Cross Examining the Psychiatric Expert By Dorothy C. Sims, Esq. Ocala, Florida
Fifteen years ago, a psychiatrist moved to town and began conducting evaluations on behalf of various insurance companies. The reports (over l00) were very similar. My clients fit the following categories:
They were blatant liars
There was nothing wrong with them, or
There was something seriously wrong with them that pre-existed, or, even caused the accident
Well, I was confused.
Either I had this Bermuda Triangle over my office sucking all the bad clients of the universe into my waiting room, or, perhaps, the doctor might be a bit biased.
Deciding it was the latter, I spent the last l0 years of my plaintiff's practice learning everything I could about the cross examination of a psychiatric witness. In so doing, my practice changed such that now I don't handle cases directly, but am retained by attorneys to take the depositions and trial examination of their psychiatric and neuropsychological witnesses. The education has been astounding. I have had doctors do amazing things. They have alleged they did not need to report those scores that were favorable to the plaintiff's and only report those scores showing the plaintiff was not brain injured. They claimed they could write a report concluding the plaintiff passed the mental status exam, when the transcript revealed they did not. They have walked out of depositions, cursed at me in Yiddish and advised me that I made them want to vomit. They have instructed me to remove my shirt during a deposition, claimed their powers of observation to be so great they could see under clothing and even identify the color of my underwear (the doctor was wrong, thank you very much).
In many of the depositions, the doctor has either obfuscated the data or outright lied. A pattern emerged.
These "experts" can be exposed. I suggest the following:
BEFORE THE EXAMINATION:
Do a Freedom Of Information Act Request to your state licensing board.
If the doctor works for a university, do a FOI request to the university too. Keep in mind, many universities will permit doctors to conduct outside consulting work. However, in order to do so, they must complete certain forms that list the income and by whom they were retained. This is very helpful in showing bias.
DURING THE EXAMINATION:
Send a court reporter who:
Never leaves your client alone, no matter how long the exam takes
(remember, some can last as long as 8 hours and the reporter needs to know this in advance).
Provides the transcript in digital format. This makes it easier to share with other attorneys and is excellent for creating questions for cross examination because word searching capabilities in a digital document speed up the process.
Never releases a copy of the transcript to the defense attorney.
Remembers that YOU hired the reporter, and the reporter answers to you. Some physicians have tried to throw my reporters out of the evaluation. They stay. Period.
Can't afford a court reporter? Send a tape recorder with your client(s) and make sure your client knows when to turn the tape over by loaning them a watch with an alarm preset to go off at the end of the tape.
Look What the Raw Data Reveals (and why they don't want to produce it)
Look for erasure marks. I had a doctor instruct a client to erase an answer that indicated the client was suicidal.
Incorrect scoring. Some doctors will score tests and testify that the patient scores out as not brain injured in concentration tests. However, the doctor input the wrong birthdate, thus comparing the plaintiff to much older and more feeble individuals. When the correct birthday is input, the results indicate impaired cognition.
False scoring. It's a great feeling in the middle of a deposition when the defense doctor admits to testifying that the plaintiff was a malingerer based on a test he or she scored incorrectly.
Using the wrong tests. Lately, many neuropsychologists have been testifying that certain malingering scales reflect lack of motivation. Be careful. Often these tests, in fact, reveal concentration problems.
Playing with cut off scores. Some doctors may testify that someone is flunked a "malingering test." The test booklet in the doctor's office reveals, in fact, the patient may have passed. Demand the test booklets and raw data.
Giving too many tests. Some tests suggest you administer several trials. Some doctors administer only one, or, if the test results are favorable to the plaintiff, they keep administering the same test until the plaintiff does poorly and only report the poor scores. The instructions are usually in the test booklet in the doctor's office.
Giving clues. Many doctors will provide significant clues such as, "Who was the president killed in the 60's in Dallas?" Then the doctor reports that the plaintiff could remember the presidents back to Kennedy and has no memory problems. Interestingly, the clues were not in the report, nor was the fact that the plaintiff left out most of the presidents between the current one and Kennedy.
Doctor interference. Some doctors administer tests and, in one case, took 6 cell phone calls during the concentration portion of the test. Other issues that affect concentration include the doctor frequently walking in and out of the room in which the is being given or refusing the patient a cigarette break. Make sure the doctor documents the effects of medication on tests. Often the defense doctor will accuse the plaintiff of exaggerating his or her inability to concentrate when, in fact, the doctor is the main cause for the concentration problems. Mild TbI can cause concentration problems but your patient may score out as even moderately brain injured depending on the doctor's behavior.
Paper reviews. If defense evaluation was done by a psychologist, was it a paper review or did the psychologist actually meet and evaluate the patient? If not, the report itself must contain a disclaimer.1
Transport client. Bring the client to the deposition of the doctor. Sometimes it helps keep the doctor a bit more honest.
Observe the doctor's waiting room. Recently, a doctor admitted the video camera I observed in the waiting room was for the doctor to spy on the evaluees. If the doctor treats patients, often pamphlets in the waiting room describe brain injury conditions that mirror your clients and are excellent for cross examination.
Using old tests. According to research done by James R. Flynn, he discovered that IQ scores increased from one generation to the next for all of the countries for which data existed. Now, this is what is known as the Flynn Effect. Let's say you are a defense doctor and you want to show a plaintiff does not have a brain injury. Administer an older version of a neuropsychological test and the plaintiff will score higher, maybe even not brain injured. Demand the doctor use the most recent test (as required by the APA Code of Ethics) and then you might find your client to test out as actually impaired.2, 3
Ignoring the RETEST effect. The doctor claims your client is not brain injured because he administered a test previously administered by your doctor and your client tested out much better. Therefore, defense doctor concludes either your client is malingering or cured. Try neither. Ask the doctor about the retest effect. Many tests, when administered twice, actually result in the patient getting a higher score the second time because they remember stories read to them the first time the test was administered. This does not mean they are better. This is simply a factor of retest effect and many studies exist to determine the exact increase in scores that might be expected based upon this phenomena.
Lees Haley Fake Bad Scale: This is a scale applied to the MMPI2 and is commonly used by defense doctors to claim the plaintiff is malingering. This test is rejected by the authors of the MMPI2 as being unscientific and over-reporting malingering.4
Rey's 15 Item Memory Test: This is a "malingering" test which defense doctors will claim show your client to be lying. However, if your client is elderly or has a low IQ they may erroneously be classified as malingerers.5 Furthermore, those with focal memory disturbances and diffuse cognitive impairment may perform poorly on this test.6
Halstead-Reitan Neuropsychological Battery (H-R): This commonly accepted neuropsychological battery comes with strict protocol requirements. The authors warn, "many altered and abbreviated versions of the tests in the HRB are being sold by numerous individuals and firms. Anyone using these versions should be aware that they have usually NOT been adequately validated, either through experimental studies or in clinical practice."
Following strict protocol is crucial when administering this test. "The only authorized version of the HRB for Adults is the one that duplicates the tests EXACTLY as they were when the validation studies were done."7
MMPI2. This test contains 567 true/false questions. However, frequently the defense doctors administer or interpret it incorrectly. Make sure and investigate the following:
Test should not be taken home (often psychologists, and even more so, psychiatrists permit it. It saves time) However, to do so violates test taking protocol.8
What software is used to grade the MMPI? The psychologists, especially if working for government or university setting, have no idea how the software was obtained or the differences between various software and simply approve the printout as gospel. "Research has shown that test interpretation services differ with respect to the amount of information and accuracy of the interpretations provided."9
Did the patient leave 30 or more questions blank? If so, the test is invalid10
If the patient is not of this culture, was a culturally appropriate scoring key and proper norms used? In 18 years of deposing psychologists and psychiatrists I have NEVER had this answered in the affirmative. Consider how someone from Cuba might answer questions (a bit high on the paranoia scale?) verses someone from the US.
The defense doctor claims your client is lying because the F scale is elevated. (F= Frequency of items endorsed, NOT Fake) "Extenuating stressful circumstances in an individual's life can also influence infrequent item responding. Stressful life factors tend to be associated with elevated F-Scale scores."11 Different cultural background can cause an increase in the F scale. Therefore, culturally appropriate scoring keys and norms are vital.12
DURING THE DEPOSITION
Bring a laptop with an air card. When the doctor fails to bring the articles he relied upon, claiming they exist, turn the computer around and tell him he is more than welcome to look them up on the internet. This works great in a video depo.
Bring a second laptop on which is loaded all prior depositions so prior testimony can be accessed with a word search function on your computer. This is much faster than tabbing hard copies.
The doctor claims to review the medical records. You are skeptical. Bring a plastic bag. At the conclusion of the deposition, seal the records in the plastic bag and advise the doctor you are giving them to the court reporter until your fingerprint expert can pick them up in the morning. Sit back and watch the fireworks.
The doctor claims he didn't recently alter the raw data and you know she/he did. Get the plastic bag out. Seal the document and advise opposing attorney you are having the ink dated at the lab of your choice. Some labs can tell you if ink is 2 years to 6 months old.
Point out the selective reporting that goes on in virtually every CME. High scales, such as scale 8 on the MMPI2 can indicate the presence of a head injury. Never have I ever had a defense doctor admit to this in a report.
Ask them if the plaintiff did well on the mental status exam. Most doctors administer the Folstein Mental Status Exam which is actually a screening device for Alzheimer's patients. However, most doctors don't score the test, fail to ask all the questions, and, more importantly, lie about the results. Ask the doctor if the patient answered the questions correctly. When the doctor says yes, present the doctor with the transcript that reflects many of the questions were answered incorrectly. Then file your Motion to Strike based on fraud.
The doctor testifies that he does 1/3 plaintiff work. Yeah, right. He/she then hands you a list of cases in which he has testified for the last several years but they do not identify if they are plaintiff or defense referral. Point out that he is hiding that information and it would only take a second or two to note on each case who referred it but in leaving that information out, you cannot address bias. Then ask the doctor to identify on the list each plaintiff referral. In every case in which I required the doctor to do this, he was only able to identify one or two percent of his referrals as plaintiff.
When faced with the task of deposing an defense oriented psychiatric expert assume you must verify everything and take nothing at face value. The health care dollar is shrinking, and, many of these well paid "experts" for the defense will stretch the limits of credibility to keep their customers happy. It's time to stop them.
Editor's Note: Ms. Sims advised she will provide emailed versions of 6-9 hour depositions of neuropsychologists and psychiatrists at no charge to assist in preparing for cross examination. Please contact her at email@example.com
Dorothy Sims is the founding partner in Sims, Amat, Stakenborg &Henry, PA with offices in Gainesville and Ocala, Florida. She has lectured throughout the US and internationally on medical/legal issues.
American Psychological Association Ethical Principles of Psychologists and Code of Conduct, General standard and forensic activities 7.2(b) & (c)(2002), at http://www.compassnet.com/dstrite/apa_ethicscode. html
J.R Flynn, The mean IQ of Americans: Massive gains 1932 to 1978, in Psychological Bulletin 95 , 29- 51 (1984).
APA Code of Ethics 9.08 (2003), at http://www.apa.org/ethics, Obsolete Tests and Outdated Test Results (a) Psychologists do not base their assessment or intervention decisions or recommendations on data or test results that are outdated for the current purpose.(b) Psychologists do not base such decisions or recommendations on tests and measures that are obsolete and not useful for the current purpose.
J.N. Butcher, et al. The Construct Validity of the Lees-Haley Fake-Bad Scale(FBS): Does this Scale Measure Somatic Malingering and Feigned Emotional Distress? 18, 473-485 (Archives of Clinical Neuropsychology June 2003). A.S. Bury & R.M. Bagby, The Detection of Feigned Uncoached and Coached Posttraumatic Stress Disorder with the MMPI-2 in a Sample of Workplace Accident Victims, 14(4), 472-484 (Psychological Assessment 2002).
Otfried Spreen & Esther Strauss, A Compendium of Neuropsychological Tests, 674 (2d ed. Oxford University Press) (1988).
See id. At 673.
R.M.Reitan & D. Wolfson,. The Halstead-Reitan Neuropsychological Battery 121, in Theory and Clinical Interpretation (Tuscon, AZ Neuropsychology Press 2d ed.) (l993).
Kenneth S. Pope, James N. Butcher, & Joyce Seelen, The MMPI MMPI-2 & MMPI- A in Court 161 (American Psychological Association 1999).
Yossef S. Ben-Porath, John R. Graham. Gordon C. N. Hall, Richard D. Hirschman, & Maria S. Zaragoza, Forensic Application of the MMPI2 194, Applied Psychology, Individual and Social Community Issues (Sage Publishing Corporation 1995).
James Butcher, MMPI-2, User's Guide 8 (Regents University of Minnesota 1998).
Kenneth S. Pope, James N. Butcher, & Joyce Seelen,The MMPI, MMPI2 and MMPIA- In Court 104 ( American Psychological Association 1999).
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