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[00:00:00] Dr. Sharp: Hello everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

This episode is brought to you by PAR.

PAR offers the SPECTRA: Indices of Psychopathology, a hierarchical-dimensional look at adult psychopathology. The SPECTRA is available for paper and pencil assessment or administration and scoring via PARiConnect. Learn more at parinc.com/spectra.

All right, y’all. Welcome to The Testing Psychologist podcast. Today’s topic is forensic assessment. We’ve talked about forensic assessment in different formats over the years but today, I am talking with Dr. Casey Mangnall. [00:01:00] We are talking about the overlap and differentiation between forensic assessment and clinical assessment.

Casey got her doctorate in clinical psychology from the University of Denver. She completed her predoctoral internship at Utah State Hospital, where she did her first dive into forensics and was instantly obsessed with forensic psychology so she went on to complete a postdoctoral in forensic psychology at Utah State Hospital.

She’s received training in a variety of forensic evaluations, including competency to proceed, mental state evaluations, violence risk assessments, and psychosexual evaluations. She also runs a private practice offering a blend of clinical and forensic evaluations, including both criminal and civil forensic evaluations.

While she’s passionate about psychological evaluations, she has many interests outside of the profession, including being active outdoors and the amazing statistic that she once walked [00:02:00] 2,660 miles from Mexico to Canada. Sadly, we did not get into that story but I now know why I’m going to have Casey back on the podcast at some point.

So this is a really cool conversation. We get into many things related to forensics. We talk about major differences between forensic and outpatient assessment, then get into a more detailed discussion of effort testing among individuals with suspected intellectual disabilities, we chat about the value of standardized testing in forensic settings, and strategies for gathering collateral data and records, and many other things. As usual, there’s a lot to take away from this conversation.

If you’re a practice owner and you’d like some support with your practice development, I would love to help you. You can check out The Testing Psychologist mastermind groups, which are group coaching experiences aimed at all levels of practice. A group of psychologists get together. We [00:03:00] support one another. We hold each other accountable. The hope is it gives you a little boost to reach any goals you may have set for your practice. You can get more information at thetestingpsychologist.com/consulting.

All right, let’s jump to my conversation with Dr. Casey Mangnall.

Dr. Sharp: Hey Casey, welcome to the podcast.

Dr. Casey: It’s good to be here.

Dr. Sharp: I’m glad to have you. You’re a former Colorado person, right? You came from DU?

Dr. Casey: Yes. I had a 4-year stint in Colorado on the Front Range.

Dr. Sharp: Sure. And it’s way better than Utah, right?

Dr. Casey: Yeah. I think everyone should move to Colorado.

Dr. Sharp: You’re like, what [00:04:00] do I say right now? Sorry, I’m ambushing you right off of that. No, Utah is amazing. So many cool spots.

I’m glad to have you here. Forensic assessment is an area that certainly falls outside my scope of expertise. And so I think it gets a little less airtime here on the podcast. I’m always thankful to have folks who are more skilled in forensic stuff to come on and chat with us. I’m excited to talk with you.

Before we get into everything though, you are one of those folks that has to do one of those disclaimers, so we’ll make a little space for you to do that now and then we can get into our conversation.

Dr. Casey: Yeah, so since I wear two hats, I run a private practice but then I also work full-time, my immediate employer is the Utah State Hospital under the umbrella of the Department of Health and Human Services. And so just a little disclaimer to say that the opinions that I [00:05:00] express on here are my own and that I’m not representing the State Hospital or DHHS. This is also not legal advice.

Dr. Sharp: Of course. All right. We got that out of the way. Let’s get into the good stuff. I’ll open with the question that I always open with, which is, why spend time on this? Out of everything that you could do with your life and your degree, why this area?

Dr. Casey: I don’t know that I have a concise satisfying response to that. I came into every aspect of psychology in a roundabout way. In undergraduate school, I studied English Literature. I liked the process of identifying themes, finding parallels, and making comparisons between things that seemed really different. [00:06:00] And so once I got into psychology, I found that that process was also very similar, especially in testing.

I spent a long time after undergraduate not knowing what I wanted to pursue and what was meaningful to me. I stumbled into psychology years after graduating but fell in love with it and had the opportunity to learn about testing by working as a psychometrist. That immediately got me out of just that process of finding, picking out the data points, and then figuring out what’s the pattern, what connects these data points and how to make sense of it, and how to give someone this really comprehensive picture through these disparate data points.

And then forensics also came much later. [00:07:00] I didn’t really have that training, the formal training and experience, in graduate school. I didn’t know that I was interested in forensics at the time. I was mostly interested in testing and then when I matched at Utah State Hospital for my predoctoral internship, I was really excited because I knew I’d be doing forensic evaluations.

And so I implicitly, I think, equated that with doing these really comprehensive evaluations with lots of different testing, discovered that that’s not necessarily the case, that testing is not inherent in it. But I think what I’ve really loved, obviously, there’s plenty of testing in forensics but I really love that process of taking what I know about psychology and about testing and then applying it to this realm outside of psychology.

So to a totally different kind of question, it’s really honed my [00:08:00] skills as a clinician and really made me step outside of that comfort zone and outside of that box. It’s a really enjoyable process for me.

Dr. Sharp: Sure. I know we’re going to talk a lot about that and some of these parallels and a lot of the differences between forensic assessment and “regular assessment”. I like hearing your story. It sounds similar to my own and I think to a lot of folks where you don’t have to know exactly what you want to do from the beginning of graduate school or undergraduate or anything like that. There’s lots of twists and turns along the path as we go along.

Dr. Casey: Absolutely. I think because of that, a huge advocate for being open to different experiences along the way, and even if you feel like you know what you want to do, maybe it’ll change. [00:09:00] I’m glad that I was open because I don’t think I would have found forensics if I had had more of a laser focus on what I thought I wanted to do when I went into graduate school.

Dr. Sharp: Yeah. I’m glad to hear that. I think it’s important for other folks to hear too, especially folks in graduate school, that things can change. I did both my internship and my postdoc in college counseling centers, which sounds crazy at this point. People come in and when I meet them, they’re like, how did you go from college counseling to testing? So there’s plenty of ways to get where you’re supposed to go.

We are going to talk a lot about forensic assessment today. I thought a place for us to start might be, I would love to get your thoughts on some of the major differences between forensic assessment on the whole and neuropsychological testing or whatever. [00:10:00] I’m not sure what we want to contrast it with or what term we want to use, maybe that’s even a great place to start.

Dr. Casey: That’s a good point. Oftentimes, in the forensic literature on this topic, it’s contrasted with therapeutic evaluation or therapeutic assessment, and that’s not Therapeutic Assessment like the school of assessment that’s really rooted in that therapeutic process, but just to contrast it, meaning evaluation that’s meant for assessment, diagnosis and treatment planning.

You could also call them clinical evaluations but I think a lot of forensic evaluations are also clinical evaluations. They’re just in a forensic context. So I typically contrast the forensic evaluation with a therapeutic evaluation.

Dr. Sharp: That’s fair. And just to be super clear, we’re not talking about therapeutic [00:11:00] assessment as a modality as the theoretical orientation, so to speak, but just the field of assessment as a whole, non-forensic assessment.

Dr. Casey: Exactly.

Dr. Sharp: Great. Let’s lay out some of the core differences that you have identified.

Dr. Casey: One, even just starting with, who the client is. A lot of times in a therapeutic evaluation, the client is going to the same as the examinee or it might be a parent or something like that but in forensics, it’s less often that the examinee is the same as the client. It comes to court ordered evaluations, the court is the client. A lot of times an attorney will request the evaluation. So then they’re the client. [00:12:00] Just that alone can get a little murky and requires a little bit of clarification, but that difference alone can really dictate a lot of difference in the purpose, nature and scope of forensic evaluation.

When it comes to the goal of a forensic evaluation, the goal is to assist the fact finder in making a legal decision as opposed to in therapeutic evaluation, the goal being to provide accurate diagnosis, relevant treatment recommendations.

So with that difference in goals, there’s a difference in the role of the evaluator. In a therapeutic evaluation, the role is really more, as you could say, helping or an advocate for the client in a way; you want them to get the [00:13:00] best treatment possible- whatever that’s going to look like for them, as opposed to in a forensic evaluation, the role is more helping the court or the fact finder. It’s not necessarily about getting the examinee treatment or things like that. And sometimes, the effect can be problematic for the defendant or the examinee. So I think a lot more risk involved in those kinds of evaluations.

Dr. Sharp: I would love to talk at some point, maybe we can bookmark this, how you thread that needle in building rapport, building trust when in the back of your mind you know, whether you’re saying it explicitly or not, that the results of the [00:14:00] evaluation may not go in this person’s favor. It’s hard not to think that there’s a manipulation involved there. I’m sure there’s a better word and a better rationalization, but I’d be curious how you navigate through that.

Dr. Casey: Yeah, totally. We can circle back to that.

Dr. Sharp: Great. I’m going to make a note and we will come back. Let’s keep talking about these differences and keep a big picture view and then we’ll dive deep into some of these areas.

Dr. Casey: I think because the issue in a forensic evaluation is helping answer a legal question, these forensic evaluations tend to be a bit more narrow and focused in their scope.

A neuropsychological evaluation can get pretty broad and pretty comprehensive, pretty [00:15:00] quickly of covering all these different areas whereas in forensics, it’s really just, well, what data do I need to block in order to answer this very specific legal question like, is this person competent to proceed in their legal case, or did they have the capacity to form the mental state at the time of the alleged offense? So really specific questions and they end up being a lot more narrow in their scope in terms of what kinds of data is collected.

I think there’s also a difference in terms of the standards that guide the evaluation process. In therapeutic evaluations, the focus is really on clinical standards, like the psychometric properties of a test and the nature of the referral question. In forensics, there are also legal standards to consider.

Different states have [00:16:00] different statutes that will guide what needs to be included in the evaluation. In Utah, we have a really robust detailed guide in our statute about what we need to include in our competency evaluations. And then there’s also some legal standards or rules about what qualifies someone to be an expert.

And so thinking about those things when you’re thinking about test selection, like has this test been subject to peer review? Is there a no error rate? Things like that. If you want, we can get into that in more detail. I think that might be getting into the weeds but just to say that there are some legal standards to consider in forensic evaluations.

Dr. Sharp: Sure. Maybe I could ask a question about that at least quickly. [00:17:00] Is it fair to say then that you, maybe not anymore, maybe you’ve learned this information over the years, but at some point, were you then paying more attention to test selection, knowing that the battery might come under more scrutiny than a therapeutic evaluation.

Dr. Casey: Yeah. I think there’s just always this thought process of like, if I were called to testify, would there be any issues raised regarding this test that I used? It’s a hard thing to anticipate but just thinking about the properties of it and any kind of limitations or weakness in the test. If there are some major problems with that test and I still choose to use it, having some really clear rationale about why I’m using it or maybe [00:18:00] why I am using a test in a way that it wasn’t developed to be used.

Dr. Sharp: Sure. Let’s take a little detour for a second. Can you give me examples of tests that you really wouldn’t give a second thought about, like these are pretty well established, I don’t have to worry about these being questioned. And then maybe an example or two of tests that are a little more questionable, or ones that you might anticipate more questions about them or about the psychometrics.

Dr. Casey: I think the standard cognitive assessments that we have out there like the WAIS or Stanford-Binet have tons of research, tons of norms. We know a lot about those measures. Those are clinical measures. I think in terms of forensic measures, [00:19:00] looking at tests that look at response style or response bias, so things like the TOMM or Green’s Word Memory, those tests have a lot of research behind them, pretty robust data collection, that went into developing them.

And then I think there’s some research to suggest that just in general, more projective style tests are not as credible to the court system. The more face valid that a test is, those tests tend to be more accepted by the court system. For example, the Rorschach, plenty of people use the Rorschach in forensic evaluations, [00:20:00] and I think it’s improved with the R-PAS scoring system. But for example, if you were to use the Comprehensive System or the Exner scoring system, there are some known problems with that scoring system. I personally would be nervous about using that approach or using that test in an evaluation?

Dr. Sharp: Sure. That’s fair. Thanks for detouring into that for a bit. Other major differences that we may need to be aware of, things you think about?

Dr. Casey: I think even just the source of information. I think the sources are very similar in forensic and therapeutic evaluations, but I think the weight that is given to different kinds of data is different. [00:21:00] Certainly in therapeutic evaluations, we review collateral data like interviews with people who know the examinee or review records but that is just a much bigger part of forensic evaluations.

Inaccurate information may be given by an examinee given the high-stakes of the situation and so a lot more weight is given to those collateral interviews, review of records. I think just that process is much more extensive. It’s not weird for me to review hundreds and hundreds of pages of records for a case in a forensic situation, whereas not super common in a therapeutic [00:22:00] evaluation.

I think too, forensics may give a little more weight to the collateral information and testing is less common, depending on the type of forensic evaluation that you’re doing. Whereas testing is a huge part of therapeutic evaluations, not to say that in every single therapeutic evaluation, clinicians give some sort of standardized measure but definitely the norm, it’s more common than not to give some testing.

Dr. Sharp: Of course. Yeah, you’ve said that two times, I want to double click on that a little bit, this idea that testing isn’t necessarily a big part of forensic assessment. Can you say more about that?

Dr. Casey: Yeah. I think it goes back to this issue [00:23:00] about purpose of a forensic evaluation to answer some sort of legal question. We could talk about the different categories of tests but there are very few tests out there that assess some sort of legal construct or some sort of psycholegal construct. Most of the tests that we have measure some sort of clinical construct like personality or intelligence or executive functioning, but that doesn’t really answer the legal question because, for example, in the case of a competency evaluation, someone can have an intellectual disability or have schizophrenia and be very ill but still be competent.

And so a lot of the psychological tests that we [00:24:00] have just aren’t that relevant for answering that legal question because a diagnosis isn’t the same as a legal opinion. The focus is really more on the functional ability. So what can a person do? Like, yes, they may be experiencing auditory hallucinations but can they still understand the evidence that could be used against them in court in order to make a legal decision for themselves. Can they still provide relevant information to their attorney?

Dr. Sharp: Right. Just hearing you talk about it, it seems like that would be hard to decouple these things in my mind. What was that process like for you, especially because you were not forensically trained from the very beginning? You moved into that world. I’m [00:25:00] curious what that was like for you, was that tough? Was it easy? How do you navigate that?

Dr. Casey: No, I was caught totally off guard. It was my first supervision on internship and my supervisor just said offhand something like, oh, yeah, I don’t do a ton of testing in my competency evaluations. I feel like there must have been a little bit of smoke coming out of my ears because I was short-circuiting. I don’t understand, you do evaluations but you don’t necessarily do testing?

Initially, it felt really uncomfortable especially as I wasn’t even an early career professional. I was a pre-career professional. I felt just a lot more comfortable having numbers to stand on. Well, here is a number from a test. [00:26:00] And so it felt really uncomfortable waiting out into this area without some hard numbers to attach an opinion to and say, well, here’s what they said. Here’s what they could do. Here’s my opinion.

Dr. Sharp: Right. Yeah, I think a lot of us get into testing, for better or worse, because there are numbers and that gives us a little sense of security even though that maybe is not totally true, but still that’s a hard thing to just leap without that safety net.

This is interesting. You talk a lot about the value of collateral interviews and record review, I wanted to go back and just ask, when you say that sometimes you’re reviewing hundreds of pages of records, I’m just curious, very practically what your system is for doing that, because I’ve [00:27:00] done, let’s just say a handful of, not forensic evaluations, but through DHS or the foster system or something, and there’s hundreds of pages of records. I’m like, do I do with all this? I’m curious how you handle massive amounts of records to review.

Dr. Casey: When I’m going through, there are usually major things that I’m looking for. Anything that gives information about a diagnosis. Anything about the nature of treatment, so anything that speaks to whether there was an inpatient or whether they were prescribed medication, their response to treatment. I really find the notes helpful.

So if someone had some sort of inpatient hospitalization, for example, I will look pretty closely to see, okay, well, how [00:28:00] are they doing when they were being observed? So having some specific bullet points of what data am I going to need helps me get through information more quickly.

Sometimes there’s hundreds of pages of medical charts that don’t mean anything to me, or scribbled handwriting. I’m not going to spend a lot of time on those. I’m going to spend more time looking for those kinds of factors that I mentioned. And then I keep up. I have an outline of notes that just helps me be able to go back and find information.

Dr. Sharp: Sure. Yeah, go ahead.

Dr. Casey: I’m probably not the most efficient at it because I [00:29:00] think I’m still developing a system to it. Fortunately, that’s built into my schedule of being, it’s known that there are going to be times when I’m going to have a case with 1500 pages of records to review. And so that gets factored into the workload. I feel like I have the time to review those kinds of records.

Dr. Sharp: Right. And just continuing with this very pragmatic theme, how do you bill for that time? I’ve heard folks bill by the inch or bill by the page count or just bill for the time it takes. How do you approach that?

Dr. Casey: When I’m in my private practice, you mean?

Dr. Sharp: Yes.

Dr. Casey: I just keep track of my time. If there’s like a, [00:30:00] I’m somewhere between not on an exact hour, I just bill like a quarter hour, half hour.

Dr. Sharp: That’s great. And are you using, sorry, I’m going very deep on this for some reason but I’m very curious of the logistics, are you flipping printed pages or are these PDFs and do you have software that… Are you scanning or searching for specific words within these documents? How does that look?

Dr. Casey: I don’t think there’s been a time I’ve gotten paper records. It’s pretty rare if I do get any kind of paper. It’s usually electronic. There’s not always a way just depending on the format to search. So I would say more often than not, I truly am just scrolling through, just really quickly scanning for any keywords.

[00:31:00] Dr. Sharp: That’s fair. Again, my brain is very concrete sometimes. I’m just thinking of these instances where I have had stacks of paper, like 2 feet tall, it’s like, what do I do with this? So I’m very curious how this works for folks who do it more often.

Dr. Casey: I have known people too who will hire someone to […] for them and then make an outline of relevant data. I don’t personally do that but I’m sure that sounds great.

Dr. Sharp: Right. Yeah, note to self. Cool. Well, I don’t know if I’ve totally taken us off track in terms of these differences between forensic and therapeutic evaluation, but there’s anything to wrap up there, any other major differences that we need to highlight? Let’s do that before we go deeper.

Dr. Casey: I talked about legal [00:32:00] guidelines that guide forensics, then there’s also some ethical guidelines. So we have the specialty forensic guidelines. One of the biggest differences is being able to offer an opinion in a situation where you weren’t able to directly assess the examinee. I think that’s a pretty big difference.

Dr. Sharp: Yeah. I think that would be very challenging for many of us.

Dr. Casey: Yeah, it can be. It depends on the extent of those collateral records and interviews.

Dr. Sharp: I know I keep drawing parallels with my own limited experience but it does have me thinking about the, so we’ve waded into these pseudo forensic evaluations where we are being asked to evaluate inmates before they’re released [00:33:00] to make recommendations for community resources. These are individuals who might have low IQ, autism, or some other mental health concern that hasn’t been previously identified. And so we use that to identify community resources.

These challenges are really; I think they’re very present because these individuals typically are not good historians. We don’t often have collateral interviews or records to look at because they’re hard to track down or maybe don’t exist or something. And then we end up in this place of making some kind of diagnostic opinion or treatment recommendation opinion based on very limited data.

I’m curious if that has come up in your experience at all. And if so, how do you navigate some of those challenges with a population that can be hard to accurately assess?

[00:34:00] Dr. Casey: Yeah, sometimes, if I’m unable to evaluate the examinee and there’s just not enough data, if I feel I cannot offer an opinion, then I will say that there’s not enough data. Here’s what I would need in order to be able to give an opinion, but at this point, there’s not enough data and I’m not going to just guess.

Dr. Sharp: That’s fair.

Dr. Casey: So that’s one way that I will go about it. There’s truly just not enough data. But sometimes it’s just getting creative with finding other ways to get that data.

One area where I have seen this come up before in Atkins evaluations. [00:35:00] Atkins V. Virginia was a landmark case law where the Supreme Court ruled that it was inhumane to give the death penalty to individuals who have an intellectual disability.

So that’s an area where it can get really tricky. So if someone’s been in custody for a really long time, there’s no collateral records from before, no one to interview, that can get really hard, especially with things like for giving an ID diagnosis. Obviously, it’s not just cognitive testing. It’s also looking at that adaptive functioning.

But for someone who’s been in prison for 20 years, I’m not sure how you really assess that if you’re not able to get some outside data about that person, especially since like many clinical [00:36:00] measures, the adaptive functioning measures weren’t developed or normed and aren’t appropriate to be given in a situation where someone’s in that kind of a structured environment, like prison because the way that they function in prison is not necessarily going to be representative of how they function outside. That can be a really difficult area to wade into.

Dr. Sharp: Absolutely. Well, that’s validating. I think that also opens the door for a discussion around the measures that we use. And like you alluded to, not all of them or maybe many of them are standardized on incarcerated individuals. And then it’s this whole can of worms of, okay, is that okay to still use these measures if they’re not normed or standardized on that population? [00:37:00] Can we dig into that whole topic for a bit?

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All right, let’s get back to the podcast.

Dr. Casey: Totally. I think maybe it would be worth taking just a step back and talking about three different categories of testing.

We have clinical assessment instruments and those are what most psychologists think of when they think of testing. Those are our cognitive measures, executive functioning, personality, so like a WAIS or PAI or MMPI, things like that.

The great thing about those measures is that usually there’s been a lot of research put into the development. And so they usually have pretty good psychometrics. The downside is that, like you said, [00:39:00] they’re not developed for use in a forensic setting. Oftentimes, minorities are underrepresented in those norms but we know they’re overrepresented in the criminal justice population. So that ends up being a pretty big issue.

And then going back to what we were talking about before- they’re not really that relevant to the legal question. They’ll talk about some of the clinical functioning pieces but it’s not really going to tell us whether or not a person is competent.

And then there’s forensically relevant instruments. Those are tests. They’re still clinical measures but they measure clinical constructs that are most closely related to the legal question. And so those, for [00:40:00] example, would be symptom validity measures like the TOMM or the M-FAST.

There’s some measures out there that can be used in parental fitness evaluations or in violence risk assessment, not really tests, but more guides to data collection, I guess. Those tend to be more relevant. Usually don’t have quite the same amount of research put into the development.

Then we have forensic assessment instruments which are tests or measures that are designed to assess some specific psycho-legal ability. So that would be like a competency tool, for example, or a test that looks at feigned legal incompetence.

Those are the three categories. The forensic assessments instruments tend to be a lot more, they’re relevant but again, not as much research put into them. [00:41:00] So those are the three categories.

Going back to this issue, I often feel pulled between, well, we have these really great tests out there that can measure some aspect of clinical functioning, but it may not be relevant to this legal question or the norms may not be that great. And so there’s this issue of what do I do? Do I use the test? Do I not?

I think oftentimes, depending certainly on the situation but it can still be appropriate to use a test, but obviously there are some really clear limitations and so I’m being really explicit about talking about the limitations of the conclusions that can be drawn based on that data.

Dr. Sharp: What kind of [00:42:00] wording might you use? Is this happening in the report? Is it happening in another document or out loud? How do you tackle that?

Dr. Casey: The first one that comes to mind is, I evaluated this individual who had a history of diagnosis for ID but was also legally blind and none of the evaluations had even mentioned that that might be an issue for interpreting his performance on those tests, even though half, maybe not quite half, but a lot of the subtests on an intelligence tests are going to be visual, right?

Dr. Sharp: Of course.

Dr. Casey: So when I submitted my report, I said, well, here’s what his IQ has [00:43:00] been estimated to be, however, he’s legally blind, there’s been no accommodation made, at least that was I was aware of, like increasing the size of the visual stimuli. So likely this under-estimates his true functioning. But even if we administered the WAIS or the Stanford-Binet with these accommodations, it’s still not going to be a valid IQ just because the tests weren’t even normed to be administered in that way. It was just a parallel talking about the limitations of that data.

Dr. Sharp: I see. [00:44:00]You gave two answers that led me to believe… You’re very straightforward about these facts or limitations. You’ve said two times, “Well, I just say that.” Is that a widely accepted practice? It seems like it should be. We just say what we need to say and be direct but I have seen so many instances of fluffy language or obfuscating the data, like not being clear.

Dr. Casey: I don’t know if it’s the most common approach. I know that a lot of leading individuals in the field really advocate for being as transparent about the limitations to our opinions or to the data. And that’s even in our ethical guidelines, just being really clear about any [00:45:00] limitations.

I can certainly relate to this pull of wanting to be helpful and maybe not feeling like, well, if I give this opinion that has all these caveats, the court just wants to know, like yes or no, is this person, whatever, are they competent or not or whatever? So I can certainly empathize with that pull to just give some information in a more black and white way.

There are individuals out there, Terry Cooker, for example, who has advocated for having a whole section in the report about data that conflicts with our opinion and the limitations to our opinion and just being really clear, like this data doesn’t fit with our opinion. Ultimately, here’s why I [00:46:00] landed on this opinion as opposed to something else. And then that way, the fact finder has all of the data and they can do with it what they will, if they decide they don’t like our opinion, they disagree, then they at least have that data.

Dr. Sharp: I like that. It seems transparent and comprehensive but not defensive. Makes sense to me.

Dr. Casey: I do think it makes evaluators look more credible. I think it can make testimony go easier. I think if you aren’t acknowledging some of that weakness and then you get asked about it and you weren’t worth coming in your report, I think that can look problematic.

Dr. Sharp: Sure. That makes me think of another question, which is this idea of putting everything in the report. I think at least on the therapeutic [00:47:00] evaluation side, there’s actually been more of a push over the last few years to write briefer reports that really include the most important information that our referral sources need but I get the sense that may not be the case in the forensic realm. What would you say about that?

Dr. Casey: Really hard line to walk. I think the emphasis is still including information that’s relevant and not including information that doesn’t need to be put out there. I think about each sentence that I write of, okay, why am I putting this in my report? How does this inform my opinion? And if I don’t really have a good explanation for it, then I take it out.

I think [00:48:00] that has been really hard because of how I was trained to write therapeutic reports. I think my natural perseverative style is to just include as much information as possible. The focus should just be on whatever data is relevant to the legal question.

They don’t necessarily need to be these super detailed reports. If you’ve reviewed 1500 pages of records, that doesn’t mean you need to have like a really detailed, lengthy background. It’s more like, okay, what data in there is relevant and what does the court need to know about that data?

Dr. Sharp: Yeah, it is a fine line. It’s hard to figure out what’s relevant sometimes. I think a lot of us err on the side of more information so that we don’t miss anything that’s relevant rather than less information that we might miss relevant material.

[00:49:00] It’s tough. I don’t have an answer either. I think we’re all wrestling with this: what qualifies as relevant and what do we actually need to put in our reports? I was curious if there’s a clear distinction in the forensic realm or if we could say, you should probably include more if you had to make a choice.

Dr. Casey: I wouldn’t say that that’s generally a rule, that they should include more because just thinking about how that report, who knows what will happen with that data once it’s put out there and how that could affect things that are not relevant to that specific question.

Dr. Sharp: It’s a great point. I appreciate you answering all these curveball questions. The audience doesn’t know this. I don’t think I’ve asked a single question that we’ve talked about before we started this podcast. In the interest of being transparent, Casey’s doing [00:50:00] great on this interview.

I do want to actually talk about something that we’ve hinted at, we’ve touched on but it is pretty important. This topic of how individuals with lower IQ or suspected lower IQ, and how we navigate effort testing in those individuals. Just what that looks like. That seems fraught but this is something that you think a lot about. I’m curious how you approach that problem.

Dr. Casey: I think you hit the nail on the head with that word ”fraught”. I think is an apt description. It’s really challenging and I don’t think there is a really straightforward answer to it because what we do know is that individuals with lower IQ tend to do worse on effort measures. We get higher rates of false positives among those individuals. [00:51:00] That they just don’t quite get the nature of the test in the way that someone with more average IQ would understand it and would interact with the process.

A lot of the manuals will say this test is not appropriate for an individual with an IQ below 60, but even that 60 to 70 range can still be problematic. We can still see higher rates of false positives. And then if you just look at the norms in the manual, that population tends to be underrepresented in the research development of the test. I don’t know what’s being done to address [00:52:00] the situation. I’m not aware of any tests out there that are specifically for individuals with ID to get at effort.

Dr. Sharp: I don’t know of any specifically. That’s a huge challenge. Maybe we take a step back just to provide a little bit of context here around, what situations are you doing an IQ test or would you be doing effort testing in forensic settings?

Dr. Casey: That’s a good question because it’s definitely not always relevant, going back to that issue of whether or not the data is relevant. It certainly can come up in competency evaluations. So is a person not able to understand or appreciate information about their case? Are they not able to learn that information because of some sort of cognitive issue like an intellectual disability? So that’s one place.

[00:53:00] Those Atkins evaluation that I mentioned, so if someone has been convicted and they’re facing the death penalty, those evaluations certainly, IQ was going to be assessed. Places where it’s less relevant would be things like child custody evaluation focusing more on the parental capabilities. They might have lower IQ but be very great parents. So those are some of the areas that come to mind immediately where IQ is going to be really important.

Dr. Sharp: That’s fair. It seems like there’d be a motivation for some individuals to try to present themselves as having a lower IQ in some circumstances. Does that come up and how do you work through them?

Dr. Casey: Yeah, there can be issues. [00:54:00] I’m always thinking about how valid or accurate those test results are, whether or not somebody is, all my reports will speak to the response style and the validity of the test results. Going back to how we talked about the collateral data being a really important part, I’m looking at, does the person have a history of academic problems like really poor grades or special education, anything. To be fair, that may not always be there in the history for someone who truly does have an intellectual disability.

Those would be things that I look for, like is there this pervasive pattern of low functioning outside of [00:55:00] this low test score and data from either jail staff or if they’re in treatment, so are there discrepancies in their presentation? Do they present one way when they know they’re being monitored versus when they think they’re not being monitored, other significant discrepancies there. Those would be some big areas that I would be looking at to determine whether or not this person may be feigning or malingering.

Dr. Sharp: Right. Okay. That makes sense to me. As we keep talking, it seems like what’s true for a lot of evaluations is true here as well. Just that collateral information is so valuable. The longer I do this, I feel like the clearer it gets [00:56:00] that our testing data is just one component of an evaluation, and the collateral information and records and history are often far more important.

Dr. Casey: Oh, totally. Even thinking about more therapeutic evaluations that I’ve done where the test data, I felt really pulled to one conclusion and then I talked to a family member and was like, oh, I’ve got this all wrong. Here’s some really rich data. And no, it’s not a test score but it’s very useful nonetheless.

Dr. Sharp: Right. Well, those were meandering about in this topic of IQ and effort and diagnosis and so forth. It makes me think back to the adaptive functioning question. We know that a big component of diagnosing and intellectual disability is adaptive [00:57:00] functioning. How are you making up for that? How are you approaching assessing adaptive functioning when the measures may not be standardized for this population or they might not be reliable reporters. How do we look at that?

Dr. Casey: It’s definitely going to be breaking from standardized administration. One way that I’ve seen it done in an Atkins evaluation, I didn’t do it but I was working with an evaluator who did. There were family members alive. This person had been incarcerated for a very long time but she asked them to fill those out.

Retrospectively, I think she asked jail or prison staff [00:58:00] to also rate them and was really clear, this test data, these numbers aren’t valid. This is not how these measures were meant to be given but there’s really no other way to get at this information. She interviewed family members, interviewed prison staff and then reviewed as much data as she could get from before that person went to prison. She just really had to be clear about the limitations that she could draw based on that data.

Dr. Sharp: Yeah. I appreciate you setting forth this model basically that it’s okay to say these are the limitations and basically I’m doing the best that I can with the data that’s out there. That’s important.

Let’s see. We’ve covered a lot of different topics. I know there’s a lot that we could [00:59:00] continue to talk about or dive into but I am curious how you talk about effort testing in the forensic setting and how you present that either to the individual or to the court.

Dr. Casey: Like when I’m administering the effort?

Dr. Sharp: Sure. Let’s start there. So you’re in the middle of an evaluation. It seems clear effort is not good. What do you do?

Dr. Casey: Fortunately, a lot of the effort measures out there have a pretty clear script about how to introduce it. Sometimes, I have mixed feelings about different tests in the way that it’s worded just because some seem to incorporate elements of suggestibility which I think is, obviously that’s very problematic, getting back [01:00:00] to the low IQ population, but I just in general, don’t love that approach of how some of the measures incorporate this language that seems a bit misleading.

When I’m administering it, there’s nothing really different than how you would go about testing in any other kind of setting. I just introduce what we’re going to be doing. I don’t really say much about it. Sometimes I will have cases where it’s very clear that the person is feigning. They will answer questions in a way that’s just very clearly and it’s inconsistent with their presentation or [01:01:00] it’s just a bizarre question that they’re asked that they answer in some way that, this is very… To me, it seems very clear what the question is getting at.

Sometimes I feel a little uncomfortable just navigating that, when someone gives me an answer where I’m just like, this is obvious that this person’s not being forthcoming. They don’t realize that it’s obvious that they’re not being forthcoming. I don’t discuss it with them.

Sometimes they’ll ask me questions. I’ve had somebody on a measure of malingered psychopathology, they were like, well, these are really symptoms people experience? This is totally what I experienced. I just couldn’t really talk about it. I’m just on to the next question.

And then [01:02:00] in the reports, I just explain what the test measures in a sentence or two, and then just usually just a brief overview, this score is or is not consistent with whatever feign psychopathology or feign legal incompetence, whatever it is. And then depending on how detailed the measure is, I might break down, something like the SIRS gives you a lot more data about how the person might be feigning. So I might go into detail and say specifically here’s the way that they presented.

Dr. Sharp: Great. Maybe I’ll start to close with the question that I asked at the beginning, which is, threading that needle between building rapport with your client when you know at the same [01:03:00] time that the test results may not go in their favor and how you reconcile that, maybe cognitive dissonance. Just how you work through emotionally for yourself.

Dr. Casey: Yeah, I don’t know that that cognitive dissonance is ever fully resolved for me. It doesn’t matter what the person was accused of doing or the context of the situation. I think every time I’m sitting with someone and I know that they are facing a very serious situation, I very much feel that sitting with them. I have the sense of like this person’s life is going to be very hard. I don’t know how it’s going to turn out for them, but I know they have a long haul ahead of them.

I am always aware [01:04:00] of that because I acknowledge it and also acknowledge that it’s not really, I guess, my mind to take on and it’s not really my place to even foray into that. I just am aware. I think it gives me comfort knowing that I feel that way when I see defendants because I think it helps me recognize that this is a person in front of me.

For me, it’s a motivator to just be as fair as I can. I’m just here. I’m not going to stray outside of the data. This is what I know and this is what I can say based on that. I also do know that [01:05:00] the attorneys have a role in this, depending on who ordered the evaluation, they can decide what they want to do with that report.

I also just know that the way that I think about an opinion in a report, I think, is maybe different than how the court interprets it. For example, when I give the opinion that someone is feigning, for example, in the past, I’ve worried that that’s going to be this huge issue and it doesn’t really seem that the court takes it as this, it’s certainly useful data but it’s not like, I don’t see them being punished because I give that opinion that they’re feigning. [01:06:00] It may not help them in the way that their attorney was hoping.

Dr. Sharp: Sure. It’s a good reminder. We can only have so much responsibility in this whole process.

Dr. Casey: In terms of the report, I am always really clear at the beginning about the nature and the purpose of the evaluation. I always remind them; you don’t have to answer my questions. I will still have to write a report but if there’s something that you don’t want to talk about, that’s fine. I think that goes a long way with people, just knowing that they have some autonomy in the process, even if it’s a small piece of autonomy.

Dr. Sharp: I got you. It seems like in my experience with the incarcerated individuals I’ve evaluated, they seem to [01:07:00] fall into two camps. There are those who are very invested in the process and excited and want to be cooperative. They believe in the possibility of help, and then others that are mostly suspicious, very guarded, and unwilling to participate. I’m curious:

1. Does that match your experience?

2. How do you work with that suspicious side to build rapport with folks who may not want to participate?

Dr. Casey: Boy, if someone seems from the get-go just not interested, very suspicious, I just ask them; do you have questions for me? Is there anything that I can clarify? Do you have any concerns about meeting with me? I’m just willing to answer whatever questions they might have about the process.

A lot of [01:08:00] times, I think, individuals that don’t want to participate, it’s also pretty clear that they’re also very ill and not receiving any kind of treatment. In those cases, there’s not a lot that I really can do. A lot of times offering to clarify any questions or concerns isn’t really going to be worth a lot to them.

Dr. Sharp: Great point. Yes. It’s tough sometimes. But again, good reminder. We can only do what we can do.

Dr. Casey: Yeah. I think just incorporating basic aspects of building rapport, I think I really try to be very clear about this is not therapy. So I’m not asking therapeutic type questions but just talking to them like they’re a person like you would just to, [01:09:00] how their day is going things like that.

Dr. Sharp: This is great. Well, I know we could talk about so many other things and we have really detoured around here and there. I appreciate your willingness to answer some of these curveball questions. As we do start to wrap up, I am curious just from your perspective, anything that you feel like you want to highlight or mention again before we say goodbye. Folks who may be listening and curious about this topic, anything we missed that it’s worth mentioning.

Dr. Casey: Barely anything we missed, but I think I talked about the discomfort that I felt when moving away from using testing in every single evaluation and being more open to using other sources of data. I think [01:10:00] anyone out there who shares that discomfort, now that I’ve worked through that discomfort, I find it really liberating that I can be really creative in how I get the data that I need. Testing is one way to do it but it’s not the only way. There’s a lot of ways to get really useful, valid data. I think that I’ve carried that back with me to doing more than therapeutic evaluations. Testing is one tool, not the only tool.

Dr. Sharp: I like that. I think that’s a really nice note to end on because, like I said, the longer that I do this, the less I rely on objective testing data from cognitive measures and so forth, that these other ways of gathering information are so valuable and the sooner we can [01:11:00] break free of the data, the better, I think.

Dr. Casey: Totally. You use the word objective and I have such a hard time with that word because I think that’s how a lot of us think about test data. I always feel cautious about that just because at the end of the day, yes, it’s a number but we’re still integrating that data. And in the process of integrating, we are interpreting, which is an inherently subjective process.

Sometimes we get test results that conflict. That’s where we have to come in with our clinical judgment and say, okay, well, how can we make sense of this data? I don’t really think of test data as objective [01:12:00] but I think that’s a really common sentiment that test data is objective, everything else is subjective.

Dr. Sharp: That’s such a good point. I appreciate you saying that. I agree 100% that it’s like the myth of objectivity, I suppose, that we have numbers. We did administer a test. We did get a score and there are so many factors influencing that score that it is hard to say it’s truly objective. Our behavior, examinees behavior, the environmental factors, any number of things.

Dr. Casey: Absolutely. Yeah.

Dr. Sharp: This is good. That’s a bit of a cliffhanger that we can end on. We could talk a lot more about that but in another way, I think it’s a nice way to tie a bow on this stuff and just encourage folks to say, hey, there’s lots of [01:13:00] other data you can gather and testing doesn’t have to be the only way.

Dr. Casey: Absolutely.

Dr. Sharp: I appreciate your time, Casey. This is really interesting for me. And like I said, I just appreciate your willingness to talk about some things that weren’t necessarily on the script. So thank you.

Dr. Casey: My pleasure. Thanks for having me.

Dr. Sharp: All right, y’all. Thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes, so make sure to check those out.

If you like what you hear on the podcast, I would be so grateful if you left a review on iTunes or Spotify or wherever you listen to your podcasts.

And if you’re a practice owner or aspiring practice owner, I’d invite you to check out The Testing Psychologist mastermind groups. I have mastermind groups at every stage of practice development; [01:14:00] beginner, intermediate, and advanced. We have homework, we have accountability, we have support, we have resources. These groups are amazing. We do a lot of work and a lot of connecting. If that sounds interesting to you, you can check out the details at thetestingpsychologist.com/consulting. You can sign up for a pre-group phone call and we will chat and figure out if a group could be a good fit for you.

Thanks so much.

The information contained in this podcast and on The Testing Psychologist website are intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for [01:15:00] professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here and similarly no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with an expertise that fits your needs.

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