Mock Individual Assessment (Rough Draft)

Create a mock forensic assessment report based on a patient in a selected vignette. Provide your diagnostic impressions based on the DSM-5 criteria.

For this assignment you are to:

• Improve your interview and referral questions for the case vignette you selected in M1 Assignment 3. Use the case vignette you selected in M1 Assignment 3 for this assignment. Next, create and document a set of mock interview questions and potential referral questions to ask your client and yourself. You can determine the questions in relation to the case vignette that you choose. You might also want to consider some of the example referral questions listed below. Analyze all the information provided in the case vignette and begin to formulate a hypothesis as to why the individual needs referral.Example Referral Questions:
  • As a forensic mental health professional, what factors need to be considered in your psychological testing for the forensic assessment report?
  • What behavioral observations do you make about the client by reading the case vignette?
  • What are your assessment options in working with the client?
  • What standards and accepted psychological tests might you apply to your client in forensic settings? Select from the instruments you researched in M3 Assignment 2 RA.
  • How will you recognize and evaluate your client’s offender behaviors associated with malingering and deception?
  • What theoretical orientation do you want to use in this case for your treatment recommendations?
  • What is the case scenario you have selected?
  • What is the reason for referral?
  • What is the purpose of the forensic assessment and report?
  • What is the nature of the problem presented in your selected case vignette?
  • What is the context in which the forensic assessment report will be used?
  • What is the background of your client? What are the symptoms displayed by your client and the significance they have in this case?
  • What is the mental status of your client? Be sure to elaborate on every major component addressed in the mental status examination.
  • What interview type and approach did you use with your client?
  • What tests are appropriate to use in your forensic assessment report? Identify one intelligence test, one objective personality test, and one projective test.
  • What collateral information will you use in the process of the evaluation?
  • How will you present your impressions of the client?
• Write a Forensic Mental Health Professional Individual Assessment Report. Use the Forensic Mental Health Professional Individual Assessment Report template (you can download the template from this link). Evaluate and interpret the information provided to you in the case vignette that you have selected in M1 Assignment 3. Synthesize the information you collected to create a Forensic Mental Health Professional Individual Assessment Report. Your findings should be in a report format. In a 10- to 12-page report, include only the following components:
  • Reason for Referral: Explain the objective of your case vignette analysis, clearly bringing out the aspects or reasons that motivated you to carry out the study.
  • Presentation: Create mock interview data and collateral information (you are to identify the questions to ask in the interview). Provide a synopsis of the interview. Provide data to support the mental status of your client, based on your forensic assessment report and the mental status components you have identified.
  • Current Life Situation and Background Information: Explain the problem provided in your selected case vignette using the interview and mental status data. How does the data relate to the background of your client and your behavioral observations?
  • Objective Testing: Identify the assessment instruments you would recommend to evaluate the client and explain the rationale for your recommendations. Describe the objective tests you have selected and their use. How did you apply these tests to your selected case vignette? Based on your study, what is your analysis of the symptoms displayed by your client? What ethical and multicultural issues do you need to address? You will apply what you have learned from M3 Assignment 2 RA into this section.Assessment Categories and Tests:
• Mental Status Exam

Appearance, Motor, Behavior, Sensorium, Thought Process, Thought Content, Communication, Speech, Perception, Mood, Affect, Cognition/Orientation, Response to Proverbs, Estimate of Intelligence, Memory, and Insight

• Substance Abuse
  • Substance Abuse Subtle Screening Inventory (SASSI)
  • CAGE Questionnaire
• IQ/Cognitive Functioning
  • Wechsler Adult Intelligence Scale, 4th ed. (WAIS–IV)
  • Wechsler Intelligence Scale for Children, 4th ed. (WISC-IV)
  • Kaufman Brief Intelligence Test, 2nd ed. (KBIT-2)
  • California Verbal Learning Test, 2nd ed. (CVLT-II)
  • Reynolds Intellectual Assessment Scales (RIAS)
• Projective Personality
  • Rorschach Inkblot
  • Thematic Apperception Test (TAT)
• Objective Personality
  • Personality Assessment Inventory (PAI)
  • Millon Clinical Multiaxial Inventory-III (MCMI-III)
  • Minnesota Multiphasic Personality Inventory (MMPI)
• Competency to Stand Trial
  • MacArthur Competence Assessment Tool-Criminal Adjudication (MacCAT-CA)
  • Georgia Court Competency Test (GCCT)
  • Competency Assessment Instrument (CAI)
• Risk Assessment
  • Violent Risk Appraisal Guide (VRAG)
  • Sex Offender Risk Appraisal Guide (SORAG)
  • Hare Psychopathy Checklist-Revised (PCL-R)
• Insanity/Criminal Responsibility
  • Rogers Criminal Responsibility Assessment Scales (RCRAS)
  • Provide your diagnostic impressions based on DSM-5 criteria. What is your principal diagnosis? What is your secondary diagnosis? Are there other conditions that may be the focus of clinical attention to consider?
  • Conclusion and Recommendations: What is your hypothesis based on the mental status examination, the interview, personality tests, and symptoms analysis? Explain your hypothesis and substantiate it, using instances from your case study. Discuss your results with conclusions and recommendations.

The final Forensic Mental Health Professional Individual Assessment Report should contain all the assigned components and the corresponding information.

Your final deliverables for this module are:

• Selected case vignette
• List of interview/referral questions
• Assessment template
• Final assessment report

Your report should be approximately of 12–15 pages.

M1 Assignment 3  My Paper

This incident happened outside Mr. P’s apartment where he was parked in his car. In this case, we find a young man who is already addicted to alcohol in his early ages. It is evident that this young man was drunk while he was driving his car back to his house.

The type of forensic assessment, in this case, is substance abuse evaluation. This is evident because the young man has been using alcohol for sometimes. According to the case, this is not the first time this person is being charged with driving under influence. His blood alcohol level was also above the legal limits meaning he had consumed much of it(Moos,2017). He also indicates that his father was an alcoholic and there is a long story of drug abuse and alcohol in his family. The young man started drinking alcohol at the age of fourteen and thought this will help him in dealing with his mother’s illness stress and also in taking care of her. He was again depressed in college and this increased his use of alcohol. This is enough evidence of substance abuse evaluation. He needs to be helped out of this as in most cases we can observe that he uses alcohol to reduce stress. This evaluation helped in identifying his weakness and realizing the reasons as to why he uses the substance.

The referrals will help in the evaluation of more comprehensive needs. For instance, in this case, we find out that the young man has got some other problems which contribute to his alcohol abuse. The referral helps in identifying the problem at hand, the social circumstances and any concern over the risk to the victim (Sahker et al,2015).

In this case, assessment helped in evaluating whether or not this young man is experiencing some problems out of alcohol consumption. It helped in realizing the reasons as to why Mr. P uses alcohol of which at many times the reason was to reduce stress. By conducting an assessment, the matter is discussed deeply. In this case, those involved may come up with a plan to help the client in the problem-solving mechanism. The report produced about his case will help in identifying the type of advice and care he needs.

The client is open as he discloses to his lawyer some of his life stories and how he ended up being a drunkard. In this case, there is the impression of openness. The man is an intellect, from the case he became a software engineer at an early age and he might become a shareholder in two years’ time. After listening to the case one becomes emotional and sympathetic. He had been disturbed by his mother’s illness to a point of becoming a drunkard meaning the affection was so strong (Melton et al,2017).

A psychologist uses assessments and tests to help in making a diagnosis of a patient’s mental health condition. The tests they perform help’s them in understanding the person’s behavior that may be causing problems, the relations between a person’s feelings and thoughts. They also help people in getting out of life experiences which are traumatic. From the case the young man it is evident that he turns to alcohol while stressed up(Maruish,2017).

Addicts are very good at lying and they do it so as to continue with this behavior. But as a psychologist, there is a close understanding of the addicts as they are biased by their addiction. The psychologist can assess the degrees and types of problems facing the addict. The report will help the psychologist in initiating the first guidance.

References

Maruish, M. E. (Ed.). (2017). Handbook of psychological assessment in primary care settings. Taylor & Francis.

Melton, G. B., Petrila, J., Poythress, N. G., Slobogin, C., Otto, R. K., Mossman, D., & Condie, L. O. (2017). Psychological evaluations for the courts: A handbook for mental health professionals and lawyers. Guilford Publications.

Moos, R. H. (2017). Evaluating treatment environments: The quality of psychiatric and substance abuse programs. Routledge.

Sahker, E., Toussaint, M. N., Ramirez, M., Ali, S. R., & Arndt, S. (2015). Evaluating racial disparity in referral source and successful completion of substance abuse treatment. Addictive behaviors, 48, 25-29.

Case Vignettes 

Case 1 

Ms. G is a forty-six-year-old Caucasian female charged with burglary. She was arrested for the offense after she was found by the police with her neighbor’s property. She was intoxicated and in possession of drugs at the time of the arrest. She also was belligerent and combative and surprised that she was being accused of a crime. She initiated a physical altercation with the police and was immediately taken into custody with the highest level of constraint to protect her and the officers from potential harm. The officers’ report indicated that Ms. G was irritable, assaultive, hyperactive, and irrational when they approached her. She was also unable to engage in conversation and believed the officers were attempting to poison her. Her energy level was excessively high, and she emphatically stated that she knew the mayor personally and would have the officers and prosecutor incarcerated for accusing her of this crime. She refused defense counsel and insisted on speaking to the judge before her pretrial. While incarcerated, she rallied the other inmates to protest the rules and initiated a hunger strike. She became more paranoid while in the holding cell, suggesting that the police planted drugs on her and were attempting to locate and kill her only remaining family member. They were, in fact, attempting to contact her brother to gather information on her mental health. Her brother provided them with relevant family history. He indicated that Ms. G had lost her parents at an early age and was separated from her brother when they went into foster care. Her brother had had minimal contact with her from the time she was four years old until she turned eighteen and found him with the help of a private investigator. They maintained only intermittent contact because Ms. G was transient, moving around the country on a regular basis. She held odd jobs, sold drugs, and lived with boyfriends to survive. To her brother’s knowledge, Ms. G had never received any mental health treatment. She also denied a history treatment. She refused to speak with the police about her charges and personal history. 

Ms. G faces a trial for her offense because she refused a plea bargain. She also refused defense counsel when it was offered. 

Determine what type of forensic assessment would be most appropriate for this case and discuss the rationale for your decision. 

Your choices are: 

• Competency to stand trial  
• Substance abuse evaluation  
• Not guilty by reason of insanity  
• Mental health treatment evaluation Case 2 Mr. P is a twenty-six-year-old single male charged with his fourth driving under the influence (DUI). He was arrested while parked in his car in front of his apartment. His blood alcohol level was just over the legal limit, and he passed most of the sobriety tests given by the officer who arrested him. During the arrest, he stated that he had returned from a going-away party for a friend and was so tired he fell asleep in his car before he was able to make it into his apartment. He admitted to drinking that evening but denied with certainty that  

he was intoxicated. His story was convincing to the officer, but his previous history of DUIs warranted the arrest. Mr. P was pleasant and cooperative during the arrest and was taken into custody without incident. He was released the next day with a court date. He obtained legal defense and faced the judge with both fear that he would be incarcerated and confidence that he had a defensible case. Much to his surprise, the judge imposed a harsh sentence—ninety-day substance use treatment—at the corrections facility. Mr. P has never been incarcerated and faces losing his job if he spends ninety days in treatment. The judge did not show him any leniency or take into consideration his position in the community, his clean criminal background, or the eight-year time span between his last and present DUI charges. Mr. P disclosed to his lawyer that his father was an alcoholic and that there is a long history of alcohol and drug abuse in his family. He also indicated that his mother was schizophrenic and he was responsible for much of her care during his formative years. He became a successful operations manager for a software engineering company at an early age and is on the fast track to becoming a shareholder within the next two years if he maintains a clear record and follows company policy. He admitted to a bout of depression in college following the placement of his mother in a nursing home. He denied a history of depression prior to that point in time but admitted that his past circumstances likely made him susceptible to emotional difficulty. He began drinking at fourteen years of age to deal with the stress of his mother’s illness and his responsibility for her. His use increased during the one year in college when he was depressed. He received the initial two of his three previous DUIs on campus that year. His third DUI was the result of driving home after having a drink to celebrate passing a difficult examination. The police in his college town were known to make a high number of drunken driving arrests that were rarely fought in court. He believes that he was simply prey for the police and denied he was irresponsible with drinking and driving. 

Mr. P admitted to recent work stress that likely threatened his position and future with the company. He denied feeling depressed or the urge to use alcohol to reduce his stress. 

Mr. P has been depressed and used alcohol excessively in the past when he faced stress and difficulty. He also denies the seriousness of the charges against him. 

Determine what type of forensic assessment would be most appropriate for this case and discuss the rationale for your decision. 

Your choices are: 

• Competency to stand trial  
• Substance abuse evaluation  
• Not guilty by reason of insanity  
• Mental health treatment evaluation Case 3 Mr. H has been charged with second-degree murder as a result of shooting a man in his apartment complex for playing loud music night after night. He admitted to killing the man and expressed remorse but felt justified in his murder because he had made so many previous requests to his neighbor to turn down his music. During questioning, Mr. H revealed that on the night of the shooting, he was instructed by the God of his universe to exterminate the noise that disturbed the angels. It was at that point when he loaded his rifle and went upstairs to kill his neighbor. The suspect is twenty-four years old with no former mental health history. He was able to discuss his past development with the detective working on the case. He presented with no hostility or irrational thoughts. He related that his development in his family was relatively uneventful  

Case Vignettes 

2 

and that he had close relationships with both his mother and father and with his two younger siblings, one brother and one sister. He had recently moved into his own apartment, after graduating from college, and is receiving support from his mother until he finds work. His father died two years ago in a tragic car accident. He felt guilty for moving but also wanted to be independent and begin his career. The suspect admitted to hearing voices on one other occasion when he was driving his car to the grocery store about one year ago. He assumed it was he himself who was talking to himself and never gave it another thought. He began to apparently feel more remorse as the interview proceeded, but the investigator was uncertain that it was genuine and wondered if he was being manipulated by the suspect. The investigator returned him to his cell to await further questioning and formal charges. 

Mr. H faces murder charges and is not clearly presenting with remorse. He has experienced recent losses and changes that have resulted in an increase in stress and responsibility. 

Mr. H has also begun to experience auditory hallucinations, which he indicated provoked him to shoot his neighbor. 

Determine what type of forensic assessment would be most appropriate for this case and discuss the rationale for your decision. 

Your choices are: 

• Competency to stand trial  
• Substance abuse evaluation  
• Not guilty by reason of insanity  
• Mental health treatment evaluation  

Case Vignettes 

LINK

Name:     Identification Number:      Date of Birth: 

Tests Date:          Time Spent: 

Interview Date:          Time Spent: 

Name of Assessment (competency to stand trial, substance abuse, not guilty by reason of insanity, or mental health evaluation). 

Introduction  

In this section, briefly introduce the main purpose of the evaluation. 

Reason for Referral  

In this section, discuss the reason this case or individual was referred to you. Also, discuss what you hope to find out about the client and the client’s role in the assessment. The points you make here will be the guides to what interview format and psychological tests you choose and what type of report you will prepare, (recommendations to the court or attorney, competency findings, or treatment recommendations). The interview data, test data, findings, and recommendations will relate to the referral question. 

Presentation  

In this section, identify interview behavior and review mental status. Discuss cooperation and willingness to discuss pertinent history and current functioning. Identify appearance features with a general description and comments concerning hygiene. Review mental status elements including attention; orientation; thought processes; thought content; short-term, long-term, and immediate memory and recall; comprehension and estimation of intelligence; response to proverbs; awareness of current events; ability to build rapport with the examiner; defenses; affect; mood; speech coherence; eye contact; reasoning ability; reality testing; judgment and impulse control; insight; and concentration.  

Current Life Situation  

Discuss the client’s current legal and occupational status relationships, and family involvement. Review the client’s perception of the offense, the purpose of the assessment, the case against him or her, and the need to have the assessment. Also, explore the client’s current relationships with professionals in the case, recent stressors, and general methods for coping. Include any pertinent information about this client’s life as it is being experienced currently. 

Background Information  

Discuss the client’s development, family experiences, abuse, traumas, birth order, mother’s and father’s occupations, family morals, family values, closeness of relationships, educational history, military history, occupational history, and legal history. Also, discuss the history of relationships with friends and spouses and personal and occupational acquaintances.  

Psychological History  

Discuss relevant psychological history including previous diagnoses and treatment. Also, review the family history of psychological difficulty and treatment. 

Substance Use History  

Discuss substance use as it relates to the age of the client when first using alcohol, marijuana, cocaine, and other substances. Also, explore abuse and dependence history and factors that sustain use. Discuss the client’s treatment history and any family history of substance use and treatment. Discuss frequency of present use, how it began, what sustains it, periods of sobriety, factors contributing to sobriety (external or internal), obstacles to success with sobriety, family history, previous attempts at treatment, number of relapses, perception of use difficulty, awareness of relapse potential, awareness of risk factors for relapse, and triggers to use and relapse.

Medical History  

Review all relevant medical history, medications, and treatments. Explore family medical history. 

Objective Testing  

Identify the full name of each test, and include descriptions of the purposes for each one used in the assessment. 

Example 

Tests administered 

Minnesota Multiphasic Personality Inventory, second edition (MMPI-2) 

The MMPI-2 is a self-administered personality inventory designed to evaluate personality traits and symptoms of psychological illnesses and personal maladaptive adjustment. 

Weschler Adult Intelligence Scales, fourth edition (WAIS 4) 

The WAIS 4 is a full-scale intelligence test used to identify intellectual functioning and potential deficits in both verbal and non-verbal areas. 

Findings 

Relate your findings in the format recommended by the test manual. Incorporate your findings with your observations of the client and the self-descriptions the client offered during the interview. Also, include test findings as they relate to collateral information on the client. 

Diagnostic Impressions 

Using the latest version of the Diagnostic and Statistical Manual of Mental Disorders provide your diagnostic impressions that may include subtypes, specifiers or rule outs.

Conclusion  

Summarize your findings by incorporating interview data, test data, collateral information, and mental status elements. Discuss your findings as they relate to your observations of the client and the referral question and purpose of the assessment.  

Recommendations 

Discuss your recommendations as they relate to the referral question, treatment needs, third party request, and the purpose of the assessment. 

Sign your name and credentials.      Date your report. 

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