2022, Vol. 21, No. 2, 146-163 | International Journal of Forensic Mental Health
Current Practices in Incorporating Culture into Forensic Mental Health Assessment: A Survey of Practitioners
Amanda M. Fanniff; Psychology, Palo Alto University, Palo Alto, California, USA
Taylor M. York; Psychology, Palo Alto University, Palo Alto, California, USA
Alexandra L. Montena; Psychology, Palo Alto University, Palo Alto, California, USA
Kenzie Bohnsack; Psychology, Palo Alto University, Palo Alto, California, USA
Forensic evaluators conduct assessments of individuals with a wide range of sociocultural identities. Although recommendations regarding how to incorporate cultural considerations in forensic evaluations have been published over the past decade, there is no clear consensus on best practices nor is it clear how evaluators interpret and apply the available recommendations. The current survey represents a replication and extension of a previous survey regarding self-reported culturally-informed practices among forensic evaluators. Subjects were forensic mental health professionals (n1⁄4258; 64.7% women, 69.4% PhD or PsyD) recruited through listservs and training events to complete a survey online or by hard copy. Evaluators reported significant challenges in conducting culturally-informed evaluations, including lack of appropriate tests for their examinees, lack of guidelines for their evaluations, lack of colleagues from diverse backgrounds, and lack of relevant research. Evaluators reported engaging in a wide range of culturally-informed practices across all domains, some being nearly universal (e.g., considered cultural context when forming diagnosis). In contrast, other practices were relatively uncommon (e.g., referred the evaluation to another professional with more knowledge/experience regarding examinees with particular identities). Results indicate a need for more research, more practice guidelines, and diversification of the forensic mental health workforce.
Culturally-informed assessment; cultural differences; forensic mental health
Summary of the Research
“The over-representation of individuals with minoritized racial and ethnic identities in forensic settings, particularly criminal and juvenile justice contexts, is well established…Forensic psychologists face an ethical and professional mandate to appropriately incorporate cultural considerations in their evaluations…A culturally ‘competent’ psychologist is also culturally humble and approaches individuals with an open, respectful, collaborative stance to attempt to ‘understand the unique intersection of clients’ various aspects of identities…’ There are no well-established standards for cultural competence in forensic contexts, but published recommendations do show considerable overlap…Some guidance specific to conducting risk assessments with diverse examinees has been offered…The ways in which evaluators translate these recommendations into practice are largely unknown. Two surveys of forensic evaluators’ self-reported practices regarding culturally-informed FMHA have been published…Although these surveys are fairly recent, there may be a rapid change in psychologists’ practices regarding incorporating cultural factors into their FMHA…This is the first survey to address practices specific to risk assessment of diverse samples” (p. 146-148).
“The current sample comprised 258 forensic mental health professionals…There is agreement that forensic evaluators must sometimes adjust their practices based on examinee identities to offer accurate and fair opinions. The respondents in the current survey reported engaging in a variety of practices that are consistent with existing recommendations; however, some practices that are consistent with recommendations are not routinely used…Evaluators reported engaging in a wide range of methods to enhance their culturally-competent forensic practice; however, they rarely referred evaluations to other professionals based on the cultural identities of the examinee…The available recommendations all highlight the need to consider cultural norms when interpreting examinee behavior and nonverbal communication. Perhaps unsurprisingly, respondents report frequent use of practices consistent with these recommendations. The reasons why the current respondents reported lower rates of talking about difficulties in communication and asking about examinee comfort is needed…” (p. 149-158).
“Respondents raised difficulties working with translators as among their biggest challenges…Respondents primarily relied upon court-approved or court-appointed translators, consistent with recommendations, but indicated that even these translators often were not well-trained and did not engage in mechanical translation…Alterations to the clinical interview and collection of collateral information may at times be necessary with examinees with different cultural identities. The respondents in this survey reported adapting their practice frequently in some ways, including asking about somatization of psychological distress…The respondents in the current study discussed immigration status with examinees significantly less frequently than respondents in the Kois and Chauhan (2016) survey…” (p. 158).
“Evaluators may have selected not applicable [to questions about assessment] because they do not give such assessment instruments to individuals whose identities are not well-represented in development samples, or they may not give any formal measures in their routine practice…Although many respondents indicated that they consider level of acculturation, less than half as many reported using formal or informal methods to assess level of acculturation…Additionally, a small proportion of evaluators reported selecting tests based on the availability of appropriate translations or norms…The importance of cultural considerations in diagnostic formulations is one of the longest-recognized requirements for conducting culturally-informed forensic evaluations…Evaluators reported routinely considering cultural context in answering referral questions…The somewhat lower frequency of considering culture-bound syndromes may relate to the limited number of such syndromes acknowledged in the DSM or the limited utility of specific diagnoses to forensic evaluations…” (p. 159-160).
“Respondents appear less likely to use most approaches to risk assessment with diverse examinees than with other individuals, with the exception of the anamnestic and unstructured approaches. This likely reflects concerns regarding how alterations of risk assessment tools might decrease their predictive validity; it also suggests a significant proportion of evaluators are more concerned about this than about the biases that may enter into a less structured evaluation process…In contrast, evaluators reported they typically did not alter their data gathering approach, which seems inconsistent with available guidance…” (p. 160).
Translating Research into Practice
“…More effective strategies for detecting biases, such as tracking one’s decisions (e.g., Gowensmith & McCallum, 2019), may facilitate better recognition of when to refer cases to another professional. Consultation with peers may also facilitate more effective recognition of biases and may facilitate culturally-informed practice when referral is not necessary or possible…Additional resources for training of neutral translators are clearly needed; given that respondents also noted institutional resistance to the expenses associated with securing neutral, well-trained translators, this need may continue to be unmet…guidance regarding culturally-informed collection of collateral information may be an area for improvement. Mental health professionals may need to rely more heavily on collateral sources when evaluating individuals with different cultural identities, particularly when tests with appropriate norms are not available…” (p. 157-159).
“…Although best practices regarding test selection are not clear, assessment interpretations should acknowledge the limitations of measures based on the examinee’s identities and address how those limitations impact test validity…Further research on the decisions of evaluators in these circumstances, including qualitative research on their reasoning, might clarify best practices…Qualitative research would elucidate the types of information sought and means of gathering that information in risk evaluations of diverse examinees. There is little guidance available regarding what specific cultural information should be included in a risk assessment…Given their influential role in decisions that impact an individual’s liberty (e.g., parole decisions), additional research is needed to guide valid, ethical risk assessment for diverse examinees…” (p. 159-160).
“…Qualitative research can help inform an emic (i.e., grounded in the norms and practices of a cultural group) rather than etic (i.e., applying the values of the outside dominant culture) approach to forensic evaluations with specific groups…Qualitative research with examinees can also provide information on which practices facilitate cultural safety in the forensic evaluation context…Research-based efforts to develop consensus among experts can help produce the types of guidelines respondents wanted. Additionally, research on effective training strategies is needed to ensure we are engaging in evidence-based teaching. Further, more objective means of evaluating forensic mental health professionals’ competencies is needed…Evidence-based coding schemes to rate practices based on observation and on written reports would be a valuable tool for supervisors and for clinicians to engage in self-assessment and improvement. In addition to research, the field of forensic psychology must find ways to recruit, retain, and support a diverse work force…” (p. 161).
Other Interesting Tidbits for Researchers and Clinicians
“Taking cultural factors into consideration when interpreting examinee behaviors is a fairly universal recommendation…Evaluations must consider cultural norms regarding nonverbal communication (e.g., eye contact, emotional display) to avoid pathologizing normative behavior…Additionally, evaluators must be aware that examinees may hesitate to share information due to cultural mistrust, or normative suspicion resulting from experiences of exploitation and racial discrimination…This may result in under-diagnosis when information is withheld during the evaluation…Second, recommendations consistently highlight the need to consider cultural factors when formulating diagnoses…Understanding cultural norms is essential to distinguishing normative behavior from symptoms of a mental health problem…Concerns regarding testing are also commonly addressed, with a focus on selecting appropriate tests and reporting the limitations of those tests…” (p. 147). “A variety of recommendations focus on competence, including (1) considering your competence to evaluate someone with the examinee’s identities prior to accepting a referral…(2) educating yourself about examinee identities…and/or (2) consulting with colleagues with relevant cultural expertise…A number of sources also highlight the need to select objective, well-trained translators…Other recommendations less commonly mentioned, such as providing informed consent in a culturally-responsive manner…Several sources noted the need to consider acculturation…Peery and colleagues (2017) noted that when examinees are less acculturated to the dominant culture, interpretation of neuropsychological testing may require more caveats and more emphasis on factors that may impact interpretation such as education level. Finally, some recommendations highlighted the importance of considering the impact of the evaluator’s identities…” (p. 148).