PERSONAL INJURY EVALUATION IN THE TORT LIABILITY SYSTEM: FORENSIC MENTAL HEALTH ASSESSMENT AND BEST PRACTICES

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1 $5. 00 VOL 27 NO 3 THE BIMONTHLY NEWSLETTER OF THE SAN DIEGO PSYCHOLOGICAL ASSOCIATION IN THIS ISSUE Personal Injury Evaluation In The Tort Liability System: Forensic Mental Health Assessment And Best Practices Cover Letter to the Editor The Rise Of Eating Disorders In Males Art + Science = Third Culture On Seeing What You Don t Know Can Hurt You! p5 p14 p17 p20 A Home Within: One Child, One Therapist, For as Long as It Takes p21 Startup Tips for Private Practice as an Early Career Psychologist p22 Updates p23 GALA Wrap-up Science Fair Speed Mentoring Event Committee Corner p30 Graduate Psychology Student Diversity Continuing Education Aging (CONA) CPA Leadership And Advocacy Day Political Advocacy - Our Responsibility As Psychologists IN EVERY ISSUE From the Editor President s Corner The Member Corner Calendar of Events Continuing Education Hours (CEU s) For SDPA Members Group Therapy Directory Classifieds p31 p32 p3 p4 p28 p33 p34 p34 p35 PERSONAL INJURY EVALUATION IN THE TORT LIABILITY SYSTEM: FORENSIC MENTAL HEALTH ASSESSMENT AND BEST PRACTICES By: Herbert N. Weissman, Ph.D., A.B.P.P. Board Certified in Clinical and Forensic Psychology I. INTRODUCTION The past decade has witnessed an expansion of best practices in psychology, a trend which promotes the development and application of evidence-based treatments and psychometrically sound measures. Science-based practices have taken hold in forensic psychology as well, where psycho-legal concepts, relevant and reliable forensic assessment instruments, and competency-based assessment paradigms help bridge the psychology-law divide. Personal injury/ disability law has come to recognize the impact on psychological and physical health of intense and protracted stressful events and negative emotional states. Legal questions in this area of the law ask psychologists to evaluate the effects that torts (civil wrongs) may have on a person s mental and emotional functioning. Causes of action in tort range widely, from intentional or negligent infliction of emotional distress, negligent conduct, and assault and battery, to employment discrimination, sexual harassment, professional malpractice, and product liability, when personal injury results. In addition to the tort liability system, there are other contexts in which personal injury and disability evaluations may occur, such as Social Security and Workers Compensation programs, Private Disability Insurance programs, and the Americans with Disabilities Act. The term disability is a legal term of art (not a medical or psychological term, except by extension), and has variable meanings, each specific to the respective legal standard it denotes. Examiners must therefore be clear about the particular kind of evaluation being sought. Legal standards in each of the respective areas of the disability domain define the requisite criteria the examiner must apply to the task of determining causation, liability, and/or damages. Lack of clarity as regards the applicable legal standard in a given case risks applying incorrect criteria and, in turn, failing to answer referral questions. All personal injury/disability evaluations involve: (1) assessment of genuineness and substantiality of complaints; (2) delineation of factors of impairment; (3) identification of protective factors, including resilience; (4) Continued on page 6

2 FALL CONFERENCE OCTOBER 13, 2012 CALL FOR PROPOSALS! Our conference theme: The Clinical Process: Integrating Theory and Practice We would like to invite you to submit proposals for the SDPA 2012 Fall Conference. Although it may seem like it s months away, the time to submit proposals is now. By receiving your proposal well in advance, we can provide the highest quality programming. If you want to present, please submit the attached proposal form. The deadline for submission is June 15th. We also welcome applications for Poster Sessions. Please your request for an application to This is a great opportunity for graduate students. We re looking forward to an exciting year of Continuing Education programs at SDPA! - Julie Myers, Psy.D. Chair, SDPA Continuing Education Committee Psychology 2000 as a Referral Source If you know or get a call from someone who needs therapy but doesn t have health insurance, is not eligible for MediCal or Medicare and has significant financial limitations Psychology 2000 may be a resource for them. More information is available at the SDPA website: Psychology 2000 Volunteer Opportunities If you would like to volunteer to be a provider for Psychology 2000 we would be very interested in having you join us. We are currently a group of 43 SDPA members. More information is available on our website: Under Community Connections you will find a current list of our participating members and information about how it works. The short version is that SDPA psychologists donate their services to people without insurance & with financial limitations who need short-term therapy. Those people in turn donate their time to an organization of their choosing, exchanging hour for hour. It s a gift that keeps on giving and a way to give back to our community. If you are interested in becoming part of this program please contact Ain Roost at 2

3 SAN DIEGO PSYCHOLOGIST SUBMISSION GUIDELINES Newsletter may be purchased for $5 per individual copy, or $25 for a yearly subscription. All articles, editorial copy, announcements and classifieds must be submitted by the 1st of the month prior to the month of publication (e.g., Jan 1 is the deadline to submit articles for the Feb/Mar issue). All articles must be typed in a Word document, left-justified, 12-pt font, single-spaced, with no formatting. Articles are submitted via to the editor at Along with your attached Word doc., please attach a professional photo of yourself to accompany your article in the Newsletter. Letters to the Editor are welcome. The editor reserves the right to determine the suitability of letters for publication and to edit them for accuracy and length. We regret that not all letters can be published, nor can they be returned. Letters should run no more than 200 words in length, refer to the materials published/related to the Newsletter, and include the writer s full name and credentials. Unless clearly specified as not a letter, correspondence with the editor may be published in the Letters column. your Letter to the Editor at All ads for mental health services must include the license number of the service provider. Classified ads should be submitted as a Word document attachment or submitted in the body of an directly to SDPA at One free 40-word announcement or classified per issue is available to Full, and Retired SDPA members. $46 for 40 words or less $6 for each additional 10 words Display Ads: Dimensions for display ads are in real inches. Display ads are to be submitted as a 300 dpi PDF file. Display ads should be ed to the SDPA office: Display Ads: Black and White 1 Issue 3 Issues** 6 Issues (1 year)*** Inside Cover $750 $2,025 $3,825 Full Page $500 $1,350 $2,550 Half Page $300 $810 $1,530 Quarter Page $250 $675 $1,275 Business Card $150 $405 $765 Display Ads: Color Inside Cover $1,150 $3,105 $5,865 Full Page $900 $2,430 $4,590 Half Page $700 $1,890 $3,570 Quarter Page $650 $1,755 $3,315 Business Card $550 $1,485 $2,805 Inserts (full page only): Black and white $250 $675 $1275 Color $500 $1350 $2550 **Reflects 10% discount ***Reflects 15% discount The Newsletter is published 6 times per year in bi-monthly issues. It is published for and on behalf of the membership to advance psychology as a science, as a profession, and as a means of promoting human welfare. The editor, therefore, reserves the right to unilaterally edit, reject, omit or cancel submitted material which she deems to be not in the best interest of these objectives, or which by its tone, content or appearance, is not in keeping with the nature of the Newsletter. Any opinions expressed in the Newsletter are those of the author and do not necessarily represent the opinions of the SDPA Board of Directors. Katherine Quinn, PhD 240 9th Street Del Mar, CA (858) San Diego Psychologist San Diego Psychological Association 4699 Murphy Canyon Road, Suite 105 San Diego, CA Fax Website: FROM THE EDITOR Happy summer, and welcome to the June/July issue of the newsletter! This issue contains several articles and updates that I believe you will find interesting and informative. Dr. Herb Weissman in his offering for CE credit, Personal Injury Evaluation in the Tort Liability System, provides an excellent article regarding the best practices in forensic mental health as related to personal injury. Dr. Deirdra Price provides an important article on the rise of eating disorders amongst men. Dr. Linda Williams, in her intriguing article, Art + Science = Third Culture, discusses the complexities of our visual system. Dr. Sandra Block contributes an enlightening article on the electronic age and the importance of risk management. And Dr. Rick Hall talks about a new program in San Diego for foster children. Lastly, Dr. Rochelle Perper offers startup tips for psychologists interested in developing a private practice. In our The Member Corner, Dr. Diana Weiss-Wisdom tells us about Dr. Akiko Mikomo, one of our SDPA colleagues who practices in San Diego, and has a fascinating background, having been born in Hiroshima, Japan. In our Committee Corner, I am pleased to provide updates from the following SDPA Committees and Committee chairs and co-chairs: Dr. Kevin Fawcett/SDPA Graduate Student Committee; Dr. Divya Kakaiya/ Diversity Committee; Dr. Julie Meyers/CE Committee, and Dr. Lynn Northrop/Committee on Aging. Thanks to all of you for these pertinent updates and invitations to our fellow SDPA members to learn more about your committees and perhaps attend a meeting or become a member. Finally, Rachelle Davenport and Dr. Janet Farrell report on the California Psychological Association Advocacy Day. Our Newsletter communicates valuable information to over 800 individuals, who in turn spread the word to others they know about SDPA and our services. What do you know and what services do you provide whereby you can spread the word about SDPA through our Newsletter? I am excited to report to you that I am beginning to hear from more SDPA members wanting to write for the Newsletter. Keep in mind that in addition to regular articles, the Newsletter especially needs high quality articles that qualify for CE credit. To learn whether material you ve written or would like to write will be appropriate for CE credit, please go to the SDPA website, or feel free to contact me. I trust you will thoroughly enjoy this month s collection of articles, and I look forward to publishing articles in the remainder of 2012 from many of you who have not yet contributed to the Newsletter. If you would like to contribute an article to the Newsletter, please contact me directly at: Thanks so much! Katherine Katherine Quinn, Ph.D. 3

4 About the Editor: Katherine Quinn is in private practice in Del Mar where she has been working with children, adolescents, and adults for the past decade. She also does business consulting and psycho-educational assessments through her company, Del Mar Assessment and Consulting. QUOTATION TO PONDER At times our own light goes out and is rekindled by a spark from another person. Each of us has cause to think with deep gratitude of those who have lighted the flame within us. Albert Schweitzer PRESIDENT S CORNER: ON THE BRAIN AND CALVIN AND HOBBES Recently the NY Times Magazine (2012) published an edition focusing on health, titled All in Our Minds. It included several articles related to brain functioning with respect to body image, intelligence, anxiety and the roles of medical hallucinogens and antidepressants in managing emotions. Throughout this issue, the writers highlighted neuroscientific research that support evidence for the role of exercise in promoting neurogenisis; addresses the role of IQ training in increasing our working memory and fluid intelligence; and discusses how body image is affected by brain chemistry. These journalistic highlights, while limited, add to the public awareness of the psychological theories and research that underpin our work. They join a long tradition of playwrights (such as Eugene O Neill, Tennessee Williams, and Henrik Ibsen), filmmakers (such as Ingrid Bergman, Alfred Hitchcock and Woody Allen), novelists (such as Ann Tyler and Philip Roth,) and poets (such as Maya Angelou and Robert Frost) who bring their psychological understanding of character and human relationships to the public realm. Our home like many of yours is a home of many contrasts: clean counters but dirty dishes in the sink; neat drawers but also junk drawers to quickly hide 4 Felise Levine, Ph.D clutter when company comes; and evenings watching Masterpiece Theater and Iron Chef. So it is no surprise that in our home the Sunday Times, professional journals and collections of Calvin and Hobbes share the same table space. Now I realize I ve made a big leap here, from the Sunday NY Times edition on health and brain research to a cartoon series about a boy and his toy tiger. But for me, each is an excellent source of information about how our minds work and the relational matrix within which we exist. For those of you who never had the pleasure of meeting these guys, Calvin and Hobbes are characters in an old cartoon series by Bill Watterson (1988). Calvin, who is about 5 or 6 years old, has the most amazing imagination. Hobbes is his stuffed tiger who comes alive through Calvin s imagination. Developmentally Calvin s brain is at the peak of fantasy play and Hobbes is always available to Calvin for comfort, for adventure and basic mischief making. Through Watterson s clever dialogue and illustrations we can almost see Calvin s neurons firing, especially when he quickly tries to solve the problems he creates. For example, Calvin and Hobbes when readying to go to sleep, first must assure themselves that there are no monsters under the bed. They call out loudly, Any monsters under the bed? Then we see little

5 voices emanating from under the bed answering their anxious question, Nope. No monsters here. Calvin and Hobbes stare at each other, as they try to deal with their fears of the dark and conceive a plan. On another night, Calvin fortifies his confidence by bragging about how big and plump he has become. Hobbes supports Calvin s bravado adding that Calvin is bigger now but not fat, and Calvin agrees. He revises his claims and adds that he is nice and lean, hoping to intimidate the monsters. Just as they are about to go to sleep, reassured in their combined courage, Hobbes sees a pool of liquid coming from under the bed. He exclaims, something under the bed is drooling. Calvin, with fluid intelligence at work, quickly shifts gears as he ties sheets together to make a strategic exit out of the window! What Watterson captures so beautifully is the fantasy play and imagination of childhood. It is material that researchers, psychologists, parents and teachers know well. So after reading the NY Times followed by a quick dose of Calvin and Hobbes, I began to think about the brain, imagination and the biopsychosocial processes that transform fantasy play and childhood imagination into adult creativity and vision. For those of us who think systemically and are involved in organizational functioning, another question emerges: How does individual imagination get translated into the vision of an organization. Of course as President of SDPA, this question is pretty intriguing to me now. Although a discussion of these questions is beyond the scope of today s column, sometimes I believe it s just fine to be curious without knowing the answers. Chairing the Board makes me think more about how we can integrate the decision-making that comes with being responsible for an organization as large as ours, with imaginative discussion that includes the play of creating new ideas. So as we continue to craft an evolving vision for SDPA, please know that your imagination is always welcome. As an aside, I started to write this column about Type A and B Personalities and Organization Functioning. Then I noticed all of the Calvin and Hobbes books left out by my husband s granddaughter. My neurons fired in a different direction, so thanks for indulging my free association. Felise Felise B. Levine, Ph.D., President, SDPA Reference All in Our Minds, The New York Times Magazine (2012, April 22). Watterson, B. (1988). Something under the bed is drooling: A collection of Calvin and Hobbes. Kansas City: Andrews and McMeel, Universal Press. LETTER TO THE EDITOR Newsletter Editor, Thank you for creating the opportunity to write to you about my thoughts on the Newsletter. I read the April/May issue and thoroughly enjoyed Dr. Weissman s article on The best interests of the child I read the article with the intention of applying for the 2 CEU credits that would be awarded after reading the article and answering the appropriate questions contained on the SDPA website. After reading the article, I put the newsletter down on my desk, not taking the time to access SDPA s web site to answer the questions. The process seemed too cumbersome and time consuming for me, so I put off that chore with the thought that I d get back to it when I had more time. Unfortunately, that time never came for me. I have been wondering if it might be possible to have the questions about the CEU article printed at the end of the article to enable the possibility of answering them immediately upon completion of the article and then faxing or mailing the answers into the SDPA office for scoring, creating an alternative to the Web Page process. I think this would facilitate my taking advantage of the CEU opportunity in each edition. I appreciate you committing your time, talent and energy to creating a very interesting and educational Newsletter for our Association. Sincerely, Hugh Pates Ph.D. 5

6 Continued from cover Personal Injury Evaluation In The Tort Liability System: Forensic Mental Health Assessment And Best Practices differential diagnosis; (5) treatment and dispositional recommendations; and (6) prognostic considerations. Personal injury evaluations occurring within the tort liability system (and also Workers Compensation Disability programs) have additional requirements: (7) delineation and attribution of factors responsible for causing the injury (liability) in the former, and apportionment of the injury in the latter. With torts, negligence and liability must be established before there can be compensation for damages. Tort claims are also typically the broadest in scope, thus making psychological evaluations of tort claims the most comprehensive of the several types of personal injury evaluations. The goal and scope in tort claims, for example, are to make the victim whole, or to restore the person to his or her condition prior to the commission of the tort (Kane & Dvoskin, 2011). In Workers Compensation, by contrast, it is to provide limited benefits to enable the worker-applicant to return to gainful employment. II. PERSONAL INJURY IN THE TORT LIABILITY SYSTEM Tort law has evolved in response to society s need to determine civil responsibility for injury. Its origins are found in common law, and its developments over time have been guided by case law refinements and statutory modifications. Individuals who are injured (either deliberately or through carelessness) may file legal causes of action in tort for physical and mental or emotional damages that arise from their injuries. A finding in plaintiff s favor requires that the plaintiff prove four legal elements in order to prevail: (1) the existence of a duty of care; (2) that this duty was breached (unfulfilled or violated); and as a result of this breach (3) measurable damages were proximately caused; (4) resulting in liability. Further, there must be a showing by a preponderance of evidence that the tortfeasor s (defendant s) conduct caused the damages. There is, however, an atypical exception in employment discrimination/hostile work environment lawsuits. In these cases psychological injuries need not be shown or proved for there to be compensation as determined in the U.S. Supreme Court decision in Harris v. Forklift Systems (l993), a decision based both on prior Supreme Court decisions and on Title VII of the Civil Rights Act of 1964/1991), requiring instead only that the discriminatorily abusive conduct had been so severe or pervasive that it was perceived to create (and did create) a hostile work environment. There are three broad classes of disorders reflected in tort claims. The first two, resulting from physical impact, have a long history of legal acceptance as compensable causes of action. Herbert N. Weissman Ph.D., A.B.P.P. These include: (1) disorders that are entirely physical, such as head trauma, loss of limb, toxic conditions; and (2) disorders in which there is an interaction of physical and emotional elements, such as traumatic brain injury with post traumatic stress, or spinal injury, with chronic pain and depression. The third class of disorders (3) is entirely functional, requiring neither physical impact (on the front end) nor physical disorder as the outcome. III. NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS Recognition of the fact that harm may result solely from the infliction of emotional distress has a far more recent history than other causes of action. The legal scholar William Prosser (l939; 1971) points out that it was not until the l930 s that claims based solely on emotional distress (without accompanying physical injury) began to attain independent status. Prior to this the courts had held that such claims were too vague for legal redress. Case and statutory law evolved to provide the legal basis for emotional distress claims. The current standing of such claims is that: (1) whether the emotional distress had been negligently or intentionally inflicted; (2) whether it had been cumulatively or traumatically caused; (3) whether it had been directly experienced, or indirectly perceived, its infliction now constitutes (potentially) a complete cause of action. Molien v. Kaiser Hospital (l980) and Dillon v. Legg (l968), both California Supreme Court cases, were precedent-setting in this regard. In Molien, the concept of negligent infliction of emotional distress came to be recognized fully as an independent tort. No longer was it necessary for there to be an accompanying physical injury. The court in Molien held that emotionally traumatic effects of an injury could be objectively ascertained, and that the authenticity of the claim could be corroborated (by experts). Legal standards would permit recovery where proof of emotional distress is of a psychologically significant nature and where there is 6

7 some guarantee of genuineness in the circumstances of the case (Molien v. Kaiser, l980). Then in 1993, the U.S. Supreme Court supported the autonomous standing of psychological distress claims at the federal level, by ruling in favor of plaintiff in Harris v. Forklift Systems, Inc., an employment discrimination case (Kane & Dvoskin, 2011, citing Call, 2003). Developments such as these could not have occurred but for psychology s significant role in providing conceptual and empirical foundations for it. For further discussion of relevant case law, see: Foote & Delahunty, 2005; Greenberg, 2003; Kane and Dvoskin, 2011; Koch, Douglas, Nicholls, & O Neill, 2006; Weissman, l984; Weissman & DeBow, 2003). IV. PSYCHOLEGAL CONSIDERATIONS Proximate cause is the legal concept central to the legal standard in tort cases. It refers to the extent to which the cause of action (i.e., negligent infliction of emotional distress) constitutes a substantial factor in causing new impairments/disorders, or exacerbating preexisting ones. A but for test is often applied, that if not for the occurrence of certain alleged actions, the claimed results would not have occurred. Whereas proximate factors of causation are central to the legal standard, they are but one set of factors to be considered in the causal nexus of impairment. Alternate ( non-proximate ) factors are of equal importance to the psychological examiner. Short of studying the full range of determinants responsible for causing a disorder, there is no way competently to ascertain the genuineness and substantiality of it, or to differentiate substantial from insubstantial factors responsible for causing it. This is because in tort law, only those disorders that are determined by a preponderance of the evidence to be substantially related to the injury are legally relevant. This standard imposes special requirements on the examiner who must be cautious not to attribute impairments to the event (i.e., accident, exposure) giving rise to an action that had not been caused or aggravated by it. The examiner s task becomes more complex with the passage of time and under conditions of protracted litigation. For example, the presence of an elevated somatic focus at time of evaluation may be multiply interpretable. It may represent the manifestation of genuine emotional distress, somatic impairment, and heightened sense of personal vulnerability, aggravated by a motor vehicle accident (MVA) (potentially compensable). It may instead reflect a reaction to stressors of the legal proceedings themselves (which may or may not be compensable). It may also reflect fluctuations in preexisting emotional conflicts or the natural progression of personality dysfunctions (non-compensable). And it may represent deception and/or supravening influences (non-compensable). It is important to note that deception (or at least partial deception, which is more often the case) and proximate cause are not necessarily mutually exclusive factors. When they co-occur, they do render more complex the forensic formulation. For example, MVA-related distress and/or functional impairments may be genuinely present, but also so may plaintiffs efforts to exaggerate their current severity and impact on their lives. V. KEY CONCEPTS The key psycho-legal concepts for the examiner to address in personal injury litigation are: (1) Causal Nexus of Impairment; (2) Baseline (Pre-Post Incident) Functioning; (3) State and Trait-Level Conditions; and (4) Vulnerability/Risk and Resilience: (1) Causal Nexus of Impairment. Legally relevant factors are those for which there is evidence of a nexus between tortious conduct and alleged impairments. The examiner s task is to rulein/rule-out such factors based on legal relevance (Weissman, l985; l991; Weissman & DeBow, 2003): (a) Proximate Cause: The extent to which the cause of action constitutes a substantial factor in causing new impairments/disorders, or exacerbating preexisting ones. A but for test may be applied. (b) Impact of Protracted Litigation: The extent to which stressful circumstances of protracted litigation result in jurisogenic symptoms or disorders. (c) Coexisting & Intervening Conditions/Events: The role of concurrent stressors, symptoms and recently acquired disorders in plaintiff s clinical status at time of evaluation. (d) Preexisting Factors: The role of previously diagnosed impairments/disorders identical to, or resembling, those being currently claimed. (e) Natural Progression: The extent to which preexisting conditions in their own evolutionary course would have resulted in the same alleged impairments. (f) Motivations (Conscious/Unconscious): The role of convenient focus, factitious disorders, malingering, and deceptive response styles in self-presentation. 7

8 (g) Degree and Extent of Impairments: Range, severity, course of impairments, and whether or not they are consistent with nature and site of alleged injury. All behavior being multiply determined, the examiner must assume that the plaintiff s self-presentation at time of examination will be affected by numerous influences. Distressful affects, exhibited in plaintiff s demeanor and utterances at time of evaluation, for example, may well be substantially caused by, and therefore attributable to, emotional impairments suffered in a motor vehicle accident (MVA) a year or more earlier (Proximate). Distressful affects may also (or instead of the MVA) be attributable to adverse events occurring (at time of evaluation) in plaintiff s life, such as family medical concerns, marital or financial problems (Concurrent), or to feigning and/ or malingering (Deception), and to impairments that preexisted the MVA (Preexisting), as well as other factors. Jurisogenic (think iatrogenic) factors also play a role, often in interaction with other influences. Referring to the stressors and frustrations that accompany protracted litigation, such factors may contribute to the intensity and breadth of whatever emotional conditions are already present. Delays, moreover, may also provide fertile ground for deception, as protracted and cumbersome legal procedures come to be negatively viewed by plaintiffs not only as denying them justice (i.e., compensation for what they have suffered), but adding to the suffering by the imposition of interrogatories, depositions, as well as psychological and other intrusive examinations. (2) Pre-incident Versus Post-incident Levels of Functioning The task of the examiner is to acquire sufficient information about the plaintiff on relevant dimensions of his/her life so as to establish a baseline description of his/her functioning at the time of the alleged injury. This information permits comparison of plaintiff s pre-incident and post-incident status for purposes of ascertaining whether there are any prepost differences, and if so the nature and quality of these differences. Chronology is key to establishing a baseline. Dimensions of interest vary, but most cases would include information about personal, family, relational, vocational, educational, recreational, spiritual, and certainly medical and mental health issues. Bio-historical and psychosocial interviewing, comprehensive record review, and third party sources are relevant here. 8 Foote (2011) describes a five-phase model for determining whether a tortious act leads to damages. It examines: (1) events, injuries and disorders that precede the act; (2) events, injuries and disorders that occur at about the same time; (3) events, injuries and disorders that occur after the events in question; (4) plaintiff s status and functional capacities at time of evaluation; (5) plaintiff s future damages and needs for intervention. (3) State and Trait Level Conditions There is theoretical and empirical support for ascertaining which factors are most important in terms of their differential contributions to the causal nexus of impairment. Dohrenwend, Link, Kern, Shrout, & Markowitz (l990) advanced three factors. The first relates to the incident itself (i.e., the injury). The second pertains to the ongoing situational processes. The third consists of personal predispositions associated with genetic vulnerabilities, preexisting Axis I and Axis II disorders, experiential history, and enduring patterns of personality functioning. In tort cases, proximate factors commonly contribute most strongly to the causal nexus of impairment, followed by preexisting and coexisting factors. Dynamics of deception and of protracted litigation operate as background features in most cases, tending to interact at a tertiary level with other factors. Axis II conditions are often mistakenly relegated to secondary status in forensic assessments. Such information, however, can often provide understandings critical to diagnostic and prognostic formulations. Underlying personality traits, whether healthy or disordered, serve to shape and define clinical symptoms and syndromes that may emerge under conditions of trauma or cumulative stress. For these reasons, they also play a decisive role in predictions about the course that treatment and rehabilitation may take. Characteristics commonly associated with personality disorders include inflexible adaptive strategies, tenuous stress tolerance, limited capacity for empathy and insight, externalization of responsibility/transfer of blame, and perpetuation of self-defeating cycles (Millon & Klerman, l996). Although rarely caused by an injury, their presence shapes plaintiffs response to it. Personality disorders hold significant implications for delineating factors of causation. To the extent that maladaptive patterns and personality disorders had served previously (prior to injury) to compromise personal, social, or occupational functioning, their existence is legally relevant. In their own natural progression, such preexisting maladaptive

9 patterns may be wholly or partially responsible for the clinical impairments claimed in the cause of action, intensified by the dynamics of protracted and stressful legal proceedings. On the other hand, Axis IV stressors (proximate) may serve to aggravate Axis I and further complicate Axis II conditions. (4) Vulnerability and Resilience An objectively minor event can have clinically significant and legally substantial impact on a psychologically vulnerable person in a protracted legal context, while an objectively major event may only have clinically limited impact on a person whose psychodynamic and personal experiential history is sound, especially where there is a personally supportive context and under circumstances in which the legal context is not itself unduly jurisogenic. The forensic mental health examiner should in every case evaluate the balance on the vulnerability-resilience dimension. It is a mistake to take at face value the argument that either side of a lawsuit puts forward. There may be significant basis for diminished functioning in a plaintiff due to adverse impact on preexisting vulnerabilities. Similarly, there may be significant basis for limited impairment and rapid recovery, due to protective factors of resilience, and other positive coping resources. (a) Vulnerability: The impact of an injury or exposure will vary as a function of such factors as: (1) the nature of the event itself (e.g., onset, intensity, frequency duration); (2) the presence of both physical impairment and emotional distress; (3) preexisting characteristics of the person (e.g., personality traits, coping styles, mental health and experiential history); (4) situational demands/context (e.g., stressors associated with protracted legal proceedings); (5) genetic predisposition and pre-trauma vulnerability generally; (6) relationship to tortfeasor, and whether the act was negligent or intentional. With children, there are additional effects, including the impact on self-regulation, trust and the child s sense of safety and security. Pynoos, Steinberg & Goenjian (1996) propose that in childhood the critical link between traumatic stress and personality is the formation of trauma-related expectations as these are expressed in the thoughts, emotions, behaviors and biology of the developing child. By their impact, traumatic experiences can skew expectations about the world, the safety and security of interpersonal life, and the child s sense of personal integrity. Also there are the potential progressive and cumulative effects on acquisition of developmental competencies to be considered, and on the achievement of developmental transitions, as well as on the emerging personality, including changes in life trajectory, risks to later physical health, and vulnerability to future life stressors. (b) Resilience: Over the past decade, research in psychology has come to shed light on positive functioning, coping, and adaptation in response to adverse events. The presence of protective factors serves to buffer, modify, or ameliorate reactions to difficult emotional experiences at all developmental levels, and thus provides an important balance to risk factors, which selectively sensitize such reactions. Despite adverse exposure, most people continue to have positive emotional experiences and show only minor and transient disruptions in their ability to function (Koch, et al, 2006). Bonanno (2004) reviews evidence that resilience represents a distinct trajectory from the process of recovery...and that there are multiple and sometimes unexpected pathways to resilience. In the developmental literature, resilience is also recognized as a protective factor that promotes positive outcomes and healthy personality functioning in children and adolescents (Haggerty, Sherrod, Garmezy, & Rutter (1994). And attachment theory usefully informs us that secure attachment is the best defense against maladaptive effects of traumatic experiences in childhood. Epidemiological studies estimate that the majority of the U.S. population has been exposed to at least one traumatic event. In their meta-analysis summarizing this research, Ozer, Best, Lipsey, & Weiss (2003) point out that roughly 50%-60% of the U.S. population is exposed to traumatic stress but only 5%-10% develop PTSD (p. 54). Resilience is thus common, but is underappreciated by mental health professionals. The percentage of exposed individuals eventually showing delayed trauma reactions also is small, occurring in approximately 5%-10% of exposed individuals (Bonanno, 2004). This research makes clear that dysfunction cannot be understood without a deeper understanding of health and resilience. A review of the available research on loss and violent or life-threatening events indicates that the vast majority of individuals exposed to such events do not exhibit chronic symptom profiles. The accuracy of the forensic examiner s diagnostic opinions about causation (e.g., based on delineating factors that render a plaintiff more or less susceptible to adverse impact), and about prognosis ( e.g., based on delineating factors that render a plaintiff more or less receptive to treatment 9

10 and recovery) depend on this order of information. VI. FORENSIC MENTAL HEALTH ASSESSMENT Forensic Mental Health Assessment (FMHA) is a subcategory of evidence-based practices in psychology. It emphasizes the application of empirically supported principles of psychological assessment to the selection of psychological measures that are appropriate to the legal questions, and which possess sound psychometric properties (APA Presidential Task Force, 2006; APA Specialty Guidelines for Forensic Psychology (SGFP), (2011). Specifically, FMHA is a domain of assessments of individuals intended to assist legal decision makers in decisions about the application of laws requiring consideration of individuals mental conditions, abilities, and behaviors (Heilbrun, Grisso, & Goldstein, 2009, p. 15). Forensic assessments rely on objective observation and the support of theory and empirical research when interpreting data to arrive at useful inferences and favor systematic procedures designed to (a) obtain specific types of information, (b) use standardized methods that mitigate examiner bias, and (c) engage in interpretive processes guided by past research on the mental states or behaviors at the heart of the examiner s inferences (p. 14). The legal issue frames the referral question for the forensic assessment, the focus of which is on assisting legal decision makers decide whether an examinee has certain capacities, abilities, or behavioral tendencies that must be understood in order to decide how to resolve the legal question (Heilbrun et al., p. 13). See Specialty Guidelines for Forensic Psychology (APA, 2011): 2.05, 9.02, 10.02, Opinions should be data-based, with full consideration given to all data sources: (1) mental status evaluation; (2) clinical-and case-oriented interviewing (biopsychosocial, with emphasis on pre-post incident functioning); (3) results of all psychological tests (including response-style and symptom validity measures); (4) third party information; (5) record review (e.g., legal, medical mental health, educational, vocational); (6) evidence-based research, including base-rate data (if available), published in peer review journals; and (7) relevant case and statutory law. Heilbrun, Grisso and Goldstein (2009) recommend that experts apply a two-pronged best-practices approach to: (1) the bases for their opinions, and (2) the level of confidence placed in them. FRE 702 addresses the former, while the reasonable degree of certainty standard addresses the latter. The reasonable degree of certainty standard is more likely met when there 10 is a confluence of findings that derive coherently from multi-modal and multi-method methodology of assessment. Alternative hypotheses can then be fully considered and ruled in or out, based on consistencies or inconsistencies in the evidence. Forensic practitioners make reasonable efforts to promote understanding and avoid deception (and do not) participate in partisan attempts to avoid, deny or subvert the presentation of evidence contrary to their own position or opinion (SGFP, 11.01). Assessment methodologies must accommodate the different questions asked in forensic versus clinical evaluations. Whereas clinical evaluations typically address questions pertaining to differential diagnosis and treatment, forensic evaluations primarily address questions of causation and prognosis. The former focuses on diagnostic issues that would have been present whether or not the alleged injury had occurred. The latter focuses on determinants responsible for causing new impairments or exacerbated preexisting ones. For example, one may conclude (Clinical Formulation) that prior to an accident/injury, plaintiff would likely have had diagnoses of: Dysthymic Disorder (on Axis I); Dependent Personality Disorder (on Axis II); Tension headaches and gastro-intestinal distress on Axis III); Problems with primary support group, and occupational problems (on Axis IV); and a Global Assessment of Functioning Score of 70 (Mild Symptoms on Axis V). Following comprehensive forensic assessment, the examiner may conclude (Forensic Formulation) that the accident/injury aggravated the aforementioned disorders, but did not cause them. The examiner may also conclude that it caused an additional disorder on Axis I, a nondisabling, and time-limited Adjustment Disorder with Mixed Anxiety and Depressed Mood; and that it also elevated symptoms of dependency insecurity on Axis II; aggravated psycho-physiological stress reactions on Axis III; added psychosocial and environmental problems on Axis IV (i.e., problems related to interaction with the legal system/protracted personal injury litigation); and diminished plaintiff s level of overall functioning (GAF/Axis V) to a rating of 60 (all potentially compensable). DSM-IV-TR (APA, 2000) reminds psychologists of the risks attendant upon using diagnostic information for forensic purposes. Clinical diagnoses do not answer legal questions. The classic example is the difference between psychosis and insanity in criminal cases. In personal injury tort cases, it should be clear that diagnoses neither provide information about the

11 nature and quality of legally relevant impairments nor about their etiology. Clinical diagnoses, in and of themselves, cannot provide this order of information precisely because they do not address whether a causal nexus even exists between (legally relevant) causes, on the one side, and alleged resulting impairments, on the other. FMHA is designed to yield forensic formulations, in addition to clinical formulations, for this very purpose. DSM-IV-TR also reminds us that it uses a two-pronged definition of mental disorder: a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning). Paying attention to case-specific empirical literature is essential. It can be done for each cause of action being forensically assessed, i.e., the likelihood of PTSD resulting from a motor vehicle accident or from employment discrimination or from sexual assault. This examiner s experience in this regard is revealing. PTSD to be the most overly used and misused diagnosis, while more relevant Axis I diagnoses are neglected, such as adjustment disorders, other anxiety disorders, somatoform disorders, and mood disorders. Axis II disorders and V Codes are often equally ignored or misapplied. The legal system needs to be educated and examiners less susceptible to biasing influences on diagnoses they apply in legal settings. PTSD has become overused for mistaken and simplistic reasons. The assumption is that if the expert elects (with or without adequate evidence) to diagnose PTSD, then the plaintiff is assured compensation, if for no other reason than that the label itself connotes both liability and causation in its very name. VII. PSYCHOLOGICAL TESTING There has been a proliferation of specialized psychological assessment instruments designed and validated specifically to address legal questions. Known as forensic assessment instruments, they contrast with clinical assessment instruments, which do not measure constructs of central importance in forensic assessment. There are no forensic assessment instruments that have been developed specifically for use in personal injury evaluations. However, there are forensically relevant instruments that address constructs that are more central in such litigation (i.e., response style measures), and which may have undergone additional validation with forensic populations. Kane and Dvoskin (2011) make the point that best practices commends forensic examiners to familiarize themselves with the relevant research in the area in which the alleged tort lies, including group data, base rates, and appropriate assessment measures. Psychological tests must meet legal admissibility standards enunciated in the Federal Rules of Evidence, and in Daubert criteria, or their equivalent state rules of evidence, including requirements for reliability, relevance, falsifiability, general acceptance within the scientific community, and peer review and publication (Kane & Dvoskin, 2011, p. l22). Examiners must be prepared for court challenges under Daubert. Frequency and usage of assessment instruments have been empirically studied. Findings from such studies assist the psychological examiner in selecting tests more likely to have gained general acceptance in their field under Frye and Daubert admissibility standards. Archer, Buffington-Vollum, Stredny, and Handel (2006) asked Forensic Diplomates and APLS Members to rate frequency of usage of adult multiscale inventories. The most frequently utilized (in descending order) were the: Minnesota Multiphasic Personality Inventory, followed by the Personality Assessment Inventory, and the Millon Clinical Multiaxial Inventory. Tests relevant to the evaluation of children and adolescents included the MMPI- Adolescent, the Millon Adolescent Clinical Inventory, Child Behavior Checklist, the Child Abuse Potential Inventory, and the Personality Inventory for Children. In their survey of tests used by clinical neuropsychologists for detecting malingering, Slick, Tan, Strauss, and Hultsch (2004) found that 79% of their sample used malingering measures in every personal injury evaluation. Fifty percent reported administering specialized tests at the beginning of assessment, most frequently the Rey 15-Item and the Test of Memory Malingering (TOMM). Tests of Effort (top 5), used often or always: The TOMM= 63%; MMPI- 2 F-K Ratio= 46%; MMPI-2 FBS Scale=43%; California Verbal Learning Test=43%; Rey 15-Item Test=42%. In their survey of psychological test usage among forensic practitioners in emotional injury cases, Boccaccini and Brodsky (l999) found a wide range and diversity of test usage, MMPI by far being the most utilized instrument (nearly 100%), followed by the WAIS, the Rorschach, SCL-90-R, and the MCMI scales. There have very likely been numerous changes in patterns of test usage since this survey was published in l999, and especially since the Daubert v. Merrell decision in l993. This U.S. Supreme Court decision provided added impetus for establishing sound 11

12 psychometric bases for assessment instruments, so that those utilized by forensic experts would meet Daubert s rigorous admissibility criteria. VIII. ADMISSIBILITY OF EVIDENCE Ethically competent practice in forensic psychology is governed by rules in both psychology and law that define and control the admissibility of evidence, how it is gathered and how it is presented. Psychological aspects of the process are governed by the psychology profession s ethics code (APA, 2002) and specialty practice guidelines (APA, 2011), and legal aspects are governed by Rules of Evidence (federal and state) (Greenberg, 2003; Weissman & DeBow, 2003). Particularly relevant in this context are Federal Rules of Evidence, FRE 702 through 705, and Federal Rules of Civil Procedure, especially FRCP 35 (Physical and Mental Examinations) and FRCP 26 (Duty to Disclose) and their state equivalents. FRE 702 (Testimony by Expert Witnesses) states: If the scientific, technical, or other specialized knowledge will assist the Trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the form of an opinion or otherwise, if (1) the testimony is based upon sufficient facts or data; (2) the testimony is the product of reliable principles and methods; and (3) the witness has applied the principles and methods reliably to the facts of the case. FRCP 35 examinations may be ordered by a court, even against the wishes of the plaintiff, in cases in which plaintiff s mental or physical condition is in controversy. If granted, the examination (Independent Medical Examination) is compelled, and hitherto privileged records about plaintiff s alleged impairments may then be released to the psychological examiner. FRCP 35 requires specification of the time, place, manner, conditions, and scope of the examination and the person or persons by whom it is to be made. Further, it specifies the information that must be contained in the report, and requirements for its timely distribution. FRCP 26 compels more complete pretrial disclosure of expert opinions and their bases. Most state courts have adopted all or part of the Federal Rules of Evidence. FRE 702 incorporates much of the language and logic of prevailing U.S. Supreme Court decisions, as articulated in Daubert v. Merrell Dow Pharmaceuticals (1993) and its progeny, that expert testimony must be both scientifically valid and relevant. Hence, it provides a useful framework also for California practitioners to understand the basics governing admissibility of expert testimony. For elaboration on FRE 702, see: (http://www.law. cornell.edu/rules/fre/acrule702.htm). IX. RISK MANAGEMENT APA professional liability insurance carriers remind us of the risks attendant upon practicing in the forensic domain (Bennett, et al., 2006). The most common problems are caused by role violations, as when a psychologist decides to accept more than one professional role in a case (Specialty Guidelines for Forensic Psychologists, 1.03 and , APA, 2011). This happens when a treating psychologist yields to an attorney s entreaties to also evaluate and testify (in a legal forum) about his/her patient s psychological condition following an accident in which injuries allegedly occurred. This is a common request by plaintiff attorneys, who may rationalize this inappropriate maneuver by extolling the benefits to the case of therapist s long-term relationship and familiarity with patient/plaintiff. The request is inappropriate for several reasons: (l) as patient s advocate, the therapist is in an unlikely position objectively to appraise credibility and deception, and may be viewed as having a stake in the outcome of the case; (2) therapist is unlikely to have performed a comprehensive case study (including comprehensive record review) of the numerous causal factors potentially responsible for what is being alleged, instead being asked to accept attorney s theory at face value; (3) the dual relationship has a strong likelihood of harming the therapist-patient relationship, particularly if therapist shares information that would weaken the case, such as a patient s general tendencies to exaggerate complaints, and to misattribute symptoms (i.e. that preceded an accident) to the accident itself. Treating therapists do have an appropriate role to play in court on behalf of their patients, which is that of a percipient (treating) expert. Permitted to testify only about what they themselves know from direct observation, treating experts are only allowed to comment about issues that are directly related to the therapy they are providing. By contrast, the expert witness can draw inferences and form opinions related to disputed issues in the case. See Federal Rules of Evidence, especially Rules , for detailed explanations of these different roles. Kane (in Kane & Dvoskin, 2011) summarizes the role of the testifying expert witness as one who does a comprehensive, impartial evaluation using a biopsychosocial approach that considers all of the pertinent evidence, uses valid and reliable methods of assessment and interpretation, considers 12

13 the professional literature in coming to conclusions, and proffers testimony that is relevant, reliable, and helpful to the Trier of fact (p. 33). Risk management principles also urge psychologists to: (1) acquire written informed consent from plaintiff, from collateral contacts, and from legal representatives; (2) form consulting relationships with colleagues, particularly if the case is complex and one s skill sets are new; and (3) ensure from the outset that there is a high level of documentation of all relevant matters, including (a) agreements pertaining to the anticipated retainer and fees, (b) potential conflicts of interest, (c) operative legal standards, case and statutory law and local rules of court, (d) information concerning time-frames for completing evaluation, preparing written reports, and providing court testimony, (e) expectations about roles and forensic services, including detailed statement of referral questions. See Forensic Specialty Guidelines: 3.01, 4.01, and X. THE PRACTICE Interested in redressing the effects of civil harms, case and statutory law has evolved to acknowledge the potentially serious effects of emotional distress on people s lives. Psychology s expertise has come to play a major role in the courts in this regard. Whether to seek and/or accept referrals for personal injury evaluations involves several sets of considerations, ranging from intrinsic interest in the legal scholarship associated with tort law and the desire to acquire forensic skills and perspectives, to interest in expanding one s practice and the tolerance for adversarial challenge. Professional practice in this forensic domain is interesting and challenging. Staying current with relevant literature in psychology and law keeps it interesting. Staying alert to ethical and professional principles of competent practice in forensic psychology helps the expert stay even with the challenges (Weissman & DeBow, 2003). And above all is the imperative to maintain one s independence as a psychologist and as a member of an autonomous profession. Psychologists have their own ethical, professional, and legal burdens to uphold. The fact that the expert is retained by an attorney or the legal system in no way diminishes the significance of this burden. About the Author Herbert N. Weissman, Ph.D., A.B.P.P., Board Certified in Clinical Psychology and in Forensic Psychology (American Board of Professional Psychology), is in the independent practice of clinical and forensic psychology in San Diego, California. He consults to psychologists and attorneys, does psycho-legal evaluations in civil areas of the law, including family law, and treats adults and adolescents in psychotherapy (Cognitive Behavioral). A Fellow of APA (Divisions 12, 41, and S.P.A.), he holds the rank of Clinical Professor of Psychiatry in U.C. San Diego s School of Medicine, and is a former President of the American Board of Forensic Psychology, the American Academy of Forensic Psychology, and of the California Psychological Association. Dr. Weissman can be contacted at , or by at His mailing address is P.O. Box , Rancho Santa Fe, CA The author reserves the right to publish portions of this article, or revisions of it, in other professional sources, giving proper credit to first being published by the San Diego Psychological Association in the San Diego Psychologist. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: Text revision (4th ed.). Washington, DC: Author. American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, American Psychological Association. (2006). APA Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, American Psychological Association. (2011). Specialty guidelines for forensic psychology. Adopted by APA Council of Representatives, 8/3/11. American Psychologist, in press. Washington, DC: American Psychological Association. Archer, A. P., Buffington-Vollum, J. K., Stredny, R. V., & Handel, R. (2006). A survey of psychological test use patterns among forensic psychologists. Journal of Personality Assessment, 87:1, Boccaccini, M. T., & Brodsky, S. L. Diagnostic test usage by forensic psychologists in emotional injury cases. Professional Psychology: Research and Practice, 30:3, Bonanno, G.A. (2004). Loss, Trauma, and Human Resilience. American Psychologist, 59:1, Bennett, B. E., Bricklin, P. M., Harris, E., Knapp, S., VandeCreek, L., & Younggren. J. N. (2006). Assessing and managing risk in psychological practice: An individualized approach. Rockville, MD: The Trust. Call, J. A (2003). Liability for psychological injury: History of the concept. In I. Z. Schultz & D. O. Brady, (Eds.). Psychological injuries at trial (pp ). Chicago, IL: American Bar Association. Civil Rights Acts of l964; U.S.C. 2000e et seq.; and 42 U.S.C A(b)(3). Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113 S. Ct (1993). Dillon v. Legg, 441 P.2d 912. (Cal. 1968). Dohrenwend, B. P., Link, B. G., Kern, R., Shrout, P. E., & Markowitz, J. (1990). Measuring life events: The problem of variability within event categories. Measuring Life Stress, 6, Federal Rules of Civil Procedure, Rules 35 and 26 (12/1/10). United States Code. Cite: pdf. 13

14 Federal Rules of Evidence, Rules (12/1/11). United States Code. Cite: Foote, W. E. (2011). Civil Rights cases: race, sex and disability; Personal Injury Law and Issues. American Academy of Forensic Psychology, Advanced Workshops, CA. Foote, W. E., & Delahunty, J. (2005). Evaluating sexual harassment: Psychological, social, and legal considerations in forensic examinations. Washington, DC: APA. Greenberg, S. A. (2003). Personal injury examinations in torts for emotional distress. In I. B. Weiner (Series Ed.) & A. M. Goldstein (Vol. Ed.), Handbook of psychology: Vol. 11, Forensic psychology (pp ). Hoboken, NJ: Wiley. Haggerty, R. J., Sherrod, L. R., Garmezy, N., & Rutter, M. (Eds.). (1994). Stress, risk and resilience in children and adolescents: Processes, mechanisms, and interventions. Cambridge, UK: Cambridge University Press. Harris v. Forklift Systems, Inc., 114 S.Ct (1993). Heilbrun, K., Grisso, T., & Goldstein, A. M. (2009). Foundations of forensic mental health assessment. New York, NY: Oxford University Press. Kane, A. W. & Dvoskin, J. A. (2011). Evaluation for personal injury claims. New York: NY: Oxford University Press. Koch, J. K., Douglas, K. S., Nicholls, T. L., O Neill, M. L. (2006). Psychological injuries: Forensic assessment, treatment, and law. New York, NY: Oxford U. Press. Millon, T. Disorders of Personality: DSM-IV and Beyond (2nd ed., l996). New York: John Wiley & Sons, Inc. Molien v. Kaiser Foundation Hospitals, 616 P.2d 813, 167 Cal. Rptr. 831 (Calif. 1980). Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A metaanalysis. Psychological Bulletin, 129, Prosser, W. L. (1939). Intentional infliction of mental suffering: A new tort. 37 Mich. L. Rev Prosser, W.L., & Wade, J. W. (1971). Cases and materials on torts (5th ed). New York: The Foundation Press, Inc. Pynoos, R. S., Steinberg, A. M., & Goenjian, A. (1996). Traumatic stress in childhood and adolescence. Recent developments and current controversies. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.). Traumatic stress: The effects of overwhelming experience on mind, body and society (pp ). NY: Guilford Press. Slick, D. J., Tan, J. E., Strauss, E. H., & Hultsch, D. T (2004). Detecting malingering: A survey of experts practices. Archives of Clinical Neuropsychology, 19, Weissman, H. N. (1984). Psychological assessment and psycholegal formulations in psychiatric traumatology. Psychiatric Annals, 14 (7), Weissman, H. N. (1985). Psycholegal standards and the role of psychological assessment in personal injury litigation. Behavioral Sciences and the Law, 3, Weissman, H. N. (1990). Distortions and deceptions in selfpresentation: Effects of protracted litigation on personal injury. Behavioral Sciences and the Law, 8, Weissman, H. N. (1991). Forensic psychological assessment and the effects of protracted litigation on impairment in personal injury litigation. Forensic Reports, 4, Weissman, H. N. & DeBow, D. M. (2003). Ethical principles and professional competencies. In I. B. Weiner (Series Ed.) and A. M. Goldstein (Vol. Ed.). Handbook of psychology: Vol. 11, Forensic psychology (pp ). New Jersey: Wiley & Sons, Inc. THE RISE OF EATING DISORDERS IN MALES Sam* gained weight during his junior year of high school. What disturbed him most about his body were his tree trunk legs. As a senior, he decided he was going to become the thinnest guy he knew. Band singers in skinny jeans were his inspiration. When he searched the web, he looked for images of thin guys. When they weren t thin enough, he viewed images of underweight female models. He even read comments on pro-ana web sites. As his weight dropped, he felt more confident and in control. In general, he acted like an average teenager. He hung out with his friends, fixed up his truck, and surfed until he dropped. Sam s weight loss alarmed his parents and friends. But he didn t enter therapy until his parents learned he passed out twice after surfing and mom discovered By: Deirdra Price, Ph.D. diuretics hidden in Sam s sock drawer. While the prevalence of eating disorders has stabilized in the female population, they have risen in the male population. In 1990, 10% of individuals with eating disorders were men. Currently, the estimate is 25%. In addition, up to 40% of binge eaters are men (Hudson et al., 2007). One college study supports these percentages. Eisenberg et al. (2011) found that 13.5% of female and 3.5% of male college undergraduates had persistent symptoms of anorexia nervosa and bulimia. Compared with heterosexual men, up to 15% of gay and bisexual men have an eating disorder (Feldman and Meyer, 2007). This may be due to a heightened emphasis on physical attractiveness in the 14

15 gay community. Within the male eating disordered population, 21% engaged in at least one type of nonsuicidal self-injury behavior (Claes et al., 2011). * Sam s name and identifying features have been changed to protect his confidentiality. Male athletes in particular struggle with eating disorders. Men who are engaged in sports will typically obsess about percentage of body fat and its relation to performance (Hudson et al., 2007). When an athlete is expected to maintain a lower body weight to compete, eating disordered behavior such as binge eating after a period of fasting, self-induced vomiting, abuse of laxatives and/or diuretics, and excessive exercise may arise. Sports related to higher incidences of eating disorders include wrestling, boxing, crewing, running, gymnastics, and light-weight football. Certain careers such as acting and modeling can also perpetuate unhealthy eating and exercise habits. Some men are on a quest to build large muscles. Pope et al., (2002) state that 3 million men take anabolic steroids or other dangerous black-market drugs to buff up their bodies. In addition, one million men have developed body dysmorphic disorder, which is an excessive preoccupation with perceived flaws in appearance such as thinning hair, fatty breasts, or small penises. One such condition is muscle dysphoria or bigarexia which is an obsession with being extremely muscular. This leads to compulsive exercising and weight training to counteract a perceived image of being small and frail. Up to 10% of men in hard-core gyms have muscle dysmorphia. When men exercise excessively, eat high protein diets, lose a great deal of weight, ingest muscle building supplements, and/or show an unwavering focus on appearance, they are admired. Their behaviors are not seen as eating disordered. Cosmetic surgeons now cater to men s desire to alter their bodies and appearance. They offer hair replacement, pectoral implants, calf implants, liposuction, face lifts, chin implants, botox injections, and facial line fillers. Conversely, overweight men are not seen as having a problem even though binge eating led to the weight gain. Men are less stigmatized for being overweight. Therefore, their problem flies under the radar. Whereas women are more concerned about their weight and report feeling fat even though they are normal weight, men are fixated on select body parts, their shape, or a certain body type. Men who develop eating disorder are also more often overweight. The question arises as to why there is an increase in eating disorders among males. It is unclear whether more are developing eating disorders or more are seeking treatment. While research on the antecedents has focused mainly on females, anecdotal information from male patients supports many of the personality and familial factors seen in the female population. Listed below are the factors that contribute to food, weight, shape, and body image issues. I. Factors Leading to Eating Disorders in Males 1. Cultural Factors: Media and advertisers are placing more emphasis on men s bodies, which increases the pressure to look a certain way. The effect is different depending on what one is exposed to. Whereas some males gravitate towards the muscle-man image, others seek slimness. Over the last 20 years, advertisers have made a concerted effort to promote an idealized image of the fit, tone, and muscular man. The trend started in 1992 with Calvin Klein s Times Square underwear ad featuring Mark Wahlberg and his six-pack stomach. One female college patient reported that her male friends spent as much time talking about their bodies as her female friends. She said the guys focused on the ways to achieve twelve-pack washboard stomach through weight lifting, diet, and supplements. Children s actions toys reflect this hyper-focus on body image. Whereas Barbie has become thinner and bustier, male action toys, such as GI Joe Extreme, have become more muscular and cut (Pope et al., 2002). The muscle definition and bicep measurement for these toys have exploded. On the other end of the spectrum, thin is in. Coleman (2010) writes, One of the side effects of metrosexuality seems to be the affliction of men with the same unrealistic body image that women have been dealing with for years. The British mannequin maker Rootstein debuts their latest male form the Homme Nouveau, with a 35-inch chest and a 27-inch waist. Perfect for the trendiest, string-beaniest clothing, sure. But there s evidence that the new paradigm has given rise to male anorexia. Mannequins reflect the desired body image at the time they re manufactured and their measurements have decreased over the decades. The Classic mannequin in 1967 had a 42 chest and a 33 waist; The Muscleman in 1983 had a 41 chest and a 31 waist; The Swimmer in 1994 had a 38 chest and a 28 waist; and The Androgyne ( Homme Nouveau ) in 2010 had a 35 chest and a 27 waist. However, cultural factors are not enough to unleash 15

16 an eating disorder. Everyone is exposed to the media and advertising. Other factors must be in place for an eating disorder to express itself. 2. Personality Factors: There are certain personality traits that a young person exhibits prior to the development of an eating disorder. These include perfectionism, obsessiveness, compulsiveness, narcissism, pessimism, worrying, high need for selfcontrol, low frustration tolerance, poor self-esteem, emotional disregulation, interpersonal sensitivity, and/or negative affect (Academy of Eating Disorders, 1999; Johnson and Connors, 1978). These individuals tend to develop certain beliefs that point to not being enough in some way, be it not smart enough, attractive enough, popular enough, etc. These selfperceptions crystallize into negative beliefs and accompanying critical internal dialogue. 3. Familial Factors: Family dynamics may contribute to the development of eating disorders. Certain parental expectations and attitudes can make the aforementioned personality traits more pronounced. These include the desire for the child to be successful and achievement oriented, have a perfect attitude, and look attractive (with an emphasis on weight and thinness). There is also chronic criticism for making mistakes, a great number of conflicts without the ability to resolve them, discomfort with expressing negative emotions, either an over- or underinvolvement in what the child does, and an inclination to control the child s behaviors (Fairburn et al., 1997; Taylor and Altman, 1997). For some individuals, there is a history of sustained and/or excessive trauma (i.e., physical, emotional, and/or sexual abuse). First degree biological relatives have a higher frequency of mood disorders, substance-abuse problems, and/or eating disorders (American Psychiatric Association, 1994). 4. Trigger Event Factor: Often a trigger event (i.e., relationship break-up, being bullied by peers, moving to a new school, starting college, parental divorce, etc.) stirs emotions that feel unbearable (i.e., loss, rejection, humiliation, anger, hurt, and/or feeling out of control). The individual discovers that eating disordered behaviors (i.e., starving, bingeing, purging, and/or excessive exercise) seems to help him cope with the experience and serves many purposes. It numbs emotions, offers comfort, provides distraction, brings a sense of control, fuels procrastination, fills an internal emptiness, punishes or rewards, and boosts self-esteem (Price, 1999). As with many females, males also believe they will feel better about themselves and be liked by others if they alter their bodies, either by bulking up or slimming down. Both strategies make the individual seem powerful and in charge for a while. Starving and excessive exercise can produce a euphoric high. Bingeing serves to soothe uncomfortable emotions and purging leads to a sense of releasing pain plus getting rid of unwanted calories. Even though the eating disorder is not a solution, the individual returns to these behaviors again and again. Over time, the behaviors seem to control the individual and not the reverse. By this time, the addictive nature of the eating disorder has taken hold. It becomes a cycle that seems impossible to break. II. Treatment of Males with Eating Disorders Because anorexia nervosa, bulimia, and binge-eating disorder are not identified with males, these problems often go unrecognized and therefore untreated. Men with eating disorders don t see themselves as having an eating disorder (Robinson et al., 2012). They deny that what they are doing is of concern. According to Pope et al. (2002), men with body image issues often don t reveal their problems for fear that they will be considered effeminate or gay. They seek treatment on their own less often than females. Their entry into treatment may be for another reason such as a mood disorder or relationship issues. Outpatient treatment for males with eating disorders is similar to the treatment for females. After a thorough assessment, it is important to create a treatment team that includes a physician, nutritionist, and/or psychiatrist who specialize in the treatment of eating disorders. A treatment strategy is then formulated. The focus of individual psychotherapy is to change unhealthy eating and exercise behaviors; address cognitive processes and distortions; increase alternate coping strategies; improve body image; understand concomitant mood and/or personality disorders; and enlist family members for support when appropriate (Price, 1999). For teens, family therapy is recommended if parents are amenable. If the patient s symptoms worsen, intensive outpatient or inpatient treatment is advised. Some eating disorders inpatient programs now recognize that eating disorders in males are on the rise and provide treatment for these individuals. Sam* is in individual and family therapy. He comes to sessions consistently. During the week, he practices eating three meals a day and has gained a few pounds, although he is not comfortable doing so. He scrutinizes the changes in his body, especially his 16

17 legs. There are days when he under-eats but not to the point of passing out. Family issues are slowly being addressed. Sam s progress is incremental and heading in a positive direction. About the Author Deirdra Price, Ph.D., President and CEO of Diet Free Solution, specializes in the treatment of eating disorders and weight control problems. She is the author of Healing the Hungry Self: The Diet Free Solution to Lifelong Weight Management. She teaches online CEU courses on eating disorders and obesity through ContinuingEdCourses.net. She has a private practice in Bankers Hill and can be reached at: and dietfreesolution.com. REFERENCES Academy of Eating Disorders. (1999). Lecture in San Diego, CA. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, D.C.: American Psychiatric Association. Anderson, A., Cohn, L., and Holbrook, T. (2000). Making Weight: Men s Conflicts with Food, Weight, Shape, and Appearance. Carlsbad, CA: Gurze Books. Claes, L., Jimenez-Murcia, S., Aguera, Z., Castro, R., Sanchez, I., Menchon, J. M., and Fernandez-Aranda, F. (2011). Male eating disorder patients with and without non-suicidal self-injury: A comparison of psychopathological and personality features. European Eating Disorders Review, doi: erv Coleman, D. (2010) Intelligencer. New York Magazine, May 10, 11. Eisenberg, D., Nicklett, E. J., Roeder, K., and Kirz, N. E. (2011). Eating disorder symptoms among college students: prevalence, persistence, correlates, and treatment seeking. Journal of American College Health, 59(8), Fairburn, C. G., Welch, S. L., Doll, H. A., Davies, B. A., and O Connor, H. E. (1997). Risk factors for bulimia nervosa: A community-based case-control study. Archives of General Psychiatry, 54(6), Feldman, M. B. and Meyer, I. A. (2007). Eating disorders in diverse lesbian, gay, and bisexual populations. International Journal of Eating Disorders, 40(3), Hudson, J. I., Hiripi, E., Pope, H. G., and Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61(3), Johnson, C. and Connors, M. E. (1978). The Etiology and Treatment of Bulimia Nervosa. New York: Basic Books. Pope, H. G., Phillips, K. A., and Olivardia, R. O. (2002). The Adonis Complex: How to Identify, Treat, and Prevent Body Obsession in Men and Boys. New York: Touchstone. Price, D. (1999). Healing the Hungry Self: The Diet-Free Solution to Lifelong Weight Management. New York: Plume. Robinson, K., Mountford, V. A., and Sperlinger, D. (2012). Being men with eating disorders: Perspectives of Male Eating Disorder Service-Users. Journal of Health Psychology, March 27. Taylor, C. B. and Atlman, T. (1997). Priorities in prevention research for eating disorders. Psychopathology Bulletin, 33(3), ART + SCIENCE = THIRD CULTURE ON SEEING We see before we use words; we recognize shape and pattern before we speak. While other species may primarily use the olfactory and gustatory sensoria, humans are primarily audio-visual centric. Seeing, however, is complex both mechanically and metaphorically. An orchestra may play a symphony of harmonic sounds just as the human visual apparatus known as the eyes play to the mind a convergence of frequencies we call the visual spectrum. Like a libretto to an opera, the cogent mind provides schemata and other narrative through which all sensory information, including the visual spectrum, may be interpreted. There is a twist of complexity to this opera: it plays to an audience of one. Adding layers of time, both in years passed and one s aspirations into the future, By: Linda Williams, Ph.D. collide with every other experience of self and other to affect this fluid, real-time libretto. The visual realm, to a sighted person, when paired with this endogenous libretto, both enlighten, confound and betray our deepest desires, drives, impulses, sense of originality, creativity and our fears. The visual apparatus, through sophisticated imaging techniques, has largely been demystified on the mechanical and machinery level. The retina may be seen as the origins of one s world view. Igor Kozak, M.D., Ph.D., Ophthalmologist and Retinal Specialist at the Jacobs Retina Clinic in La Jolla, takes the orchestra metaphor further and states, Human perception acts as a prelude; it enters through the corneal window and propagates to the retina, the most complex and sensitive matter in the universe, where magnitudes of 17

18 acts are orchestrated and further conveyed to produce a great finale in our brains. As a result of this orchestral performance visual information filters through the cognitive world. When we see, we see upon incident, by choice, or by force. We do not always choose to see and yet all information becomes uniquely ours a libretto with an N of 1 and a variable pool of x. Psychologists, across theoretical disciplines, have opened the window to the cognitive process, the handler, and supreme artist of all afferent visual material. The retinal physician may peer under microscope to the back reaches of the human eye assessing for health, or disease process; yet does that physician know the depth and breadth of the retina beyond this binary construct? Or, does the psychologist wonder about the retinal machinery or ways in which myopia or presbyopia may affect one s schema, attitudes or drives? Fifty-three years ago, on May 7, 1959, a physicist and novelist by the name of C. P. Snow, exposed the wide chasm between the culture of the sciences and the culture of the humanities. C. P. Snow s famous 1959 Rede lecture delivered at the University of Cambridge, titled Two Cultures, created a valuable discourse that continues today. The two cultures, according to Snow, represented the culture of the Sciences and the culture of the Humanities. The lecture noted the disappointing chasm which appeared between the two fields; leaving each rather impoverished of the other. Snow formulated discrete sides in a match: the Literary Intellectuals versus the Empiricists. Snow was an astute observer since he was both an accomplished Physicist and Novelist. Snow was quoted as saying, A good many times I have been present at gatherings of people who, by the standards of the traditional culture, are thought highly educated and who have with considerable gusto been expressing their incredulity at the illiteracy of scientists. Once or twice I have been provoked and have asked the company how many of them could describe the Second Law of Thermodynamics. The response was cold: it was also negative. Yet I was asking something which is about the scientific equivalent of: Have you read a work of Shakespeare? I now believe that if I had asked an even simpler question such as, What do you mean by mass or acceleration? which is the scientific equivalent of saying, Can you read? not more than one in ten of the highly educated would have felt that I was speaking the same language. Snow described the need to bridge that chasm so that both fields could emerge with fluency that would enhance, strengthen and deepen the work of the other. The field of Psychology sits within the reaches of what Snow described as the Third Culture. Psychologists are uniquely trained in the empirical model, with critical thought, rigor and disciple of scientific study using convergent and divergent thinking. This rigorous model of thought may be applied equally to perception and cognition or the phenomenological and interpersonal. We bridge the social science and the natural sciences we are both empiricists and philosophers. We are also all artists of our specialty; masterfully blending our skill sets often as an improvisation when we sit before a new patient or client. The Third Culture: Art, as an Internal and External Event James Turrell s Wedgework V, on exhibit at the Museum of Contemporary Art in San Diego is said to produce Extreme retinal responses that may disorient and be perplexing.... This exhibit of light uses tricks of illusions and visual distortion but one s schemata represents what one may see in scenes and ideas as well as relationships between concepts. When we have richness to an experience that provides an opportunity for storytelling we tend to create memories around the narrativized experience. We make sense of the distortions; we have a unique experience. Thoughts will likely vary the spectrum from person to person on any given solitary or shared visual experience. If we consider the sourcing of possibility within our reaction sphere we enjoin our history, 18

19 attitude, individual preference, fears and hopes into a seemingly innocuous perceptual experience. Looking at Wedgework V, am I seeing the real that is outside of me located at the Downtown museum? Or am I staring at my internal experience of Art, that flash before my eyes that simultaneously embodies the totality and convergences of my thought, experiences and memories? Will I get more from this viewing experience if I have had a more depthful and rich life experience? If my vocabulary is broad or if I speak more languages or live in a multicultural presence of mind? One s ability to articulate an experience through an internal dialogue and between person and person in discourse bring another dimension to the real. Brian Bommeisler, of Soho, NY; instructor and contributor to the 4th definitive version of the bestselling book, Drawing on the Right Side of the Brain remarks on Wedgework V, stating, James Turrell s Wedgework V 1975 (23 X 24 X 12 ) at the Museum of Contemporary Art, San Diego consists of a series of projections using red light, that collectively resemble a series of abstract paintings. These figments of light are arranged like the pages of an enormous book and they confront the viewer with silent thoughts of time and space. In this piece the right hemisphere is inundated with thoughts of quiet and wordless euphoria. Often red carries a connotation of violence and anger, but with Turrell it has an intense meditative quality. The shapes that they conjure evoke the lozenges in the paintings by Mark Rothko and the abstract geometrical forms found on the canvases of the Russian painter Kasimir Malevich. But it is the light, that strange glowing light that one is moved by. That beautiful light projected in a cavernous space as bewildering as the Cave of Shadows dreamed up by Plato. As academic and professional disciplines and information converge into one viewing experience of the Turrell, or viewing a tree or even a dance piece, our retina catches the light particles and one wonders deeper now, about the individual differences and adaptations involved within the visual spectacle we call seeing. I encourage all readers to see for themselves. The MCASD has graciously extended a 2 for 1 offer on admission and a $10 off membership through the month of June. You may view Turrell s work among other artists who use light through August. Please see their website: About the Author Linda Williams is the new Chair of the Arts and Media Committee. The convergence of her interest in Psychology, Neuroscience and the Arts has led to a developing interest in the perceptual realm as a whole. Her interests span from an observer-student to a practitioner and teacher. As an observer-student, Dr. Williams is drawn to the Surrealists and is fascinated by imbedded uses of language and schemata. She notes that while Sigmund Freud may have been infamous for phrasing a cigar is just a cigar, Renee Magritte played with images and words, looking deeply into imagery and representations. Ceci n est pas une pipe or, This is not a pipe plays on perceptions and perspective of reality. Dr. Williams other interests include the sensory, cognitive and artistic aspect of illusions both auditory and visual. The literal aspect of Art is captivating and instructive unto itself but as a practitioner, bridging the metaphorical application of the Arts into therapy may lead to broader and richer awareness and understanding of self and other thereby prompting new ways to perceive leading to new perspectives. Dr. Williams is a Licensed Clinical Psychologist in private practice. Dr. Williams specializes in Neuropsychological testing; Educational and Creativity consultation. She uses negative space, metaphor and other tools of classic perspective to assist in new ways to perceive and problem solve. She has an office in Coronado and Carlsbad. Please feel free to with feedback: Special thanks to: Igor Kozak, MD, Ph.D., Brian Bommeisler, Philip Skaller and Rebecca Handlesman of MCASD. REFERENCES Snow, C. P. (2001 [1959]). The Two Cultures. London: Cambridge University Press. Solso, R. L. (2003). The Psychology of Art and Evolution of the Conscious Brain. Cambridge, MA: MIT Press. Write to Us We welcome letters. The Editor reserves the right to determine the suitability of letters for publication and to edit them for accuracy and length. We regret that not all letters can be published, nor can they be returned. Letters should run no more than 200 words in length, refer to material published/related to the newsletter, and include the writer s full name and credentials. your letter to the Editor at 19

20 WHAT YOU DON T KNOW CAN HURT YOU! Before I attended APAIT s latest workshop on Risk Management in the Electronic Age I didn t know that I should know the answers to the following questions: What the heck is encryption anyway? Off-site storage of records? Who? Me? My patient wants to: send me her dreams by , follow me on Twitter, friend me on Facebook, invite me on LinkedIn. Is this a bad idea? And what does APAIT mean by risk management? Let s answer the last question first. I was trained to think of risk management as How will this or that intervention affect this patient? Am I hurting or helping this client? How likely is he to act on his suicidal impulse? And while those questions still inform my clinical interactions, now I also think long and hard about the risks and benefits of the electronic age of communication. The whole thing doesn t come easy because, I confess, on the other side of my Social Security card it reads digital immigrant, not digital native. My 22 year old son, a true digital native, swims in the communication sea of Facebook, Twitter, LinkedIn, blogs, , text messaging and 37 other forms of communication that I haven t even heard of yet. In sad comparison I am still hauling my 10 year old laptop with 10 years of patient data on it into the office, can just barely send a text (on my non-smart phone), and I pray daily that the HIPPA police do not know that I exist. But the APAIT workshop has brought me into the light and I am going to share a very brief bit of learning with you. What the heck is encryption anyway? Here is APAIT s definition: the conversion of data into a form, called a hypertext that cannot be easily understood by unauthorized people. Okay I get that. But how do you do that with your data short of tossing your laptop into the path of a semi? In the By Sandra Block, Ph.D. workshop I learned how to upload selected files or the entire contents of my computer s data to an entity (i.e. truecrypt.org or symantec.com) that throws the information into a blender and transmits all back to you in an indecipherable format. You then create an encryption key that will allow only you to restore the data to a readable format. Why is this good idea? Suppose your laptop is stolen - it happens; ask me how I know. If your data is encrypted (and you have onsite or offsite data back-up) you hop in the car, drive to Fry s and buy a new laptop. If your data is not encrypted you: (1) notify every client you saw in the last ten or fifteen years that their protected health information (PHI) is now floating in the wind; (2) notify Health and Human Services that you are in violation of HIPPA and (3) notify the media if the affected clients number above 500. This is going to put a serious dent in your peace of mind. Off-site storage of records? Like so many professionals I stopped copying data to a flash drive and upgraded to an external hard drive for a routine back-up. The on light indicating a scheduled back-up in progress erased some of my worry but not all of it. What if my cat and my coffee cup met up on the desk and the hard drive was damaged? What if some enterprising thief took the laptop AND the hard drive? A solution to these worries is off-site storage. Companies like carbonite.com, mozy.com and backblaze.com (there are many others) will perform routine back-ups at little cost. Again, if your hardware disappears off-site storage is a life - and practice - saver. My patient wants to: send me her dreams by , text me his insights, follow me on Twitter, friend me on Facebook, invite me on LinkedIn. Is this a bad idea? You bet it is. All of these means of communication are, well...communicating with a lot of other people. Sending anything beyond an appointment date and time with is like sending a postcard out into the electronic universe. The same is true of texting. Remember that social media like Facebook, LinkedIn and Twitter are for your personal and professional communications; keep your security settings high and 20

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