Dis1 jb

Test Usage in Four Common Types of Forensic Mental Health Assessment

Jennifer L. McLaughlin and Lisa Y. Kan Sam Houston State University

Without established standards of care for different types of forensic mental health assessment, practice surveys can provide information about current trends among evaluators and gauge how “typical” practice follows best practices. This study provides an update on the use of assessment tools in evaluations of response style/malingering, competency to stand trial, mental state at time of alleged offense, and nonsexual violence risk. Almost all forensic evaluators (n � 102) indicated that they use assessment tools to some extent when conducting these types of forensic mental health assessment. Of the 4 instrument types—multiscale inventories, forensic assessment/relevant instruments, cognitive/neuropsychological instruments, and projective techniques—evaluators reported using multiscale inventories at higher rates in evaluations of mental state at time of offense and forensic assessment/relevant instruments at higher rates for the other 3 issues. Projective techniques were used the least often across all forensic issues. We also considered how evaluator variables relate to differences in test usage. Finally, we compare our results with those of previous practice surveys and discuss the implications of these findings.

Keywords: forensic assessment, practice survey, psychological testing

In forensic mental health assessments (FMHAs), evaluators assess relevant psychological and legal constructs with the primary goal of assisting the trier of fact, whether it be a judge or jury, in addressing specific legal questions (Heilbrun et al., 2003). FMHAs involve obtaining, interpreting, and integrating multiple data sources, including record review, clinical interviews, and testing (Melton, Petrila, Poythress, & Slobogin, 2007; Zapf & Roesch, 2009). Clinical interviews may be structured or unstructured, and testing may use clinical assessment instruments (e.g., cognitive and neuropsychological tests, personality inventories), forensically relevant instruments (FRIs; i.e., those that measure clinical con- structs related to legal issues, such as response style and psychop- athy), or forensic assessment instruments (FAIs; i.e., those that directly measure legal constructs, such as functional abilities re- lated to adjudicative competence; Melton et al., 2007; Otto & Heilbrun, 2002). Institutions may require the use of particular procedures or tests for specific forensic questions, and some states have firm guidelines on particular assessment procedures. For

example, Texas requires specific components in sex offender risk assessments, including a sex offender screening tool (Tex. Gen. Laws ch. 62, § 1.01, 2005). Finally, evaluators must be able to support their techniques in court according to the jurisdiction’s standard of evidence.

However, most forensic evaluations do not have statutory re- quirements that dictate the approach evaluators must take (Zapf & Roesch, 2009), not all evaluators work in institutions with proce- dural guidelines, and courts often lack sufficient knowledge to determine whether evidence is scientifically sound (Melton et al., 2007). FMHA scholars and practitioners have provided some guidance in terms of identifying training needs and professional competencies (e.g., DeMatteo, Marczyk, Krauss, & Burl, 2009; Varela & Conroy, 2012) and developing practice resources. There are multiple authoritative texts on conducting FMHAs (e.g., Hei- lbrun, Grisso, & Goldstein, 2009; Melton et al., 2007; Otto & Weiner, 2013; Packer, 2009; Weiner & Hess, 2006), and the Oxford University Press publishes the series “Best Practices in Forensic Mental Health Assessment” (Heilbrun et al., 2009). The American Psychology–Law Society (AP-LS) and the American Academy of Forensic Psychology, two primary professional orga- nizations in the field, recently updated the Specialty Guidelines for Forensic Psychology (American Psychological Association, 2013b), which provide guidance for the “complete specialty prac- tice area” (p. 8), rather than any specific type of FMHA, unlike those published by the American Academy of Psychiatry and the Law (Giorgi-Guarnieri et al., 2002; Gold et al., 2008; Mossman et al., 2007). The only FMHA-specific practice guidelines published by the American Psychological Association (APA) are on child custody evaluations and evaluations of child protection matters (APA, 2010, 2013a; Heilbrun & Brooks, 2010). Importantly, “best practices” and guidelines are generally aspirational and nonbind- ing versus the minimally acceptable level of practice legally en- forced in standards of care (Heilbrun, DeMatteo, Marczyk, & Goldstein, 2008; Slobogin, Rai, & Reisner, 2008).

JENNIFER L. MCLAUGHLIN is a clinical psychology doctoral student at Sam Houston State University where she also earned her masters degree. Her clinical and research interests include multicultural issues in forensic psychology. LISA Y. KAN received her PhD in clinical psychology from Sam Houston State University. She is currently an assistant professor and member of the doctoral program faculty in the Department of Psychology and Philosophy at Sam Houston State University. Her research interests include multicul- tural and practice issues in forensic psychology. THIS ARTICLE IS BASED on Jennifer L. McLaughlin’s masters thesis. Portions of this research were presented at the 2013 annual conference of the American Psychology Law Society. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Lisa Y. Kan, Department of Psychology and Philosophy, Sam Houston State University, Campus Box 2447, Huntsville, TX 77341-2447. E-mail: [email protected]

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Professional Psychology: Research and Practice © 2014 American Psychological Association 2014, Vol. 45, No. 2, 128–135 0735-7028/14/$12.00 DOI: 10.1037/a0036318

128

Without clear standards of care, how can forensic psychologists assure that their practice is “competent enough”? A likely resource is other forensic evaluators to identify how colleagues and peers typically conduct a specific type of FMHA. This might be done through education, training, consultation, supervision, or literature review. Practice surveys are particularly relevant, as they identify current trends among evaluators, which can inform standards of practice and care (Heilbrun et al., 2008), as well as highlight potential problems.1 In addition, such surveys can describe what is generally acceptable to the field (e.g., Lally, 2003), the basis of evidence admissibility in Frye v. United States (1923) and a component of the admissibility standards in Daubert v. Merrell Dow Pharmaceuticals (1993).

We focused on test usage because, unlike clinical interviews and record review, there is less consensus on whether and which tests should be used in some types of FMHA (Giorgi-Guarnieri et al., 2002; Heilbrun & Collins, 1995; Lally, 2003; Melton et al., 2007). For example, clinical assessment instruments measure a person’s current cognitive, personality, or psychological functioning. Such information may have limited relevance in evaluations of criminal responsibility/mental status at time of alleged offense (MSO). This type of FMHA involves the assessment of the defendant’s thoughts, beliefs, and behaviors before, during, and immediately following the alleged offense to determine whether (and to what extent) the defendant’s understanding of the nature and/or wrong- fulness of his or her actions was impaired as a result of a mental disease or defect (Melton et al., 2007; Packer, 2009). Thus, it is the defendant’s prior functioning that is of primary interest in MSO evaluations, not his or her current functioning. Competency to stand trial (CST) evaluations, while present focused, require a specific assessment of the defendant’s current ability to demon- strate a factual and rational understanding of the legal proceedings, as well as the ability to consult effectively with counsel (Melton et al., 2007; Zapf & Roesch, 2009). Clinical assessment instruments do not directly measure these functional abilities.

Self-report studies, however, suggest that evaluators consider acceptable, and often incorporate, the use of multiscale inventories and intelligence measures in forensic evaluations, including those for MSO and CST (Archer, Buffington-Vollum, Stredny, & Han- del, 2006; Borum & Grisso, 1995; Lally, 2003). In particular, all psychologists in one study (Borum & Grisso, 1995) reported some use of clinical instruments; in contrast, 36% and 46% reported never using FAIs in their CST and MSO cases, respectively. Interestingly, rates of test usage are substantially lower when they are based on a review of FMHA reports. Heilbrun and Collins (1995) found that only a minority of reports by psychologists included any testing (13% of inpatient and 41% of outpatient evaluations). Warren and colleagues (Warren, Murrie, Chauhan, Dietz, & Morris, 2004; Warren et al., 2006) too found that tests were used in only approximately 17% of CST and 22% of MSO evaluations conducted in Virginia.

On the other hand, there is widespread support for the use of measures in violence risk assessments, a type of FMHA in which evaluators might be asked to estimate the likelihood of future violent behaviors within a specified timeframe, identify risk and protective factors, and recommend risk management strategies (e.g., Conroy & Murrie, 2007; Heilbrun, 2009; Skeem & Mo- nahan, 2011). Risk assessments can provide relevant information in various decisions, such as those for civil commitment and

sentencing (Viljoen, McLachlan, & Vincent, 2010). Scholars have made significant progress in the development of risk assessment approaches and instruments in the past decades, and the fallacies of using an unstructured approach are well documented (see Camp- bell, French, & Gendreau, 2009). Both actuarial and structured professional judgment approaches involve the use of assessment tools that specify which and how risk factors are considered (Heilbrun, Yasuhara, & Shah, 2010). Indeed, some experts suggest that evaluators will likely need to defend why they did not use an instrument when conducting a risk assessment (Conroy & Murrie, 2007; Viljoen et al., 2010). Even when using specific instruments is inappropriate (e.g., due to mismatch between evaluee and nor- mative sample; APA, 2002, 2013b), a structured approach is so important that evaluators should “structure” their assessments through systematic consideration of empirically identified or per- sonally relevant risk factors (Heilbrun et al., 2009). Recent surveys indicate that evaluator opinion and practice are in line with these recommendations. Lally (2003) found that an FAI, specifically the Psychopathy Checklist—Revised (PCL–R), is the only “recom- mended” instrument for violence risk assessments. Likewise, Vil- joen and colleagues (2010) reported that more evaluators used risk and psychopathy assessment tools almost all or all the time com- pared with tests for psychopathology or cognitive abilities.

In addition, experts suggest that every FMHA, regardless of the referral question, should include an assessment of response style or malingering (Frederick, 2012; Melton et al., 2007; Zapf & Roesch, 2009). This type of assessment aims to determine whether evaluees are feigning, exaggerating, or minimizing symptoms of cognitive deficits, psychopathology, or functional abilities, for an external gain they would not otherwise be granted (e.g., lesser sentence, mental health treatment, early discharge; Frederick, 2012). The potential consequences of misclassifying honest or dishonest re- sponders are serious (D’Amato & Denney, 2008; Rogers, Vitacco, & Kurus, 2010; Simon, 2007), and researchers have developed multiple tools to increase evaluators’ ability to accurately assess response style. Currently, a wide range of assessment tools is available, either as individual measures or as validity scales within other instruments (Boone, 2009; Heilbronner, Sweet, Morgan, Larrabee, & Millis, 2009; Rogers et al., 2010), for different target behaviors (e.g., psychopathology, cognitive functioning; Freder- ick, 2012). Thus, experts recommend the inclusion of empirically supported instruments in assessment of response style or malin- gering (Frederick, 2012; Heilbronner et al., 2009; Nussbaum, Hancock, Turner, Arrowood, & Melodick, 2008). Despite these recommendations, it is unclear how often evaluators use instru- ments to assess response style or malingering. Lally (2003) found that his respondents considered both the Minnesota Multiphasic Personality Inventory—2 (MMPI–2) and the Structured Interview of Reported Symptoms (SIRS) as “recommended” instruments, and Archer et al. (2006) reported that the SIRS and Test of Memory Malingering (TOMM) were the most popular among specialized tools for malingering.

This study provides an update on the use of tests or assessment tools in four common foci in FMHAs—response style/malinger- ing, CST, MSO, and risk for future nonsexual violence. We also

1 For a thorough discussion of the relationship between standards of practice and standards of care, see Heilbrun et al. (2008).

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129TEST USAGE IN FMHA

examined whether and how evaluator variables relate to test usage. Specifically, we hypothesized that test usage would be higher among evaluators who completed their degree more recently and those who completed a postdoctoral fellowship in forensic psy- chology because they are more likely to be aware of the recent advances in test development for FMHAs (Heilbrun et al., 2008; Viljoen et al., 2010). In addition, we hypothesized that test usage would be higher among those who practice in one of the 17 states that specifically require FMHA training (Heilbrun & Brooks, 2010).

Method

Participants

Forensic evaluators (N � 115) in professional psychological practice consented to participate in the online survey. Of these, 103 completed at least the demographic section of the survey. One respondent indicated that her clinical practice did not involve any FMHAs; thus, her responses were dropped from all analyses. In the final sample (n � 102), most participants identified as Cauca- sian (91.2%) and had earned a PhD (75.5%), on average, 14.24 years (SD � 11.60) before. The majority (84.3%) reported com- pleting some formal training in forensic psychology, either through a postdoctoral fellowship (45.1%) or state/institution-required training (70.6%). In addition, 52% reported practicing in a state that requires training in FMHA and 16.7% reported receiving board certification from the American Board of Forensic Psychol- ogy (ABFP). Participants reported working in a variety of settings, with the most endorsed setting a state/federal institution (44.1%). See Table 1 for additional participant demographics.

Procedure

The data were collected as part of a larger study on evaluator beliefs, personality, and test usage (McLaughlin, 2013). We iden- tified potential participants through three methods and recruited them through e-mail. First, the primary author contacted the Web- master of AP-LS, who sent an initial recruitment e-mail to all nonstudent members of AP-LS, followed by a second e-mail 2 weeks later. Second, the primary author individually e-mailed psychologists who received board certification from ABFP, using the publicly available e-mail directory. Lastly, we asked potential participants to distribute the survey information to their colleagues. Potential participants needed to have a graduate degree in psychol- ogy, be in professional practice (i.e., not currently completing a postdoctoral fellowship), and have conducted an evaluation ad- dressing at least one of the four forensic issues in the previous 6 months.

The recruitment message provided a brief description of the overall study, inclusionary criteria, contact information, and a link to the online materials on Survey Monkey. The link directed the participants to the confidentiality and consent agreement, and they were required to provide informed consent before beginning the survey.

We were unable to estimate the response rate for several rea- sons. AP-LS did not provide the number of nonstudent members in its e-mail directory, and not all nonstudent members engage in forensic practice. We have no information about the number of

invitations sent by participants, and some likely received multiple invitations, for example, from a colleague and e-mails from AP- LS. Our final sample size is comparable to those of other practice surveys (Borum & Grisso, 1995; Lally, 2003).

Materials

The online survey included three sections. The first section included demographic questions regarding the participants’ per- sonal characteristics (e.g., age, race, gender), graduate training, and training and practice in forensic psychology. Specifically, participants estimated the portion of their practice devoted to conducting forensic evaluations and the number of times they addressed each of the four forensic issues (i.e., response style/ malingering, CST, MSO, risk for nonsexual violence), as well as other types of FMHA, in the past year. The second section (not presented here) consisted of the Goldberg Five-Factor Markers (Goldberg, 1992) personality measure. The third section included four subsections, one for each forensic issue, that asked about the evaluators’ perceptions of the use of four types of instruments. Examples of multiscale inventories (e.g., MMPI–2, MMPI–2— Restructured Form, Millon Clinical Multiaxial Inventory, Person-

Table 1 Characteristics of Participants

Variable Value

Mean (SD) age (years) 46.41 (13.44) Gender: Female, % 51.0 Ethnicity, %

African American 2.00 Asian American 3.90 Caucasian 91.2 Hispanic 2.90 Other 2.00

Highest degree, % PhD 75.50 PsyD 23.50 MA 1.00

Mean (SD) years since degree attainment 14.24 (11.60) Work environment, %

Academic 16.70 State/federal institution 44.10 Hospital 24.50 Independent practice 37.30

Any forensic training, % 84.30 Forensic postdoctoral training 45.10 State/institution training 70.60

Practice in a state that requires forensic training, % 52.00 Board certification in forensic psychology, % 16.70 Mean (SD) percentage of practice devoted to

forensic evaluations (n � 100) 67.39 (32.80) Mean (SD) number of times forensic issue was

addressed in past year Response style/malingering (n � 99) 39.61 (107.16) CST (n � 101) 34.12 (46.62) MSO (n � 98) 14.12 (25.61) Nonsexual violence risk (n � 96) 20.28 (38.11) Other types of FMHA (n � 43) 27.53 (63.05)

Note. n � 102, unless otherwise noted. Evaluators could choose more than one category for the variables ethnicity and work environment; therefore, the percentages do not add to 100%. CST � competence to stand trial; MSO � mental state at time of alleged offense; FMHA � forensic mental health assessment.

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130 MCLAUGHLIN AND KAN

ality Assessment Inventory), cognitive/neuropsychological instru- ments (e.g., Wechsler scales, Halstead Reitan Neuropsychological Battery, Trailmaking Test), and projective techniques (e.g., Ror- schach Inkblot Test, Thematic Apperception Test) were the same for each forensic issue, as evaluators might use the same instru- ment(s) for different purposes. For instance, an evaluator might use the MMPI–2 to assess both response style and psychopathol- ogy as part of an MSO evaluation; in the survey, participants were asked to endorse the use of MMPI–2 for the forensic issues separately. Examples of FAIs/FRIs were specific for each type of FMHA, such as the TOMM and SIRS for assessing response style/malingering and the MacArthur Competency Assessment Tool for CST. Participants also estimated the percentage of eval- uations for which each type of instrument was actually used for each forensic issue.

All participants were asked about their perceptions and practice in assessing response style/malingering because it is considered a part of all forensic evaluations (Frederick, 2012; Melton et al., 2007; Rogers, 2008). For the other forensic issues, participants only answered the respective questions if they addressed the issue in the past 6 months. Therefore, participants could answer ques- tions pertaining to one, two, or three additional forensic issues.

Results

Participants varied widely in the portion of their practice de- voted to forensic evaluations, from 10% to 100% (M � 67.39%, SD � 32.80). Response style/malingering was the most common forensic issue addressed, with respondents reporting that they evaluated the construct an average of 39.61 times (SD � 107.16) in the past year, followed by CST (M � 34.12, SD � 46.62), risk

for nonsexual violence (M � 20.28, SD � 38.11), and MSO (M � 14.12, SD � 25.61). Approximately 35% reported conducting other types of FMHA in the past year. However, seven participants reported that they did not assess response style/malingering in the past year, despite addressing other forensic issues, and a majority (82.4%) indicated that they addressed other forensic issues more frequently than they did response style/malingering.

Regarding test usage, one participant did not answer any ques- tions regarding test usage for any of the four forensic issues and was therefore not included in further analyses. All other partici- pants (n � 101) reported using assessment tools to some extent. Only one of 82 (1.2%) evaluators who assessed CST and four of 72 (5.6%) who assessed nonsexual violence risk indicated never using any assessment tool, versus 12 of 68 (17.6%) who assessed MSO. Mean frequencies (i.e., percentage of cases) of test usage differed by type of assessment tool and type of FMHA (see Table 2). FAIs/FRIs were the most frequently used in evaluations of response style/malingering, CST, and risk for nonsexual violence, and multiscale inventories were the most frequently used in MSO assessments. Evaluators used projective techniques the least often across all four forensic issues.

To compare our results with previous surveys, we also cate- gorized the frequencies of usage based on the categories in Borum and Grisso (1995). For evaluation of response style/ malingering, more participants reported “almost always” (81– 100%) using FAIs/FRIs than other instrument types (see Table 2). The pattern was similar for CST and nonsexual violence risk evaluations, and more participants reported they “almost al- ways” used multiscale inventories in MSO assessments than other instrument types.

Table 2 Frequencies of Test Usage for Four Forensic Issues

Instrument type Mean (SD) percentage

of cases

Categories of test usage frequency (%)a

Never (0%)

Rarely (1–10%)

Sometimes (11–40%)

Frequently (41–80%)

Almost always (81–100%)

Response style/malingering Multiscale inventories (n � 101) 52.21 (39.13) 9.9 17.8 14.9 25.7 31.7 FRI/FAI (n � 100) 66.44 (35.70) 2.0 15.0 10.0 25.0 48.0 C/N (n � 100) 21.41 (27.48) 30.0 28.0 22.0 15.0 5.0 Projective (n � 100) 4.86 (15.97) 81.0 8.0 7.0 3.0 1.0

CST Multiscale inventories (n � 82) 26.80 (33.20) 29.3 25.6 13.4 19.5 12.2 FRI/FAI (n � 82) 42.83 (39.96) 11.0 25.6 20.7 13.4 29.3 C/N (n � 82) 26.62 (29.69) 12.2 30.5 36.6 9.8 11.0 Projective (n � 82) 2.52 (11.00) 87.8 7.3 2.4 2.4 0.0

MSO Multiscale inventories (n � 68) 38.40 (39.04) 23.5 20.6 13.2 23.5 19.1 FRI/FAI (n � 68) 20.79 (34.80) 57.4 14.7 7.4 5.9 14.7 C/N (n � 68) 20.88 (26.77) 27.9 27.9 26.5 11.8 5.9 Projective (n � 68) 4.79 (15.72) 80.9 10.3 4.4 2.9 1.5

Nonsexual violence risk Multiscale inventories (n � 72) 49.13 (40.23) 16.7 15.3 16.7 22.2 29.2 FRI/FAI (n � 72) 78.68 (32.98) 5.6 4.2 8.3 18.1 63.9 C/N (n � 70) 26.91 (31.76) 24.3 28.6 21.4 15.7 10.0 Projective (n � 70) 6.10 (16.25) 78.6 8.6 7.1 5.7 0.0

Note. Percentage of cases refers to the proportion of cases in which participants reported using the instrument type for the forensic issue. CST � competence to stand trial; MSO � mental state at time of alleged offense; FAI � forensic assessment instrument; FRI � forensically relevant instrument; C/N � cognitive/neuropsychological instruments. a Values in these columns represent the percentage of respondents whose reported test usage frequency falls within that frequency category.

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131TEST USAGE IN FMHA

Finally, we used nonparametric tests to examine whether and how test usage differed based on completion of postdoctoral train- ing in forensic psychology, state requirements for FMHA training, and recency of degree attainment, to accommodate the nonnormal distributions of the test usage data (see Table 3). We focused on the use of multiscale inventories, FAIs/FRIs, and cognitive/neuro- psychological tools given that only a few evaluators reported using projective techniques. To minimize the risk of Type I error, we set a more stringent statistical significance level at p � .001 (using Bonferroni correction [Warner, 2008], based on dividing the stan- dard statistical significance level of p � .05 by 36 comparisons).

There were no significant differences in test usage based on evaluators’ postdoctoral training in forensic psychology or states’ requirements for forensic training. The only significant finding involved years since degree attainment, which was negatively correlated with the use FAIs/FRIs in nonsexual violence risk assessments (rs � �.38, p � .001, one-tailed).

Discussion

In this study, our primary goal was to describe evaluators’ test usage of four common types of FMHA— response style/malin- gering, CST, MSO, and nonsexual violence risk. In general, the reported use of each instrument type averaged about 50% or less, regardless of the forensic issue. Two notable exceptions are the use of FAIs/FRIs in evaluations of response style/malingering and nonsexual violence risk; evaluators reported they used FAIs/FRIs in an average of 66% and 79% of their cases, respectively. This is encouraging, given the accumulating empirical support for these structured assessments for evaluating response style and violence risk (e.g., Conroy & Murrie, 2007; Rogers, 2008; Skeem & Mo- nahan, 2011). Furthermore, the occasional use of other instrument types, such as multiscale inventories and cognitive/neuropsycho-

logical measures in CST evaluations, is consistent with the lack of consensus on the usefulness of such clinical assessment instru- ments in FMHAs (Giorgi-Guarnieri et al., 2002; Melton et al., 2007). On one hand, clinical assessment instruments do not spe- cifically address the psycholegal issue at hand, whether it be CST, MSO, or risk of nonsexual violence. On the other, they do offer structured approaches to assess clinical constructs, such as psy- chopathology and intelligence, which can be relevant to FMHAs. Their use might be particularly appropriate when evaluators are required to offer a rationale for observed functional impairments (e.g., a defendant cannot consult with defense counsel because of severe intellectual disability; Mossman et al., 2007) or when they need to clarify diagnoses to provide appropriate treatment recom- mendations.

More disconcerting, however, is the result that a majority of participants indicated that they assessed other forensic issues more frequently than response style/malingering, despite the fact that various experts (Frederick, 2012; Melton et al., 2007; Rogers, 2008) consider response style an integral part of all forensic evaluations. Our respondents simply might have misunderstood the instructions to count each forensic issue separately if they address multiple ones in the same evaluation. Or they might have worked in settings in which different evaluators are responsible for different aspects of forensic evaluations, although this is unlikely to be true for most of the respondents. A less innocuous reason is that evaluators are indeed omitting assessment of response style in forensic evaluations, which is arguably inconsistent with best practices.

Another finding worth additional consideration is the use of FAIs/FRIs in nonsexual violence risk assessment. On the one hand, it is clearly the most used instrument type for the issue, with respondents indicating its use in approximately 79% of their cases on average, which is consistent with practice guidelines (e.g., Skeem & Monahan, 2011). However, interpreted another way, evaluators reported they did not use FAIs/FRIs in about 20% of their cases. This might be reasonable and appropriate given that evaluators must consider the instruments’ relevance for the partic- ular evaluee in that particular context when determining whether and which tests to use (APA, 2002, 2013b; Heilbrun, 1992; Varela & Conroy, 2012). One potential reason for not using assessment tools is the mismatch between the evaluee and the instrument’s normative sample, which is common when working with diverse evaluees (Weiss & Rosenfeld, 2010). As Singh, Grann, and Fazel (2011) pointed out, normative samples for risk assessment tools tend to be predominantly Caucasian. Correspondingly, they found some evidence that predictive validity tended to be higher when study samples were predominantly Caucasian in their meta- analysis of violence risk assessment tools. In addition, many studies on risk assessment instruments failed to provide a thorough demographic breakdown of participants and neglected to include the racial makeup of their participants (Gonzalez, 2013), which makes it difficult for evaluators to determine whether the instru- ment is appropriate for use. Problems with using risk assessment tools also arise when there are limited records available for eval- uees. The PCL–R (Hare, 2003), a common FRI in risk assess- ments, relies heavily on records, to the extent that its use is allowed without interviewing the evaluee but is discouraged if sufficient records are unavailable. Without PCL–R results, use of other common risk instruments is restricted, as the Historical-Clinical-

Table 3 Relationship Between Test Usage and Evaluator Characteristic

Postdoctoral training

State- required training

Years since degree

attainment

Test usage z p z p rs p

Response style/malingering Multiscale inventories �1.20 .12 �1.24 .11 .007 .47 FAI/FRI �0.18 .43 �1.28 .10 �.14 .09 C/N �0.57 .29 �1.15 .13 .10 .17

CST Multiscale inventories �0.75 .23 �0.32 .38 .09 .21 FAI/FRI �1.24 .11 �1.58 .06 .15 .09 C/N �1.77 .04 �1.82 .03 .05 .34

MSO Multiscale inventories �0.71 .24 �1.44 .08 .10 .20 FAI/FRI �0.83 .21 �0.04 .49 .28 .01 C/N �0.43 .34 �1.03 .15 .29 .01

Nonsexual violence risk Multiscale inventories �1.04 .15 �0.73 .23 .11 .18 FAI/FRI �1.84 .03 �2.61 .004 �.38� .001 C/N �0.32 .38 �0.06 .48 .03 .40

Note. CST � competence to stand trial; MSO � mental state at time of alleged offense; FAI � forensic assessment instrument; FRI � forensically relevant instrument; C/N � cognitive/neuropsychological instruments. � Significant at p � .001, one-tailed.

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Risk Management—20 (Webster, Douglas, Eaves, & Hart, 1997) and the Violence Risk Appraisal Guide (Quinsey, Harris, Rice, & Cormier, 1998, 2006) incorporate the PCL–R total score. Of course, there are less defensible reasons for not using risk assess- ment tools, including evaluators’ unfamiliarity with, or lack of competence in, using them (Tolman & Mullendore, 2003). The time and effort required to gather and review information neces- sary to use these instruments might deter their use among some evaluators. Systemic constraints, such as time limits in assessing risk during temporary holds for involuntary hospitalizations and lack of assessment measures provided by institutions, likely limit test usage, regardless of evaluators’ intentions or desires to engage in best practices.

Perhaps most unexpected was the overall lack of significant differences on test usage based on evaluator characteristics. Con- trary to our hypotheses, evaluators who completed postdoctoral training in forensic psychology or practiced in states with required FMHA training did not report significantly higher rates of test usage. This might be due to the study’s sample, as most reported completing some forensic training. The primary methods of re- cruitment involved e-mailing psychologists board certified by ABFP and members of AP-LS; therefore, respondents (regardless of training requisites) might be equally likely to attend the orga- nizations’ presentations on FMHAs. The only significant differ- ence involved the use of FAIs/FRIs in nonsexual violence risk assessments. Consistent with our hypothesis, evaluators who had received their degree more recently were more likely to use fo- rensic instruments. This might be attributed to their being more aware of the recent advances in test development for FMHAs (Heilbrun et al., 2008; Viljoen et al., 2010).

How do our results compare with previous practice surveys? Like the psychologists in Borum and Grisso’s (1995) study, almost all of our respondents reported using assessment tools to some extent. The pattern of test usage across different forensic issues (i.e., multiscale inventories more frequently used in MSO evalu- ations and FAIs/FRIs more frequently used for the other three issues) is consistent with Lally’s (2003) results on which tests were “recommended” for these types of FMHA. In addition, our finding that a majority of respondents “almost always” use FAIs/FRIs in nonsexual violence risk assessments is congruent with Viljoen et al. (2010).

Taken together, we conclude that assessment tools are routinely used in these four common types of FMHA. Use of some specific instrument types might be lower than expected or desired, but such findings should not be considered recommended or acceptable practice. Rather, we interpret them as indicators of areas for improvement, either in further promotion and education of existing measures or in development of better tools. We agree with other scholars’ (e.g., Borum & Grisso, 1995; Conroy & Murrie, 2007; Viljoen et al., 2010) assertion that evaluators should provide sound rationale for their decisions not to use assessment tools in FMHAs, especially for issues for which empirical evidence strongly support such usage (e.g., risk assessment). There are clear preferences for the use of certain instrument types among all four issues, partic- ularly for the use of FAIs/FRIs in nonsexual violence risk assess- ments. However, the use of forensic instruments in nonsexual violence risk assessments is influenced by recency of evaluators’ degree. These results, along with evidence that evaluators might not assess response style/malingering in all FMHAs, highlight the

importance of developing and maintaining professional compe- tence (e.g., APA, 2002; Varela & Conroy, 2012).

Professional competence in forensic psychology includes spe- cialized knowledge and skills, which are primarily developed at the postdoctoral level through a variety of avenues (Forensic Specialty Council, 2007; Otto & Heilbrun, 2002; Packer, 2008). Formal postdoctoral fellowships, typically 1 to 2 years long, offer intensive training and supervised experiences in forensic psychol- ogy (DeMatteo et al., 2009). The AP-LS/APA Division 41 Website and the Association of Psychology Postdoctoral and Internship Centers provide directories of postdoctoral fellowships with a forensic component. Completion of fellowships often provides the postdoctoral students with supervised experiences necessary for licensure in some states (DeMatteo et al., 2009), and it can lead to early eligibility for board certification in forensic psychology (American Academy of Forensic Psychology, n.d.; Packer, 2008). However, the likelihood of obtaining a fellowship is very low: Malesky and Proctor (2012) identified only 32 positions (of which 29 were funded) among 16 formal postdoctoral fellowships in forensic psychology for 317 applicants in the year 2008–2009.

Beyond formal fellowships, practitioners can gain postdoctoral training in forensic psychology through state certification pro- grams or continuing education (CE) workshops (DeMatteo et al., 2009), with supplemental supervised experience (Packer, 2008). For example, Virginia requires evaluators to complete a 5-day program at the Institute of Law, Psychiatry, and Public Policy to be eligible to conduct CST and MSO evaluations with adults (Insti- tute of Law, Psychiatry, and Public Policy, 2012). CE workshops on forensic psychology are widely available and can be several hours to several days long. AP-LS typically offers CE workshops before its annual conferences, and the American Academy of Forensic Psychology provides several intensive programs through- out the year. Some states also require periodic recertification or a minimum of CE hours in forensic psychology each year, which can help evaluators stay informed about advancements in the field (Heilbrun & Brooks, 2010).

Finally, regardless of training, experience, or recency of degree attainment, evaluators need to maintain competence and stay abreast of relevant literature. Evaluators can learn about the latest research, practice recommendations, and legal developments by attending conferences and CE workshops, joining listservs, and reading texts or journals dedicated to forensic psychology such as the series in “Best Practices in Forensic Mental Health Assess- ment,” Law and Human Behavior, and Psychology, Public Policy, and Law. Staying informed allows evaluators to maintain an em- pirically and legally informed basis to justify their work, an inte- gral part of competent forensic practice (e.g., Conroy & Murrie, 2007; Nicholson & Norwood, 2000).

This study has several limitations. First, we recruited partici- pants mostly by e-mailing psychologists board certified by ABFP and members of AP-LS. As Archer and colleagues (2006) pointed out, these evaluators might be systematically different from those who do not hold memberships in professional organizations and thus might not represent the “average” forensic evaluator. Simi- larly, there might be important, but unknown, differences between those who agreed to participate in online research and those who did not. Future studies should also recruit participants in person (i.e., at conferences, workshops, work sites) and through other means (e.g., state registry of licensed psychologists) to address

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these concerns. Second, we focused on the use of different instru- ment types for different forensic issues rather than test usage overall or specific instruments. We chose to do this to shorten the survey and encourage participation, but we cannot identify which instrument(s) evaluators tend to use for different purposes. Future studies should address such questions to further inform practice trends.

Third, we did not ask participants to provide rationale for their use (or nonuse) of assessment tools. Evaluators should only use instruments in cases for which there is sufficient justification (Nicholson & Norwood, 2000), and understanding their decision- making process can more clearly inform standards of care. Al- though evaluators will likely benefit from the use of instruments in most instances, there are appropriate reasons why evaluators do not use assessment tools in every case. Just as we are concerned about lower-than-expected test usage being erroneously consid- ered as recommended or acceptable practice, high utilization rates stemming from improper use of instruments should not form the basis for standards of care either. Thus, frequency of test use is only one of many pieces of information necessary for understand- ing competent practice. Competent evaluators should be able to provide explicit, thoughtful, and empirically based rationale for their decisions, from using assessment tools to forming their con- clusions, and future research should aim to explore such reasoning using both quantitative and qualitative methods. This can help better identify areas of training or development necessary to ad- vance the field of FMHAs.

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Received July 17, 2013 Revision received January 13, 2014

Accepted January 24, 2014 �

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