EDITOR'S NOTE: This article was commissioned by The Advocate to inform its readers of the standard of practice for social histories in capital cases where a defendant's life is at stake and where the constitutional focus is not only on the client's crime but also who the client is. It is likely that social histories of a lesser degree will increasingly be relevant in non-capital criminal cases where the mental state of the accused is informed by the context revealed by a social history.

This paper explores the features of social histories in forensic mental health practice. The title refers to social histories but in fact the better term is biopsychosocial evaluation since it is a more comprehensive concept. In forensic practice, particularly in capital cases, the social history becomes the organizing representation of clinical content and thus must capture biological, psychological, and social characteristics of the individual.

There are three mental health evaluations that have use in forensic environments: psychiatric evaluations, psychological assessments and biopsychosocial evaluations. Statutes and individual court practices influence which of these three is relevant in various proceedings. The psychiatric evaluation typically focuses on the diagnosis of mental disorder or mental state of a defendant. The psychological assessment uses various instruments to outline and define personality traits, emotional or psychological disorders and intellectual capacity. The biopsychosocial is the integrative assessment of an individual that brings medical, psychological, social, familial, educational, economic and cultural factors into a comprehensive evaluation of the person. It can either precede other more specific evaluations or it can serve as the summative assessment that blends findings from other reports. Where the psychiatric is performed only by psychiatrists and psychologicals by psychologists, the biopsychosocial is performed by clinical social workers, psychologists and other nonmedical mental health professionals. When correctly performed, the biopsychosocial evaluation summarizes all the significant factors in a defendant’s life and presents the most salient characteristics in comprehensible ways. This comprehensive quality accounts for the increasing importance of these evaluations in criminal proceedings - particularly for capital cases.

In clinical settings outside the forensic realm, the biopsychosocial evaluation summarizes the person’s development and current living situation so as to set the stage for treatment. In fact, the objectives and methods of the treatment plan should arise directly from the findings of the biopsychosocial assessment. In clinical situations, the biopsychosocial is but a tool to support the treatment process; its only readers should be other clinicians and its contents should be understood solely in the context of treatment processes. Non-clinical uses of clinical information, however, appear to be on the increase. Disability claims and insurance claims call for the release of medical records and numerous other legal and quasi-legal proceedings drag clinical records into their processes. Furthermore, clinicians from all mental health disciplines find themselves drawn into courtroom proceedings to render opinions about their clients based on what has been learned during treatment episodes. What one learns in the context of treatment is likely to be very different from what is learned in forensic processes. The translation from therapist-helper to courtroom player creates considerable ethical quandary for the conscientious clinician (Strasburger, Gutheil, & Brodsky, 1997). There is perhaps wisdom in keeping the two realms distinct rather than allowing them to be blended into one all-embracing role for the clinician.

The use of a clinical document for other than clinical purposes is generally a misuse of the information.

What is at issue here is not the use of mental health experts, but the proper way to go about using biopsychosocial information in forensic settings. The recommended way to do this is not to use existing evaluations which have been written out of context, but to conduct evaluations with the forensic situation clearly defined as the purpose and audience of its findings. Nonmedical mental health professionals might feel intimidated by psychiatric presence in criminal proceedings. This discussion of the ingredients of a biopsychosocial is intended to increase the level of professional competence and personal confidence in these evaluations. Thoroughness is the essential factor and the clinician who pays attention to detail will have no reason for anxiety about other professional opinions that vary from the biopsychosocial. Well-developed psychiatric and psychological opinions should cover much of the same ground as that covered by the biopsychosocial evaluation.

The term forensic is used throughout this paper as if it were a unitary notion. It is not; it covers a waterfront of legal and quasi-legal proceedings in criminal and civil areas. There are considerable differences in the form and content of forensic evaluations in these different environments. This discussion focuses on the criminal arena within which there are three distinctly different forensic perspectives that condition the nature and methods of the evaluation. This perspective arises out of the legal context of the assessment. The three contexts include defense, prosecution and friend of the court.

As the reader reviews the purposes of the forensic biopsychosocial below, attention should be paid to the legal context of the evaluation. For example, the defense posture generally calls for more attention to the individual and complicating features of a case - the mitigating and aggravating circumstances. A prosecution perspective, on the other hand, will bundle the pathological descriptors that convey the degree to which the defendant is different from "us", the jurors and officers of the court and how he is incapable of reform. The friend of the court position most nearly approximates traditional clinical perspectives in that it appears to be more "objective" (an illusion) by not taking an adversarial role as do the two others. The "friend", however, can be drawn into the adversarial process upon rendering an opinion. The "default" perspective used throughout this paper is the defense role, but the reader should be alert to the different possibilities as each topic area is covered.

The purpose of a forensic biopsychosocial is four-fold: 1) to present salient clinical features in a narrative context, 2) to present a plausible portrait of the person that invites empathy, 3) to offer a comprehensible context for the actions taken by the individual and 4) to assess the individual’s potential for change or rehabilitation.

1. The Narrative Context: In clinical settings, professional descriptions of a "client" are often collages of information about his or her key life events, symptoms, thought processes and qualities of emotion and mood. The professional understands the structure of the information and has little difficulty moving from one domain of information to another. There is a conceptual order to the clinical document that follows agreed upon formats for describing the client’s level of functioning. By contrast, there is merit to using a historical or narrative structure for presenting information in forensic evaluations so that jurors can begin to understand the evolution of the person in the environment. The narrative context does not mean that the evaluation must be written in a strictly historical way, but that the fundamental narrative structure of the individual’s life is captured in the report. The narrative can be part of the summary of findings, where the clinician gives a meaningful view of the individual or it can be at the introduction of the evaluation. At a minimum, the clinician should use narrative to capture the presenting situation for the evaluation - namely, the events leading up to and including the crime.

2. Plausible Portrait: The prosecution's presentation of facts in a criminal proceeding is designed to show how the defendant is different from the others in the courtroom. There is a circularity to its argument: the person’s acts demonstrate his or her barbarity and the very barbarity of the individual helps explain why he or she could have done what he or she is accused of. The intent of the approach is to convince the juror of the "otherness" of the criminal, the demonic quality; it is designed to destroy empathic feelings, for if one can identify with the criminal, then punishment becomes harder to decide. Prosecution wants to reduce the defendant to an abstraction or a "thing" that is distinctly different from the juror. Defense strategies, on the other hand, attempt to diminish the willful quality of the defendant and so they either demonstrate the degree to which the defendant was a victim or they aim at establishing the image of a real person with whom the jury can identify. Juries have difficulty with portrayals that exaggerate the victimhood of the defendant. What is more compelling is a realistic portrait of the individual as someone with whom one can identify; it must be a plausible person - neither too demonic nor too helpless.

 

 
 
 
 
 
 
 
 
 

The applied behavioral sciences have tended to move away from the study of intentionality. Most clinical discussions of a client’s behavior will focus on the various biochemical, social, environmental and developmental influences that can account for the client’s actions. Intentionality is generally not a concern except with those individuals who are seen as being personality disordered. In these cases, the clinicians may attribute problems to intentionality.

Criminal justice, however, places a high degree of importance on intentionality since it is a formative ingredient in determining degree of criminality. The forensic portrait should capture the degree to which the individual truly has available choices and the degree to which he or she recognizes and acts on those choices.

3. Environmental Context: No one exists in a vacuum. The art of forensic assessments for the defense lies in conveying the texture of the defendant’s world. Choices always seem abundant when the crime is reviewed in the courtroom. In the removed and rational environment of the trial, it is in fact difficult to imagine a defendant not having choices. One of the goals of the forensic biopsychosocial is to render the constraints of the individual’s world. This is not an easy task, since the evaluator might not have a good feel for the substance of the individual’s environment and culture. If the evaluation does not capture this quality of the individual, it will have missed a salient feature that is essential for the juror to understand. The evaluation should define the specific features of the environment, both during the defendant’s development and during the period when the crime was committed. The prosecution stance is that the defendant’s environment afforded as many positive as negative choices.

4. Rehabilitation Potential: The evaluation should describe the individual’s strengths or redeeming features that point toward positive change with appropriate support or treatment services. A very bleak and tormented life might show considerable potential for growth and development in spite of all the grim historical events. Prognostic statements should be framed in terms of realistic potentialities.

These four purposes guide the organization, the content, and tenor of the evaluation and, as mentioned above, they must be adjusted to the particular legal context of the evaluation.

The preferred practice is to use clinical procedures to produce forensic documents, not to make forensic use of clinical documents. In other words, the forensic evaluation should be a special procedure that is distinctly set apart from clinical functions per se. The reasons for this include the ethical concerns about the degree to which the client understands the context for personal disclosures. An evaluation that took place as a part of treatment is quite different in its impact upon the client’s decisions about disclosure. When the individual has made these disclosures as a part of treatment, there is generally a very different motivation from what one might see in forensic settings. One cannot assume that the disclosures made in the course of clinical discussion would necessarily be made in the forensic case. Ethical and legal dimensions of these evaluations must be followed in order to not compromise a client’s privacy, liberty interests, or the professional’s credibility. There are six major steps in conducting the forensic biopsychosocial assessment:

1. Proper Order or Contract - the Context for the Evaluation: The evaluator needs to have clear understanding of the contract or order under which the evaluation is to be done. The evaluator should get a clear authority for the work before beginning. The evaluator should have a clear understanding with the attorney as to the desired goal and the methods of defense that the attorney is planning to use. Much grief can be avoided by having this frank discussion at the very beginning of the case, rather than later when a clash of values or approach has arisen. The clinician must establish the parameters of truthfulness that are not to be abridged in the process. Wise forensic practice flourishes neither in rigid ethical "purity" nor in meretricious opinions. The evaluator should assess the attorney’s strategy to determine his or her degree of accord with it in ethical terms. It is not the business of the mental health professional to raise concerns about the purely legal dimensions of the case, but ethical issues can be cause for concern and they should be resolved prior to becoming heavily involved in the case.

2. Informed Consent: The defendant should be given clear and relevant information about the nature of the evaluation and the legal context within which it will be done. Often the individual has but a crude understanding of the processes involved in court proceedings and all of the evaluations that might be enlisted. The evaluator has an ethical duty to explain this in detail irrespective of what the attorney might or might not have done. The evaluator should also obtain permission to interview family members and other collaterals. Technically, this permission is not required, but, in the interest of preserving an ethically sound relationship with the defendant and family, it is advised to seek it. Once the interviewer has established contact with collaterals, there is a duty to obtain their informed consent and permission to participate in the assessment. The consent must be in written form with all signatures witnessed.

3. Releases of Information and Review of Records: The evaluator should obtain authorization to release any and all medical or psychological records from the defendant’s previous providers to the clinician. This should include records from inpatient stays, residential care for substance abuse or other disorder, and any and all outpatient records.

 

 
 
 

Criminal records, evidence of placement in group homes, fostercare or other social service interventions in the individual’s youth are helpful. The more information the clinician has, the better the evaluation.
 

6 Elements of the Evaluation Process 1. Numerous interviews of client; 2. Collateral interviews of family, significant other persons;  3. Review of records; 4. Taking of life and health history, and doing a mental health exam; 5. Review of reports of other professional opinions of the client;  6. Application of research data

4. The Evaluation: The actual evaluation might be conceived of as a process rather than a discrete interview. The evaluation consists of six major elements:

 

 
 
 

a) There will be numerous interview sessions. This allows for questioning from different perspectives and within differing contexts, thus giving the clinician the opportunity to check the reliability and consistency of critical responses.

b) Collateral interviews with family members and sexual partners are critical. If possible, these interviews should be conducted as home visits. Obviously, time constraints limit one’s ability to do this, but much can be learned from seeing the defendant’s home and from experiencing his or her culture in an immediate way. The perspectives gained from other family members are also crucial in forming meaningful impressions of the family of origin and the veridical strength of the defendant’s version of this past. These collateral contacts also help in gaining information about the individual’s current family and social relationships. When the case involves spousal homicide, the collateral interviews are essential as they can establish the vital context within which the crime was committed and can ramify the personal qualities of the defendant in ways that can be very helpful.

c) Police reports, investigative reports, witness statements and factual evidence should be reviewed by the clinician. This information should be viewed as simply one version of the reality - not the absolute truth to which one tries to get the defendant’s responses reconciled.

d) The interviews with the defendant will involve taking the life and health history and doing a mental status examination. The full content of this part of the biopsychosocial will be reviewed fully in the balance of this paper.

e) The various reports and records from other providers should be integrated into the clinical assessment. Part of the task of a forensic biopsychosocial is to assimilate disparate professional opinions, histories of treatment and other assessments into a coherent picture. Differences of perspective should be accounted for and reconciled where possible. When this is not possible, the differences of opinion should be explained along with their underlying assumptions or biases.

f) Research data should be applied to any clinical opinions about the defendant. The clinician should even cite contradictory research findings and show how and why one perspective on this is chosen over the others. Citations should be from empirical research, not "authorities" who have propounded theories or voguish "disorders" in popular books. Theory has sometimes been helpful in welding together the many disparate pieces of information about a defendant’s mental or emotional condition, but in the harsh cross examination environment of today, empirical findings will be far more potent.
 

1. Identifying Information and Context of the Evaluation: The clinician should state the individual’s full name, age sex, race, marital status, address, and occupation and location where and when the interviews have been conducted.

2. The Defining Reason for the Evaluation - Presenting Problem: There are two principal presenting situations for defense-related forensic evaluations: 1) situations that call for opinions to guide the determination of guilt or innocence and 2) situations that call for information to assist in sentencing options. The first of these focuses more on the individual’s moral and cognitive capacities to form intent where the second focuses more on mitigating factors and rehabilitation capacities. In setting forth the presenting problem, the clinician might use: 1) the defendant’s view of the circumstances before and after the period of the crime, and 2) a summary of "objective" reports from the police or victims.

1. The clinician should elicit the individual’s understanding of the circumstances of the referral and the reason for the evaluation. Secondly, the clinician should have the individual describe the circumstances of the crime as a way of gaining his or her understanding of the events and the "frame" that the individual is putting on the experience. The salient features of the individual’s view should be recorded in his or her own words in quotes. The individual’s accounting of the facts is important, but, perhaps, even more important to the evaluative process is the rationale that the individual gives to the events. The individual’s attributions of intentionality to others can be significant as it can provide leads to family or social relationships that might have had significant impact on the individual’s behavior. Reports of severe distortions of power and control are among the more meaningful elements that the clinician should pay heed to. The assessment of the individual’s cognitive capacities must be integrated into the dimension of guilt ascertainment.
2. The clinician should either distill a brief account of the events as they are defined by official reports or simply give evidence of having reviewed witness statements, police reports and any other factual evidence. This is done as a way of grounding the evaluation and also as a way of showing the court that the clinician is aware of the "official" version of events and has not blindly followed the defendant into a swamp of distortion.

3. Early Personal and Nuclear Family History: This part of the biopsychosocial establishes the basic developmental and core family features from birth through adolescence. It encompasses the genetic, cultural, social, and interpersonal aspects of the early family environment and the role that these elements play in the formation of the adult character.

1. Genetic influences and intergenerational trends: The most effective way to obtain and represent all of the genetic loads on character formation is through the use of a genogram. This simple graphic tool lets the jury and other evaluators see the accumulative quality of genetic and intergenerational influences that are of a destructive nature. By representing two generations preceding the defendant, one can observe a pattern of biological factors that can become a part of mitigation in defense process. This is a two-edged sword, however, and must be displayed with caution as the genetic influences can easily be characterized as "wired in" and can be used to rationalize either death or long terms of incarceration since the prospects for change are seen as small. Biogenetic disorders have the advantage of being seen as outside the scope of individual intentionality and thus offer substantial mitigative strength, but caution is advised in cases where there might be a tendency to view the individual as beyond rehabilitation.
 
The genogram offers the clinician a device for selective representation of traits and trends in the family. For example, if the case involves a crime where alcohol or drugs were a factor, then the genogram can focus on the presence of drug or alcohol problems in the family. Likewise, seizure disorders, mental retardation, learning disabilities and other traits can be selected for their relevance to the issue at hand.

In order to construct the genogram in a convincing and competent manner, the clinician must have a thorough command of those disorders that show high comorbidity coefficients and a high degree of intergenerational transmission. The tracing of single disorders will catch but a small part of the genetic pattern while sensitivity to comorbidites will identify the full array of potential limitations with which the individual was struggling. The clinician must also be alert to comorbidities that do not share obvious genetic or biological commonalties such as the co-occurrence of schizophrenia and PTSD. Clinical wisdom tends to look down the most traveled pathways; but forensic process often calls for innovative examination of less frequented associations.

 
1. Nuclear family characteristics: The nuclear family contains numerous elements of relevant history. Among the more important influences of the family is the degree to which violence was a part of the environment. There are two aspects of violence that are particularly relevant to the forensic biopsychosocial evaluation: 1) being a victim of violence as a child and 2) witnessing violence toward other family members. Both of these should be explored in any evaluation of defendants charged with violent offenses. Particular attention should be paid to the age at which the individual was first exposed to violent behavior as evidence suggests that the earlier the trauma, the greater the likelihood of damage to the formation of self. At later years violence damages emotional systems and behavioral learning, but, in early development, it acts directly on identity and self. Normal development calls for an interplay of natural biological processes with environmental nurturance: violence truncates natural potential.
 
Sexual abuse has effects on the development of self and self concept, the emotions, and behaviors that are similar to those of violence. The earlier the age of exposure, the greater the likelihood of damage to self. Later exposure is more likely to be correlated with Post-Traumatic Stress Disorder than to damage to the formation of self. The individual who was exposed to sexual abuse in childhood carries a heightened risk of being sexually or physically abused in adulthood. This is attributed to the victim’s tendency to adopt survival techniques in childhood that become counter-productive in adulthood. The coping style of being avoidant or dissociative can lower the individual’s ability to defend herself against the intrusions of a perpetrator.

The high degree of acceptance of sexual abuse as a factor in psychopathology has perhaps led to too simplistic a use of it in understanding the evolution of self and symptom. Too often, one discovers a history of "sexual abuse" with little or no specificity. The forensic evaluation that rests on this kind of simplification will probably be unconstructive. Physical and sexual abuse need to escape their simplistic labels. The biopsychosocial should define the specific acts that were perpetrated on the individual and leave the "abuse" term out of the evaluation.

 
With childhood sexual and physical abuse, the clinician should assess the degree to which the child was subjected to threat and fear. Research on psychological symptoms resulting from abuse suggests that terror is one of the more powerful contributors to pathology. Violent acts might have been infrequent and brief in duration, but a pervasive atmosphere of fear and intimidation, threat, and pernicious attitude toward the child can be profoundly damaging to the evolving sense of self. Persistent and pervasive fear is now understood as having effects on brain areas such as the hippocampus which is involved in storing and retrieving memories. The assessment of terror in the individual’s life is one of the pivotal factors in understanding the individual’s worldview and capacity to think, feel, and behave.
 
Another ingredient that is a significant contributor to symptoms and distorted self-formation is the element of objectification involved in sexual abuse. Paradoxically, we humans seem to be better equipped emotionally to deal with abusive acts that are personally directed versus those that are the result of merely using us as objects of gratification. The clinician should assess the degree to which the individual was subjected to a perpetrator’s instrumental style of sexual or physical abuse.

As appealing as the signal events of abuse can be in the forensic evaluation, the combined influences of other factors such as neglect, substance abuse or dependence, and rigidity of parental beliefs and behaviors should be examined. There are few "single bullet" theories that can explain complex human behaviors and the successful forensic evaluation will pay heed to the multiplying effects of various factors rather than merely settling with the most obvious one. Sexual trauma at an early age (ages 4 - 7) combined with neglect offers one of the most potent ways to destroy the evolving self. Not unlike the recent attention to psychiatric comorbidities, the combined effects of destructive interpersonal and familial relations deserves close attention in the forensic evaluation. The question that arises from this inquiry is "what adversity did the individual face in meeting the challenges of development and what are the probable effects of the missing fundamental biopsychosocial ‘nutrients’ to that development?" A sophisticated assessment of the abuse phenomena will conflate 1) the history of specific abuse with 2) the elements of terror and instrumentality and with 3) the ambient environment of neglect.

In many forensic cases, the individual will have had foster placements during childhood. These placements, along with other early residential treatment placements should be explored in some detail. Early foster care can have ramifications on the degree to which the child found dependable and reliable attachments. Some foster placements are very positive and others merely repeat abusive or emotionally neglectful experiences for the child. It is probable that the individual’s account of these foster placements is distorted, but whether true or not, these accounts represent the individual’s perspective on this period of life. The unsettled nature of fostercare can have untoward effects even when the foster parents have been helpful.

With all of these history events, it is critical that the evaluation read "the client reports a history of this event at age X" rather than "at age X, the client experienced this event". The first version records the phenomenological where the second suggests fact. With all history issues, the report should consistently make a distinction between what is known versus what is reported by the individual. This is critical to the science of the matter, the ethics of proper evaluation, and the perceived accuracy of the evaluator.

As mentioned earlier in this article, the clinician should use great care in delineating the abuse history. A too morbid picture can easily lead to a juror’s conclusion that the individual is hopelessly damaged and beyond rehabilitation. The attempt at portrayal of profound victimization can backfire into a depiction of pathology with which the juror cannot identify and toward which there is only a feeling of fear. Should the clinical portrait create a feeling of fear in the juror, then the aims of the defense will not be met while those of the prosecution will be.

Procedural tips:

 
The clinician who wishes to obtain a useful early history of personal and family events will adopt a noncommittal posture that makes untiring use of generally open-ended questions. Occasionally, in searching out antisocial antecedents, it is helpful to use presumptive questioning. Presumptive questioning asks the individual about events presuming they occurred - as in "Going back into, say, the first or second grade, what was the earliest fight you remember being in?" The presumption is that the individual had actually been in fights. If the individual was not in fights, he can easily deny it. This line of questioning however can lead to discovery of antisocial items by normalizing them in the interview. The clinician should be very cautious about even subtle displays of affect during this questioning process since it possible to influence the individual’s account of sensitive matters. There should be very few questions that can be answered with "yes" or "no" and the clinician should not provide answers through the content of the question. The style ought to be so matter-of-fact as to not give the individual suggestions of desired content.

Interesting information can be discovered by asking the individual to describe how other family members might view events. This can lead to a quasi-objectivity where the individual shows the degree to which he is aware of others’ view points. This can be done in the context of questions about key events in the individual’s development.

Example: "Could you describe for me what it was like in your family when you were in grade school? And what about before that? Do your brothers/sisters see it the same way? How do you think they would describe your family at that time? What was the hardest thing to deal with? What were the best things about your family? When you were a child, to whom did you feel closest? Why? How did you react to what was happening when X happened to you? How did your brothers/ sisters react when these things happened? If I were interviewing your mother/father, what would they say about you at that time? How would they describe you?"

When seeking additional information about the sequence of events, ask, "And then what happened?" instead of more close-ended (but seemingly obvious) questions like "And did he do this to you many times or only the one time?" The more indeterminate the question, the greater the opportunity for the individual to give authentic responses. Obviously, there are times when the clinician must hone in and probe for specifics through more determinate questioning, but as a general rule, the less restricted mode is recommended.

The least advised way to get abuse information is to ask, "Were you abused as a child?" The defendant situation provokes intense motivations to see self as a victim of others. For the clinician to walk into this with simplistic questions is to do a disservice to the individual. The task of the forensic evaluator when working for the defense is to avoid stereotypy; simplistic questions exaggerate the superficial traits of the individual and thus contradict the intent of the process.

1. Early development and personal events. There are four domains that should be covered in this section: 1) prenatal factors (if known), 2) early childhood development and adaptations, 3) middle childhood and 4) adolescence.

1. The individual’s prenatal conditions can be relevant to the understanding of cognitive ability, impulse control and other aspects of the adult personality. This information is obviously not easy to obtain in most cases and it can be subject to substantial distortion. It is, nonetheless, an important area for inquiry and, should there be any relevant findings, they should be identified in the report. Among the features that can be relevant are: pre- and perinatal maternal use of alcohol, tobacco, cocaine and marijuana. These substances have been shown to influence fetal and early childhood development of cognitive capacity, behavioral controls and emotion regulation. There is no certain relationship between the maternal use of these substances and impaired outcomes for the child, however, and clinical inferences from these data should be treated carefully. Again, as with abuse histories, a conclusive portrayal of severe neurocognitive harm caused by maternal drug use during pregnancy can lead to a juror’s belief that the individual is incapable of change or rehabilitation.

 

 
 
 

If obtainable, the individual’s developmental milestones should be correlated with norms. Delays in development are not uncommon among individuals who are affected by violence and who perpetrate crimes. These findings, when discoverable, should be referenced but used with care in forming clinical conclusions.

2. The early childhood of the individual can show traits that are significant to the clinical impression of the adult defendant. Early incidents of aggressive behavior - particularly when accompanied by injurious aggression - are among the more reliable indicators of antisocial personality formation. When these traits are accompanied by quasi-adult or truly adult sexual behaviors during early childhood, the likelihood of antisocial personality becomes all the greater. The combination of aggressive temperament and childhood exposure to family violence is a particularly robust predictor of adult antisocial personality. Other early childhood adaptations should be evaluated and compared to later behaviors. This can be helpful in sorting out the contributions of temperament and signal events in shaping later adaptive patterns. In general, the more persistent and earlier the trait (particularly the more antisocial ones), the greater the likelihood of its continuity through adulthood. There should be inquiry into symptoms of early childhood disorders such as enuresis, phobias, sleep problems, and communication problems.

3. As the child moves into school years, there are more measures of social and intellectual adaptations. Early social patterns should be assessed including: the types of friends, forms of socialization (one-on-one or small group), relations with adults, younger children, and older children (including exposures to harmful influences of older children). The clinician should be sensitive to the progressive features of the individual’s intellectual adaptations and expressed abilities. Changes or halts in progress can be indicators of signal events in the child’s life and can prompt further inquiry. The changes in content as grades increase can also be an explanation for gradual decreases in school performance and possible intellectual deficits. These "nontraumatic" factors sometimes seem less appealing than the more dramatic events of a defendant’s presentation, but they call for close attention, particularly when the clinician begins assessing for cognitive functioning. It is useful to note whether there were close attachments to any parent or adults during this period of development. If the child grew up in an abusive environment, it can be helpful to learn whether he or she had the ability to garner surrogates from teachers, other adults, school counselors, etc.

4. Adolescence is an important watershed for markers of problem behaviors - particularly for the understanding of antisocial and personality disordered individuals. Personality begins its final "packaging" during this period of development and patterns of adaptation to pleasurable experiences, social, and other stressors and the challenges of responsibility are significant to the development of the adult personality. Among the themes to be explored are: educational attainments, the onset and character of sexual relationships, drug and alcohol exposures, and socialization.

 

 
 
 
 
 

It is not uncommon to see changes in the individual’s academic performance during adolescence. Lay wisdom attributes this to the various psychosocial dimensions of the teen experience, but the clinician should also be sensitive to the increased demand for abstract thinking in high school material. Poor academic adaptations can be indicators of poor parental support for education, disturbed home environments, fundamental cognitive incapabilities, drug and alcohol use or, more likely, several of the above combined. This period of academic performance should be reviewed carefully and correlated to other events in the individual’s life.
 

5. During adolescence the individual begins to develop interest in sexual relationships. For some adolescents this transition is gradual and tentative while for others it is abrupt and decisive. It can be very important to capture the emerging patterns of sexual relating in the adolescent. Partner battery and sexual assault begin to emerge in adolescence. The assessment should also explore the degree to which the individual evidenced dependency in early dating patterns.

4. Adult History: The history of adult functioning covers nine major areas: 1) marital and/or partner relationships, 2) parenting or caregiver roles and behaviors, 3) patterns of substance use and other compulsive behaviors, 4) educational attainments, 5) vocational attainments, 6) current living environment, 7) economic security and status, 8) social and recreational pursuits, and 9) religious or spiritual values.

1. Marital and/or partner relationships: The evaluation of partnering should encompass a history of relationships plus a depiction of current ones. There are seven major dimensions to the evaluation of marital and partner relationships: a) mate selection, b) role definition, c) expectations of the partner and relationship, d) attachment behaviors, e) conflict resolution, f) relationship dissolution, and, in certain cases, g) domestic violence and where indicated, h) lifestyle or sexual orientation. Throughout each of the seven, the clinician should be sensitive to patterns and themes rather just isolated facts. Relationships are, in some respects, difficult to assess due to the contributions of the other person (who might not be available to the evaluator). Patterns that repeat over several relationships, however, make for defensible inferences.

1. Mate selection: This item shows marked sex or gender differentials in forensic populations. Lay thinking assumes that both genders make active choices about partnering and that the resultant relationship is the product of free choice. This commonly held belief may need revision when working with forensic populations in general and in domestic violence cases in particular. The argument for mutuality of partner choice might have validity in middle class and nondisturbed groups of people. Furthermore, it might have meaning with males, who still today remain the seekers of partners, but it has questionable validity with females - particularly in lower socioeconomic groups who may agree to relationships rather than actively choosing them. Lower income women with less education have a very complex set of issues that affect mate choices. This might be an offensive notion to those who have sought increased independence of women in the past three decades, but the sad reality is that men still dominate the partner selection processes - particularly in lower socioeconomic sectors of society. The significance of this idea cannot be underestimated when domestic violence is a feature of the relationship. Among forensic concepts, one of the more enduring and pernicious ones is the belief that domestic violence victims continually seek out abusive partners. The clinician is strongly encouraged to discard this notion. A realistic appraisal of the woman’s actual choices in partnering need close review; she very rarely has the range of healthy choices available that we believe she has. When we add to the formula some of the preconditions within which a poor woman operates, the situation takes on a grimmer prospect. If she is from lower socioeconomic strata, she earns little money and has great economic need for a male wage earner. If she has a child or children, this need is all the greater. As an uneducated, low wage earner, she less likely to be mixing with upwardly mobile males. Furthermore, the disparity between her wage and that of males in her class is very great. A recent graduate male MBA might earn more than an equal female MBA, but the difference is not likely to be as great as that between a minimum wage female and a male who is a skilled or semi-skilled laborer. The male wage is likely to be three to four times hers. Her mate selection is far from free in the sense that we usually like to think of it.

The concept of free mate choices has meaning with males and it is viable to use this in the biopsychosocial evaluation. In cases where domestic violence persists over multiple relationships, we can assume not that the woman is seeking abusive partners, but that the man is seeking likely victims. This notion should not surprise us; perpetration of abuse is closely allied with other deliberative steps toward domination of partners. Why would it not influence mate selection?

With the whole notion of mate selection, the clinician is cautioned to exercise care with the use of assortive mating assumptions. The literature on assortive mating is lengthy, but still heavily imbued with theory that is inspecific about the selection variables that might lead to mate choices. Mate choices should be examined in light of real economic and cultural factors, not merely psychological or romantic ones.
 
 

2. Role definition: The clinician will want to evaluate the roles that the defendant has taken in marital or partner relationships. Primarily, this involves an examination of the distribution of power and control among the partners. In addition, the clinician will need to assess the boundaries of partners with each other. Are there signs of enmeshment or disengagement? These two concepts, for all their theoretical frailties, still have some merit in appraising the degree to which individuals are constructively engaged in the relationship. Over involvement in the affairs of one can suggest enmeshment while withdrawal and avoidance can suggest disengagement.
Procedural tips:

The ascertainment of power and control is at times difficult. Rather than pursuing direct frontal questioning about this, the clinician might make use of some simple devices that give data from which inferences can be made. For example, one might inquire about who writes checks, who reconciles accounts, who "manages" the cash. Inquire about how decisions are made when an appliance breaks down, who decides about repair versus replacement, who makes the choice about replacement equipment. Who is responsible for the details of daily living in the home - cooking, cleaning, dishes, childcare and what division of labor exists here? Once the clinician has information about the handling of money and daily tasks, one has a relatively clear picture of the distribution of power and control. The response to concrete questions is generally more productive than the more abstract questions about roles in the relationship.
 

3. Expectation of the partner and the relationship: It is useful to understand what the individual expects from spouses or partners and what he or she sees as needs that should be met in the relationship. This sometimes must be framed in a historical way. E.g., "When you first got married, what kinds of things did you think your wife should do for you?" and, "later on, did your thinking change about this?" - " How so?"

4. Attachment in adult relationships: The clinician should examine the ways in which the couple came together and stayed together. What was the attractive element and did the individual know what it was at the time? The clinician will need to examine the degree to which the individual appears engaged with his or her partner and the degree to which engagement is sustained through stressful events. Attractive force between the two can be a function of companionability, interpersonal need and sexual attraction. Sexual and romantic dimensions should be explored to ascertain the degree to which they motivated the forming of the relationship and the degree to which they play a part in the current status of the relationship. Sexual behavior needs detailed inquiry when there is evidence of sexual parameters to the crime, when there is evidence of sexual dysfunction, or where the defendant has raised a sexual concern about the relationship.

5. Conflict resolution and communication styles: The clinician needs to explore how conflict arises in the relationship, over what issues and by what methods are they resolved. Defendants might have need to either exaggerate or deny conflict in the relationship. This is an area in which collateral information is very important. Even in undisturbed relationships individuals exhibit substantial distortion about the kinds, causes and results of conflict. The clinician should use presumptive questioning in some cases with this issue. E.g., "When you and your wife are really angry with each other, what’s it usually about?" "When you are arguing with each other, what usually brings it to an end?" "Who brings it to an end?" "What is the usual way that you get control?" "How do you make others do what you want them to?" These questions might offend the sensitivity of some clinicians, but their purpose is to enter into the world of the individual who might use battering or control in relationships. Questions about conflict resolution often lead to domestic violence issues.

The clinician will need to form an impression of the communication styles of the defendant and his or her partners. This is perhaps more art than science, but an effort should be made to get a picture of the ways in which the couple communicate about positive as well as negative matters.
 
6. Relationship dissolution: The clinician should obtain a history of the individual’s ending of relationships. It is useful to know whether there is mutual consent or whether the defendant or the other is usually responsible for ending the relationship. This item can be useful in forming inferences about dependency. It is also useful to know whether the dissolution was the result of violence or other infraction by the defendant such as extramarital affairs or other illicit pursuits versus a long pattern of not getting along.

7. Domestic violence: When there is reason to believe that domestic violence played a role in the defendant’s life a full domestic violence assessment should be undertaken. This will involve a review of patterns of violence from either the perpetrator or victim perspective as indicated by the individual’s situation. When the defendant is a victim of domestic violence, the full history of abuse should be explored in great detail since there is evidence that victims are likely to have histories of childhood abuse in addition to their adult experiences. Likewise, perpetrators typically have violent and abusive backgrounds. When domestic violence is a part of the defendant’s presentation, this issue should receive prominent treatment in the biopsychosocial evaluation.

8. Sexual Orientation: The individual's sexual orientation should be referenced but clinicians are warned that it is not necessarily significant. Failure to note it can be very damaging when the prosecution attempts to use it in a stigmatizing way when the individual is gay or lesbian. The clinician should be familiar with cultural features of gay and lesbian cultures so that inferences about partnering can be informed. Gay and lesbian relationships have features that might appear pathological when viewed without an understanding of their differences from hetero couples. In general, clinical inferences arising from sexual orientation should be made with caution. Homosexuality offers an inviting target for seeing the individual as "different" from the jurors and officers of the court. The biopsychosocial can contextualize homosexuality in ways that let the jury see the individual, not the "gay" object.

2. Parenting and Caregiver Roles: The clinician should evaluate the various caregiver or parental roles that the individual has. Again, as with other topic areas, this should be done historically and in the current circumstances. Patterns of caregiving can be important in forming a clinical picture of the individual and they can be significant mitigating factors in the sanctioning process. The impression of criminality can be greatly diminished by a history of careful and concerned parenting in a situation of great adversity. Parenting is difficult to assess with only the defendant’s information and thus collateral data is very important. Among the themes that should be explored are: the quality of the parental attachment to the child, the degree of involvement in the child’s schooling and recreational activities, the methods for insuring the health, safety and security of the child, and the methods for handling discipline. Have the defendant’s children been removed by Protective Services? For what period of time? Was this due to acts committed by the defendant or because of a failure to adequately protect the children from harm caused by others? What steps were taken by the individual to remedy the situation and did this result in a return of the children?
Other caregiver roles should be explored including whether the defendant is responsible for the care of adults who cannot provide for their own needs. This might include elderly relatives or adults with disabilities. If there are caregiver duties, what financial support helps the individual with this? Are there social security benefits involved? Has the individual been a responsible custodian of the resources for the disabled person or is there evidence of diversion for the individual’s own benefit? Are there incidents of abuse of the dependent person? If so, how were these resolved?

3. Patterns of substance use and other compulsive behaviors: It is not uncommon for defendants to have drug and/or alcohol abuse histories. The assessment of these issues requires attention to detail as the ramifications of the different patterns can be of considerable importance in estimating the degree of impairment and rehabilitation potential. The clinician should view the substance use history from a developmental perspective since there is evidence that the timing of initiation of routine use constitutes a significant marker for the degree of addictive disorder. Exposure and recurrent use of psychoactive substances before age 14 appears to be strongly correlated with adult dependence or heavy abuse. Among the factors involved in the assessment of substance use are the following: a) the substances that have been used by the defendant and the quality of mental state that the substance provides (i.e., satiation, stimulation, etc.), b) the age of first exposure and recurrent use, c) the quantity used, d) the frequency and concentration of used substance, e) efforts to control or stop the use of the substances, and f) changes or shifts from one substance to another. As a general rule, the earlier the use of substances, the greater the likelihood of entrenched addictive pattern and the less likely the recovery from it. This is particularly true for alcohol where studies have shown that early use in males is correlated with paternal use and antisocial traits. These patterns require close assessment because the conclusions and opinions that result can be of such consequence to the individual.
In forensic evaluations, the cluster of behaviors typically associated with substance use (such as criminal conduct to procure or pay for substances) are as important as the use itself. Furthermore, the distinction between abuse and dependence is sometimes difficult to determine in forensic cases when the individual might have made many changes (at least temporary ones) since the charges. In these cases, the clinician is put in the position of determining what the level of use was some weeks, months or even years ago - a daunting task considering the potential distortions that the defendant and family can bring to bear in these circumstances. The substance use disorder should be examined in the context of all the features of the individual’s lifestyle to help in determining the degree to which substances are central or peripheral in his or her life.

As part of the assessment of substance use, the clinician should also evaluate the defendant’s risk factors for HIV infection. When the individual gives evidence of IV drug use, the risk potential for HIV infection should be considered as very high. This item should also be addressed when the defendant’s overall risk status is evaluated.

In addition to substance use, the clinician should assess for the presence of other behaviors that possess addiction-like qualities. This includes compulsive behaviors that are hedonic such as gambling, risk-taking behaviors (fast driving), compulsive sexual acts and other behaviors that appear to have a compulsive quality that interfere with social or vocational pursuits.

4. Educational attainments: The clinician assesses educational attainments with an eye to three dimensions in the individual’s performance: a) social and cultural influences on education interests and attainments, b) family pressures and disturbances that might have affected attainments, and c) intellectual ability. The clinician should track the individual’s school performance through early grade school, middle school and secondary grades. It is useful to note the point at which the individual began to perform poorly. Math performance may change by the third grade when mathematics disorders tend to appear. Typically, overall academic performance more likely to change around late middle school or early high school years (grades 8-9). This is cause for further evaluation since there can be any number of inferences to draw from this. The failures can be due to any one or a combination of all of the three dimensions noted above. The clinician should pay particular attention to the cultural factors in the individual’s nuclear home and community as this can be a very powerful determinant to educational performance. While clinicians are often reluctant to explore the issue of low intellectual functioning because of the potential for damaging labeling, it is nonetheless, a critical issue in forensic evaluations and should be addressed directly. It relates to the cultural and familial issues in that severe neglect in early childhood can have disastrous results on the development of intellectual ability and, where formal intellectual assessment instruments have been used, inferences about environmental factors might be constructive when there is evidence that habilitative services might exact some degree of growth. Problem solving capability is a critical ingredient to rehabilitation potential and this function is directly related to intellectual ability.

5. Vocational attainments: The individual’s vocational history should be assessed with attention on the long and short-term patterns of employment. Is there evidence of a pattern of frequent job changes with intervals of unemployment in between? Is there, on the other hand, a pattern of sustained employment with ever increasing levels of responsibility? How does the individual end his employment and what are the reasons for leaving a job? Is the work gainful? Is the level of employment commensurate with the individual’s level of educational attainment? The clinician should also assess the degree to which the work environment forms the socializing network for the individual. Work relationships have become among the strongest in our contemporary culture and the exploration of these can reveal important aspects of the individual’s level of functioning. Many individuals will show very poor pre-employment skills including the social skills necessary for communicating with supervisors, co-workers, and the public. This also includes awareness of punctuality, attendance, conflict resolution in the workplace and other social skills.

6. Current living situation: "Current," as it is used here, means from the time of the commission of the crime to the present. The clinician should obtain a clear picture of the living environment within which the defendant lived at the time of both the crime and the signal events that led up to it. The home space should be evaluated for safety and privacy. Housing environments where there is a high incidence of drug related crime and shootings have obvious effects on the mental and emotional state of their inhabitants. Crowding in the home environment should also be examined. The clinician should evaluate the impact of the home and community on the emotional state of the residents. If the defendant is currently housed in a correctional facility, this should be noted along with the stressors that accompany such a setting.

7. Economic security and status: The defendant’s economic circumstances should be elucidated in the assessment. The individual’s income sources should be documented and compared or contrasted to expenses. The accounting for an individual’s financial resources can lead to many other lines of inquiry on both the expense and revenue sides. This can include hints about gambling, extramarital affairs, drug abuse, prostitution and other illicit forms of income.

 

 
 
 
 
 

Spending patterns need to be evaluated although most clinicians tend to avoid this area of inquiry. If the individual has credit cards, the clinician should inquire about the amount of debt on them. Unsecured loans are common among poor people and the accumulated debt from these loans should be evaluated as to its extent and purpose. These loans are often taken out to relieve debts to other creditors and the combined interest should be noted. The clinician should also sum the defendant’s entire known debts. In assessing expenses it is important to identify rent-to-own charges. Poor people frequently fall prey to these methods of purchase and can incur substantial debts.

The clinician should note whether the individual has any form of health insurance or whether he or she might be eligible for Medicaid or Medicare.

8. Social and recreational pursuits: The assessment should include reference to any form of social outlets that the defendant has by history. This would include the individual’s circle of friends or peers (constructive or unconstructive), formal group allegiances, self help group participation, and any signal friendships. The evaluation should also note any recreational activities that the individual has pursued including sports, hobbies or paravocational activities.

9. Religious or spiritual values: The individual’s religious values can be a significant contributor to behavior patterns, though not always in expected ways. Decisions about remaining in relationships, child discipline, sexual conduct and drug taking or drinking are the more likely areas that might show religious underpinning.

5. Risk Assessment: The individual must be assessed for the degree of risk for 1) harm to self, 2) harm to others and 3) victimization by others. This tripartite risk assessment should be longitudinal and developmental where indicated. For example, in some cases the defendant will have a lengthy history of violence toward others while in other cases the violence is a new behavior. Violence and suicidality should be evaluated in the context of the individual’s development and environmental factors and should be examined for duration over time. In doing this, the clinician is assessing whether the risk factors constitute traits of the individual versus states of mind that arose in reaction to unusually stressful events.

1. Harm to self - suicidality: Suicidality is difficult to assess with much objectivity in forensic cases since there are so many factors that propel the defendant toward a suicidal stance. These stressors can either fuel a genuinely lethal suicidal disposition or can merely motivate ploys to elicit sympathy. In either case, the science of prediction is insufficiently endowed to allow for dismissal of even the most transparent threats. It is, therefore, axiomatic that the clinician should take all suicidal threats seriously as if they were direct expressions of actual intent. To take seriously, however, does not mean that all threats or suicidal statements must lead to rescues and hospitalization. The burden placed on the clinician is to wade through the defendant’s statements and arrive at reasonable safeguards that can diminish risk in the short run. Suicidality is the one finding that can place a duty to care on the clinician even while in the process of merely evaluating the individual for forensic purposes. Threats to others made in the context of the evaluation create duties to warn and protect, but the presence of suicidality creates the duty of care. This duty of care might be discharged by using any number of supports in the individual’s family or residential setting along with medical and/or verbal therapies. The duty does not immediately impose a need to use inpatient care but it does mean that some reasonable plan of care is put in place.

1. Predisposing factors: Suicidology literature identifies numerous disorders as being risk factors for suicide. Among these are: depression, alcoholism, drug dependence, personality disorder (particularly borderline and antisocial types), schizophrenia, familial history of suicide, impulsivity, chronic and disabling or terminal disease, history of severe childhood physical and/or sexual abuse, and recent severe personal losses (by divorce or death). The presence of any one or more of these disorders simply means that the individual’s risk for suicide is increased. Almost by definition, forensic cases will involve these disorders. As a general rule, the greater the degree of psychopathology, the greater the risk for suicidal lethality.

 

 
 
 
 
 

The history of abuse has complex associations with suicidality and should be assessed very carefully. With childhood sexual abuse self-mutilation is a likely adult symptom and the individual might represent his or her acts as suicidal in nature. Close investigation will generally show that the mutilative act, however, has very different dynamics from suicidal gestures or attempts. The dissociative processes involved with mutilation are generally referred to as parasuicidal thoughts and behaviors. The clinician should take steps to evaluate whether the defendant shows a pattern of self-mutilation or suicidality or both.

2. Suicidal ideation: There are distinct thought patterns associated with suicidality. These include both declarative statements of intent and automatic thought processes that form a template of negative beliefs in the individual. The clinician should examine both domains of thinking. The degree of lethality is associated with two factors: a) the degree of expressed intent and b) the degree of hopelessness. Research points particularly to the second of the two as being an important indicator of lethality. When the individual has a belief that under no circumstances can he or she be better off, then risk is high. The assessment of thinking can be guided by reviewing Beck’s triad of thinking about self, world and future. The ideas associated with the future are the ones that cue the clinician about the degree of hopelessness. Expressed intent is also important and should be assessed by inquiring into the rationale and the individual’s ideas of what he or she envisions happening after the act. Essentially, the clinician is looking for what the individual sees as the goal or outcome of the act. This can elicit the manipulative agenda that always needs assessing in the forensic suicidal situation.

3. Actuality of the plan: Expressed intent and rationale for the intent is important, but the clinician should also inquire about method of suicide. There are two ingredients to this: a) the degree of specificity and detail associated with the plan and b) the feasibility of the plan. The individual who has a high degree of detail in the plan, who knows, for instance how much Valium or Elavil is necessary to cause death, and who has the medicine, is at high risk. The individual who has but vague ideas about method and who has few means to obtain the methods for suicide is at lower risk.

2. Harm toward others: It should be self-evident that a forensic biopsychosocial should thoroughly explore the individual’s risk for harm to others. The predisposing risk factors for this are much the same as for suicide with several additions: learning disabilities (particularly low verbal processing), closed head injury or other trauma to the brain, and ADHD. When the clinician assesses this area of the individual’s history, a developmental approach is recommended. Violence rarely arises out of nothing; there are almost always many precursor behaviors or a history of violent acts that precede the current one. This item should be explored using the method of presumptive questioning mentioned above. The clinician should be inquiring into early violent or abusive acts as a way of determining the degree to which the aggression is integrated into personality versus a reaction to extreme circumstances. One of the better ways to do this is to ascertain how early the aggression is manifested in the individual. In general, the earlier the pattern, the greater the likelihood of its incorporation into personality and the greater the likelihood of its future expression. The assessment of risk for harm to others should be expressed "high," "moderate" or "low" risk language as opposed to predictive statements. The risk should also be stated with contingencies. For example, the individual might have a low to moderate risk while on medication, but high when off it.

1. Biological and genetic influences: While many clinicians might be reluctant to consider biogenetic loading on violent conduct, it is nevertheless, a topic that must be explored. There is considerable evidence that pronounced antisocial traits have strong biogenetic transmission factors. This has also been demonstrated with a particular type of alcoholism that is associated with antisocial behavior. Where there is a family history of violence, alcoholism associated with antisocial traits, learning disability, ADHD, closed head injury or other trauma to the brain, and B cluster personality disorder, there is an increased likelihood of biogenetic predisposition toward aggressive styles of behavior. The clinician should make use of genograms to assess the extent of familial history of violence and aggression.

 
Another biological factor that should be incorporated into the risk assessment for harm to others is closed head injury or other brain trauma. The clinician might eschew much inquiry in this area because of dubious reliability of information and the lack of neurological expertise. While there are definite limits on the scope of this area of inquiry, the clinician should still take as detailed a history of potential head trauma as possible. This can be done by inquiring into bike accidents, automobile accidents, injuries from fights, drug overdoses resulting in loss of consciousness, alcoholic blackouts, arrest related head injuries, falls, swimming or diving accidents, inhalant abuse, and childhood physical abuse by a parent or caregiver. Mental retardation in combination with any of the above predisposing factors becomes yet another multiplier in the equation. In the mental status examination, the clinician will assess cognitive functioning in more detail. This information should obviously be correlated with the history of head trauma to form a thorough risk assessment of the individual.

2. Childhood experiences: The literature is complex on this matter as with most in the forensic areas, but, as a general rule, childhood exposure to violence is correlated with adult expression of violent behavior. While it is an unsupported hypothesis to suggest that childhood victims become adult perpetrators, it is nonetheless true that adult perpetrators have in most case been victims. The victimization can increase the risk that an adult will be violent. Again, as a general rule, the degree of physical violence experienced by the child either as a victim or as a witness tends to correlate with the degree of violence expressed by the adult. Brutalization seems to be an inculcated trait. Clearly, the combination of genetic predisposition with childhood exposure to violence is an indicator of very high risk for adult violent behavior.
When the defendant’s crimes are sexual in nature, it is likely that there have been childhood sexual abuse incidents or the witnessing of sexual violence during childhood. It is rare, though possible, for adult sexual criminality to arise in the absence of childhood exposure to this behavior.

3. Developmental patterns: The clinician should, as mentioned above, use presumptive questioning to obtain a picture of early childhood violent acts committed by the individual. This history should be taken in a careful sequence with particular attention to preadolescent expression of violent behavior. As socialization patterns ramify in adolescence, the clinician should be looking for those anti-social acts that are most influenced by social environment versus those that pre-date gang or other social involvements.

4. Thought processes: The earliest literature on the antisocial personality identified thought patterns that marked these individuals as different from others. The clinician should examine the thinking behind violent acts to determine the degree to which violence is dissonant or congruent with self. Domestic violence victims, for instance, might find their own violent acts to be out of keeping with their view of themselves. This dissonance can be very important in forming an impression of lethality. In general, the degree to which violence is integrated into the view of self is correlated with the degree to which the individual is likely to persist in violent acts in the future.

5. Outcomes and consequences: The clinician, in taking a history of the individual’s violent behavior, should note what the outcomes were. This refers to the actual harm done to others. Defendants can be forthcoming about fights they have had in the past, but generally need more probative questioning about the degree of harm or injury they have caused. Obviously, there is substantial difference between an individual who has been in several fights and who has bruised his victims, versus the one who has put three people in a hospital. When the defendant reports not knowing what harm he has caused, one can be reasonably sure of denial. The clinician should also assess whether weapons were used against others and, if so, what harm resulted.

3. Risk of victimization: The individual’s risk for being victimized is an important part of risk assessment. This should include an assessment of risk while in detention where appropriate. Due to disorder, alleged offense or other factors, the individual might be at greater risk than others in correctional facilities. Likewise, the individual who is on bail during the evaluation should be assessed for risk factors in his or her home or residential setting. Domestic violence victims are likely to be at heightened risk unless they have made arrangements that protect their safety and security. When the defendant is a domestic violence victim who has then killed an abusive spouse, the individual’s risk for harm from the husband’s family should be assessed. As a general rule, the greater the history of abuse victimization, the greater the risk for future harm as well. This has been noted even with a history of sexual abuse. Rape victims, for instance, have a higher reported rate of previous sexual assault or abuse than do women who have not been raped. Survival patterns perhaps serve some important functions for victims, but they do not always safeguard against future abusive acts. The clinician should take the history of childhood victimization and evaluate the individual’s current situation in context with that history.

6. Mental Status: The mental status assessment is a systematic representation of observed behaviors, thinking patterns and emotional qualities in the individual. This assessment consists of both informal and formal evaluative procedures. In assessing cognitive capacity it is useful to follow the standard mental status questions pertaining to memory, judgment and abstracting ability. The responses must be interpreted in the context of the individual’s current circumstance and cultural background, however. There are eight components to the mental status assessment.

1. Appearance: The clinician should note the individual’s appearance in concrete terms, paying attention to hygiene, grooming and appropriateness of clothing (appropriate to the individual’s culture). The clinician should also form an impression of whether the individual appears his or her stated age.

2. Affect, emotion and mood: The clinician should identify the individual’s generally sustained emotional tone and inquire about the individual’s reported mood. The reported mood should be reconciled with observed affect. The individual’s tenor of emotion and range of expressed emotion should be integrated with her or his history and presenting situation. The mental status assessment should pay attention primarily to the individual’s qualities at the time of the interviews, but should view these findings in the context of the individual’s history. Incongruities between expressed emotion and life situation or thought processes point toward the need for further evaluation.

3. Motor activity: The clinician should assess the individual’s displayed motor activity. This includes the degree of agitation, restlessness or, conversely, the lack of usual activity. It will also include observation of tics, repetitive motions, unusual gaits and any other unusual postures or movements. In depressed persons, psychomotor retardation might be evident.

4. Speech and qualities of verbal expression: The clinician should examine the ways in which the individual links ideas and sentences, the volume of verbal activity and the vocabulary used by the individual. The linkage of sentences and ideas can evidence disorder in thought process caused either by affective disorder or thought disorder. The association of one thought with another can be heavily influenced by mania, depression or schizophrenia. The volume and quality of vocabulary should also be noted. The individual might make use of a very impoverished vocabulary or one that is marked by neologisms, words that are made up by the individual. The clinician will use care in making inferences about the vocabulary since the individual’s culture can be the primary contributor to this rather than mental disorder. Does the individual produce a huge or very small quantity of words? Are answers typically elaborated on or merely answered with a word or two? The clinician, in evaluating this field should be attentive to the qualities of the expressive ability, not so much to actual content or meaning of the thoughts.

5. Thoughts, perceptions and beliefs: The clinician will assess the content and meaning of the individual’s expressed ideas. This includes three components: a) expressed worries or preoccupations, b) perceptions and c) fundamental beliefs that have significant influence over behavior.

1. The clinician will elicit the individual’s concerns, worries and any obsessions or pre-occupations if they are present. With individuals who have a history of substance use disorder, gambling, sexual deviance or compulsion, the clinician will want to elicit the content of obsessional thinking around these subjects. Traumatic content might also emerge as a persistent and intrusive set of ideas or worries.

2. The clinician needs to explore whether the individual has perceptual disturbances such as hallucinations or misperceptions of real objects. This will also include distorted perceptions of circumstances and social situations. Individuals with severe personality disorder will typically give evidence of marked perceptual distortions of social events and contexts. It is important to assess perceptions, however, within the cultural context of the individual. This can not be over-emphasized in domestic violence cases where the influences of the "Stockholm" syndrome exert profound impact on the individual’s perceptual field.

3. The individual’s key beliefs and automatic thoughts should be assessed. Using traditional cognitive therapy approaches, the clinician can obtain the individual’s most prominent automatic thoughts that guide emotion and behavior. The individual’s basic beliefs about life, moral or religious beliefs, social custom and other features can be helpful in assessing either the individual’s motivating principles or rationalizations. Strong biases or negative beliefs such as racist or sexist ideas should be noted if they are relevant to the criminal activity. It is also important to explore the individual’s moral thinking. While this might seem ridiculous with anti-social personalities, it is, nonetheless, a useful area of inquiry. Many "antisocials" in the broader sense of the term have moral standards such as not "ratting" on fellow gang members or of not hurting children, etc. Years ago (under the DSM-II) these individuals were diagnosed with the label "dyssocial personality" and there is some value to the term. More importantly, however, it can be fruitful to learn whether the individual has moral values that direct some of his or her conduct. Kohlberg and Gilligan offer two sets of insights that can be very important to forensic evaluations of domestic violence cases. Kohlberg’s traditional understanding of moral thinking describes male patterns as rule following behavior while Gilligan has shown that women’s moral thinking is relationship contextual. While men rely on codes of conduct (look at gangs again), women are more likely to solve moral issues based upon the nature of their relationship to the other person.

5. Cognitive status: The assessment of cognitive status and capacity is one of the more complex and worrisome features of the biopsychosocial assessment. The individual’s cognitive capacity can be significant to a finding of guilt or innocence and can, to a lesser extent be relevant to sentencing. The individual’s cognitive integrity is in some respects the heart of the biopsychosocial assessment as all of the individual’s biological, social, developmental and environmental factors shape the fundamental cognitive abilities that govern how an individual navigates in the world. The clinician will want to ground observations in formal assessment questions and/or references to the individual’s history. The cognitive status should be evaluated in the following areas:

1. Level of consciousness: When the individual is not alert, she or he should be assessed for intoxication or other phenomena that can alter consciousness.

2. Orientation: The clinician should explore the individual’s orientation to self, place and time when there are indications of disturbance of thinking, as in schizophrenia or dementia. Orientation to time should be carefully judged if the individual is in an institution. Living in these environments destroys both reference to date, day of the week and even time of day and it destroys the significance of the passage of time. Orientation to time becomes, therefore, meaningless.

3. Attention and concentration:The individual’s degree of attending should be assessed. This can be done by giving her or him an exercise such a subtracting serial sevens from 100 or repeating key phone numbers backwards. Impairment of concentration can be either indicative of serious mental disorder or simply high levels of stress and preoccupation. When the clinician observes attentional deficits, the individual’s history should be consulted to see if there are situational or developmental factors relevant to this phenomenon. Initial indication of impairment should result in further testing to obtain a more discriminating picture of the condition.

4. Language comprehension: The individual should be able to identify phenomena or objects. If there is evidence of inability to do this, it might be an indication of serious cognitive impairment secondary to tumor, head injury or mental disorder. The individual’s basic ability to read and write should be assessed. Does the individual comprehend the words and concepts used in the interview? Again, as with other aspects of the biopsychosocial, the clinician should be aware of cultural factors that can influence these findings.

5. Memory: The clinician should examine the individual’s memoral capacity for short term, intermediate term and long term functions. All memoral impairments must be reconciled with history findings. Short-term memory is assessed by giving the individual three unrelated words to recall in three to five minutes. If the individual fails to do this, the test should be done again two or three times throughout the interview. Long term memory is assessed by obtaining information from the individual’s past (as in several years ago). Intermediate memory tests should focus on events that are days to weeks old. Memoral disorder requires very careful assessment. Deficits can be either attributable to psychological (trauma) or neurological events (strokes, head injury, etc.) or psychiatric illness (schizophrenia). Forensic cases sometimes present the clinician with instances of selective memoral impairments where one set of events is remembered with clarity while others are not. The use of the term "selective" implies a deliberative act and should be avoided in all but the most egregious cases. Memory is a complex cognitive process and is influenced by many factors. The safest clinical path is depict it accurately and thoroughly, but to be parsimonious in drawing causative inferences.

6. Fund of information: The individual’s fund of basic information about the world should be assessed, but in the context of his or her world. This might mean that the individual has an abundant fund of information about her extended family, but hasn’t a clue who is president of the United States. One can ask the individual to give the number of nickels in a dollar and other money related questions. The clinician should move from personal spheres to public ones in assessing this area of cognition.

7. Calculation: Appropriate to the individual’s level of education, he or she should be evaluated for basic arithmetical ability. Simple addition and subtraction equations can be used for this purpose. One can ask the individual to make change on imagined purchases.

8. Spatial representations: The individual should be asked to make Bender-Gestalt drawings on a plain white sheet of paper to detect signs of certain neurological deficits. These include simple geometrics as well as a clock face, cross figure and intersecting wavy lines.

9. Abstraction: The individual’s ability to work with abstract ideas is an important part of overall cognitive capability and it should be assessed within the context of the individual’s educational and cultural background. Abstraction is tested by the use of proverbs and reasoning exercises that call for the detection of similarities in named objects. One of the advantages of using proverbs is that they can be adjusted to different cultural contexts when indicated.

10. Executive functioning: The clinician should assess the individual’s ability to plan future actions and to inhibit impulses. This is essentially an evaluation of frontal lobe functioning in the individual. When the individual has a history of traumatic brain injury, this issue needs particularly close attention. Traumatic brain injury often affects the frontal and prefrontal lobes and this creates impairment of executive functions. The individual can be asked, "When you feel the urge to ____ [drink more, steal something, drive fast, etc.], what keeps you from doing it?" Or, "How do you plan out your time off from work?" "What is the furthest time in the future that you might plan something?" "How do you budget your money and how do you keep within your pay amounts?"

11. Judgment: The clinician should assess the individual’s quality of judgment as evidenced in the traditional questions about why people pay taxes, why cars are licensed, what would he or she do with a stamped addressed envelope that was on the sidewalk, etc. The responses on these items give one the feel for the way in which the individual makes judgment decisions. After examining some of these more abstract questions, it can be useful to ask the individual to give some examples of actions he or she has taken that would be good examples of sound judgment. The individual’s selection of items can be almost as informative as the content of the decision that he or she reports. As referenced above, the individual’s moral thinking should be examined. It should be looked at descriptively and then should be evaluated for its degree of congruence with the individual’s culture and society at large.

7. Medical Conditions: The individual should be assessed for health problems with particular attention to those disorders that might have impact on mental functioning. Individuals with chronic and largely untreatable conditions can be subject to mood disorders, distortions in thinking and behavior problems. The biopsychosocial assessment should include a review of systems so that the clinician can detect unnoticed disorders that might require either a referral for treatment or that might influence a clinical impression of mental disorder. In the assessment of domestic violence, the clinician should pursue questions about the history of injuries incurred in these acts and the treatments that might have been received. Some individuals will give evidence of lasting impairments from these injuries because of the severity of attack and a spousal prohibition of seeking medical care.

The individual’s health history cannot be taken by simply asking whether the individual has any physical problems. The inquiry must be formal and go through all organ systems. A health history or screening form of some sort should be employed. This can include basic information about family diseases that have strong correlation with genetic transmission. If, for instance the clinician is evaluating an individual who gives evidence of memoral vagueness and poor cognitive complexity and it is discovered that he or she has an extensive family history of early-onset Alzheimer’s Disease, then the relevance of clinical findings takes on new dimensions.

8. Functional Assessment: Individual who present with significant levels of impairment and diagnoses of major mental disorder need to be assessed for their level of functioning. This is done because diagnosis and clinical descriptors alone fail to capture the degree to which disorder interferes with the individual’s life. A functional assessment identifies those areas daily living that are impinged upon by disorder or condition. It must include the findings from the assessment of physical as well as mental health. Self care, shopping, tending to financial matters, securing medical and other treatment services, using transportation, keeping house, maintaining social contacts, all form a part of the functional assessment.

The clinician should also assess the individual’s adaptive strengths that can be built upon in either treatment or rehabilitative care. The individual might have demonstrated capacities that have either been ignored in the psychiatric or psychological evaluations because they are not overtly clinical in nature. Even simple social skills or avocational interests should be reviewed for their potential as positive factors in the individual’s future.

9. Integrative Assessment and Clinical Impression: The integrative assessment of the individual needs to account for all the disorders and significant findings of the preceding headings. What this assessment does is pull the elements together into a comprehensible whole that makes sense of all the comorbidities and problems from the history. This is the place in the evaluation where the themes mentioned at the beginning of this article become important. The integrative assessment should build a plausible portrait of the individual and place the individual’s decisions in the context of real life stressors and real environmental factors. The salient must be delineated from the plethora of details and it must be rendered in plain and clear ways. Labels may be used - but with caution. They can have the opposite to the intended effect. Instead of summarizing, they can have the effect of overriding all of the complexities that the biopsychosocial has developed.

The integrative assessment should show how all the parts of the history work together to produce a life with which others can identify. Severity must be shown, but made familiar, not bizarre. If there is substance abuse, it must be woven into the fabric of the individual’s existence, not left hanging as a separate and independent pathology.

Lastly, the integrative assessment draws inferences about the degree of freedom within which the individual lived. It delineates constraints in the person’s life; constraints caused by cognitive impairment, by heritable mood disorder, by poverty, by being the repeated victim of battery, etc. It renders the individual as one who is making decisions, but in a very limited world of options.

10. Recommendations: The clinician should state those services or settings from which the individual might take benefit. This is most important in sentencing processes where the court must consider rehabilitation potential. It is foolish to offer prognoses given the level of impairment of most forensic cases, but a description of services that the individual can benefit from is a realistic undertaking. These recommendations should be specific and should relate clearly to the salient features of the individual. They should be feasible and not idealistic.

The biopsychosocial is a complex evaluative tool that can bring greater depth and realism to the handling of forensic cases. In defense strategies, it can form the backbone of the humanistic defense where the pain and suffering of the defendant can be translated into meaningful food for thought in the juror. One of the ironies of the process is this: in order for the assessment to adequately render the humanity of the defendant, it must first make use of the most detached clinical processes. Strong feelings (positive or negative) on the part of the examiner in the assessment phase can lead to distorted findings and these distortions can have profound consequences for the life or freedom of the defendant and for the conscience of the clinician.

Additional Readings and References:

American Psychiatric Association, (1995). Practice guidelines for psychiatric evaluation of adults. Supplement to the American Journal of Psychiatry. 152 :11. 67-80.

Blume, J. (1995). Mental health issues in criminal cases: the elements of a competent and reliable mental health examination. The Advocate, August 1995 at 4-12.

Haney, C. (1995). The social context of capital murder: social histories and the logic of mitigation. Santa Clara Law Review, 35. 547- 609.

Melton. G.B., Petrila, J., Poythress, N.G., & Slobogin, C. (1997). Psychological Evaluations for the Courts: A Handbook for Mental Health Professionals and Lawyers. New York, NY: Guilford Press.

Monahan, J. & Steadman, H.J. (1994). Violence and Mental Disorder: Developments in Risk Assessment. Chicago, IL: University of Chicago Press.

Strasberger, L., Gutheil, T. & Brodsky, A. (1997). On wearing two hats: role conflicts in serving as both psychotherapist and expert witness. American Journal of Psychiatry 154,4:448-456.

Weiner, I.B. and Hess, A.K. (1987). Handbook of Forensic Psychology. New York, New York: John Wiley & Sons.
 
 

Robert Walker is Assistant Professor at the University of Kentucky Center on Drug and Alcohol Research in Lexington, Kentucky. He was the Center Director for the Bluegrass East Comprehensive Care Center for nineteen years. He holds a Master’s Degree in Social Work from the University of Kentucky. He is also an Assistant Professor in the College of Social Work and is a member of the Exam Committee for the American Association of State Social Work Boards, the organization that provides licensure exams in that discipline. He serves as an investigator for the Social Work Licensing Board in cases of alleged sexual misconduct.
 
 

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