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Forensic Assessment* AAPL Practice Guideline for the Forensic Assessment* 1. Statement of Intent standards in the relevant jurisdiction and to complete This document is intended as a review of legal and the evaluation at hand. psychiatric factors to offer practical guidance in the 2. Introduction performance of forensic evaluations. It is a guideline developed through the participation of forensic psy- Forensic assessment is one of the basic building chiatrists who routinely conduct a variety of forensic blocks that form the foundation of the practice of assessments and who have expertise in conducting psychiatry and the law, in addition to report-writing these evaluations in a variety of practice settings. The and giving testimony in court. Similar to any foun- developmental process incorporated a thorough re- dation, the integrity of the process depends on how view that integrated feedback and revisions into the well each brick is laid upon the other. In psychiatry final draft. The final version was reviewed and ap- and the law, the quality of the final product depends proved by the Council of the American Academy of on the quality of the assessment, regardless of the Psychiatry and the Law on October 26, 2014. Thus, practitioner’s report-writing skills. the Guideline reflects a consensus among members Forensic psychiatrists are often called on to act as and experts about the principles and practices appli- consultants to the courts, lawyers, regulatory agen- cable to the conduct of forensic assessments. How- cies, or other third parties. The referring agent has a ever, it should not be construed as dictating the stan- specific psycholegal question that requires an expert dard for forensic evaluations. While it is intended to opinion, generally to advance a legal requirement. To inform practice, it does not present all currently ac- respond to that question, forensic psychiatrists gen- ceptable ways of performing forensic evaluations, erally conduct an assessment. and following its recommendations does not lead to This Guideline is the product of a consensus based a guaranteed outcome. Differing facts, clinical fac- on the available literature and knowledge in a broad tors, relevant statutes, administrative and case law, range of forensic assessments. The field of psychiatry and the psychiatrist’s judgment determine how to and the law, along with the rest of medicine, is in- proceed in any individual forensic assessment. creasingly using an evidence-based approach.1 The Guideline is for psychiatrists and other clini- Evidence-based medicine is defined by Sackett et al. cians working in a forensic role who conduct evalu- as “the conscientious, explicit, and judicious use of ations and provide opinions in legal and regulatory current best evidence in making decisions about the matters. Any clinician who agrees to perform forensic care of individuals” (Ref. 2, p 2). Sackett and collab- assessments in any domain is expected to have the orators made the point that all clinical assessments qualifications necessary to meet the professional are, to a certain extent, individualized, based on the unique factors of each case. * The AAPL Task Force on a Forensic Assessment Guideline consisted of: Graham D. Glancy, MBChB, FRCP(C) (Chair); Peter Ash, MD; Erica PJ Bath, MD; Alec Buchanan, PhD, MD; Paul Fedoroff, MD; Richard L. Summary 2 Objectives of the Guideline Frierson, MD; Victoria L. Harris, MD; Susan J. Hatters Friedman, MD; ● To provide practical guidance for the performance of forensic Mark J. Hauser, MD; James Knoll, MD; Mike Norko, MD; Debra psychiatric assessments. Pinals, MD; Marilyn Price, MD, CM; Patricia Recupero, MD, JD; ● Charles L. Scott, MD; and Howard V. Zonana, MD. To provide information for clinicians and trainees. ● To improve resources for teaching and training. The following members of the Task Force composed a Steering Com- ● To create a template to improve consistency of assessments. mittee for development of the Guideline: Drs. Glancy, Buchanan, ● Norko, Pinals, and Zonana. To help identify future research directions. Acknowledgments: The authors thank the following for their assis- tance and advice in preparing this Guideline: Jacquelyn Coleman, Elizabeth Ferris, Stefan Treffers, Dylan Glancy, and Kirsten Donovan. The recommendations in the Guideline do not set Disclosures of financial or other potential conflicts of interest: None. a standard of practice and are not a substitute for Volume 43, Number 2, 2015 Supplement S3 Practice Guideline: The Forensic Assessment knowledge-seeking, experience, or training among The authors also drew attention to aspects of the practitioners. It is the individual responsibility of interpersonal relationships between parties, which each clinician to make appropriate decisions and may be significant. Kenneth Appelbaum,18 com- judgments that are based on the circumstances of menting on the article, cautioned mental health ex- each case. It is also recognized that policies and pro- perts to ensure the accuracy and veracity of their cedures change with the passage of time and from assessments. Mossman and colleagues19 attempted one setting to another. to measure the accuracy of assessments in a quanti- The writing of forensic psychiatric reports is be- tative manner. They compared multiple ratings per yond the scope of this Guideline. Report-writing is a evaluee and concluded that evaluators are very accu- vast topic in itself that has been covered in several rate. However, recent research has examined the other publications.3–9 quality of forensic reports and rated them as medio- The text provides an overview that is applicable to cre, noting that there was fair agreement between the various types of assessments: for criminal cases (com- evaluators’ conclusions and court findings.20 petence to stand trial and culpability); for risk or Wettstein struck an optimistic note, stating, “in dangerousness (of violence, sexual violence, or crim- the long-term future, we expect that quality improve- inal recidivism); and for civil proceedings (disability, ment at a more sophisticated level will transcend any- fitness for duty, testamentary capacity, guardianship, thing discussed heretofore” (Ref. 11, p 172). This child custody, malpractice, and civil commitment). view built on his previous work with Simon,21 in which It is intended to complement, not replace, existing they described general guidelines, shaped by the ethics practice guidelines published by the American Acad- principles of general and forensic psychiatry, as well as emy of Psychiatry and the Law (AAPL) that focus in case law and statutes. Such guidance was intended to more depth on particular areas of evaluation. help practitioners maintain the integrity of forensic psy- chiatric consultation and examination. 3. Quality Improvement in Forensic Practice 4. Ethics Foundation Several studies and articles have assessed the qual- The American Medical Association’s Code of Eth- ity of forensic psychology and psychiatry prac- ics states that “physicians have an obligation to assist tice.10–16 A review of the literature concluded that in the administration of justice.”22 Forensic psychi- the level of practice falls short of professional aspira- atrists are physicians who are trained to diagnose and tions for the field, although there have been incre- treat patients within the ethics principles embedded mental improvements during the 1990s.12 No stud- in the doctor–patient relationship. However, as Paul ies to date have observed forensic psychiatric Appelbaum23 has stated, the role of the forensic psy- interviews, although some, mainly in the field of psy- chiatrist in assisting court and other agents some- chology and the law, have looked at the content of times demands that the psychiatrist step outside of forensic reports. In particular, these have examined the doctor–patient relationship. The psychiatrist is the psychological tests used in criminal forensic eval- primarily serving the interests or needs of the court, uations,13 emotional injury cases,14 child custody as- the retaining attorney, or another third party, but sessments,17 and neuropsychological assessments.16 their interests may or may not serve those of the The results demonstrated significant inconsistencies evaluee.24 Therefore, in this context, the forensic and variable standards. One study,15 for instance, noted practitioner strives for objectivity in seeking to an- poor agreement on such basic points as the presence of swer a psycholegal question. a mental disorder and the psychiatric diagnoses submit- The ethical practice of forensic psychiatry has ted by opposing experts. Given these findings, it is im- therefore been a subject of significant discussion in portant to enhance the potential for consistent practices the psychiatric literature, with competing, comple- that can inform forensic assessment. mentary, and sometimes conflicting models of ethi- In 2010, Griffith and colleagues4 conceptualized cal practice offered.23,25–36 Stone37 has stated that the forensic psychiatric report as a performative nar- the role of the forensic psychiatrist is so framed that rative. Although their article concentrated on the the formulation of ethics guidelines is impossible. written report, it suggested that psychiatrists “lis- This view was countered by Paul Appelbaum,23 who tened hard to the voices they heard” (Ref. 4, p 42). attested that the primary value of forensic psychiatry S4 The Journal of the American Academy of Psychiatry and the Law Practice Guideline: The Forensic Assessment
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