The Goal and Scope of a Clinical versus Forensic Evaluation

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The purpose of any evaluation should be evident by asking, “What is the referral question?” and should always be clearly stated at the beginning of a report. The nature of the referral question guides the type of examiner that should be sought to answer it, which in turn influences the various methods used to conduct the evaluation. Among other things, clinical and forensic evaluations are differentiated by the referral questions that initiate them.

In a clinical mental health evaluation, referral questions center around diagnosis and treatment planning. Assessment is conducted for the purpose of determining the condition from which the patient suffers, and relieving symptoms by recommending optimal treatment approaches and other interventions. Examiners thoroughly interview their patients, conduct relevant clinical examinations (physical or laboratory), and may conduct psychometric testing (psychological and neuropsychological) if mental health or neurocognitive functioning are at issue. Clinicians review available medical or treatment records, and if possible incorporate information gleaned from family members and significant others into their workups. Clinical reports are brief and are written for the purpose of facilitating communication between treaters.

Typical clinical referral questions include:

Is the patient presently suffering from a neurocognitive disorder? If so, what type? How severe are the symptoms? Are symptoms acute versus chronic? Are symptoms static versus progressive/deteriorative? Can the individual continue to work and live independently? Will there be a time when changes in work status or greater supervision are warranted? Are there any limitations that should be placed on the patient’s daily activities now? What treatment or rehabilitative efforts are appropriate? When will the patient reach maximum medical improvement?

In a forensic mental health evaluation, referral questions in criminal cases center around psycholegal issues. The primary goal of the evaluation is to address whether an individual’s functional or legal capacities are or were impaired in order to facilitate legal and administrative decisions. Diagnosis, while certainly a factor contributing to the forensic examiner’s response to the legal question, is peripheral, and with the exception of juvenile proceedings, treatment recommendations may not be relevant at all or be of relatively lesser interest to the legal system. In civil matters, referral questions also center around psycholegal issues, though in tort cases greater emphasis falls on diagnosis and treatment. Consistent with the goal of forensic evaluation, this focus is not for the purpose of determining optimal treatment and alleviating suffering, but rather for determining fault and damages, legal concepts that facilitate legal decision-making. In quasi-legal matters, such as fitness for duty, workplace violence or pension disability, any focus on diagnosis and treatment recommendations is secondary to rendering opinions that will aid the employer or board in making administrative decisions. Forensic reports are more extensive than clinical reports. Among other things, forensic examiners incorporate a greater amount of (third party) collateral information, conduct and detail more extensive personal history interviews, offer detailed supporting evidence for their opinions which conform to the language of relevant statutes and guidelines, and clearly state limitations.

In the forensic mental health field, typical referral questions involve criminal and civil competencies, criminal responsibility, causation, aggravation, contributory negligence and related factors in civil matters, fitness for duty and/or disability in quasi-legal matters, malingering and deception, capital and noncapital mitigating factors, post conviction treatment recommendations, and risk determinations:

Was the individual competent to have waived his rights under Miranda or to have consented to a search? Was s/he competent to have made changes to a will, medical directives, a retirement portfolio or to have entered into a legal agreement? Is the individual presently competent to stand trial, enter into a plea arrangement or otherwise proceed? Was s/he legally insane at the time of the offense? Was s/he capable of forming intent to commit the offense? Did s/he suffer from diminished capacity (as legally defined) at the time of the offense? What is the cause of the plaintiff’s disorder? What other factors or circumstances have prolonged or exacerbated plaintiff’s symptoms? Did plaintiff himself contribute to the symptom picture? Would plaintiff have required the same level of care but for the injury, or, when might we reasonably have expected plaintiff to require this level of care irrespective of injury based on empirical and actuarial data? Is the employee or licensed professional fit for duty, and if not, what measures must be taken to restore fitness? Does the employee or student pose a violence risk or other danger to the workplace or school environment? Is the pension applicant permanently disabled under the legal definition? Has the individual presented in a genuine manner and are collateral data available to corroborate the onset, nature and severity of self-reported symptoms and functional incapacities? Can malingering reasonably be ruled out? Are there mitigating or aggravating factors to consider at sentencing? Does the individual pose a recidivism risk or a risk for violence within the institution or community?