Chartered psychologists Dr Richard Cosway (pictured right) and Dr Hugh Koch (pictured below) discuss key factors to be borne in mind when assessing psychological trauma.
Guidance given for the instruction of experts to give evidence in civil claims clearly endorse the overriding duty of experts to help the court obtain evidence, which is independent, reasonable and fair. This is regardless of the pressures of litigation. To achieve this when assessing psychological trauma, several key factors require consideration in every case: –
Reliable diagnosis, consistency of evidence from different sources differentiating effects of index event from other events, interpretation of GP (and other) medical notes, prognosis and appropriate treatment and culminating in an overall robust and impartial opinion which withstands scrutiny and challenge.
a) Reliable Diagnosis
The two diagnostic classification systems of DSM V (American) and ICD 10 (European) allow clinicians (psychologists and psychiatrists) to assess two aspects of trauma in a structured way in terms of type of reaction (e.g. stress, anxiety, depression) and levels of severity (acute, chronic, sub clinical (i.e. not clinically significant). This has crucial implications for both prognosis and treatment assessment (Koch & Kevan, 2005). Certain diagnoses such as post-traumatic stress disorder (PTSD) and chronic pain need extra careful assessment as they have very significant effects on occupational, social and psychological functioning and also have higher quantum implications (Koch et al 2015).
b) Consistency of Evidence
Experts are typically presented with several different sources of evidence which they have to weigh up in relation to each other: claimant self report, GP and hospital attendance history, significant other witness statements, other medical evidence and, on occasion, surveillance evidence.
Experts have the skill to ‘stand apart’ from any one source and withhold opinion and conclusions until all available sources of information or alternative range of opinions have been considered.
Experts also have skills in assessing claimant response style and provide opinion of consistency of evidence including level of magnification, exaggeration or truthfulness (Koch, Beesley and Farrant, 2015).
c) Interpretation of GP and other medical history
GPs are typically reliable historians of claimants’ medical attendances before, during, and after the index event, which is subsequently litigated. Such data is contemporaneous and nearly always uncontaminated by the legal process. Greater analysis of the types of interpretation that can be made of GP attendance records is needed to clarify for the Courts how the GP records can helpfully reinforce or contradict claimant based self report (Koch et al 2014).
d) Prognosis and Appropriate Treatment
Experts routinely assess from available records and self report the duration of the psychological trauma and subsequent sequelae. Where the psychological difficulties persist, then the expert is required to recommend any appropriate treatment in line with current research (e.g. SIGN and NICE recommendations) and also indicate a sensible prognosis in terms of recovery time. This is based on an assumption of a motivated claimant who wishes via their own efforts or with treatment offered, to resolve their psychological difficulties. The effect of the ongoing litigation must be taken into account in that it can frequently reinforce or maintain preoccupation with thoughts and memories of an adverse index event and make “moving on” more difficult.
We plan to follow up this article with regular articles on reliability factors in psychological assessments, interpretation of GP notes, chronic pain post-DSM 5, and other contemporary issues.
Koch H.C.H. and Kevan T. (2005) Psychological Injuries. XPL Press, St. Albans
Koch HCH, Mackinnon J, Harrop C and Boyd L (2015) Expert Evidence in Chronic Pain. Expert Witness Journal. Winter
Koch HCH, Newns K, Willows J (2015) Unreliable pre-index accident history: What does it mean? Forensic Expert E-Journal (tbc)
Koch HCH, Leckart B, Shannon K & Hetherton J (2014) Reviewing Medical Notes. Expert Witness Journal. Autumn.
Koch HCH, Beesley F and Farrant A (2015) Psychological-Training for Lawyers: Effective CPR-related Communication with experts. Forensic E-Journal (in submission)
More details can be obtained for Dr. Richard Cosway (www.hughkochassociates.co.uk)
Dr Richard Cosway is a chartered psychologist at Hugh Koch Associates LLP and holds monthly clinics in Edinburgh and Glasgow.
Dr Hugh Koch is a chartered psychologist and director of Hugh Koch Associates LLP. He holds monthly clinics in London and Cheltenham