2. If the examinee has a somatization disorder or factitious disorder with physical symptoms, the medical history is unreliable and therefore must be independently verified.
3. If the examinee has a history of antisocial personality disorder,
longstanding substance dependence, dissociative disorder, or demonstrates
evidence in the examination of malingering, the entire history is unreliable
and therefore must be independently verified.
A psychiatric examination for forensic purposes is much more of a fact finding task than a clinical examination. There is no patient-doctor or patient-psychotherapist relationship in the forensic setting. In the clinical setting, the clinician uses the subjective material to gain an understanding of the patient's view of the world. An attempt to verify the patient's version of the history would be inappropriate (barring an emergency in which vital information was necessary such as an overdose), a violation of confidentiality, and completely undermine the trust necessary to proceed in therapy. These considerations do not apply in a forensic setting where it is vital to verify as many elements of the history as possible. In summary, a clinician should refrain from any investigative work, while the forensic examiner should immerse himself in getting the facts straight.
This being said, the three principles as described above should be obvious, but are rarely applied. I believe that this is because most examiners are much more accustomed to the clinical rather than the forensic model. They are not used to questioning the historical validity of a claim and are frankly uncomfortable with the whole process. A clinician who always trusts at face value the absolute historical accuracy of his patient's reported psychological injury should stay as far away as possible from the forensic arena, as he will certainly be exposed as an incompetent naïf in deposition or in cross examination. While it is true that examinees are usually truthful, in a forensic setting there are plenty of reasons to stretch the truth or manufacture outright lies. Exculpation from guilt, child custody, revenge, and monetary reward are powerful incentives to fabricate and exaggerate.
Even mental health clinicians who have little desire to pursue a forensic career should be cognizant of the dangers of treatment when the patient has a legal matter pending on emotional damages or disability. Recovery tends to be delayed because there is a direct conflict of interest between recovery of mental health and recovery of damages. Resolution of suffering will reduce an award for permanent disability and the claimant may be more interest in the latter than the former. Phobias in an unadulterated clinical setting can often be resolved in eight or ten sessions, but this hardly ever happens when there is a pending lawsuit or insurance claim. Treating on a lien is a morass of ethical and billing problems. It is an obvious conflict of interest to treat to write any kind of forensic report for a patient treated on a lien and the American Academy of Psychiatry and Law considers all lien-based treatment to be unethical. The treating clinician should always remember that the claimant's version of events is subjective and may not be verified through investigation or discovery. It is therefore financially quite risky for a private practitioner as there is little hope for service reimbursement for hours of treatment effort if the lien is ultimately denied.