenges to the forensic evaluator’s interpretation and conclusions emerged. Despite the PAI’s popularity, the utility of the instrument is determined by specific, empirically supported, contexts. As such, forensic evaluators must consider how the PAI may inform decision making given examinee characteristics and the psycholegal question.

Acquisition and Interpretation of Digital Information in Forensic Assessments

Despite the now ubiquitous presence of technology in everyday life, there is little written on the subject of personal digital data as it pertains to forensic mental health evaluations. Ethical concerns and limited consensus guidance on this issue have previously made it challenging to use this information in a responsible way. This Perspectives article elaborates on the different types of personal data that exist and the practical aspects of acquiring such information, including data location and legal considerations. Incorporation of personal digital information into the forensic assessment as a form of collateral information is discussed, along with the current state of the literature on technology use and its relationship to psychopathology and risk. Given the important role of technology in the life of the modern individual, deeper research into this topic will be necessary in the immediate future to establish practice standards for the safe and ethical use of digital information in both forensic and non-forensic mental health assessments.

The impact of misdemeanor arrests on forensic mental health services: A state-wide review of Virginia sanity evaluations.

We examined the prevalence of criminal defendants facing only misdemeanor charges and referred for forensic mental health evaluations of legal sanity (criminal responsibility) in a state-wide sample of sanity reports. We sought to describe this population of defendants, particularly as compared to defendants facing felony charges and referred for evaluation of legal sanity. We hypothesized that, among those referred for sanity evaluations, defendants facing only misdemeanor charges would have higher rates of serious mental illness than would defendants charged with felonies, as evidenced by their mental status during the evaluation and at the time of alleged offenses. We also hypothesized that defendants charged with only misdemeanors would be more often opined insane, as compared to those charged with felonies. We reviewed a statewide sample of 926 court-ordered sanity evaluation reports in Virginia and coded numerous variables describing the defendants, sanity evaluation process, resulting reports, and legal opinions offered within the reports. Approximately 22.3% of sanity evaluations involved defendants charged only with misdemeanor offenses. Defendants facing only misdemeanor charges were 1.82 times more likely to be opined insane than were defendants facing only felony charges, primarily due to their increased likelihood of experiencing psychotic symptoms at the time of the offense (1.83 times more likely than defendants facing felony charges). The merits of pursuing the insanity defense in response to misdemeanor charges are questionable given the cost- and resource-intensive outcomes associated with insanity acquittals. Diversion strategies may be a more efficient response to those defendants with serious mental illness facing only misdemeanor charges. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Review of: Forensic Mental Health Evaluations in the Digital Age: A Practitioner’s Guide to Using Internet‐Based Data

Review of: Forensic Mental Health Evaluations in the Digital Age: A Practitioner’s Guide to Using Internet‐Based Data

Piloting forensic tele-mental health evaluations of asylum seekers

While the number of medical human rights programs has increased, there is substantial unmet need for forensic evaluations among asylum seekers throughout the United States. From September 2019 through May 2020, the Mount Sinai Human Rights Program has coordinated pro bono forensic mental health evaluations by telephone or video for individuals seeking protected immigration status who are unable to access in-person services. The national network clinicians conducted 32 forensic evaluations of individuals in eight U.S. states and Mexico seeking immigration relief. Remote forensic services have been a relevant solution for individuals in immigration detention, particularly during the COVID-19 pandemic.

Assessing Negative Response Bias in Competency to Stand Trial Evaluations

Steven J. Rubenzer, PhD ABPP. New York: Oxford University Press, 2018. 288 pp. $41.95. It is axiomatic in a forensic mental health evaluation that an evaluee's responses may be distorted in some way, either over- or under-reporting symptoms. In the context of criminal cases, the former is more

Tipping the scales of justice: the role of forensic evaluations in the criminalization of mental illness.

An unprecedented number of individuals with mental illness are represented in the criminal justice system. The unending growth of mentally ill populations in the justice system has led to jails and court dockets being increasingly overwhelmed with cases involving mental illness, state hospitals devoting far more beds and resources to forensic cases, and people without a criminal commitment left waiting for mental health services as forensic cases are prioritized. Although a forensic mental health evaluation is only one component of this larger system, common problems with forensic mental health evaluations can exacerbate the criminalization of persons with mental illness in many ways. This article reviews the current literature regarding issues of quality, reliability, and validity of forensic mental health evaluations, discusses the broader impact of these issues, and offers potential solutions for the field.

Forensic mental health evaluations in the Guantánamo military commissions system: An analysis of all detainee cases from inception to 2018

Even though the Bush Administration opened the Guantánamo Bay detention facility in 2002 in response to the September 11, 2001 attacks in the United States, little remains known about how forensic mental health evaluations relate to the process of detainees who are charged before military commissions. This article discusses the laws governing Guantánamo's military commissions system and mental health evaluations. Notably, the US government initially treated detainees as “unlawful enemy combatants” who were not protected under the US Constitution and the United Nations Convention Against Torture and Other Forms of Cruel, Inhuman or Degrading Treatment, allowing for the use of “enhanced interrogation techniques.” In subsequent legal documents, however, the US government has excluded evidence obtained through torture, as defined by the US Constitution and the United Nations Convention Against Torture. Using open-source document analysis, this article describes the reasons and outcomes of all forensic mental health evaluations from Guantánamo's opening to 2018. Only thirty of 779 detainees (~3.85%) have ever had charges referred against them to the military commissions, and only nine detainees (~1.16%) have ever received forensic mental health evaluations pertaining to their case. Of these nine detainees, six have alleged mental torture while in US custody. This paper shows that leaders in the United States and Europe should consider whether counterterrorism policies that supersede traditional health and human rights complicate the ability of future governments to prosecute cases when successive leaders change laws, a pertinent consideration as North American and European states grapple with the return of foreign fighters.

Psychiatric Comorbidity of Sex Offenses in a Military Forensic Sample.

To examine the prevalence of psychiatric disorders among service members charged with sexual offenses. The sample comprised service members charged with any type of sexual offense and referred for forensic evaluation (N = 67). Forensic mental health evaluations (competency to stand trial, criminal responsibility, risk assessment) of service members charged with sexual offenses were examined and the assigned clinical diagnoses (according to DSM-IV or -5) were enumerated to provide natural frequencies and percentages. Data were collected from February 2018 to May 2018. Findings suggest that alcohol use disorder is the most prevalent disorder both at the time of offense (28%) and time of the forensic evaluation (38%). The 2 most prominent diagnostic categories were substance use disorders and trauma-and-stress-related disorders. Identification and treatment of psychiatric disorders among service members charged with sexual offenses may facilitate rehabilitation, reduce recidivism, and offer public health benefits. This topic should be further studied in a larger sample to effectively address this public health problem.

Recording routine forensic mental health evaluations should be a standard of practice in the 21st century.

The standard of practice for forensic interviews in criminal and delinquency cases, other than those conducted as part of brief preliminary screening evaluations or in emergency situations, should include a digital recording requirement. This standard should be adopted because of the greater availability of, and familiarity with, recording technology on the part of mental health professionals, the greater use and proven effectiveness of recording in other contexts of the criminal justice system, and the improvement in court presentation and accuracy of judicial determinations involving forensic assessments that recording will provide. The experience of practitioners with recording since professional associations last studied the issue should be taken into account, as informal data suggest it has been positive. Unfortunately, the legal system is unlikely to prompt this advance without its reconsideration by the forensic mental health professions, because current constitutional jurisprudence does not require recording and effectively makes it contingent upon request by examiners. Forensic evaluators thus have a valuable opportunity to educate the legal system on the utility and importance of this key reform, and so should adopt it as a best practice.