Court Report (MSc. Forensic Psychology)

Psychologist’s Report Name: Mr. E Date of Birth: 21/04/1988 Age: 28 years Date of Primary Interview/s: Unknown Legal Issue: Mr E. is charged with one count each of Stalking and Domestic Violence Date of Report: 24/05/16 Introduction I am a Licensed Psychologist in the State of California and have served as an expert witness for 10 years in the Central and Eastern California District Courts. I am currently in private practice in Orange Heights, Pasadena, and have previously practised in the United Kingdom as a chartered clinical psychologist with the NHS and Child and Adolescent Mental Health Services, as well as a forensic consultant working with youth offending services, government crime agencies and the Metropolitan Police. For two years, I assisted with research into the experiences of adult depression and have a special interest in neuropsychology, psychopathology, and adolescent mental health issues. Reason for Referral Mr E. was referred by the California Probation, Parole and Correctional Association (CPPCA) for psychological evaluation whilst being held in detention pending prosecution. He is charged with one count each of stalking and domestic violence, whilst violating the terms of a restraining order. The purpose of the psychological evaluation is to provide a general assessment of the risk of future aggression as well as of the risk of further aggression towards his victim. Also included is a summary risk formulation and recommendations for treatment. Background information and Mental Status examination: Background information has been provided by the probation services in the form of a Mental Status Examination (MSE) and Clinical Interview (CI). The formulation, risk assessment and recommendations are based solely on the information given. Very little is known about Mr. E’s adolescence or schooling, besides the fact that he is originally from Africa and is in possession of permanent residency status in the United States. The Mental Status Examination revealed no apparent psychotic or mood disorders or cognitive defects. Mr. E did not appear either depressed or manic and his memory and attention were unimpaired. Although an intelligence test was not conducted, he is estimated to be within the average range of intelligence. One abnormality revealed was that Mr. E appeared to possess slightly immature judgement when presented with hypothetical, practical scenarios. Despite the results of the MSE, this abnormality is likely a symptom of an undiagnosed mental disorder (see clinical factors). Summary Clinical Case Formulation A risk formulation attempts to understand the underlying mechanism of an offender’s potential for harm in order to develop appropriate measures to enable change (Logan, 2014). The following summary risk formulation accounts for the individual’s risk factors and current mental state, although his history as provided is incomplete. It is based on the biopsychosocial model (Henderson & Martin, 2014) making use of the “5P’s” model (Weerasekera, 1996). The presenting problem is the risk of future violence and/or stalking. The brief MSE screen indicates that there are no significant predisposing biological factors impacting risk. Social predisposing factors are more significant and suggest a history of antisocial behaviour. Mr. E has a history of alcohol abuse (including public intoxication) and the criminal activities of illegal drug selling, destruction of property and gang involvement. He gave his own indication of previous violence by stating that he would hurt people “because he liked to”. He was also arrested in the past for sexual activity with a minor, has only ever been in short-term employment and did not finish school. The main precipitating factor to the index offence are his immature judgement and lack of insight: both symptoms of the possible undiagnosed mental disorder. Perpetuating factors in Mr. E’s life are his belief that he has no positive influences and that he does not trust people. He believes he has no friends, and practical problems such as lack of transport make it hard for him to attend important meetings. The most significant perpetuating factor, however, is his ongoing, misguided notion of “helping” people, possibly linked erotomanic delusions. He also consistently denies responsibility for his actions. There are positive, protective factors worth noting: There seems to be some indication of remorse. He indicates that he realizes that what he was doing was wrong and that he wants to “have a life”. Mr. E also states that he wants to be “good”. He has the ambition of being employed again, wanting to look for work and get a job “right away”. General assessment of risk of future aggression Mr. E was assessed using the HCR-20 (Version 3) risk assessment, the most commonly used structured professional judgement of the risk of violence (Logan, 2014). As a set of clinical guidelines for assessment and management, it examines historical, current and future risk factors in separate categories, leading to overall predictions for imminent violence, future violence and serious physical harm. Mr. E was judged as having a high risk of future violence, with a moderate risk of serious physical harm and a moderate risk of imminent violence, including towards his victim, “AT” Historical Factors The scores in the initial three categories of the historical scale of the HCR-20 (previous violence, other antisocial behavior and relationships) correlate to the predisposing factors mentioned in the formulation. Monahan (1981) and Klassen and O’ Connor (1994) note that past offending patterns can be expected to predict future violence. Whilst his account of the two index offences contradicts the victim’s account (and the validity of the subsequent charges), Mr. E’s CI does make an explicit reference to “hurting people for no reason at all” in the past and that it was “easy” to do. Although the extent of the injuries sustained because of the domestic violence offence are unclear, it is possible that prior offences caused serious injury, making Mr. E’s risk of violence high not only on the historical scale but also in terms of future violence. The threat of imminent violence, especially against the victim, is moderate: Although Mr. E shows a lack of judgement in breaking the conditions of his restraining order against his victim and in wanting to see his victim when he is released, this is counterbalanced by indications of remorse and a desire to change. A stronger protective factor against imminent violence is his indication that he wants to stay with a different female friend, and not his victim, and that would not want to seek further contact with his victim. A second set of predisposing risk factors is revealed by Mr. E’s history of other antisocial behaviors, including destruction of property, gang activity, public intoxication and drug selling. This category also scored as a high risk in the HCR-20 assessment. However, besides apparently damaging his victim’s car, there is no real evidence that the historical offences are 1.) ongoing and 2.) indicative of future violence against the person. For these reasons, there is a moderate score for offences such as substance abuse. The index offence of stalking is generally defined as an antisocial behavior but Mr. E’s actions are more likely features of de Clerembault’s syndrome or “erotomanic” stalking. This stalking is very likely linked to an undiagnosed mental disorder discussed in more detail in the clinical section and is not done with the intent of violence or sexual sadism (more commonly linked to psychopathy or narcissistic personality disorder). In terms of the potential diagnosis, Mr. E fulfills a typical criterion of blaming the victim’s family (Meloy, 1999): Referring to his first girlfriend, he blames her brother for beating her up and her sister having a temper and being jealous of him. He also accuses AT’s mother of threatening to take the children away and that she might have “feared” her husband. It is noteworthy that he describes his first relationship as when he started “following” a girl, suggesting an early pattern of stalking-type behavior. Another predisposing factor correlating to high risk on the historical scale is Mr. E’s inability to form and maintain stable relationships, as well as an inappropriate relationship in his historical sexual activity with a minor. Social support networks, including intimate or non-platonic relationships, have been cited as safeguards against the risk of future violent crime (Klassen & O’Connor, 1994; Swanson 1994) but most of Mr. E’s relationships have been short-term, placing him at higher risk of future violence. His longest relationship began with when the partner was underage. Hayden (2009) defines violence as behaviour which breaks more serious social norms and involves a physical threat or contact and Mr. E’s “relationship” could therefore be regarded by some experts as an act of sexual violence. The final predisposing historical factor for future violence would be Mr. E’s history of short-term employment. Researchers have noted a strong positive correlation between low employment or unemployment and an increase in the rate of violent crime, including domestic violence (Raphael and Winter, 2001). Mr. E states that he has only ever had temporary jobs, e.g. at the DIY store, and that his longest period of employment was for four or five months at a restaurant. Therefore, according to this employment history, he poses a risk for future possible violence. Clinical factors Regarding clinical factors, especially those associated with the index offences, there is a very strong overlap of precipitating factors (triggers) with perpetuating factors. The three most significant precipitating factors to consider on the HCR-20 Clinical scale are Insight, Instability, and Symptoms of Major Mental Disorder - also an item on the Historical Sale. It is highly likely that Mr. E’s risk of violence is linked to an undiagnosed mental disorder, or to a mental disorder that has not been disclosed. The MSE states that there is no mental disorder present but information revealed in the Clinical interview strongly suggests that Mr. E may have Delusional Disorder. According to the DSM V (Sect. 297.1) this is one of the less common psychotic disorders, in which patients have delusions but not the other classical symptoms of schizophrenia such as thought disorder, hallucinations, mood disturbance or flat affect. These delusions need to have been present for at least one month for the person to be diagnosed and Mr. E’s symptoms exceed this timeframe. Such delusions would also help explain Mr. E’s lack of insight and fit into sub-category of “non-bizarre” delusions i.e. those relating to situations and/or emotions in others which are possible but not likely. For example, it might be possible that his “help” was welcome to his previous partners and to his victim, AT, but it is highly unlikely. It is also unlikely that drawings and songs which were sent to his victim from prison were wanted. Mr. E’s feelings of still being in “in love” with his victim are not reciprocated and he is also under the delusion that they have an “intimate” relationship. Whilst he makes contradictory claims about wanting to see her again, the fact that charges have been brought against him and that his victim has expressed her own desire not to see him indicates that she perceives him as a threat. If he is still under the delusion that his “help” is welcome to his victim(s), it will difficult for him to establish and maintain proper interpersonal boundaries. The lack of insight associated with this disorder is noted by Bourgeois (2015) and is evident in Mr. E’s reactions to his victims’ emotions. He seems perplexed that AT did not understand his offer to help her and states that “maybe she was not prepared for the responsibility”. His response of laughing at her statement that she locked herself in the closet because of his threatening behaviour is very inappropriate too and shows a lack of insight into his victims’ emotions. Persecutory symptoms such as blaming others and erotomanic stalking, which have both been discussed, are also often cited as features of this disorder (Spitzer, 1990). It has also been noted that some cultures have widely accepted beliefs that may be considered delusional in other cultures. As Mr. E is originally from Africa, it might be the case that his behaviours are deemed more acceptable in his original sociocultural setting. However, this is hard to corroborate, as it does not specify which country he was originally from. Mr. E expresses his delusional beliefs with a high degree of persistence, thus it is highly likely that these beliefs continue to have a negative effect on his life and wellbeing (Munro, 1999). Other perpetuating factors such as Mr. E’s perception of having no friends, not trusting people and not having access to basic amenities such as transport are important too, but not as significant. If diagnosed with Delusional Disorder, it would be the most important perpetuating factor for future offences, especially if it remained untreated. It has been argued (Bezuidenhout, 2007) that crimes such as stalking, as well as jealous and domestic violence, are more likely to be committed whilst under the influence of these delusions. Protective Factors The strongest protective factor against the future risk of violence is Mr. E’s expression of remorse and desire to change his life by getting a job and becoming a better person. It is also a positive factor that he has a friend to stay with when he is released from jail. However, it is difficult to gauge the truth or accuracy of this response, especially as he may still be delusional. His history suggests a repeated pattern of negative behaviours in romantic relationships and his claim about not “threatening” AT does not correlate with the Domestic Violence charge against him. Another statement saying that he will not be seeking any further contact with his victim is later contradicted by a typical expression of wanting to “help” her because is still “in love with her”. His promise to not “force” her like he did before cannot be regarded as a protective factor if he is still under the delusion that she would want to see him. Imminent/future risk of violence to victim Because Mr. E’s contradictory claims make it difficult to judge his true intent regarding the victim, his threat of imminent violence against her has been scored as moderate. However, all the risks already highlighted in the historical and clinical evaluation apply directly to the victim and she remains at risk so long as Mr. E’s delusions remain untreated. For these reasons, and as his treatment guidelines recommend, it is important that Mr. E is paroled to a different county to AT for her own protection. This might also lessen the chance of any delusional plans Mr. E might have to visit her. It is also a possibility that the victim is at risk of violence from her own husband who may well be jealous, as Mr. E claims. Recommendations: Level of management and supervision required If it is the case that Mr. E has no prior convictions for domestic violence, it is likely that he would be granted parole without detention. If prior convictions are found, the state of California requires that he remain in prison for at least 30 days, the average minimum time excluding a felony conviction, which is not the case. Regardless of whether this is a first-time conviction, it is recommended that Mr. E be remanded in custody for at least 30 days post-sentencing to undergo a psychiatric evaluation. It has been indicated that he may be suffering from an undiagnosed mental disorder and it is important for the safety of the public and his victim that this evaluation takes place before the parole conditions are established. According to the MSE, Mr. E does not appear to be at risk of suicide or self-harm but he will still need close supervision when in contact with other inmates. His lack of judgement and insight can make him insensitive to the emotions of others and this might place him at risk. Rules of probation to reduce risk It is recommended that a parole period last at least 24 months and that Mr. E be placed in the California PCSD “High Control” category as he has the potential for physical assault, as well as a record for drug dealing and sex with a minor. If diagnosed with the suspected disorder, Mr. E would qualify as a mentally disordered offender (MDO), meaning that extra precautions would be necessary to protect not only himself and the community. Because of the staking offence, it is recommended that Mr. E be placed in an alternative county to the victim and, because of his issues with homelessness, it is further recommended that this is in a residential community correctional facility where there is easy access to an ISMIP parole outpatient clinic (POC). As he has expressed a desire to work, he should also be placed on a state Education and Employment Program. Parole officers should make regular scheduled office visits to Mr. E, including occasional unannounced home visits. Officers also need to monitor closely any attempts to re-engage with illegal drug selling and, more importantly, Mr. E’s personal relationships (including internet usage). This especially concerns any unsolicited contact with his victim, as it is assumed that a restraining order will still be in force. His general mental wellbeing needs to be closely monitored and he must be referred to the POC immediately if there are any concerns. Additional Testing/ Treatment According to guidelines published by the APHA and NCCHC, it is recommended that Mr. E obtain two mental health screenings whilst in custody. The first is a brief screen to test for his suitability to the specific environment of the prison itself. As he might be a vulnerable MDO, this would include practical matters such as considering the personalities of any potential inmate/s, and whether they might trigger any inappropriate behaviours. Secondly, Mr. E requires a more comprehensive mental health evaluation to test for the suspected Delusional Disorder and/ or other mental illness. This is to be conducted by an appropriately qualified mental health professional and should be completed as soon as possible, whether a custodial sentence is enforced or not. Mr. E would also benefit from an adult intelligence test such as the Wechsler Adult Intelligence Scale-Revised, as no formal record of an intelligence score exists. This, along with standard adult Literacy, Numeracy and Functional Skills Tests, would be beneficial in helping him to help him engage with educational programmes. A standard medical check-up by an MD would also be helpful to see if there are any further urological problems. Treatment with prognosis and time frame If diagnosed, Delusional Disorder can be difficult to treat. According to Fochtmann (2005), this is not only because the delusions are so central to the patient’s life but also because the delusions may not be very disruptive in the absence of other major psychotic symptoms, which Mr. E does not appear to show. As an added complication, patients sometimes neglect medication because part of the delusion is to feel as if they don’t need it. Cognitive Behavioural Therapy (CBT) is known to be effective in lessening the strength of delusional conviction as it decreases the effect of delusional beliefs and curbs action on the beliefs (O’Connor, Stip & Pelissier, 2007). Training in social skills would be beneficial too and might help Mr. E to feel more in control of social situations and interact better with those perceived to be judging him, possibly taking away the feelings of powerlessness underlying his delusions (Liberman, 2008). It is recommended that the therapy be supportive and non-confrontational and that therapeutic goals are reached in conjunction with Mr. E’s own input. Cultural factors have been mentioned and should also be considered. The main goal should be for Mr. E to improve his social functioning and to work on maintaining appropriate boundaries with others. Studies show that medication helps at least 50% of patients with Delusional Disorder and that the most effective drugs overall are neuroleptics such as Pimozide or Olanzapine (Munro, 1995). Antidepressants, particularly SSRIs, can also be helpful with some delusion disorders (Hayashi et al., 2004). A course of medication might lead to a significant improvement in Mr. E’s mental health. Suggested timing of case review It is suggested that a review of Mr. E’s case takes place within as least three months. Some of the risks Mr. E poses are unknown, not only because of the lack of history, but also due to his contradictory statements (see limitations). Because of these, and the potential dangers posed to his current victim through undiagnosed mental illness, it is essential that his case be very closely monitored. If necessary, further risk assessments should be conducted, especially if any attempts are made to contact the victim. Although similar cases are usually reviewed yearly by the county, the case should be reviewed every six months after the initial review. This is to ensure that Mr. E is making suitable progress and that his threat level for the risk of violence has not increased. Limitations of this report There are some significant limitations with this report. As has been mentioned, there is a lack of background information on Mr. E’s childhood, adolescence and previous mental health history, including convictions. It is not known which country Mr. E is originally from or where he attended school. This kind of information is crucial when constructing a risk formulation and, as such, some of the predictive validity of this assessment is speculative. The contradictory information provided by Mr. E in the Clinical Interview is problematic too and makes it difficult to gauge the extent of his true risk, besides to work on the assumption that he is clearly under the influence of erotomanic delusions. These contradictory statements make it hard to know whether his risk of imminent violence is as high as his general risk. The Risk Management scale of the HCR-20 is also problematic. It is very hard to predict how he will react to future treatment programs when so little is known about his past engagement with supervision. Because of this, the success of these measures can only be predicted as having a moderate chance of success. The report also includes very little information which accounts for the victim’s experience of the alleged domestic violence. For example, it does not include the extent of her injuries and whether any of those injuries might be serious enough to constitute a felony offence. This lack of information makes it very difficult to establish an exact forensic picture of the index offences. A final limitation is the fact that the information in the interview was given through a translator and some of the original meanings or facts may have been lost in the interview process. S.J Melmoth, Ph.D (CA license PSY28047) HCR-20 Risk Assessment: Mr. E Reflective Diary Entry: 23/05/17 Right from when I returned to lectures, I had feared writing this court report and placed myself under a lot of pressure to try and do a good job. Writing the report has felt like a bit of a journey. It was a challenge to try and assimilate all the readings and consider all the different styles of report writing and still try and make the report authentic and accurate. My old tutor always used to tell me that objectivity is all about doing “justice to the subject matter” and I suppose that’s what I have tried to do: to try and envisage Mr E. as a real person with real problems and to help him (and his victim) to the best of my ability as a pretend professional. Writing the report also made me realise the kind of pressures that expert witnesses might find themselves under, especially with time constraints. Some of the other students felt frustrated by the gaps in Mr. E’s history but I never found that it was something which bothered me too much. I think psychologists are sometimes required to fill in gaps and create a general clinical picture using all the evidence provided, so I really enjoyed that investigative aspect.