Forensic Psychology – Case Study

Argosy University Comprehensive Examination
MA Forensic Psychology

Fall B, 2016

(Thursday, October 27 through Wednesday, November 2)

Case Vignette for Comprehensive Examination
Please read the vignette carefully. Based on information provided in the vignette, please compose a well-written and organized response to each of the questions that follow:

IDENTIFYING DATA:

Mr. L is a 45-year-old, single, African American male who has been incarcerated in Florida State Prison since 2009. He is currently serving a 15-year prison sentence for attempted murder. On July 20, 2016, Mr. L was charged with 1 Count of Attempted Murder in the Second Degree and 1 Count of Aggravated Battery (great bodily harm) on two inmates he is housed with at Florida State Prison.

On September 3, 2016, Mr. L was committed by Judge Watkins to the Department of Children and Families for further evaluation and on September 15, 2016, he was admitted to Treasure Coast Forensic Treatment Center. His Commitment Order requests an evaluation to assist the Court in its determination of the Defendant�s Competency to Proceed and Mental State at the Time of the Offenses (1 Count of Attempted Murder in the Second Degree and 1 Count of Aggravated Battery).

INSTANT OFFENSE:
According to the Offense Event Report submitted July 20, 2016, Mr. L allegedly walked into a cell of another inmate, wrapped a sheet around his neck, attempted to strangle him but instead proceeded to physically attack him until he was unconscious. Following the attack, while walking towards the day room, he allegedly grabbed an inmate walking by him and bit his left ear, resulting in a condition where the top of his earlobe was missing.
RELEVANT HISTORY:

According to his prison records, Mr. L�s responses are typically inconsistent, vague, and cynical. Overall, Mr. L is considered a poor historian and, therefore, information reported by Mr. L should be considered unreliable. All information obtained by Mr. L should be validated through other sources.
Personal, Social, Family, Education, and Work History:
Records indicate that Mr. L was born and raised in Lake County, Florida. His parents reportedly separated when he was 11 years old. Although he left home at the age of 14, remained close with his mother. He has no contact with his father since his father left at age 11. According to Mr. L, throughout his childhood he witnessed his father abuse his mother emotionally and physically. He also reported that his father disrespected and undervalued women in general. Reportedly, Mr. L left home because he did not want to comply with the rules his mother enforced. He stated that he recognized increased negative feelings towards his mother so decided to leave before their relationship became more dysfunctional. Mr. L has one brother, five years older than him, who has a history of psychiatric problems and remains estranged from the family. Mr. L reported that he had another brother, two years old than him, who was killed at the age of 15 after being shot during gang-related activity. One record indicates that he was married and has four children. Another record indicates that he was never married and �may� have children.
Regarding education, Mr. L was reportedly placed in Special Education classes from 6th grade through 8th grade. He dropped out of school during freshman year of high school. In terms of occupational history, one record indicates that he did construction and farm work. Another record indicates that when asked about employment, he answered, �I�ve been in prison more times than not� I ain�t had time to work.� Reportedly, Mr. L received disability in the past. He has no military history.
Mental Health History:
According to records, Mr. L has an extensive history of psychiatric treatment. He has had approximately 10 admissions to the Chattahoochee State Hospital, where he was initially diagnosed with Schizoaffective Disorder, Bipolar Type and Polysubstance Abuse. Over the years and after numerous psychological evaluations, he also received diagnoses of Schizoprhenia, Paranoid Type; Bipolar Disorder; Antisocial Disorder, and Malingering. One evaluator suggested that he has psychopathic tendencies. History of psychiatric treatment includes prescriptions for Invega, Lithium, Vistaril, Thorazine, Seroquel and Haldol. However, therapeutic response to these medications (i.e., symptom reduction and stabilization) was intermittent and inconsistent with medication regimens. Documentation consistently described Mr. L as being physically aggressive, manipulative, and difficult to treat. He was also consistently described as being able to present with specific mental health symptoms at times appearing convenient for him. It should be noted that throughout the course of his life, he has spent time between psychiatric facilities, forensic hospitals, jails and prisons.
Mental health records indicate a history of being �loud� and �hyperverbal at times.� He is able to �manipulate the conversation and repeatedly go off task; however, he is easily redirected.� His thought process has been described as �disorganized� and this thought content evidenced �paranoid, sexual, and religious themes.� Mr. L wished for �lethal injection� because �I know I�ve done wrong, and the only way to make sure I don�t do it again, is to die.� Mr. L stated that �when he got angry, he did not think straight, and that he knew it was wrong.�
History of delusional thinking and hallucinatory experiences is vague and inconsistent. Mr. L has been observed conversing with �Jesus�. However, there is also report of Mr. L stating, �You know I�m faking and I know I�m faking, but nobody else can figure it out. I�m gonna say and do whatever it takes to get a disability check and not go back to prison�. Additionally, when a nurse encouraged him to take his medications, he replied, �What for? This place is a cakewalk nurse, and I love cake, see these teeth, they are rotten from cake.� Another records quotes Mr. L asking, �What would you rather do, face life in prison or act crazy?�
Mr. L�s behavior is generally threatening, manipulative, aggressive, and unpredictable. He is typically noncompliant with rules and regulations. He has a history of repeated and severe episodes of aggression, primarily unprovoked. Such episodes include attacking other inmates and patients (when in psychiatric hospitals) with food trays, chairs, and garbage cans. He has spit and thrown urine on nurses during medication pass. He has also stored razors he was given to shave (while supervised) to cut other inmates and patients when he had the opportunity. He also has a history of sexual preoccupation, whereas he makes sexual remarks towards and requests of female staff, masturbates in front of others and laughs at their reaction, and discusses with male officers and other staff what he would do to a female if he could. One report provides details of another attack by Mr. L on another inmate two years ago, leaving him in a coma for several months, followed by additional attacks on three different inmates within a two week span, resulting in one hospitalization. The report specifies that Mr. L�s �aggressive behavior is geared toward people he believes will not fight back.� On one occasion, after an assault, he �stated he selected the victim because he was a weaker one.�
Due to the chronic nature of Mr. L�s violence and discrepancies over diagnosis throughout the years, forensic hospital administrators have discussed whether he is appropriate for a forensic hospital. The argument is that housing him in an environment with vulnerable individuals (i.e., people with severe and persistent mental illness) puts them at great risk of harm. Additionally, staff members are at risk of harm, as forensic hospitals are prohibited from following safety/security procedures that correctional facilities are permitted to follow. It has been reported that correctional facility administrators claim he is too mentally ill to be held responsible for his actions and therefore push for commitment to forensic facilities. It has also been reported that a majority of psychiatric and forensic psychiatric facility administrators claim he is not mentally, needs to be held responsible for his actions, and must be managed in correctional facilities. It should also be noted that thoroughness of previous evaluations, lack of adequate testing, and accuracy of diagnoses have been scrutinized over the years due to a variety of factors.
Physical Health and Substance Abuse History:
Records indicate that Mr. L has a history of hypertension but, overall, he has reported his health to be �good�. Records also indicate that Mr. L suffered a head injury in the during a fight freshman year. Mr. L was also reportedly stabbed in the head and raped while in prison. His medical history is reported to include the presence of blood in his urine.
According to records, Mr. L began abusing alcohol at the age of 13, marijuana at the age of 15, and cocaine at age 16. Mr. L also has a history of regular nicotine use. Mr. L reported that he routinely used said substances up through his incarceration in 2009. He added, however, that he has used various drugs while incarcerated whenever he could obtain a substance.
MENTAL STATUS EXAMINATION (CURRENT OBSERVATIONS):
Mr. L is an African-American male who is 6 foot, 2 inches in height and approximately 230 pounds. Generally, his grooming and hygiene is fair. He has short, somewhat unkempt black hair, a beard, and wears a beanie cap on his head that he covers over his eyes when he does not want to talk or becomes agitated. He has several missing teeth and maintains poor oral hygiene. During two interactions with you, he was cooperative and engaging, and he displayed normal eye contact. He was alert and oriented to person, time, place and situation. No abnormal behaviors, disturbances in gait, or resting or intention tremors were observed. Generally, ability in terms of attention and concentration was within normal limits; however, at times he strays from task or shifts focus for the purpose of what appears to be an attempt to control the conversation or situation.
There did not appear to be any disturbance in expressive or receptive language. Immediate, recent and remote memory appeared adequate, based on his ability to recall past events as well as recent events with ease. His thought process was clear, organized and goal-directed. There were no observations of any perceptual abnormalities, and, when asked, he denied perceptual disturbance. No delusional content was observed.
Mr. L denied homicidal and suicidal ideations, intentions or plans. However, it should be noted that Mr. L does tend to make intermittent statements regarding both homicide and suicide. Mr. L stated to, �I can�t help it, it�s in my blood. Medication can�t help me. I�m going to kill someone before it�s all over. I�m angry. I�ve evil.� With regard to suicide, he makes statements requesting �lethal injection� because he �just wants to die.� At times, he states that he does not deserve to live because of the �things� he has done. He stated, �I want to kill so they can take my life. I�m tired of living.�
Task Identification
You are a forensic mental health evaluator being asked to evaluate Mr. L and make service recommendations while he is being treated at the forensic hospital. You are working closely with the Forensic Psychologist who will be evaluating his Competence to Proceed and Mental Status at the Time of the Offense. You are to produce a written case report addressing the questions, below. The report will be submitted to the appropriate supervisor and may be presented to the court.

Exam Questions

Based on the vignette provided above, please compose a well-written and organized response to each of the following questions. When writing your responses, please:

� Use APA (6th Edition, Second Printing) Style, with 1-inch margins, double-spaced, 12 font, with a reference list at the end.
� Write clearly and concisely.
� Cite appropriate, and especially current, literature (empirical and/or theoretical).
� Avoid all sexist idioms and allusions.
� Remember to demonstrate your multicultural competence where appropriate.

Psychological Theory and Practice

A. What assessments (general and specific) would you conduct to enhance your understanding of the client�s problems and how would your choice of assessment(s) inform your diagnostic impression and treatment planning? Assessments may include structured or unstructured interviews, valid and reliable assessment measures, and/or formalized assessment procedures that may be conducted by yourself or by someone else referred by you.

B. Provide your diagnostic impressions (based on the DSM-5) for this individual. In narrative form, please describe how the individual meets the diagnostic criteria for the disorder(s) chosen in addition to the differential diagnostic thought process that you used to reach your hypotheses. Be sure to include any additional (missing) information that is needed to either rule out or confirm your differential diagnoses impressions.

Legal Theory and Application

A. Explain the background, current presentation, and behavior of the client utilizing theories of offender and/or victim psychology and personality/psychological theories to support your position. Do not simply restate the client�s presentation from the vignette. Instead, provide a theoretical-based discussion of the client�s behaviors as presented in the vignette.

B. Describe the psycholegal standards and/or definitions for each of the following: competence to stand trial, risk of dangerousness, and insanity. Identify and describe one or more landmark case(s) for each standard (at least three cases total). Describe the elements or issues that a mental health professional usually focuses on when assessing a person�s adjudicative competence, risk and insanity, and any additional items that might be especially important to focus on in the provided vignette.

Research and Evaluation

A. Describe tests or assessment procedures you would employ to address the psycholegal issues of (competence to stand trial, risk of dangerousness, and insanity). You may refer to these from the Psychological Theory and Assessment Section “A” if you already covered them there. Discuss what the anticipated conclusions would be based upon information provided in the vignette.

B. Develop one empirically supported therapeutic treatment plan for the client in the vignette. Please make sure you summarize the empirical evidence with appropriate citations to support your treatment choice(s) in working with your client. Be sure to discuss the effectiveness and limitations in working with this particular client, including this client�s background, using the above treatment plans.

Interpersonal Effectiveness
A. What diversity factors, cultural considerations, or other demographic variables pertaining to this client would you take into account in rendering a diagnostic impression, choosing assessment measures, forming case conceptualizations, and designing the treatment plan? Be sure to discuss cultural/diversity factors that could apply even if they are not explicitly mentioned in the vignette.

B. Your writing, use of citations, ability to form a logical argument, and proper APA Style, including the use of paraphrasing, will be evaluated as a measure of your interpersonal effectiveness. No response is required for “B”.
Leadership, Consultation, and Ethics
A. Describe how you would work as a consultant for his treatment team. Describe how you would recommend triaging and treating this case. Include a description of the various members of the professional team with whom you would be likely to interact. Additionally, explain the roles and responsibilities of each member of the treatment team.

B. What are the ethical and legal dilemmas this vignette introduced? What would be your immediate steps and why? Please be specific and make sure that you describe your process of ethical decision making and the solutions/consequences to which this process might lead. Your discussion should be informed by the American Psychological Association�s Ethics Code as well as the Specialty Guidelines for Forensic Psychologists

******Some information to help with the paper along with references that need to be incorporated into this paper.

Comp Exam Notes
Answer questions in body of paper � each question must start on a new page!
Psychology Theory & Practice
I would use these assessments and also reference a clinical interview along.
Mental Status Exam (MSE), MacArthur Competence Assessment Tool � Criminal Adjudication (MacCAT-CA), The Rogers Criminal Responsibility Assessment Scales (R-CRAS), The Suicide Assessment Five �Step Evaluation and Triage (SAFE-T), Minnesota Multiphasic Personality Inventory-II (MMPI-II)
Give reasons why this assessment�s are needed, relate back to the vignette and cite why you are choosing it for your specific scenario
Beck Depression inventory if applicable
Substance abuse if applicable
Briefly summarize history � may include interviewing spouse if relevant
Additional psychological testing – make sure to do baseline assessment testing i.e. How often does he subject think about suicide?
Be prepared to speak about cultural differences. i.e gay, different race, or whatever the difference is, speak about it. The SPFG, you can cite this guide and cultural issues
Differential diagnosis � i.e � I thought it was this, but after reviewing this, I know believe that this fits because of this reason.
Legal Theory & Application:
A) Cognitive behavior or social learning theory � how could one learn to do this erratic behavior?
Positist Theory � actions learned from parents
Once you have identified the theories, tie it back into the vignette
Clinical symptomology � forensic involvement of the client � theoretical formulation tied back into vignette
Positive theory does not always explain but it could be this?��.cite the theory and the reason it did not apply
B) Application � Psycho legal � cases below to cite
Tarasoff , Dusky, McNaughten, Durham � then explain the elements to help your defense
Standard and definitions � describe elements and relate vignette
– At the current moment Jane Doe is acting so incompetent that she is not competent to stand trial. Further assessment is needed to accurately assess

Research & Evaluation
A) Forensic test assessment: procedures comp to stand trial � cite
Tie in treatment go back and refer to question. The theories of treatment. Triage � Jane Doe is still erratic, need to consult psychiatric doctor, her pain level is still at x, she may need meds, follow with medical doctor, psychological crisis interrogation � may need to consult social worker- follow up care. Want to see improvement from her baseline assessment. Assess an appropriate treatment plan, ie. Therapy
Relapse prevention plan �
Interpersonal Effectiveness
A) Factor or cultural consideration, American Soman, lesbian according to the APA guidelines cite what you can and relate back to vignette. Gender, age, disability, sexual orientation, identity development, demographic location. According to APA no bias should exist
Leadership, Consultation and Ethics
Attorney, clinician, medical pain meds � Stabilize, address pain, work on discharge if applicable.
State how you would work on interdisciplinary team � find source and cite. Also cite APA code that speaks to working with other professionals
Informed Consent
Site ethics code here � rights of others � you can use the Bush Decision making model in tis section, make sure to cite
Potential problems � applicable laws, consultation to protect, always seek consultations
The below are suggestions from one of my instructors:
With insanity or other situations you will not be able to address all possible laws, since they do change somewhat by state. You should however be prepared with a few key landmark cases as they apply to the case study discussion such as M’Naughten and Durham. You can find some relevant cases at:
https://www.aapl.org/landmark_list.htm
Ah, I see now. Yes, most every case will have different people to interact with. Some will be one-time debriefings or interviews, while others will be ongoing. It depends on the actual case. For example, for CST, you would be consulting with witnesses and attorneys, while on the treatment side, you may be interacting more with the psychiatrist, physician etc. The team work may evolve over time also from the initial assessment roles through the ongoing treatment. See also the rubric page 11 for some more ideas.

The Melton text: Psychological Evaluations for the Courts is my usual “go to” text. (ps recommend it if you don’t have it, but I’m not sure of the cost of it these days). There is not a separate section just on interactions, but as I mentioned, there are brief pieces dependent on the specific type of case (for example, child custody, or types of interactions on the court level etc.) I’ll keep looking around a bit, but have not seen a single article/book just on this topic, so much as sections discussing information sharing in certain contexts.
*CBT is certainly one of the most common treatment approaches, and a good base, but you have also learned several theories that specifically apply that approach to criminality.
***Do not insert any information or make things up. In real life it is very common to have incomplete information. Based on your diagnosis and the information provided you should be able to discuss in detail which diagnosis best fits (and exclude others since they do not). I would generally recommend staying away from Internet sources. They are a poor quality source without research backing. In general, if you had one or two it would not be bad, but if for example they were Wikipedia, for example, or something that gave you mis-information, it could be bad.
*********Books that were used in my degree program: references below, please use when possible
Forencis Psychology � Matthew Huss, 2009 great book for reference
Abnormal Psychology, 6th edition � Susan Nolen � Hoeksema
Criminal Behavior: A Psychological Approach, 10th edition. Curt R. Bartol & Anne M. Bartol
Internship, Practicum and field Placement Handbook, 7th edition � Brian N. Baird
Investigative Psychology: Offender Profiling and the Analysis of Criminal Action – David Canter & Donna Young
Principals of Writing Research Papers, 3rd edition � James D. Lester Jr.
Forensic Psychology: Emerging Topics and Expanding Roles � Alan M. Goldstein
Introduction to Forensic Psychology: Research and Application 3rd edition � Curtis R. Bartol & Anne M. Bartol
Practical Research: Planning and Design, 10th Edition � Paul D. Leedy, Jeanne Ellis Ormrod
Psychological Testing: Pricinpals, Applications and Issues 8th edition – Robert M. Kaplan, Dennis P. Saccuzzo

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