Clinical and Forensic Applications of the Personality Assessment Inventory (PAI) Presented by. Mark A. Ruiz, PhD, ABPP

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1 Clinical and Forensic Applications of the Personality Assessment Inventory (PAI) Presented by Mark A. Ruiz, PhD, ABPP 2016 ABPP Annual Conference & Workshops Chicago, IL Saturday, May 14, 2016

2 Clinical and Forensic Use of the Personality Assessment Inventory (PAI) Mark A. Ruiz, PhD ABPP James A Haley Veterans Hospital University of South Florida Statement of Conflict of Interest Dr. Ruiz does not receive any ongoing financial or material support from the publisher (PAR, Inc.) or the author (Dr. Leslie Morey) of the PAI. Copyright permissions were obtained from the PAR, Inc., but they had no input regarding the content of this presentation. Dr. Ruiz was a paid consultant for the PAI Interpretive Report for Correctional Settings (PAI CS) in Dr. Ruiz does not receive royalties from this or any PAI product. PAR employee from Learning Objectives Describe major trends in existing PAI research. Describe and analyze PAI indicators or profile invalidity. Identify strengths/weaknesses of the PAI as it pertains to clinical evaluations. Analyze and interpret specific PAI score configurations. Interpret PAI results pertaining to opinions of risk, treatment needs, and responsiveness. List the strengths and weaknesses of the PAI when used with racial/ethnic minorities. Compare and contrast the PAI with other commonly used measures. Disclosure for Case Studies The case studies presented here are fictitious. Any resemblance to an actual case(s) is coincidence and unintended. APA Ethical Standard 4.07 Case studies were developed to illustrate clinical issues encountered in real world forensic practice. Spirit and intent is to capture clinical complexity. Please treat case studies as confidential. Please do not disseminate profiles/case studies. Copyright and test security protections. PAI profiles were reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.., N. Florida Ave, Lutz, Florida from the PAI Software Portfolio (PAI SP) by Leslie C. Morey, PhD and PAR staff, Copyright 1990, 1991, 1993, 1995, 1998, 2000, 2005, 2005 by PAR, Inc.. Further reproduction is prohibited without permission from PAR, Inc.

3 Training Outline Part 1. Foundation Part 2. The Case for Self Report Assessment Part 3. Evaluation of Response Styles Part 4. Evaluation of Risk to Self and Others Part 5. Evaluation of Treatment Needs Part 6: Evaluation of Treatment Responsiveness Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., N. Copyright 1990, 1991, 1993, 1995, 1998, 2000, 2005, 2005 by PAR, Inc.. Further reproduction is prohibited Foundation Conceptual development (Morey, 1991) Emphasis on content validity Non overlapping scales Rational and empirical development process Sample Primary normative samples Standardization Sample (N = 1,000) 85% Caucasian, 48% male, 84% > high school education, 72% between yo. Clinical Sample (N = 1,265) 79% Caucasian, 61% male, 80% > high school education, 86% yo. Corrections sample (N = 1,155) 38% White/Caucasian, 68% male Education M =11 (SD 3), M age 33.6 (SD 8.9). Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., N. Florida Ave, Lutz, Florida from the PAI Software Portfolio (PAI SP) by Leslie C. Morey, PhD and PAR staff, Copyright 1990, 1991, 1993, 1995, 1998, 2000, 2005, 2005 by PAR, Inc.. Further reproduction is prohibited

4 T-score 110 T-score 110 Sample SOM 80 ANX DEP 80 SUI 70 NIM 70 ARD SCZ BOR 60 PAR 60 ICN STR NON INF DRG 40 PIM MAN ANT ALC RXR 40 AGG WRM Scale ICN INF NIM PIM SOM ANX ARD DEP MAN PAR SCZ BOR ANT ALC DRG AGG SUI STR NON RXR DOM WRM Raw PAI T Corr. T Corr.G. T Complete % PAI Community Norms (N = 1,000) Correctional Norms (N = 1,155) Correctional Norms (Gender) Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., N. Copyright 1990, 1991, 1993, 1995, 1998, 2000, 2005, 2005 by PAR, Inc.. Further reproduction is prohibited Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., N. Copyright 1990, 1991, 1993, 1995, 1998, 2000, 2005, 2005 by PAR, Inc.. Further reproduction is prohibited Item Content Items written to capture phenomenology & experience Item section Empirical, Logical/rational, Psychometric Expert sorts were conducted during development Bias review panel PAI A appropriate to adolescents. Multiple choice response options Overstated Pathology Response Styles (Rogers, 2008) Simulated Adjustment Disengaged Readability Developed at 4 th grade reading level. Mean 8.2 words per item Schinka & Borum (1993) Clinical scales average 4 th grade reading level Validity scales average 5th grade reading level Most phrases and vocabulary at 6 th grade level. Recommended 5 th 6th grade completion (regular classes, passing grades) NIM MAL RDF PIM DEF CDF ICN INF? Crit.

5 Psychopathology Personality Internalizing Externalizing Thought Disorder Personality Disorder Interpersonal Behavior ALC/ SOM DEP ANX ARD ANT AGG MAN PAR SCZ DRG BOR ANT PAR DOM WRM SUI/ SPI VPI Dominance (DOM): The level to which a person is controlling, submissive, or interpersonally dominant. High DOM Treatment Low Warmth Hostile Dominant Hostile Friendly Dominant Friendly High Warmth Distress Readiness Submissive Submissive MCE STR NON RXR TPI Low DOM Warmth (WRM): Extent to which an individual is affiliative, warm, and caring in relationships.

6 Training Outline Part 1. Conceptual Overview Part 2. The Case for Self Report Assessment Part 3. Evaluation of Response Styles Part 4. Evaluation of Risk to Self and Others Part 5. Evaluation of Treatment Needs Part 6: Evaluation of Treatment Responsiveness APA Ethical Guidelines & Code of Conduct Ethical Guidance 9.01 Bases for Assessments Base opinions on information and techniques sufficient to establish the findings. Provide opinions only after conducting an examination of the individual adequate to support findings. Explain the sources of information on which conclusions are based. Use instruments that whose reliability and validity have been established for the population tested. Use methods that are appropriate to the individual s language preference. Specialty Guidelines Forensic Psychologists American Psychological Association (2002, amended 2010) American Psychological Association (2013) Use of Multiple sources of information Forensic clinicians avoid relying on one source of data and corroborate important data whenever feasible Selection & Use of Assessment Procedures Forensic practitioners make known that examination results can be affected by factors unique to the forensic context (e.g., response style, situational stress). Limitations of Rating Instruments Lack of field validity (Murrie et al., 2009) N = 333 male offenders undergoing SVP evaluation PCL scores not valid predictors of sexual re offending Subset of prolific evaluators did have more valid PCL scores Case law review (DeMatteo et al., 2014) Poor reliability between state/defense experts Often greater than 1 SEM Dichotomous judgments based on PCL SV (kappa =. 29). PCL Total Scores After Experimental Manipulation % of opposing evaluator pairs had differences >2 SEM Complex judgments require increased specificity reasonably good match flavor and intent Adversarial Allegiance = problem 0 Case 1 Case 2 Case 3 Case 4 Prosecution Defense Murrie, Boccaccini, Guarner, & Rufino (2013). Are Forensic Experts Biased by the Side that Retained Them? Psychological Science, 24,

7 Known or Potential Error Rates Scale PAI α (K = 8) PAI-A α (Clinical) Negative Impression Management (NIM) Positive Impression Management (PIM) Somatic Complaints (SOM) Anxiety (ANX) Anxiety-Related Disorders (ARD) Depression (DEP) Mania (MAN) Paranoia (PAR) Schizophrenia (SCZ) Borderline Features (BOR) Antisocial Features (ANT) Alcohol Problems (ALC) Drug Problems (DRG) Scale PAI (K = 8) PAI-A (clinical) Aggression (AGG) Suicidal Ideation (SUI) Stress (STR) Nonsupport (NON) Treatment Rejection (RXR) Dominance (DOM) Warmth (WRM) Standard Operation of the PAI Audio Version Spanish Language Version PAI PAR Iconnect Personality Assessment Inventory Adolescent (PAI A) Fewer items than PAI 264 items versus 344. Designed for adolescents 12 to 18 years of age. Large community and clinical samples. PAI items were selected for the PAI A based on whether the item retained its original meaning when read by adolescents. Main strength Same structure as the PAI. PAI Adolescent PAI Short Form Main weaknesses Not developmentally specific; not well researched.

8 Is the PAI appropriate? General acceptance Weighted Scores MMPI NO /? YES PAI MCMI 3 PAI-A PAI Short form Spanish/ Audio Version WRAT, MMSE PAI 16 Personality Factors Questionnaire NEO Personality Inventory Revised Evaluation Evaluation Evaluation Evaluation A Survey of Psychological Test Use Patterns Among Forensic Psychologists (Archer et al. 2006) California Personality Inventory N = 131. Division 41 members, AAFP Diplomates PAI Case Law Survey (Mullen & Edens, 2008) Sexually Violent Predator 4% Other 6% Civil Cases Indeterminate Sentencing 9% Other 7% Criminal Cases Competency 19% Personal Injury 22% Custody 43% Sex Offenses 12% Insanity 14% Death Penality 16% Mental Disease 2% Disability 25% Sentencing 21%

9 Training Outline Part 1. Conceptual Overview Part 2. The Case for Self Report Assessment Part 3. Evaluation of Response Styles Inconsistency (ICN) Empirically derived scale that measures the consistency in which a respondent completed items with similar content. Composed of 10 item pairs; five which are generally answered similarly and five which are opposite in meaning. Item pairs differ in content so that ICN total score is not generally associated with one disorder. Part 4. Evaluation of Risk to Self and Others Part 5. Evaluation of Treatment Needs ICN ICN C Part 6: Evaluation of Treatment Responsiveness Inconsistency Corrections Index (<5% positive) ICN Interpretation T-score Interpretative significance < 64T Respondent answered items consistently. Appropriate attention to item content. 64T-72T Moderate level of inconsistency in responses. May be due to carelessness, confusion, or disorganized attempts at impression management. Interpretive hypotheses must be made with caution. >73T Significant inconsistency in responses. Individual did not answer items consistently or did not appropriately attend to the item content. Completely random PAI protocols would result in scores at this range. No clinical interpretation is recommended. Infrequency (INF) Measures the tendency to respond to items in an atypical manner. Item content is unusual, but not necessarily bizarre. Items were selected on the basis of very low endorsement frequencies in both the Census matched community sample AND the Clinical normative sample. INF

10 INF Interpretation T-score Interpretative significance < 60T Individual attended appropriately to item content. Did not answer in grossly atypical ways. 60T-74T Some degree of atypical or unusual responding. Interpretive hypotheses must be made with caution. >75T Significant degree of atypical or unusual responding. No interpretive hypotheses are recommended. Identification of Random Responding (Morey, 2007) Identification rates (%) Community Clinical Total Random ICN > 64T or INF >71T 13% 21% 99% ICN >64T & INF > 71T 3% 2% 77% ICN > 73T or INF >75T 6% 7% 94% ICN >73T & INF >75T.2%.2% 43% 2 3% of individuals in corrections settings had ICN or INF >80T (Ruiz, Poythress, Lilienfeld, Douglas, 2008). Problem with partial random responding Sensitivity Back Random Clark, Gironda, & Young (2003) Responding (BRR) Level All ICN > 73T INF > 75T ICN or INF Negative Impression Management (NIM) Measures the extent to which the respondent is presenting an overly negative impression. Items assess an exaggerated unfavorable presentation. Individual reports bizarre and unlikely symptoms. Items were selected, in part, on low endorsement frequencies. Sensitivity Siefert et al. (2007) Specificity BRR 50 BRR 100 BRR 150 BRR 200 SUI Dif > 5T ALC Dif > 5T NIM Both

11 NIM Interpretation Malingering Index (MAL) T-score Interpretative significance < 73T Few indicators of negative response distortion in the protocol. 73T-83T Moderate exaggeration of complaints and problems. Some degree of unlikely/bizarre symptom reporting. >84T Presentation of an extremely negative distortion. Endorsement of unlikely/bizarre symptoms is evident. May be a cry for help. Deliberate distortion is very possible. NIM > 92 = No clinical interpretation. Eight indicators that commonly appear in PAI profiles of simulators instructed to feign mental illness. Presence of each feature is summed to obtain total score (0 8) MAL = 3 (84T) Questions of malingering MAL = 5 (111T) Likely malingering 1.if NIM >= 110T 2.if NIM INF >= 20T 3.if INF ICN >= 15 4.if (PAR P PAR H >= 15) 5.if (PAR P PAR R >=15) 6.if (MAN I MAN G >=15) 7.if (DEP >=85) and (RXR >= 45) 8.if (ANT E ANT A >= 10) Rogers Discriminant Function (RDF) Effortful/Deliberate Non effortful Weighted combination of 20 PAI scales designed to discriminate simulated profiles from those of legitimate patients (Rogers et al., 1996) RDF 60T Possible feigning. RDF 70T Overt attempt to malinger. Debates regarding its utility, mostly in relation to poor correspondence to the SIRS (Rogers, Bagby, & Dickens, 1992) Does not include NIM. RDF MAL MAL RDF NIM DEP SCZ N = 447. Morey (1996). NIM

12 Detection of Over reporting (Hawes & Boccaccini, 2009) Clinical Opinion Weight of the Evidence NIM MAL RDF d k d k d k Uncoached Coached Larger effects found for simulation studies when compared to criterion groups. Larger effects for detecting severe mental illness. Best overall classification: NIM > 81T; MAL >84T MMPI 2 Effect sizes comparing simulators versus genuine patients (Rogers et al., 2003) : F scale: d = 2.21 Fp scale: d = 1.90 Clinical History Testing Results Conceptual coherence Case 1: Amenability to treatment Case 1 Referral Question Mental health evaluation for sentencing mitigation and amenability to drug offender probation and treatment. Charge(s): Felony drug possession, Violation of probation (prior drug offense). Demographics: Female, single, never married. No children. No high school diploma or GED, school behavior problems. Unemployed. Clinical interview highlights: Gang affiliations, possible involvement in gangrelated drug trafficking. Somewhat disengaged from interview. Limited history of outpatient counseling no psychiatric medications. WASI II FSIQ 4 = 109 IQ TCU Drug Screen II Elevated impairment Drug of choiceopiates, marijuana, alcohol (to lesser extent) Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., N.

13 Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., N. Positive Impression Management (PIM) Measures the level at which a respondent is presenting an overly favorable impression and a denial of problems/symptoms. Items selected from individuals asked to provide positive impression response sets. Items ask respondent to acknowledge relatively minor personal faults. PIM PIM Interpretation T-score Interpretative significance < 44T Individual appears to have answered the items in a candid manner. He/she is not holding back. 44T-56T 57T-67T Individual did not attempt to present self in an overly favorable light. Scores in this range are unusual in clinical settings. Some degree of positive response distortion. Individual has denied common faults that most people acknowledge. Interpretations should be made with caution. >68T Significant positive response distortion. Respondent portrays him/herself in an unrealistically positive manner. Individual is saying that he/she is free from common flaws that most people admit. No clinical interpretation. Evaluating Parenting Capacity Carr, Moretti, & Cue (2005) MMPI-2 L MMPI-2 F MMPI-2 K PAI PIM.66*** -.50*.73*** PAI NIM *** n = 28 Mothers and fathers undergoing parental capacity evaluations. Approximately 20% (N = 51) of participants had an invalid PAI protocol. Approximately 49% of the sample had an invalid MMPI 2 profile. 64% of participants who had an invalid MMPI 2 profile had a valid PAI profile.

14 PAI profiles in child custody evaluations T SCORES Defensiveness Index (DEF) Eight configural features that appear more commonly in PAI profiles of simulators instructed to fake good than in profiles of non clinical & clinical samples (Morey, 1996) Presence of each feature is summed to obtain total score 0 9 (one item double weighted) DEF 70T (raw = 6) = possible defensiveness PAI SCALE SCORES Cashel Discriminant Function (CDF) PIM Predicted Scores (Morey & Hopwood, 2007) Used college students and jail inmates instructed to fake good to construct discriminant function equation of PAI scales that differentiated these from honest profiles (Cashel et al., 1995) Minimal overlap with PIM Modest correlation with DEF DEF CDF PIM DEP SCZ Deviation scores Technique for quantifying the level of leakage in the profile. Positive Response Distortion Lack of Insight True Score Attempts to untangle the contribution of underreporting. Defensiveness N = 447. Morey (1996).

15 Detecting Concealed Psychopathology Kurtz, Henk, Bupp, & Dresler, (2015) Students (N = 344) completed PAI on 2 occasions, including 1 role play for job selection. Reduced scores for most PAI scales during role play. Support for PIM deviation scores. PIM Deviation Scores Convergence M Discrimination BOR S ANT A ANT E ANT S AGG P ANT AGG Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., N. Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., N. Florida Ave, Lutz, Florida from the PAI Software Portfolio (PAI SP) by Leslie C. Morey, PhD and PAR staff, Copyright 1990, 1991, 1993, 1995, 1998, 2000, 2005, 2005 by PAR, Inc.. Further reproduction is prohibited

16 Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., N. Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., N. Case 2 Referral Question Risk assessment for sexual re offending. Case 2 Charge(s): Lewd and Lascivious acts; Distribution of obscene materials via computer. Demographics: Male, Married, 4 children, Professional employment. Clinical interview highlights: Remorseful. Focused on saving career. No substance abuse. Superficially cooperative, but the impression is that he is not entirely forthcoming about his past. Recent psychiatric hospitalization, emotionally distressed at times. SVR 20 Risk Factors Relationship difficulties No sexual deviancy. Adolescent (late) victim Unrelated, stranger victim. No use of force. Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.., N.

17 Case 2 Part 1. Conceptual Overview Training Outline Part 2. The Case for Self Report Assessment Part 3. Evaluation of Response Styles Part 4. Evaluation of Risk to Self and Others Part 5. Evaluation of Treatment Needs Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.., N. Part 6 Evaluation of Treatment Responsiveness Conceptual Model Guiding Evaluation (Andrews & Bonta, 2010) Needs Risk Antisocial Features (ANT) Designed to measure personality and behavioral features of antisocial personality/psychopathy Measures egocentricity/lack of empathy, risk taking behavior, and antisocial cognitions and behaviors. Well validated predictor for offending and violence. Antisocial Behaviors (ant-a) ANT Egocentricity (ant-e) Responsiveness Stimulus- Seeking (ant-s)

18 Can the PAI be a proxy for the PCL R Douglas, Guy, Edens, Boer, & Hamilton (2007) PCL R Factor 1 Factor 2 Sample 1 (n = ) ANT =.07 DRG =.01 DOM =.16 Sample 2 (n = 60 85) ANT =.08 DRG =.05 DOM =.35** Sample 1 ANT =.42* DRG =.48* DOM =.07 Sample 2 ANT =.49* DRG =.35* DOM =.06 ANT Interpretation T-score Interpretative significance < 60T Individual reports being interpersonally considerate and warm; moderate control over impulses. 60T 69T 70T-81T Moderate degree of impulsivity and risk-taking behavior. Others view them as disinhibited and interpersonally cold and callous. Person reports being impulsive and hostile, and is likely to have a history recklessness and/or antisocial behavior. Not likely to have many close friendships. >82T Prominent features of antisocial personality disorder. Likely to be unreliable, exploitive, and interpersonally callous. Likely to conflict with authority and have prominent impulsivity and aggression. Aggression (AGG) Scale designed to assess cognitive and behavioral manifestations of aggression, anger, and hostility. Taps fundamental aggressive features that are not necessarily specific to any disorder. Aggressive Attitude (agg-a) AGG Verbal Aggression (agg-v) Physical Aggression (agg-p) AGG Interpretation T-score Interpretative significance < 60T Person has a reasonable control over the expression of anger and hostility. Score <40T may suggest an overly meek person. 60T 69T 70T-81T Person reports being impatient, irritable, and likely to have a short-temper. May experience excessive anger and is easily provoked. Chronically angry person. Likely to express anger without reservation. Subscale elevations point to how anger is expressed (e.g., verbal, physical). >82T Clinically significant anger and high potential for aggressive behavior. Individual is overtly hostile and easily provoked, and may have history of violent actions. Functional impairment related to aggressive acting out is likely.

19 Dominance (DOM): The level to which a person is controlling, submissive, or interpersonally dominant. Low Warmth High DOM Hostile Friendly Dominant Dominant Hostile Friendly Submissive Submissive Low DOM High Warmth Warmth (WRM): Extent to which an individual is affiliative, warm, and caring in relationships. Violence Potential Index (VPI) 20 profile characteristics that have been identified in the literature as risk factors for violence. Sensation seeking Impulsivity Substance abuse Dom > Warmth 10T (Hostile Dominance) VPI > 87T moderate risk for violence VPI >121T significant risk for violence. Externalization Disinhibition, impulsivity, excitement seeking. Substance abuse Damage to brain circuitry regulating emotions & decision making. Mental Health and Substance Use (Ruiz, Cox, Magyar, & Edens, 2014) Re Offending Rate 4 5 years after In jail Addiction Treatment General Offending Rate Violent Offense Rate r β r β ANT.19*.25*.23*.31* ANT A.19*.19.28*.26* ANT E.22*.30*.27*.37* ANT S *.25* PAI Sex Offender Specific Studies Boccaccini et al. (2010) ANT and AGG predictive of re offending in sex offenders Boccaccini et al. (2013) BOR and ANT predict re convictions in a small sample of committed offenders N = 124. AGG AGG A.18*.20.27*.23* AGG V.21*.23*.24*.19 AGG P Caperton et al. (2004) ANT/AGG predicted institutional misconduct in a small sex offender sample. Primary Source: Goldstein & Volkow (2002). Drug addiction and its underlying neurobiological basis. American Journal of Psychiatry.

20 Predictors of Violence Meta Analysis (Gardner, Boccaccini, Bitting, & Edens, 2015) ANT Institutional Misconduct k= ANT d =.39 AGG d =.37 VPI d =.26 BOR d =.32 DOM d =.09 Recidivism k = 5 11 ANT d =.31 AGG d =.23 VPI d =.19 BOR d =.12 DOM d =.19 Violence k = ANT d =.26 AGG d =.40 VPI d =.28 BOR d =.11 DOM d =.20 VPI Violence Risk AGG DOM/ WRM Range d =.50 to.79 for risk specific measures (Yang, Wong, & Coid, 2010) Risk for Suicide Suicidal Ideation (SUI) scale Content focuses on hopelessness, thoughts of dying, suicidal ideation, and plans to commit suicide. Current and historical wording of items. Independent of the Suicide Potential Index (SPI). SUI Critical Items (CI) 4 items address current thoughts or preparatory indicators. Items 60, 100, 140, 260, 340 Suicide Potential Index (SPI) Profile characteristics reflecting psychopathology associated with increased suicide risk. SPI > 81T = increase risk for suicide SUI Interpretation T-score Interpretative significance < 60T Person denies, or has minimal, thoughts of suicide or death. 60T 69T 70T-83T Person may entertain periodic and transient suicidal ideation; also likely to be pessimistic and sad. Person reports significant suicidal ideation. Person likely to be anxious, depressed, hopeless, and social isolated. >84T Often associated with severe suicidal ideation and imminent plans for self-harm. Immediate intervention is required. Person has a profound sense of despair and sadness, and may have taken steps towards suicide. Significant potential for completed suicide.

21 MINIMAL RISK MODERATE RISK Low SUI Low SUI Low SPI High SPI SUI Critical items SUI Critical items +/ Suicide Risk HIGH RISK IMMINENT RISK High SUI High SUI Low SPI High SPI SUI Critical items + SUI Critical items + Clinical History PAI Test Findings Opinion Scenario 1. Patient with a history of depressive disorder and multiple suicide attempts via overdose requiring medical intervention. Two psychiatric hospitalizations. Currently taking fluoxetine but not in psychological treatment. Scenario 2. Patient with an adjustment disorder due to recent divorce. Engaged in counseling but not on psychiatric medications. SUI 75T SUI Critical Items + SPI 85T SUI 65T SUI Critical item 60 + SPI 54T The patient is at high risk for suicide. He has a history of depressive disorder and multiple suicide attempts involving physical injury. On psychological testing (PAI) he endorsed increased thoughts of suicide and death, with some of the thoughts reflecting immediate risk based on their recent and specific nature. He also produced a configuration of test scores which reflect distress and mental illness commonly associated with suicidal behavior. Although the patient endorsed periodic and transient suicidal ideation on the PAI, he does not appear to be in significant emotional distress based on the clinical history and other testing indicators. However, he admitted to thinking of ways to kill himself on one PAI item and this requires follow up. Case 3: safeguard evaluation Referral Question Mental state at the time of offense, current treatment needs within the jail. Charge(s): Murder, 2 nd degree (1 count), Aggravated assault great bodily harm. Demographics: Male, Single, no children. College degree. History of professional employment. Clinical interview highlights: Long history of heavy drug use, but had period of good functioning through college and early career. Intelligent, cautious during questioning. 1 prior episode of addiction treatment. HCR 20 highlights Prior violence (1 conviction) Employment problems Unresponsive to addiction treatment Exposure to de stabilizers (drug involved peers, sex industry involvement) Insanity defense. (1) AFFIRMATIVE DEFENSE. All persons are presumed to be sane. It is an affirmative defense to a criminal prosecution that, at the time of the commission of the acts constituting the offense, the defendant was insane. Insanity is established when:(a) The defendant had a mental infirmity, disease, or defect; and (b) Because of this condition, the defendant: 1. Did not know what he or she was doing or its consequences; or 2. Although the defendant knew what he or she was doing and its consequences, the defendant did not know that what he or she was doing was wrong. Mental infirmity, disease, or defect does not constitute a defense of insanity except as provided in this subsection. (2) BURDEN OF PROOF. The defendant has the burden of proving the defense of insanity by clear and convincing evidence.

22 Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.., N. Case 3 Case 3 Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.., N. Case 3 Case 4 Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.., N. Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.., N.

23 Case 4 Case 4 Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.., N. Case 4 Part 1. Conceptual Overview Training Outline Part 2. The Case for Self Report Assessment Part 3. Evaluation of Response Styles Part 4. Evaluation of Risk to Self and Others Part 5. Evaluation of Treatment Needs Part 6. Evaluation of Treatment Responsiveness

24 Borderline Features (BOR) Scale designed to measure severe personality disorder often associated with Borderline Personality Disorder. Includes assessment of emotional dysregulation, identity confusion, poor self worth, interpersonal dysfunction, and destructive impulsivity. Alcohol Problems (ALC) Scale designed to measure signs and symptoms of alcohol use disorders. Content includes questions about abstinence, alcoholrelated problems, loss of control of alcohol use, and alcohol cravings. BOR ALC Affective Instability (bor-a) Identity Problems (bor-i) Negative Relationships (bor-n) Self-Harm (bor-s) ALC Estimated Concurrent Validity of the PAI ALC Scale in College Students Ruiz, Dickinson, & Pincus (2002) Examined relationship between ALC scores and SCID IV Alcohol Use Disorder Diagnoses Sample = 200 college student drinkers. Participants administered protocol individually. ALC r AUC Quantity/Frequency.63** Binge Drinking.60** Alcohol Expectancies.47** Maladaptive Coping.66** Alcohol Abuse DX.74** Alcohol Dependence DX.84** Drug Problems (DRG) Scale designed to measure signs and symptoms of drug use, abuse, and dependence. Content focuses on drug use history (both prescription and illicit) as well as drug related functional impairment. Less reliable than the other scales. DRG DRG Estimated

25 Addiction in Federal Inmates Patry, Magaletta, Diamond, & Weinman (2010) N = 1,120 federal inmates participating U.S. BOP Mental Health Prevalence Project Data were gathered over an 18 month period. 14 different facilities, 3 different security levels. PAI, administrative, and clinical data were collected on newly admitted inmates PAI profile of 160 individuals in a methadone maintenance treatment ALC ALC pr DRG DRG pr Hx of Addiction Treatment.19*.02.33*.27* Hx of Mandated Treatment.10*.06.10*.05 Clinician Recommends Tx.20*.02.34*.29* Substance Use Diagnosis.19*.02.31*.25* Violent Conviction.11*.11* ICN INF NIM PIM SOM ANX ARD DEP MAN PAR SCZ BOR ANT ALC DRG AGG SUI STR NON RXR (Alterman et al. 1995) Anxiety Related Disorders (ARD) Assesses clinical and behavioral manifestations of anxiety disorder symptoms. Content reflects obsessive compulsive thoughts and behaviors, specific and excessive fears, and symptoms related to traumatic stress. Subscales are required to clarify full scale elevations. Depression (DEP) Reflects signs and symptoms of depressive disorder. Item content includes issues about pessimism, negative expectations, unhappiness, and vegetative symptoms. ARD DEP SUI? MAN? Obsessivecompulsive (ard-o) Phobias (ard-p) Traumatic Stress (ard-t) Cognitive (dep-c) Affective (dep-a) Physiological (dep-p)

26 Mental Health Needs Rogers, Ustad, & Salekin (1998) Somatic Complaints (SOM) Schedule for Affective Disorders & Schizophrenia (SADS) PAI scales ANX DEP MAN PAR SCZ ANX ARD DEP MAN PAR SCZ Scores reflect the degree of concern about physical functioning and health matters. Extent of perceived impairment arising from somatic symptoms. SOM N = 80. Participants were referrals to an acute mental health service within an urban correctional facility. Conversion (som-c) Somatization (som-s) Health Concerns (som-h) SOM Interpretation Anxiety (ANX) T-score Interpretative significance < 60T Few bodily complaints. Person may be optimistic, alert, and effective. 60T-69T 70T-87T Some concern about health and bodily functioning. More common in elderly patients and patients with medical conditions. Significant concerns about health and physical functioning. Concerns about poor health and medical problems. May be seen as unhappy, complaining, and pessimistic. >87T Preoccupation with health and physical functioning. Perceives severe impairment arising from somatic symptoms. May view self as disabled and may resist psychological explanations of problems. Scores reflect the degree of anxiety, tension, and negative affect experienced by the respondent. Covers different manifestations of anxiety expression, including rumination, worry, and physical tension and stress. Cognitive (anx-c) ANX Affective (anx-a) Physiological (anx-p)

27 ANX Interpretation T-score Interpretative significance < 60T Few complaints of tension or anxiety. Person describes self as calm, optimistic, and stress tolerant. 60T-69T 70T-90T Moderate degree of anxiety and stress. Person is worried, sensitive, and emotional. Significant anxiety and tension. Increased worry. Person may be seen as high strung, nervous, timid, and dependent. >90T Generalized impairment related to anxiety. Significant time spent worrying, unable to control worry, poor distress tolerance. Likely to have a clinically significant Anxiety Disorder. Case 5 Treatment Needs Referral Question Patient entering a chronic pain rehabilitation program. Demographics: Female, married. 3 children, 2 step children. Associates degree. Unemployed. Clinical interview highlights: Guarded, limited self disclosure, minimal adult social relationships. Chronic pain (back, knees) with no significant nonmedication pain control interventions (e.g., physical therapy). Medications: Oxycontin and Xanax prescribed by a pain management outpatient clinic. Case 5 Case 5 Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.., N.

28 Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.., N. Case 5 Section from PAI Clinical Interpretive Report Clinical Features The PAI clinical profile is marked by significant elevations across a number of different scales, indicating a broad range of clinical features and increasing the possibility of multiple diagnoses. The configuration of the clinical scales suggests a person with a history of drug abuse who is experiencing a number of physiological problems that may be partially related to their use of drugs. These somatic problems might involve withdrawal symptoms or they might be medical complications of drug abuse. The combination of substance use and physical symptomatology is probably causing severe disruptions in her relationships and her work, and these difficulties appear to be serving as additional sources of stress. The respondent demonstrates a degree of somatic concerns that is unusual even in clinical samples. Such a score suggests a ruminative preoccupation with physical functioning and health matters and severe impairment arising from somatic symptoms. These somatic complaints are likely to be chronic and accompanied by fatigue and weakness that renders the respondent incapable of performing even minimal role expectations. The client is likely to report that her daily functioning has been compromised by numerous and varied physical problems. The client feels that her health is not as good as that of her age peers and likely believes that her health problems are complex and difficult to treat successfully. Physical complaints are likely to include symptoms of distress in several biological systems, including the neurological, gastrointestinal, and musculoskeletal systems. The item endorsement pattern indicates that she reports symptoms consistent with both conversion and somatization disorders. The client is likely to be continuously concerned with her health status and physical problems. The client's social interactions and conversations tend to focus on her health problems, and her self image may be largely influenced by a belief that she is handicapped by her poor health. Case 6: Inpatient Evaluation Referral Question Patient is a 37 year old married female who was admitted to inpatient psychiatry due to worsening depression and a recent suicide attempt by means of Tylenol overdose. Demographics: Married. 2 children. High school graduate with Associates degree. Part time employment in a retail store. Clinical interview highlights: Engaged in the interview. Intelligent, appropriate. However, inappropriate selfdisclosures, lack of insight, minimization of substance use, and superficial adult social relationships. Currently taking venlafaxine (Effexor) and hydroxyzine prescribed by primary care provider.

29 Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.., N. Case 6 Case 6 Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.., N. Training Outline Part 1. Conceptual Overview Part 2. The Case for Self Report Assessment Part 3. Evaluation of Response Styles Part 4. Evaluation of Risk to Self and Others Part 5. Evaluation of Treatment Needs Nonsupport (NON) Measures perceived lack of social support, including the availability and quality of supportive others. Item content assesses the nature of relationships with family, friends, and acquaintances. NON Part 6. Evaluation of Treatment Responsiveness

30 Treatment Rejection (RXR) Measures attitudes and characteristics associated with an interest for psychological change. Item assess an unwillingness to change, a refusal to accept responsibility for problems, and a denial of life difficulties. Treatment Responsiveness Caperton et al. (2004). N = 137 male inmates in a sex offender treatment program. About 1.5 year follow up. PAIs administered as part of program assessment. rpb Base Rate ANT r pb AGG r pb VPI r pb RXR r pb General Infraction 64%.24**.24**.19**.07 Non compliance 10% * Major Infraction 19%.28**.19**.18*.02 RXR ANT was found to be the primary predictor of outcomes when controlling for the effects of VPI and AGG. Is there little reasons to consider AGG and VPI scores beyond ANT when considering the prediction of misconduct? Treatment Responsiveness cont Magyar, Edens, Lilienfeld, Douglas, Poythress, & Skeem (2012) Case 7: Treatment amenability Referral Question Mental health evaluation for sentencing mitigation. N = 331 male offenders in residential drug treatment. Prospective data from clinical records and counselor interviews. Outcome Odds Ratio 95% CI General Non compliance AGG > 70T 2.07** ANT >70T Disruptive Behavior AGG > 70T 2.32** ANT >70T 2.29** BOR >70T 1.89** Aggressive Acts AGG > 70T 2.80** ANT >70T 2.79** BOR >70T 1.86** Effects also found for Hostile Dominance Charge(s): Aggravated Child Abuse, Resisting arrest with violence, Violation of probation. Demographics: Male. Single, never married. High school graduate, some college. Clinical interview highlights: Remorseful, but limited insight. Minimized substance abuse problems. WASI II FS IQ 4 = 101 No verbal or performance differences HCR 20 highlights Prior violence (x2) Young age at first violent incident Negative attitudes Plans lack feasibility

31 Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.., N. Case 7 Case 7 Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.., N.