Transcript La_Paloma_2015 - Dr. Thomas Brunner

Advanced Family Law Conference, Psychologist Panel,
Tucson, Arizona, 2015
Forensic Therapy 101:
Evidence-Based Resources,
Therapy Recommendations,
& Best Practices (2015)
Thomas M. Brunner, PhD
Forensic, Clinical, and Consulting Psychology
www.doctorbrunner.com
Dedication
Four Goals
 Best practices update: psychotherapy (AAFC term)
 Tips for not fumbling the therapy ball
 Make an immediate impact with one worrisome case
 Identify a way pointer for how we evolve the system
Who does Forensic Therapy?
 A diverse mixture of professionals
 Dramatically varying levels of training
 Negatively defined (i.e., context dependent)
 Professional serving a client in the legal system
American Psychological Association Forensic
Guidelines (2011): What is forensic psychology?
For the purposes of these Guidelines, forensic
psychology refers to professional practice by any
psychologist working within any sub-discipline of
psychology (e.g., clinical, developmental, social,
cognitive) when applying the scientific, technical, or
specialized knowledge of psychology to the law to
assist in addressing legal, contractual, and
administrative matters.
AAFC-Guidelines for CourtInvolved Therapy (2010)
 Distinctions - those conducting “psychotherapy”:
 Community Th* (CL** not involved in legal system)
 Court Involved Th (CL involved in legal system at some point)
 Court Appointed Th (Court designates which therapist)
 Court Ordered Th (Treatment ordered, no therapist named)
*denotes “therapy”
**denotes “client”
Behavioral health: A young science
 No basic unit of analysis yet (Focus: alleviate
distress)
 E.g., Biology=cell/Physics=atom
 No unified model - human functioning (vs Western
medicine)
 Cultish-quality (“True Believers” vs. social scientists)
 Schools of thoughts (e.g., psychoanalysis) morphing
into systematic taxonomy (e.g., behavioral analysis)
Who does therapy well? Psychologist perspective –
Heed the “Iron Triangle”
 Use empirically supported treatments (EST’s) or principles
 Applied via Systematic Treatment Selection (STS)
 Personality driven: (def: individual’s collection of states and traits)
-E.g., ADHD Experienced, Expressed, and Controlled uniquely
Truth about Effectiveness
 Several professional bodies (e.g., LCSW, Counselors,
Psychologists, Psychiatrists)
 Who has the therapy “black belt”?
 EST-based or draw from principles or clear rationale
 STS/Personality tailored
 Measured outcomes (using “Psychological Vital Signs”)
 Refer to social science literature for treatment rationale
What are the “gold standard” references?
 Empirically Supported Treatments (EST’s)
 Adults:
 https://www.div12.org/psychological-treatments/
 -Search by disorder or by treatment (over 60 techniques)
 Minors:
 http://effectivechildtherapy.org/content/specific-treatments
 http://effectivechildtherapy.org/content/about-child-adolescent-
symptoms
Attention Deficit Hyperactivity Disorder
Bipolar Disorder
Borderline Personality Disorder
Child and Adolescent Disorders
Chronic or Persistent Pain
Depression
Eating Disorders and Obesity
Generalized Anxiety Disorder
Insomnia
Mixed Anxiety
Obsessive-Compulsive Disorder
Panic Disorder
Posttraumatic Stress Disorder
Schizophrenia and Other Severe Mental Illnesses
Social Phobia and Public Speaking Anxiety
Specific Phobias (e.g., animals, heights, blood, needles, dental)
Substance and Alcohol Use Disorders
Trend: Organizations needing more
advanced mental health management
to minimize risk, decrease
recidivism, and protect
minors/victims
Like schools, the courts are
increasingly “mental health centers”
Examples of radioactive problems requiring comprehensive
treatment recommendations to contain pathology
+ protect child and victims
 Borderline Personality Disorder
 Substance abuse
 Pathological lying
 Explosive Anger
 PTSD
 Coercive-controlling violence style (e.g., Beck)
 Entrenched Narcissism
The wisdom of (fictitious) Los Angeles attorney Mickey Haller:
“You know what my father said about innocent clients?... He said the
scariest client a lawyer will ever have is an innocent client. Because if
you f____ up and he goes to prison, it’ll scar you for life… He said there
is no in-between with an innocent client. No negotiation, no plea
bargain, no middle ground. There’s only one verdict. You have to put an
NG up on the scoreboard. There’s no other verdict but not guilty”
Levin (Haller’s assistant) nodded thoughtfully.
“The bottom line was my old man was a damn good lawyer and he
didn’t like having innocent clients,” I said. “I’m not sure I do, either”
--Michael Connelly, The Lincoln Lawyer (2005)
Poor assessment >therapy “handoffs” do not
adequately protect the “innocent” clients
 Ultimate focus: legal system categorization
(e.g., insight)

Critical psycholegal variables glossed over

Therapy structuring, particulars are afterthoughts
 Poor/Vague Psychological Assessment –

85% analysis, 10% integration in summary &

5% structuring treatment recommendations
 No statutory criteria or guidelines requiring specific
kinds of recommendations
AAFC-Guidelines for Court-Involved
Therapy (2010)
 Whether therapist “court appointed” or “court-ordered”…
 “…the Court may describe the expected treatment”
-P.2, AFCC, 2010
We must evolve to live up to Parens
Patriae
[Latin, Parent of the country.] A doctrine that
grants the inherent power and authority of the
state to protect persons who are legally unable
to act on their own behalf.
“Recommendation” Statute mirroring
specificity of best interests statute
(AZ 25-403)

The court shall, driven by best interests of minors and/or victims,
and aligned with AZ 25-403, outline an increasingly specific set
of treatment parameters, in proportion to the level of impairment
identified, regarding not just the type, frequency, and intensity of
treatment(s), but also - and based on reference to court ordered
psychological assessment data gathered:

--articulate areas of needed insight and what kind of data would
compellingly indicate client is taking appropriate responsibility
that would reasonable ensure safety of victims or family
members, and

--define likely empirically supported treatments/principles and
measurable criteria for defining successful treatment of
psychological variables critically bearing upon psycholegal issues.
Examples of how the forensic
therapy role is hampered…
 Much less defined
 Most vulnerable
 May be artificially time-limited
 Attorney defined/coerced/manipulated
 Psycholegal focus leads to hollow improvements
Ten Differences Between Therapeutic and Forensic Relationships*
The goal of the professional in each
relationship
Care Provision
Therapist attempts to benefit the
patient by working within the
therapeutic relationship
Forensic Evaluation
Evaluator advocates for the results and
implications of the evaluation for the benefit
of the court
Forensic Therapy
Improve psychological functioning especially related
to improving psycholegal variables
Whose client is patient/litigant?
The mental health practitioner
The attorney
The Attorney and Therapist
The relational privilege that governs
disclosure in each relationship
Therapist-patient privilege
Attorney-client and attorney work-product
privilege
Varies
The cognitive set and evaluative attitude
of each expert
Supportive, accepting, empathic
Neutral, objective, detached
Hybrid of both, but possibly because of care
provision align with client
Therapy techniques for treatment of the
impairment
Forensic evaluation techniques relevant to
the legal claim
Therapy techniques for treatment of the impairment
and psychological protocols
The nature of the hypothesis tested by
each expert
Diagnostic criteria for the purpose of
therapy
Psycholegal criteria for purpose of legal
adjudication
Hybrid of first 2 columns
The scrutiny applied to the information
utilized in the process and the role of
historical truth
Mostly based on information from the
person being treated with little scrutiny
of the information by the therapist
Litigant information supplemented with that
of collateral sources and scrutinized by the
evaluator and the court
Depends, can be affected by “demand
characteristics”
The amount and control of structure in
each relationship
Patient structured and relatively less
structured than forensic evaluation
Evaluator structured and relatively more
structured than therapy
Patient (and possibly attorney) Structured
The nature and degree of
“adversarialness” in each relationship
A helping relationship; rarely
adversarial
An evaluative relationship; frequently
adversarial
Potentially adversarial
(possibly toward evaluator)
The impact on each relationship of
critical judgment by the expert
The basis of the relationship is the
therapeutic alliance and critical
judgment is likely to impair that
alliance
The basis of the relationship is evaluative
and critical judgment is unlikely to cause
serious emotional harm
Need alliance and critical judgement and savviness
with psycholegal dynamics
How success is defined
Increased insight and behavioral
change
Identify psycholegal factors to legal status
Level of improvement in psycholegal status
The differing areas of competency of each
expert
*Adapted from Greenberg, Stuart A., Shuman, Daniel W., Irreconcilable Conflict Between Therapeutic and Forensic Roles, Professional Psychology: Research and Practice (1997) Vol. 28, No. 1, 50-57
Look, all we can do is review
diagnoses and make generic
recommendations …
 Selection of diagnosis as grouping variable lacks sensitivity to
demand characteristics of treatments (Beutler, 2000, 2005)
 Symptoms are targets, but should not be exclusive target, as the
effective mechanisms of change transcend diagnostic categories
 Wide variability in receptivity to treatment because…
 There are patient indicators not captured by diagnosis that can
serve as contraindicators for treatment

Dx alone not good distinguishers of appropriate treatment to use
Why need more than
diagnoses > EST’s?
Want development of intuitive judgement but within
optimally empirically grounded decisional structure that
uses existing research findings
to define both state and trait-like patient indicators
and contra indicators
for utilizing different psychotherapeutic strategies,
in the form of classes of interventions
Leave treatment details up to the
therapist?
 Complexity demands substantive frontloading beyond diagnosis
 Less structured, more chance therapy litigated away
 Minimizes therapist being tag-teamed > impotency
 More chance for assessment findings to fizzle

Substantive frontloading: more durable protection of innocent
 Attorneys/Court/Victims/client better defined success formula
 Ambiguity is exploited by perpetrator’s attorney
How to not fumble the therapy ball
 Judges:
 more specificity with Tx recommendations
 More accountability with Tx success criteria
E.g. measuring “insight”
 Psychologists:
 MUCH more “prescriptiveness” with Tx rec’s

Attorneys:
 More substantive discussions/framework for therapy
 Demand more specificity from evaluators
Your worrisome case
 What is something you can do to
….ensure the therapy ball not fumbled
…..assessment findings do not fizzle
…..push for more specificity from evaluator
……or more “ownership” by offender via clear therapy goals
So why is a successful handoff of the
therapy ball so important again?
Single greatest indicator of which children
will be resilient in face of
challenging situations:
Presence of a
Mentor
“Better to have died as a small
child than to fumble this football.”
--John Heisman