1 Archives of Clinical Neuropsychology 16 (2001) 271±291 Practices in forensic neuropsychology: Perspectives of neuropsychologists and trial attorneys Steven M. Essig, Wiley Mittenberg*, Randy S. Petersen, Silvia Strauman, Joan T. Cooper Nova Southeastern University, Fort Lauderdale, FL, USA Abstract Members of the National Academy of Neuropsychology and the Association of Trial Lawyers of America were surveyed concerning current practices in forensic neuropsychology. The majority of neuropsychologists and attorneys reported that attorneys never observe neuropsychological testing. Attorneys reported receiving raw data in almost all of their brain injury cases, but neuropsychologists reported that they produce raw data in only a minority of their forensic cases. Similarly, fewer neuropsychologists than attorneys acknowledged that they are asked to provide information to assist the lawyer in preparing for the cross-examination of the opposition's expert or to prepare the plaintiff for the opposition's evaluation. Lawyers typically spend up to an hour preparing their clients for neuropsychological evaluations and commonly cover test content, detection of malingering, and brain injury symptoms. Other topics addressed include attorney influence on findings, fees and billing, board certification, use of technicians, and methods used to generate referrals or locate experts. Areas of agreement and divergence between the groups were identified and ethical issues raised by identified practices were examined. D 2001 National Academy of Neuropsychology. Published by Elsevier Science Ltd. The growth of neuropsychology as a clinical specialty over the past decade is well documented. Numerous articles published during that time have revealed the practices, beliefs, and standards of the profession as reported in the survey responses of practicing neuropsychologists (e.g., Guilmette, Faust, Hart, & Arkes, 1990; Putnam, 1989; Putnam, DeLuca, & Anderson, 1994a, 1994b; Sweet & Moberg, 1990; Sweet, Moberg, & Westergaard, 1996). More than 10 years ago, Schwartz (1987) recognized that neuropsychologists had become integral contributors in the forensic arena, particularly in the litigation of cases * Corresponding author. Wiley Mittenberg, Center for Psychological Studies, Nova Southeastern University, 3301 College Avenue, Fort Lauderdale, FL /01/$ ± see front matter D 2001 National Academy of Neuropsychology. PII: S (99)
2 272 S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271±291 involving claims of brain injury. A recent survey identified the legal system as the third most prevalent source of referrals for neuropsychologists, increased from fourth only 5 years earlier. Only neurology and psychiatry are more popular sources (Sweet & Moberg, 1990; Sweet et al., 1996). However, despite the prediction of ``an ever-increasing role for specialization in forensic neuropsychology'' (Bigler, 1986), little information is available concerning the practices and beliefs of practitioners in this field. Nor is there much information available about beliefs and practices of personal injury attorneys as they relate to issues germane to neuropsychology. As the subspecialty of forensic neuropsychology continues to grow, the need to determine and develop guidelines for practice becomes paramount. Such information will be useful not only to practitioners who seek information as to the prevailing standards in the field, but also to the legal system as it attempts to better define the role of neuropsychology in personal injury litigation. The purpose of this study was to examine the practice of forensic neuropsychology from the perspectives of both the clinicians who practice it and the individuals who most frequently hire and cross-examine them, that is, personal injury attorneys. Information was obtained from neuropsychologists concerning forensic practice demographics (e.g., percentage of practice involving brain injury litigation, percentage of forensic cases where retained by plaintiff, referral sources, referral questions, board certification, use of technicians, billing, and fees). Attorneys were queried concerning similar facts (e.g., percentage of practice involving claims of brain injury, referral questions, sources of referrals for expert neuropsychologists, importance of board certification, billing, utility of information obtained from neuropsychologists, and types of experts retained in brain injury cases). Special emphasis was placed on determining the practices of both neuropsychologists and attorneys vis-aá-vis issues that are of topical interest in forensic practice: presence of third parties during testing, disclosure of test battery prior to examination, disclosure of raw test data, and bias in test results due to attorney influence. By examining the practices and beliefs of both groups, and determining areas of agreement and disagreement, standards for the practice of forensic neuropsychology will begin to be revealed. 1. Method An anonymous questionnaire consisting of 17 questions was sent to 250 randomly selected members of the National Academy of Neuropsychology (NAN) in August Simultaneously, a similar questionnaire consisting of 18 questions was sent to 500 randomly chosen members of the Motor Vehicle Collision, Highway, & Premises Liability section of the Association of Trial Lawyers of America (ATLA). The ATLA is a national organization comprised primarily of litigators who represent plaintiffs. This section of ATLA was selected because it could not be determined a priori which attorneys handled cases involving head injuries and it was assumed that many of its members would represent clients litigating brain injury claims. Addressed and stamped return envelopes were included in these mailings. Twenty-one questionnaires sent to neuropsychologists and 27 attorney questionnaires were returned by the Post Office as undeliverable. A total of 70 neuropsychologists returned the completed forms. Four of the respondents indicated that they were not involved in personal
3 S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271± injury evaluations. This represented an overall useable return rate by neuropsychologists involved in personal injury litigation of approximately 29%. Fifty-six completed questionnaires were received from attorneys. However, four responding attorneys indicated that they did not handle personal injury cases involving known or suspected brain injury. Thus, an overall useable return rate of 11% was obtained from attorneys handling brain injury claims. This relatively low rate of return may reflect a lack of involvement in brain injury cases on the part of the individuals who received the mailing. Most personal injury attorneys represent clients with heterogeneous injuries, only some of whom make claims for brain injury. As mentioned above, attorneys specializing in brain injury litigation could not be identified before mailing. In addition, attorneys' lack of interest in behavioral research may have impacted on the return rate in the present study. The following data and analyses are based on the responses of 66 neuropsychologists and 52 attorneys, all of whom indicated that they are actively involved in the arena of litigation of personal injury cases involving known or suspected brain damage. 2. Results and discussion Tables 1 through 6 present the items contained in the surveys sent to attorneys and neuropsychologists and the percentage of endorsements in each response category. For questions posed to both attorneys and neuropsychologists, a priori intergroup comparisons were conducted utilizing the chi-square test for independent proportions. For items where differences in the proportion of individuals endorsing a particular response category was of interest, either inter- or intragroup post hoc comparisons were performed using a z-test for dependent or independent proportions, as warranted. Table 1 Neuropsychologist Survey % Response Category Attorney Survey % What percentage of your practice consists of personal injury evaluation involving known or suspected brain injury or damage? 0 None ±25% ±50% ±75% ±100% 4 In what percentage of your personal injury cases do you work for the plaintiff? 3 None 33 1±25% ±50% ±75% ±100% What percentage of your practice consists of personal injury litigation involving known or suspected brain injury or damage?
4 274 S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271± Practice demographics: neuropsychologists The overwhelming majority (94%) of all responding neuropsychologists reported that some portion of their practices involved personal injury evaluations of brain injury claims. This data appears to represent an increase from a decade earlier when 68% of surveyed members of Division 40 of the American Psychological Association (APA) reported that they accepted forensic personal injury referrals (Putnam & DeLuca, 1990). In the present study, of those respondents who reported that they conduct personal injury evaluations, 90% indicated that these types of cases constitute up to one half of their caseload, with the modal response (70%) in the 1% to 25% range (see Table 1). This is consistent with the earlier survey, which reported that personal injury matters constituted 11% of referrals for neuropsychologists engaged in primary employment settings and 22% for those in private practice (Putnam & DeLuca, 1990). However, more than one third (40%) of the 1990 sample indicated that virtually none ( < 1%) of their referrals were personal injury cases, and one fourth of the respondents reported that such cases made up more than 25% of their caseload. In contrast, the data in the current study suggests that only 6% of neuropsychologists do not perform personal injury evaluations and 41% report that such cases constitute more than one fourth of their referrals. Thus, it appears that a greater percentage of neuropsychologists are involved in personal injury cases than were being referred such matters at the beginning of the decade. Likewise, such cases make up a greater proportion of many neuropsychologists' total workload. When engaging in brain injury related litigation, 38% of forensic neuropsychologists are primarily hired by plaintiffs' attorneys, whereas 59% do some, but not most, of their forensic work on behalf of plaintiffs (see Table 1). Three percent are never retained by plaintiffs' counsel. In contrast, 10 years earlier, neuropsychologists reported that approximately 60% of their personal injury referrals were from plaintiffs' attorneys (Putnam & DeLuca, 1990). This shift suggests that the discipline of neuropsychology has gained some measure of acceptance with the more conservative defense bar Practice demographics: attorneys Similar to neuropsychologists, 93% of responding attorneys indicated that at least some portion of their practice involved brain injury claims. Of these respondents, most (94%) reported that brain injury claims constitute up to one half of their practice (see Table 1). Fewer than 6% focus primarily on such claims. This result is not unexpected, given that most personal injury attorneys who litigate motor vehicle and premises liability cases will represent clients with a variety of injuries, many of whom will not have suffered head injuries. Table 2 depicts the frequency with which attorneys hire various types of experts. When litigating cases involving known or suspected brain injury, plaintiffs' attorneys are more likely to retain the services of neuropsychologists and neurologists than any other types of experts or consultants. Neuropsychologists are retained by 62% of attorneys in most of their brain injury cases with the modal respondent indicating that they hire neuropsychologists in all or almost all (76±100%) of these cases. Forty-six percent of attorneys retain neurologists in almost all of their brain injury cases. On the other hand, 73% of attorneys reported that they
5 S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271± Table 2 Cases hired % Type of expert None 1±25% 26±50% 51±75% 76±100% Neuropsychologist Neurologist Neurosurgeon Psychiatrist Physiatrist Other never hire physiatrists, and 48% indicated that they do not utilize the services of neurosurgeons or psychiatrists. These data suggest that neuropsychologists are retained by plaintiffs' attorneys more frequently than any other type of expert. Neurologists are the primary competition for forensic neuropsychologists, and in many cases, experts in both fields may be hired to provide complementary input Sources for finding neuropsychological experts The most popular method utilized by attorneys to locate neuropsychological experts and consultants are referrals from other attorneys (75%) and from health care professionals (69%; see Table 3). Similarly, recommendations from attorneys and health care providers are the primary means by which neuropsychologists publicize their services to the legal community. Fewer attorneys use conferences or presentations, membership directories of neuropsychological organizations, and advertisements to find forensic neuropsychologists. The ``other'' category was endorsed by attorneys who indicated that their choice of neuropsychological experts was based upon personal knowledge of the experts or their reputation in the community. Only 2% of neuropsychologists advertise their availability for forensic work, whereas 21% utilize directories or conferences or presentations as a method of attracting legal cases. A sizeable percentage (17%) of attorneys take advantage of expert referral services to locate neuropsychological experts. However, significantly fewer neuropsychologists (2%) are listed with such services in an attempt to publicize their availability, c 2 (1, 118) = 9.352, p <.005. Expert-referral services, specifically those that are nationwide, have a vast database of experts of all types, including neuropsychologists. Attorneys in need of an expert provide the service with information about the type of case they are handling and the required characteristics of the expert (e.g., years of experience, board certification, number of times testified in trial, etc.). They are then provided with the names of experts who meet their criteria. This avenue may prove to be a rich, yet, to date, relatively untapped source of forensic referrals for neuropsychologists Board certification Table 3 contains data concerning the boards, if any, by which forensic neuropsychologists are certified, and attorneys' attitudes regarding certification. Board certification is an
6 276 S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271±291 Table 3 Neuropsychologist Survey % Response Category Attorney Survey % What methods have you used to publicize or advertise your services as a neuropsychological expert/consultant? What methods have you used to find a neuro- psychological expert/consultant? 58 Referrals from other attorneys * Referrals from health care professionals Conferences/presentations Directories 21 2 Advertisements * 10 2 Expert referral service** 17 6 Other 19 If you are board certified, indicate your board certification. By which of the following professional boards is it important to you that your retained neuropsychologist be certified? 15 American Board of Clinical 30 Neuropsychology * 11 American Board of Professional 25 Neuropsychology * N/A Any board is acceptable None/Board certification not important** Other 4 What tasks are you typically asked by an attorney to perform? What tasks do you typically ask your retained neuropsychologists to perform? 97 Conduct neuropsychological assessment Prepare a report of findings Provide deposition testimony Provide trial testimony Educate attorney about neuropsychology Assist attorney in preparing for cross-examination of opposition's expert * 12 Provide information to be used to prepare plaintiff for neuropsychological exam** What referral questions are you asked by an attorney in your cases involving known or suspected brain damage? What referral questions have you asked of neuropsychologists in your cases involving known or suspected brain damage? 100 Was brain damage caused by incident 98 that is subject of litigation? 97 Has plaintiff suffered brain damage? From what types of functional 96 deficits is plaintiff suffering? Are plaintiff's deficits: 82 genuine vs. malingered? organic vs. psychological? 85 (continued on next page)
7 S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271± Table 3 (continued) Neuropsychologist Survey % Response Category Attorney Survey % 77 What type of rehabilitation 98 does plaintiff require? In what percentage of your suspected brain injury (damage) cases does an attorney insist that you administer the tests yourself, rather than use a technician?** 85 None ±25% ± 50% ± 75% ± 100% 37 Note. N/A = not applicable. * p <.05; ** p <.01. In what percentage of your cases involving known or suspected brain damage do you insist that your neuropsychologist administer the tests him/herself?** important criterion to attorneys in selecting a neuropsychological expert/consultant. Only a small minority (12%) of attorneys indicated that board certification is not important. Almost half indicated that any board certification is acceptable, whereas 30% preferred that their expert be certified by the American Board of Clinical Neuropsychology (ABPP/ABCN) and 25% preferred American Board of Professional Neuropsychology (ABPN) certification. Many respondents apparently drew little distinction between the two boards. Twenty-four percent of the attorneys endorsed both ABCN and ABPN. These results suggest that many attorneys may not be aware of the distinctions between the different boards offering certification and that their sole concern is that a prospective expert has been certified by some professional board. Despite a clear preference by attorneys to hire neuropsychologists who are board certified, more than half of the respondents who practice forensic neuropsychology were not certified by any board. Of those that were certified, 15% received their certification from ABPP/ ABCN, 11% from ABPN, and 20% were certified by ``other'' boards, primarily various boards of forensic psychology (e.g., American Board of Forensic Psychology, American College of Forensic Examiners) Neuropsychological services provided As is evident from the data contained in Table 3, forensic neuropsychologists are typically asked to provide a variety of services in personal injury cases. In addition to conducting assessments and preparing reports of their findings, neuropsychologists are often asked to provide deposition and trial testimony. Neuropsychologists are also routinely asked to educate the attorneys that retain them about neuropsychology. It appears, however, that the experts may not be fully aware of the uses to which that information is being put. More than three fourths of attorneys utilize retained neuropsychologists to help prepare them for crossexamination of the opposition's experts. However, significantly fewer neuropsychologists (58%) acknowledge that they typically perform such a service, c 2 (1, 118) = 5.58, p <.05.
8 278 S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271±291 Table 4 Neuropsychologist Survey % Response Category Attorney Survey % What payment arrangements do you make with attorneys? What payment arrangements do you make with neuropsychologists? 61 Periodic billings Retainer * Letter of protection Lien 29 9 Other 12 How much do you typically bill per hour for forensic neuropsychological assessment? * 3 < $ $101 ± $126 ± $151 ± $176 ± > $ Flat Fee 10 How much do you typically bill per hour for forensic neuropsychological testimony? How much are you typically billed per hour for forensic neuropsychological assessment? * How much are you typically billed per hour for forensic neuropsychological testimony? 0 < $ $101± $126 ± $151± $176± >$ Flat Fee 8 On average, what percentage of fees billed to an attorney who has retained you actually get paid? * p <.05; ** p <.01. On average, what percentage of fees billed to you by retained neuropsychologists are paid? 0 None 0 3 1± 25% ±50% ±75% ± 100% 92% When queried whether neuropsychologists are asked to provide information to help the attorney prepare his or her client for the opposition's neuropsychological examination, an even more striking discrepancy is observed. More than one third (38%) of attorneys acknowledge that this is something they typically ask of their experts, whereas only 12% of neuropsychologists acknowledge that they are asked to do so, c 2 (1, 118) = 11.15, p <.01. Thus, it appears that some forensic neuropsychologists are unaware that the information they provide to attorneys is being used to ready the plaintiff for the opposition's examination and to discredit the findings and conclusions that are derived from that evaluation. This use of information obtained from neuropsychological consultants or experts may raise an ethical dilemma for the neuropsychologist if the attorney is using the information
9 in an improper or inappropriate manner. Attorneys see the preparation of their clients for forensic examinations as one aspect of their duty to zealously advocate on their clients' behalf (Youngjohn, 1995). Wetter and Corrigan (1995), in a survey of practicing lawyers, reported that most attorneys believed that their clients should receive either as much information as possible (42%), or at least a moderate amount (41%), of information about the tests and testing procedures prior to the examination. Such advance knowledge could result in invalid test data. Thus, information provided by a neuropsychological consultant may be used to improperly coach a plaintiff in preparation for a forensic examination. Additionally, an ethical quagmire arises when a consulting neuropsychologist provides an attorney with scientific information and knowledge that will be misused to discredit an opposing expert at trial and confuse a jury (Adams, 1997; Guilmette & Hagan, 1997; McSweeny, 1997). The APA Ethics Code, Standard 1.16 (American Psychological Association, 1992) proscribes participation in activities in which there is a likelihood that the psychologist's skills or data will be misused by others. The uses described above may constitute such misuse. It would place an impossible burden upon forensic neuropsychologists to require that they make themselves aware of all of the uses to which the information they provide to attorneys will be put. However, they have an obligation to take reasonable steps to ensure that the information they provide is used in an ethical and responsible manner and if they learn that it has been misused, to take reasonable steps to correct or minimize the misuse (American Psychological Association, 1992, Standard 1.16b; Committee on Ethical Guidelines for Forensic Psychologists, 1991) Referral questions S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271± As indicated in Table 3, both attorneys and neuropsychologists report that issues of the existence and cause of brain damage are typical referral questions in personal injury cases. Ninety-four percent of attorneys and 97% of neuropsychologists indicated that the question of whether the plaintiff has suffered brain damage is commonly posed. Similarly, 98% of the attorneys, and all of the neuropsychologists reported that the experts are asked if the brain damage is a result of the incident that is the subject of the pending litigation. This is not surprising in light of the observations of Richardson and Adams (1992) who reported that of the jurisdictions that had considered the issues, all permitted neuropsychologists to testify about current brain functioning. The large majority permitted such experts to testify regarding causation. In light of the frequency with which neuropsychological experts are asked to provide deposition and trial testimony, there would be little reason to ask these questions if courts were not allowing them to present their conclusions. Given the frequency with which these matters are referred to forensic neuropsychologists, the prevailing national standard appears to be to permit neuropsychologists to render such opinions. Other commonly asked questions include requests to determine the nature of the plaintiff's functional deficits, whether the plaintiff is malingering, the nature of rehabilitation services the plaintiff requires, and whether the plaintiff's problems are organic or psychological. One can surmise from this data that neuropsychologists are being permitted to offer expert testimony as to all of these issues as well.
10 280 S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271±291 Table 5 Neuropsychologist Survey % Response Category Attorney Survey % How much time do you typically spend preparing a client for a neuropsychological examination? None 25 < 15 minutes ±60 minutes 37 1±2 hours 15 >2 hours 2 What topics do you typically cover with a client while preparing him/her for a neuropsychological examination? Test content 21 Detection of malingering 19 Symptoms of traumatic 19 brain injury Symptoms of post concussion 13 syndrome What not to divulge in the 12 interview What to divulge in the 10 interview How to respond to tests 8 Neuropsychological test validity measures 4 In what percentage of your cases involving known or suspected brain damage do you request disclosure of the specific neuropsychological tests that will be administered to your client by the opposition's neuropsychologist?** 36 None ±25% ±50% ±75% ±100% 40 In what percentage of your suspected brain injury (damage) cases are you requested to disclose the specific neuropsychological tests that will be administered to the plaintiff?** In what percentage of your suspected brain injury (damage) cases do you actually disclose the specific neuropsychological tests that will be administered to the plaintiff?** In what percentage of your cases involving know or suspected brain damage do you receive disclosure of the specific neuropsychological tests that will be administered to your client by the opposition's neuropsychologist?** (continued on next page)
11 Table 5 (continued) Neuropsychologist Survey % Response Category Attorney Survey % 42 None ±25% ±50% ±75% ±100% 33 Which of the following tests do you typically administer as part of a neuropsychological evaluation? Which of the following tests do you typically review with your client prior to neuropsychological testing? 77 MMPI-2** Rey 15-item Memory Test** 2 27 Portland Digit Recognition Test** 6 24 Dot Counting Test** 4 20 Hiscock Forced Choice Test** 2 20 Warrington Recognition Memory Test 6 In what percentage of your suspected brain injury (damage) cases does an attorney inform you of what findings would most benefit his/her client, or suggest what your findings should be?** In what percentage of your cases involving known or suspected brain damage do you inform a potential neuropsychological expert what findings would most benefit your client, or suggest what his/her findings should be?** 53 None ±25% ±50% ±75% ±100% 6 In what percentage of your suspected brain injury (damage) cases are you informed by an attorney of areas that he/she does not want you to investigate? * 88 None ±25% ±50% ±75% ±100% 2 * p <.05; ** p <.01. S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271± In what percentage of your cases involving known or suspected brain damage do you inform your neuropsychological consultant/ expert of areas that you do not want him/her to investigate? * 2.7. Use of technicians The use of trained nondoctoral technicians to administer tests and collect data is a common and widely accepted practice in clinical neuropsychology. Fifty-nine percent of neuropsychologists typically use a psychometrician, technician, or other type of assistant to collect test
12 282 S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271±291 data (Sweet et al., 1996). The Ethics Code (American Psychological Association, 1992), the Division 40 Task Force Guidelines (Division 40 Task Force on Education, Accreditation, and Credentialing, 1989), and the National Academy of Neuropsychology (1999a) endorse such a practice, provided that the supervising psychologist monitors and maintains a high level of quality assurance. The experience of neuropsychologists in a forensic setting is consistent with this typical clinical practice (see Table 3). The majority (85%) of neuropsychologists report that they are never told by the attorneys that retain them that they must administer the tests themselves. However, attorneys and neuropsychologists differ as to the reported proportion of cases in which lawyers demand that the testing be done by the expert, c 2 (1, 117) = 30.27, p <.001. More than one third (37%) of attorneys report that they always or almost always insist that the experts administer the tests without the aid of a technician. This discrepancy may represent a lack of overt communication between attorneys and experts on this subject. Attorneys may not be aware of the standard in clinical practice and may believe that their retention of an expert contains an implied request that the testing be carried out without the use of an assistant. Neuropsychologists, on the other hand, may make the opposite assumption. They may believe that because the use of technicians is so widely accepted in clinical practice, the use of an assistant is acceptable in a forensic case Billing practices Attorneys and forensic neuropsychologists utilize various billing arrangements. According to the data contained in Table 4, the most common practice, according to attorneys (62%) and neuropsychologists (61%), is to periodically bill for services. This is consistent with the pattern previously reported in general clinical practice, where 54% of neuropsychologists in a primary employment setting and 73% in private practice utilize an hourly billing procedure for assessment (Putnam & DeLuca, 1990). The majority (60%) of neuropsychologists have also entered into retainer agreements with attorneys, wherein they receive a lump sum at the time they are retained, against which fees are then billed. Only 38% of attorneys, however, acknowledge ever entering into such an arrangement. This discrepancy, c 2 (1, 117) = 4.546, p <.05, may represent a lack of desire on the part of attorneys to publicly acknowledge their willingness to pay retainers, which require them to pay funds out-of-pocket before the case is resolved and a recovery obtained. Far fewer cases involve the use of a letter of protection or a lien. These procedures involve an agreement that the expert will be paid from the plaintiff's financial recovery at the conclusion of the case. Although there is some incentive for attorneys to utilize such financial arrangements, they are not favored by experts. In addition to requiring an expert to wait months or years for payment, such arrangements create an atmosphere ripe for the emergence of partiality. When the neuropsychologist's fee is related to the attorney's success in proving the case, the stage is set for potential bias (van Gorp & McMullen, 1997). By making receipt of payment contingent upon the plaintiff's success in the litigation, the incentive to make findings that will help maximize recovery is created and ultimately reinforced. van Gorp and McMullen (1997) suggested that the agreement contain language providing that the expert will be paid regardless of whether the retaining party
13 receives compensation for his injuries as a solution to this problem. Even in the presence of such language, however, in cases where the plaintiff loses or recovers less than expected, attorneys often try to negotiate a reduction of expert fees in order to minimize litigation costs that must be paid by the plaintiff. The larger the recovery, the more money the plaintiff will receive, and the less need there is to reduce expert fees. Thus, the incentive to make findings that are helpful to the plaintiff's case still exists. Many attorneys recognize that a lien or letter of protection arrangement can raise a question of an expert's bias in the mind of a jury. This is true even if the parties have agreed that the expert will be paid regardless of the outcome of the case. As a result, these financial arrangements are less popular than periodic billing. Other alternatives utilized by neuropsychologists and attorneys include billing the plaintiff's insurance carrier and billing in one lump sum after services are rendered Fees S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271± Table 4 presents information concerning the typical fees charged for forensic assessment and testimony. Neuropsychologists report that their hourly fees for forensic neuropsychological assessment services vary from less than $100 (3%) to more than $200 (14%). More than half (61%) of the neuropsychologists bill from $101 to $175 per hour. Attorneys, however, report that they are billed significantly more than neuropsychologists contend, c 2 (1, 117) = 13.32, p <.05. Attorneys indicate that they are never billed less than $100 per hour and that their modal bill (35%) is greater than $200 per hour. Significantly more attorneys than neuropsychologists report assessment billings in excess of $200 per hour, z(1, 117) = 2.65, p <.01. This discrepancy may reflect a lack of distinction between billings for assessment and testimony services by the attorneys. The majority of both attorneys (61%) and neuropsychologists (71%) indicated that bills in excess of $200 per hour are typical for time spent testifying at deposition or trial. Ten years ago, the billings of neuropsychologists for legal activities (e.g., consultation, deposition) averaged approximately $150 per hour (Putnam & DeLuca, 1990). It appears that over the past decade the hourly rates for forensic neuropsychological activity have increased. One respondent suggested that parity exists for expert testimony fees rendered by neuropsychologists and physicians, who average $280 per hour for this service. Not all neuropsychologists bill on an hourly basis for forensic work. Eight percent of neuropsychologists and 10% of attorneys report that flat fee billing for assessment is the norm, with fees ranging from $1000 to $2000. Flat fees charged for testimony ranged from $750 to $10,000. The overwhelming majority of both attorneys (92%) and neuropsychologists (86%) reported that all or almost all of fees billed by the experts are paid Attorney influence on evaluation In an insightful article, Lees-Haley (1997) warned of the influence that attorneys have on the neuropsychological data gathered in a forensic examination and, by inference, the conclusions drawn therefrom. Such influence may be exerted by various means. Table 5 presents a variety of information that bears upon this issue.
14 284 S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271±291 As discussed above, attorneys view preparing their clients for forensic examinations as part of their responsibility. By advising their clients about the nature of the tests they will take and how to respond in a manner that will most benefit their cases, attorneys can confound the data and raise questions about the validity of the results. The present study revealed that most attorneys (75%) spend some time (modally 15 to 60 minutes) preparing their clients for forensic neuropsychological examinations. The topic most commonly covered in preparation for neuropsychological evaluations is the content of neuropsychological tests. Forty-four percent of attorneys report that in the majority of their cases they request disclosure of the specific neuropsychological tests that will be administered to their clients, and 41% reportedly receive this information in most of their cases. In contrast, neuropsychologists indicate that this practice is far less common, c 2 (1, 114) = 16.11, p <.003. Although most neuropsychologists acknowledge that, on occasion, they provide attorneys with specific information about the tests that will be administered, only 17% report complying with this request in the majority of their forensic cases. Even if attorneys are not able to obtain the names of tests that will be administered, a list of the most popular tests used in forensic neuropsychological evaluations is readily available (Lees-Haley, Smith, Williams, & Dunn, 1996). Thus, many plaintiffs will have some knowledge of the tasks they will be asked to perform and the questions to which they will be asked to respond prior to the examination. Although only 8% of attorneys appear to specifically instruct their clients how to respond to neuropsychological tests, advance knowledge of test content may be sufficient to allow the plaintiff to respond in a manner that does not reflect his or her current level of cognitive functioning and thus alter the expert's conclusions. Nor can neuropsychologists necessarily rely on techniques developed to detect exaggeration of symptoms and poor motivation. The detection of malingering is another topic that attorneys commonly review with their personal injury clients. Test selection may help the forensic neuropsychologist to avoid using malingering tests that have been reviewed with the examinee. The MMPI-2 (Hathaway & Mckinley, 1989), typically administered by a majority of neuropsychologists, is the most frequently administered of the measures commonly used to detect malingering. However, 29% of attorneys routinely review this test with their clients in preparation for a neuropsychological examination. Thus, the likelihood that a given examinee will have been educated about this test is good. Other tests commonly administered to detect malingering are infrequently discussed between the attorney and client. Results of the present survey indicate that the Portland Digit Recognition Test is typically administered by 27% of neuropsychologists but only 6% of attorneys routinely inform their clients about this test, c 2 (1, 118) = 35.50, p <.001. In addition, the Rey 15-Item Test is given by 56% of neuropsychologists, but only 2% of attorneys inform plaintiffs of this test, c 2 (1, 118) = 39.04, p <.001. Similar results are observed with the Hiscock Forced Choice Test and the Dot Counting Test. By choosing one of the tests less commonly reviewed by attorneys and clients, the expert may be less likely to encounter a patient who has been taught how to respond in a way that will avoid detection. It must be noted, however, that each of these tests utilizes a similar paradigm for the detection of malingering; that is, simple tasks that even individuals with moderate brain damage can perform successfully. Educating a client about this technique may be sufficient
15 to permit the plaintiff to recognize and avoid detection on tests aimed at uncovering less than optimal effort. Other topics reviewed with clients in preparation for neuropsychological evaluation include the symptoms of traumatic brain injury and postconcussion syndrome. Ten percent of attorneys inform their clients of what information they should tell the examiner during the evaluation and 12% tell their clients what information they should not divulge. There is ample anecdotal evidence of attorneys teaching their clients how to act and what to say in order to improve their cases and increase their damages (Lees-Haley, 1997; Rosen, 1995). Thus, it comes as no surprise that a substantial number of attorneys inform their clients about the physical and emotional sequelae of brain injury and coach them about how to respond to questioning during the interview process. This may result in plaintiffs successfully feigning symptoms of brain injury. The data derived in the present study confirms the observations of Lees-Haley (1997) and others that attorneys prepare their clients for forensic evaluations and cover topics that may have a direct influence on the data obtained and, ultimately the opinions formed. Attorneys can influence the findings of their experts by more patent means as well. The role of the plaintiff's or defense attorney is to assemble the best case possible for his client, one that supports or undermines a causal relationship between the incident that is at the heart of the litigation and the plaintiff's injuries. Simultaneously, the more significant the plaintiff's injuries, the greater the monetary damages to which he or she may be entitled; the less serious the injuries, the smaller the recovery. van Gorp and McMullen (1997) recognized that toward the goal of presenting the strongest arguments available, both plaintiffs' and defense attorneys may use a number of subtle or overt techniques to pressure an expert to form opinions and express findings in a light that will be most beneficial to the retaining party. One means of attempting to influence a neuropsychologist's conclusions is to inform the expert of what findings would most benefit the retained party or, more blatantly, to suggest to the expert what his/her findings should be (Lees-Haley, 1997). Attorneys and neuropsychologists disagree as to how often this type of coaching occurs, c 2 (1, 117) = 24.67, p <.001. Only 12% of attorneys admit that they ever engage in this practice, with the remaining respondents (87%) reporting that they never do so. In contrast, almost half (47%) of responding neuropsychologists indicated that this practice does occur. Another means of influencing a forensic neuropsychologist's findings is to inform the expert of certain areas potentially damaging to the retaining party's case that should not be investigated as part of the evaluation (Lees-Haley, 1997). Some examples might include a premorbid history of neurologic disorder or the existence of a learning disability. Both groups are in agreement that this more overt method of influence is uncommon. Ninety percent of attorneys and 88% of neuropsychologists report that this practice never takes place Providing raw data S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271± The question of whether neuropsychologists should release raw data has been debated in the literature for several years. One school of thought recommends that all raw data obtained in a neuropsychological evaluation be included in the report as a routine practice
16 286 S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271±291 (Freides, 1993; Matarazzo, 1995). Proponents of this position contend that by providing all raw data, including that which is not supportive of the expert's conclusions, the integrity of those conclusions is maintained. It is argued that this practice reduces the need for protracted discovery in forensic cases and minimizes deposition time and litigation expense (Freides, 1993). It also allows another neuropsychologist to draw his or her own conclusions based upon the data obtained rather than having to blindly accept those contained in the report. Disclosure of raw data also permits other neuropsychologists to readily make longitudinal comparisons. Those opposed to the practice of divulging raw data contend that providing such information to persons who are not qualified to use it (i.e., attorneys) constitutes a violation of Standards 2.02b and 2.10 of the APA ethics code (American Psychological Association, 1992; Binder & Thompson, 1994; McSweeny, 1999; Naugle & McSweeny, 1995). These standards require that psychologists take reasonable steps to prevent the misuse of information, including refraining from providing raw data to those who are not qualified to use it, and to maintain the integrity and security of tests in a manner that is consistent with the law and professional ethics. If raw data, including test protocols and responses, are provided to opposing counsel, such information may be misused for adversarial purposes. In fact, tactics such as the use of individual test responses during cross-examination are suggested to attorneys as proper and effective ways to discredit a party or expert (Ziskin & Faust, 1988). In a legal case, raw data is routinely requested by the opposition via a subpoena for records. Those authors who oppose routine disclosure of raw data in all neuropsychological reports recognize that a subpoena in a pending lawsuit cannot be ignored. Rather, they recommend that when a subpoena is received, the neuropsychologist inform the requesting attorney of the conflict between the subpoena and the APA code of ethics. If the attorney will not agree to withdraw the subpoena, it is suggested that the neuropsychologist agree to provide the information directly to a qualified licensed neuropsychologist of the attorney's choosing, assuming that the examinee has signed a release (Binder & Thompson, 1994; McSweeny, 1999). Florida recently codified this recommendation when it enacted legislation prohibiting psychologists from releasing raw test data, including protocols, test questions, and written answer sheets, to anyone other than another licensed psychologist, or pursuant to court order (Florida Administrative Code, 1997). Table 6 indicates the experiences of neuropsychologists and attorneys concerning the issue of raw data in personal injury cases. A majority of both attorneys (67%) and neuropsychologists (52%) report that in more than half of their cases involving claims of brain injury, a request is made for the production of the raw data obtained in the opposition's forensic examination of the plaintiff. Although attorneys are claiming that they make such requests more often than neuropsychologists claim to receive them, c 2 (1, 115) = 32.82, p <.001, both groups acknowledge that such requests are relatively common. Likewise, attorneys and neuropsychologists differ significantly in their opinion of how often raw data is actually supplied to the opposition, c 2 (1, 114) = 13.51, p <.01. The modal attorney response indicates that almost half (44%) of attorneys receive raw data in 75% to 100% of their brain injury cases, whereas the modal neuropsychologist response (32%) indicates that they provide raw data to the opposition in one fourth or less of their forensic cases. The discrepancies that exist
17 Table 6 Neuropsychologist Survey % Response Category Attorney Survey % In what percentage of your suspected brain injury (damage) cases are you requested to provide the opposition with the raw data obtained in your examination?** 4 None ±25% ±50% ±75% ±100% 65 In what percentage of your suspected brain injury (damage) cases do you actually provide the opposition with the raw data obtained in your examination?** 12 None ±25% ±50% ±75% ±100% 44 In what percentage of your cases involving known or suspected brain damage does an attorney or his/her representative request to sit in on the neuropsychological testing?** In what percentage of your cases involving known or suspected brain damage do you request the opposition's neuropsychologist's raw data obtained in his/her examination?** In what percentage of your cases involving known or suspected brain damage do you receive the opposition's neuropsychologist's raw data obtained in his/her examination?** In what percentage of your cases involving known or suspected brain damage do you request to sit in on neuropsychological testing by the opposition's consultant/expert?** 53 None ±25% ±50% ±75% ±100% 10 In what percentage of your cases involving known or suspected brain damage does an attorney or his/her representative actually sit in on the neuropsychological testing? * p <.05; ** p <.01. S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271± None ±25% ±50% ±75% ±100% 8 In what percentage of your cases involving known or suspected brain damage do you actually sit in on neuropsychological testing by the opposition's consultant/expert? between the two groups may be the result of the attorneys trying to appear as if they are zealously representing their clients by regularly demanding the production of raw data and/or neuropsychologists trying to look as if they are behaving ethically by successfully opposing such requests.
18 288 S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271± Presence of third-party observers Over the past several years, the right of attorneys (or their representatives) to attend and observe the neuropsychological examinations of their clients has been the source of much discussion in the literature, the courtroom, and in state legislatures. Plaintiffs' attorneys present several rationales in support of their requests to observe testing. They contend that their presence is required to ensure that the defense examiner does not question the plaintiff concerning inappropriate matters (e.g., liability). They further argue that the presence of a third-party observer ensures proper administration of testing procedures and permits them to verify that the bases for the expert's conclusions are accurate (Fisher, 1999). Another, often unstated reason that attorneys want to observe the examinations of their clients is that they may obtain information about the way that it was conducted that may be useful in discrediting the expert during cross-examination (McCaffrey, Fisher, Gold, & Lynch, 1996). Neuropsychologists oppose the presence of third-party observers for a number of reasons (McSweeny et al., 1998). Neuropsychological tests were typically standardized in the presence of only two people, the examiner and the subject. The presence of a third party compromises standardized administration of the tests and calls into question the validity of the results and the conclusions drawn therefrom. (American Psychological Association, 1985; McCaffrey, et al., 1996). In addition, neuropsychologists have an ethical obligation to ``maintain the integrity and security of tests and other assessment techniques'' (American Psychological Association, 1992, Standard 2.10) as well as to take steps to prevent others' misuse of information derived therefrom (American Psychological Association, 1992, Standard 2.02). Once an attorney has observed the testing materials and watched the tests being administered there is nothing to stop him or her from using that information to prepare other clients for similar examinations. Finally, social facilitation theory holds that the presence of a third party in the testing environment alters performance on cognitive tests. (Binder & Johnson-Greene, 1995; McCaffrey, et al., 1996). More specifically, the examinee will perform better than usual on simple or well-learned tasks and worse on complex or novel tasks when a third party is present. Support for this theory comes from Binder and Johnson-Greene (1995) who reported a case where performance on the Portland Digit Recognition Test was significantly worse in the presence of a third-party observer. This phenomenon may result in a misrepresentative sample of the examinee's current level of functioning and, subsequently, improper conclusions. Legislatures have begun to address this problem. For example, Arizona recently enacted legislation that gives the party to be examined the right to have a representative present ``unless the presence of the third party may adversely affect the outcome of the examination'' (Arizona Rules of Civil Procedure, Rule 35a). Despite legislative attempts to resolve this issue, however, individual disputes over the presence of third-party observers will continue to be decided by the courts. Some jurisdictions begin with the presumption that third-party observation should be permitted, some make the opposite assumption. However, the basic rule under which most courts operate is that if the presence of a third party would interfere with the expert's ability to conduct a meaningful evaluation, the observation will not be permitted (McCaffrey et al., 1996).
19 S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271± Virtually all courts review requests to permit or exclude an observer on a case-by-case basis, balancing the party's desire for a fair examination process against the confounding effect that the presence of a third party may have on the process (McCaffrey et al., 1996). It should therefore come as no surprise that courts have handed down decisions that have both permitted and prohibited the presence of third-party observers. In Ragge v. MCA/Universal Studios (1995), a federal appellate court ruled that the plaintiff was not entitled to have a third-party observer present at the neuropsychological examination. The court stated that ``third party observers may... contaminate a mental examination.'' In Medrano v. BEC Construction (1991), a Florida appellate court excluded a third-party observer based on the objections of the neuropsychologist. Other courts have permitted the presence of third-party observers. In Parsons v. Hytech Tool and Die, Inc., a New York appellate court ruled that the trial court had improperly required the plaintiff to undergo a neuropsychological examination without having counsel present. One factor that courts may look to in determining whether to permit or exclude the presence of a third party is the standard in the profession. The official position of the NAN (National Academy of Neuropsychology, 1999b) is that neuropsychologists should make every effort to exclude third-party observers from the evaluation. As can be seen from the data contained in Table 6, more than half (53%) of neuropsychologists reported that attorneys never ask to sit in on neuropsychological testing, and significantly more (88%) reported that they have never in fact had an attorney sit in on a forensic examination, z(1, 66) = 4.81, p <.001. This suggests that neuropsychologists are successfully refusing to permit third parties to contaminate their evaluations. Attorneys, on the other hand, overwhelmingly indicated that they never request to sit in on (73%) or actually observe (75%) their clients' examinations. These results are consistent with a recent survey of NAN members where more than half of the respondents indicated that requests from attorneys to observe testing were ``never'' made and 43% reported that such requests were only made ``sometimes.'' Additionally, more than 80% indicated that they never permitted a third-party observer (McCaffrey, Dilulas, & Gold, 1999). Based on the available data, it appears that the prevailing legal and neuropsychological standards are not to allow attorneys to observe the testing of their clients. 3. Conclusion Surveys such as the current one represent a step in the process of establishing standards for the practice of forensic neuropsychology. By examining information about the practices, beliefs, and experiences of neuropsychologists who are retained in personal injury cases, and the attorneys who retain them, we can begin to discern the patterns that emerge. In so doing, we can begin to better define the subspecialty of forensic neuropsychology. This information will not only allow neuropsychologists to determine if their practices are in keeping with those of their colleagues, but will also give attorneys and the courts a basis for determining what practices constitute standards for the profession. Courts may give considerable weight to established professional standards when contemplating what practices will be permitted in the context of litigation.
20 290 S.M. Essig et al. / Archives of Clinical Neuropsychology 16 (2001) 271±291 More information about the specifics of forensic neuropsychology practice will have to be gathered to fully define the field. Given the response rates in the current survey, these data may not necessarily be representative of the field, and may not reflect the actual percentages of attorneys or neuropsychologists who engage in each activity. The current survey is also limited to the practices of plaintiffs' attorneys. The strategies and practices of defense counsel are likely to differ significantly. Subsequent surveys may also be able to look at longitudinal trends and allow us to chart change and growth. In the meantime, this survey establishes a baseline for issues relevant to forensic neuropsychologists involved in personal injury lawsuits. References Adams, K. M. (1997). Comment on ethical consideration in forensic neuropsychological consultation. The Clinical Neuropsychologist, 11 (3), 294 ± 295. American Psychological Association. (1985). Standards for educational and psychological testing. Washington, DC: Author. American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1597 ± Arizona Rules of Civil Procedure, Rule 35a, (amended 1997). Bigler, E. D. (1986). Forensic issues in neuropsychology. In: D. Wedding, A. M. Jr. Horton, & J. Webster (Eds.), The neuropsychology handbook: Behavioral and clinical perspectives ( pp. 526 ± 547). New York: Springer. Binder, L. M., & Johnson-Greene, D. (1995). Observer effects on neuropsychological performance: A case report. The Clinical Neuropsychologist, 9, 74 ± 78. Binder, L. M., & Thompson, L. L. (1994). The ethics code and neuropsychological assessment practices. Archives of Clinical Neuropsychology, 10 (1), 27 ±46. Committee on Ethical Guidelines for Forensic Psychologists. (1991). Specialty Guidelines for forensic psychologists. American Psychology-Law Society News, 11, 8±11. Division 40 Task Force on Education, Accreditation, and Credentialing. (1989). Guidelines regarding the use of nondoctoral personnel in clinical neuropsychological assessment. The Clinical Neuropsychologist, 3 (1), 23 ±24. Fisher, J. M. (1999). Presence of third parties during evaluations: who is evaluating whom? Journal of International Neuropsychological Society, 5, 158 ±159. Florida Administrative Code, Rule 64B ,, (amended 1997). Freides, D. (1993). Proposed standard of professional practice: Neuropsychological reports display all quantitative data. The Clinical Neuropsychologist, 7, 234 ±235. Guilmette, T., Faust, D., Hart, K., & Arkes, H. (1990). A national survey of psychologists who offer neuropsychological services. Archives of Clinical Neuropsychology, 5, 373 ± 392. Guilmette, T. J., & Hagan, L. D. (1997). Ethical considerations in forensic neuropsychological consultation. The Clinical Neuropsychologist, 11 (3), 287 ± 290. Hathaway, S. R., & McKinley, J. C. (1989). Minnesota multiphasic personality inventory-2. Minneapolis, MN: University of Minnesota Press. Lees-Haley, P. R. (1997). Attorneys influence expert evidence in forensic psychological and neuropsychological cases. Assessment, 4 (4), 321±324. Lees-Haley, P. R., Smith, H. H., Williams, C. W., & Dunn, J. T. (1996). Forensic neuropsychological test usage An empirical survey. Archives of Clinical Neuropsychology, 11 (1), 45 ±51. Matarazzo, R. G. (1995). Psychological report standards in neuropsychology. The Clinical Neuropsychologist, 9 (3), 249±250. McCaffrey, R. J., Dilulas, E., & Gold, B. A. (1999). NAN membership survey on third party observers during neuropsychological testing. Archives of Clinical Neuropsychology 14 (1), 99± 100 [Abstract].
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