Motor vehicle accidents, or crashes, are the most common trauma in westernized countries. In the United States in 2003, there were over 6 million motor vehicle accidents, resulting in 42,000 fatalities and nearly 2.7 million personal injuries (US Dept of Transportation, 2004). Almost everyone will have been in a car accident by the age of 30.
Less commonly known, these car crashes are associated with many psychological injuries. Posttraumatic stress disorder (PTSD) is the most investigated consequence of motor vehicle crashes (MVCs). Based on the available studies to date, we estimate that between 10 and 45 % of survivors of car crashes will develop PTSD, with much of the variation dependent upon the number of males in the sample (more males lower percentage of PTSD), and the timing and site of the evaluation (e.g. emergency room, physician’s office, or community survey) (c.f. Ehlers, Mayou & Bryant, 1998; Blanchard, Hickling, et al 1995, 1996). One consistent finding is that following a serious motor vehicle accident; PTSD and other psychological injuries occur very frequently.
The purpose of this article is to help private practice clinicians better understand some of the issues involved in assessing and treating patients with PTSD or other psychological injuries following a motor vehicle crash. Several important, interrelated issues will be addressed. These include appropriate assessment techniques, unique treatment issues, the impact of insurances systems, (including No Fault and Worker’s Compensation Insurance), forensic concerns, and the possibility of court appearances and expert testimony. To do this, we will proceed from the first phone call to possible testimony in court.
The Phone Call: The referral to see the patient can come from three likely sources; the patient, their treating physician or health care specialist, or a lawyer. The first critical question is, “Do you want to see the patient?” Does the presenting problem sound like something you are comfortable treating? Do you understand the possible problems that might arise such as the need for a neuropsychological evaluation if there is concern of concussion or head injury? Might there be another agenda, such as a search for an unsophisticated expert, to gather evidence to bolster a compensation claim? Be alert to legal questions potentially associated with a client’s presentation. In a recent request to examine a case the lawyer calling wanted to know if the car accident and brain injury that occurred, could have led to later paranoia and possible impulse and anger issues that culminated in a murder. The lawyer was told this was not an area of expertise, and it was hoped he could find someone better qualified.
Preauthorization: Assuming the case is something you are comfortable treating, how does one proceed? In this type of case, it is important that the insurance and payment issue is clarified. If the treatment is considered causally related to the motor vehicle accident, then nearly all payment is handled by a case manager for a no fault or worker’s compensation case. This is one of the people who provide approval for payment. If the case is older, and no longer managed by that insurance, you still need to have this issue clarified, before you submit billing to any third party payor, as they will assume it is accident related and that no fault or worker’s compensation insurance is the appropriate party for payment.
The Initial Evaluation: Before you start the diagnostic interview, it is important to appreciate that everything you do will be scrutinized. Several times. Lawyers, psychologists, psychiatrists, other physicians, as well as insurance adjusters may all review and critique your report. Insurance companies will not typically pay for your services unless you send them copies of all notes, evaluations, and related materials that help them decide their responsibility for the case. Lawyers will request complete files, including at times, copies of the file folder itself (it can only guessed just in case something has been written on it that they wished to review). The only caveat is that at least in New York State, we are not allowed to send other doctors’ notes as they are not ours to release. But be assured, if you go to court, you will be asked if you were aware and acquired needed information from other treating professionals. Your clients should understand the limitations to confidentiality posed by their insurance claim.
The initial evaluation begins with a good quality, comprehensive interview. You will ask about the crash, gain details of the accident from the patient’s perspective, and in general perform a thorough evaluation, which includes a medical and psychosocial history, mental status examination, and a look at possible earlier trauma, etc. This takes time, (at least 75-90 minutes is recommended). A motor vehicle accident interview is available to interested readers (Blanchard & Hickling, 2004).
The standards for this type of clinical and forensic evaluation are high given the potential use of the information obtained (c.f. Koch, et al, 2005). We would strongly recommend that any clinician performing these evaluations become competent in the administration of the Clinician Administered PTSD Scale (CAPS). This is considered by many to be the gold standard for assessing PTSD. Interested readers are referred to the National Center for PTSD website for further information (www.ncptsd.org). In addition to the CAPS, we have found it useful to have the patient complete several self-report forms including the PTSD Checklist (PCL), the Impact of Events Scale (IES), the Travel Anxiety Questionnaire (TAQ), (again found in the 2004 text), and measures of depression such as the Beck Depression Inventory (BDI-II), and the State Trait Anxiety Inventory (STAI). In terms of reporting the test findings, we have historically summarized and even listed endorsed symptoms as part of our reports. Our thinking behind this is that we know the reports are going to be critically reviewed, so that transparency in diagnostic decision-making will benefit all parties. We often have the patient read the draft of the evaluation for accuracy, and to clarify what is being conveyed in the report and future communications.
Malingering: There can be large, sometimes multimillion dollar, financial settlements for MVCs with personal injuries, including psychological injuries. One of the necessary questions that therefore arise is the question, “Might this person be exaggerating or even faking their symptoms for financial gain?” As a result some clinicians have used well-established tests such as the MMPI-2, or the Personality Assessment Inventory (PAI) or the Structured Interview for Malingered Symptomatology (SIMS) to try to gain a better understanding of this possibility. We believe that while such tests of response style are useful in forensic evaluations, there are inherent risks in their use. First, the current state of the art for such instruments is about an 80 percent hit rate, which implies the potential for mislabeling 20 percent of truthful patients as malingerers. Tread carefully in diagnosing malingering. Second, while aware of the risk of malingering, your first role in a clinical (as opposed to purely forensic evaluation) setting is to assess and in all likelihood treat the patient. If you give tests of any sort, you need to believe that test results will contribute to the effective treatment of the patient. Attempt to avoid mixing the roles of treating clinician and independent forensic examiner. Third, if you do use tests of symptom exaggeration or malingering, ensure you are able to coherently explain findings on such tests for this population of patients to a critical audience of other experts, lawyers, and potentially juries.
Our experience led to several studies, where we studied intentionally faking MVC survivors or simulators, to see if we could catch them in our standard clinical practice. Even when we trained the best “fakers” we could find, trained actors, our very experienced graduate student assessors were able to correctly identify 91% of the potential subjects as either fakers or true patients by use of an interview alone (Hickling, Blanchard, Mundy, & Galovski, 2002). That finding helped our confidence that clinicians can be sensitive discriminators of potentially malingering individuals, at least as well as the currently available psychological instruments An excellent review of the issues regarding tests of malingering and effort is found in Koch, et al’s (2005) text.
The initial evaluation is always prepared with the likelihood that it will be sent to referral sources, insurance companies and any other location the patient selects, including lawyers. The patient needs to know at the beginning of the assessment that, due to the need to share information in personal injury cases, all evaluations, questionnaires, and subsequent chart notes will at some time be available to insurance company reviewers in order for treatment services to be paid. Signed releases are critical to have in the chart. The report typically concludes with all diagnoses, and how they are causally related to the MVC. To paraphrase an insurance executive from Lloyds of London who presented at a conference I was at, “They don’t mind paying for what is attributable to the accident, they just don’t want to pay for more”.
It is for this reason that consideration of all prior conditions needs to be addressed, as well as any comorbid conditions. Again, as the treating provider for the patient, you may need to become an advocate for treatment and further evaluations, and will need to be able to argue for these in the face of anticipated disagreement.
Prior or comorbid conditions may in fact have put the patient at greater risk of presenting with PTSD following the MVC, (c.f. Blanchard & Hickling, 2004). There are often comorbid diagnoses, and these need to be described within the report. Possible issues of whether there is in fact PTSD or not, another anxiety disorder (e.g. an adjustment disorder, anxiety NOS, a specific phobia to driving), or a depression, need to be articulated and supported. Again, issues of possible head injury, contribution of ongoing pain, and possible referral to specialists such as neurologists, hand specialists, pain management, psychiatrists, are frequent and something the private practitioner must be comfortable doing as part of their practice.
A variety of factors put an individual at higher risk for developing PTSD, including prior history of MVCs, other prior trauma, past psychiatric history, gender, fear of dying during the collision, that may seem to cloud causality issues, but the law has been fairly clear not to blame someone for being more vulnerable than another individual. The legal principle in these matters is that defendants must take plaintiffs as they find them. This is a separate issue from the pre-trauma presence of the same condition. Thus, even if a claimant had multiple MVCs preceding the insurance-covered MVC, if he/she had no previous history of PTSD or driving phobia, the insurer would be liable for those latter conditions.
Your goal is simply to do the best possible work you can, as well as to be clear and honest in your written and oral opinions. Knowledge of the DSM is critical, as there are often varied opinions about how clinical presentations can be viewed. This is one of the reasons why we include in most reports the patient’s description of what happened at the MVC, and list all their symptoms. As your treatment will be based upon your assessment, the better it is conducted, the easier the maneuvering through the possible insurance, clinical and legal entanglements.
Treatment: This is not a paper about the treatment of PTSD following a MVC. Fortunately there have been several good empirically based treatments for MVC related PTSD. These are summarized and offered in several recent texts (e.g. Blanchard & Hickling, 2004; Hickling & Blanchard, 2006; Ehlers & Clark, 2000). While the data for effective treatments is growing, it is important to keep in mind that the improvement of symptoms to the point where the diagnostic criteria for PTSD is no longer met, is different than being able to say a patient is free from all symptoms. Treatment for full recovery often is much more complex, and may well involve additional comorbid conditions such as depression and dealing with physical pain and may also need to address related issues of anger, mortality, guilt, driving anxiety and other concerns. Two recent reviews can be found in Eliabeth Carll’s (2007) book, Hickling & Blanchard (2006), Duckworth, Iezzi and O’Donohue (in press) soon to be released nook dedicated to MVA trauma and concerns and Hickling, Kuhn, & Beck (in press).
Documentation of treatment for insurance claimants also presents special complications. The first, stated earlier, is that the psychologist can expect to have all notes reviewed and read at several times during the course of treatment. This may be by the insurance company, using independent experts such as other psychologists. Chart notes may even be read aloud in court. It is important therefore to be discrete about what one records, transparent in your description of treatment activities and patient problems, and to consider other peoples’ privacy such as family members or other individuals mentioned in the confidence of the session. Years later you may find yourself in court explaining your notes and treatment. Ideally, notes are typed (especially if you have poor handwriting making it hard to read years later).
Retraumatization: Retraumatization is the process where exposing the patient to events related to the MVC can actually worsen their psychological condition (Pitman, 1997). Courts and deposition appearances, as well as meetings with independent medical examiners can provoke increased anxiety and symptoms in patients dependent upon how they are conducted. The legal system in the US is adversarial by design. Adverse reactions to some of the events found in today’s system of personal injury law and related payment for services rendered, will become a part of the clinical treatment. In fact, there is evidence that the evaluation process itself increases psychological distress at least in VA disability applicants.
Records: You should keep all records for a sustained period of time, dependent on legal requirements in your state. Treatment is often concluded long before the legal case is settled, even after a case is settled, appeals may occur, and your records may be needed again. No record should be shared without a patient’s written permission. Even if there is a signed consent for the release of the records provided by a lawyer of insurance company, these may be time limited and not directly related to psychological records or issues. The releases do not allow you to share the records you obtained from other doctors or agencies. When in doubt, please confer with your own attorney.
If you treat a substantial number of people involved in insurance claims, your records will be the subject of subpoenas or court orders. When receiving such documents, relax, read carefully to determine precisely what is being requested, and if need be consult, the patient, his/her lawyer, and if still uncertain, your own lawyer. Most clinicians find these situations daunting, but a few well-placed telephone calls to local authorities (regulatory bodies, lawyers) can make this experience less threatening. You may also be subpoenaed to appear in court. If this is the case, clarify whether you are being subpoenaed as a “fact” witness (i.e. you will not be asked for an opinion but merely to answer questions of fact), or as an “expert” witness where your opinions will be sought. Learn about the difference between these two types of testimony before doing this type of work.
Court: While court appearances are infrequent, if you do much of this type of work, you will eventually testify in court. If you are not comfortable with testifying in court and being critically cross-examined, please don’t work with this population. Ill prepared, legally naïve, and/or uncooperative expert witnesses harm both the system and patients. There are several excellent books to help you in preparing for court testimony (e.g. Brodsky, 1991,1999; Barsky & Gould, 2002). It is wise to review such source books before going to trial. The treatment for the patient may be concluded before a court date, or it may still be ongoing. Obviously, if the patient is still receiving treatment, they need to be prepared for your frank, and potentially unflattering, testimony. Once you’re in court you cannot control the questions put to you, and must answer in a clear and honest manner, including potential disclosure of damaging information to his/her case. For example, in personal injury claims, patients are expected to reduce their losses by faithful attendance and participation in appropriate treatment. Therefore, treating clinicians may be asked by defense lawyers about the attendance of the patient in treatment and completion of prescribed homework.
Patients are often nervous about going to court, and may have unrealistic expectations. They expect justice, and to be able to express their experience of loss during their day in court. They may be looking for the person who harmed them to apologize, or at least acknowledge how badly they’ve been hurt by the MVC. Claimants are often disappointed if they hold unrealistic expectations. Personal injury settlements and trials are dominated by economic losses (e.g., past and future wage loss), legal issues about liability, and procedural wrangling. The legal system can do no more than provide injured parties the opportunity to reduce the economic impact of their injuries. Apologies by defendants rarely occur. Helping the patient identify their distorted beliefs, and the influence of these on their emotional distress can be an important aspect of treatment if handled well. For example, ruminative anger – left unmanaged - is known to interfere with the successful treatment of PTSD. It is important that the private practitioner knows the system well enough to help the patient with their expectations, and to help them prepare for the reality of what is before them.
Summary: Colleagues have asked us how to proceed with most of these concerns. They sometimes ask, “Is it forensic work?” One answer has been, “Yes and no”. This type of work seems like a hybrid with elements of both clinical and forensic activities. Most of us see ourselves exclusively as treating psychologists. Our job is to help people as best as we can. But, the need to deal with insurance companies, lawyers, and court testimony, requires clinicians to tolerate a higher level of scrutiny of our clinical activities and opinions. Such work becomes forensic whenever disagreement exists about the extent of a person’s injuries or the causes of these injuries. If you are unable, or uninterested in managing the forensic aspects of working with this population, perhaps you should turn away such referrals. Work in this area is plentiful, and psychologists’ roles and knowledge are valued and respected by all parties. In court and in your office you will be accorded expert status, although your treatment or opinions may be the subjects of disagreement. It is important to keep in mind that the term forensic refers to debate and rhetorical argument. Before working with this population, it is essential that you be comfortable with entering into debates about your opinions in individual cases. You can make a real difference to patients and to society more generally if you enter into this area well educated and prepared.
References
Barsky, A.E., & Gould, J.W. (2002). Clinicians in court: A guide to subpoenas, depositions, testifying, and everything else you need to know. New York; The Guilford Press.
Blanchard, E.B. & Hickling, E. J. (2004). After the crash: Psychological assessment and treatment of survivors of motor vehicle accidents. 2nd Edition. Washington, D.C.: American Psychological Association, Brodsky, S.L. (1991). Testifying in court: Guidelines and maxims for the expert witness. Washington, D.C.: American Psychological Association.
Brodsky, S.L. (1999). The expert expert witness: More maxims and guidelines for testifying in court. Washington, D.C.: American Psychological Association.
Carll, E. (Ed.). (2007). Trauma Psychology: Issues in violence, disaster, health and illness.(Vol. 2), Westport Ct.: Greenwood Praeger.
Duckworth, M., Iezzi, T., & O’Donohue, B. (Eds.) (In Press). Motor Vehicle Collisions: Medical, Psychosocial, and Legal Consequences. Elsevier Inc.
Ehlers, A., Mayou, R., & Bryant, B. (1998). Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents. Journal of Abnormal Psychology, 107, 508-519.
Ehlers, A., & Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder. Behavior Research and Therapy, 38, 319 – 345.
Hickling, E.J. & Blanchard, E.B. (2007). Motor vehicle accidents and psychological trauma. In (E. Carll, Ed.). Trauma Psychology: Issues in violence, disaster, health and illness. (Vol. 2), Greenwood Praeger.
Hickling, E.J., Kuhn, E., & Beck, G. (In Press). Treatment of Posttraumatic stress disorder consequent to motor vehicle collisions: Contributions from a clinical science. (In M. Duckworth, T. Iezzi, & B. O’Donohue, Eds.) Motor Vehicle Collisions: Medical, Psychosocial, and Legal Consequences. Elsevier Inc.
Hickling, E.J., Blanchard, E.B., Mundy, E., & Galovski, T.E. (2002). Detection of malingered MVA related posttraumatic stress disorder: An investigation of the ability to detect professional actors by experienced clinicians, psychological tests, and psychophysiological assessment. Journal of Forensic Psychology Practice, 2, 33-53.
Hickling, E. J. & Blanchard, E.B. (2006). Overcoming the Trauma of Your Motor Vehicle Accident: A Cognitive Behavioral Treatment Program, Workbook. Oxford University Press, New York.
Hickling, E. J. & Blanchard, E.B. (2006). Overcoming the Trauma of Your Motor Vehicle Accident: A Cognitive Behavioral Treatment Program, Therapist Guide. Oxford University Press, New York.
Koch, W.J., Douglas, K.S., Nicholls, T.L., & O’Neill, M.L. (2005). Psychological injuries: Forensic assessment and law. New York; Oxford University Press.
Pitman, R.K., Sparr, L.F., Saunders, L.S., & McFarlane, A.C. (1996). In B.A. van der Kolk, A.C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body and society (pp. 378-397). New York: Guilford Press.
U.S. Department of Transportation (2004). Traffic Safety Facts 2004: A Compilation of Motor Vehicle Crash Data from the Fatality Analysis Reporting System and the General Estimates System. Washington, DC: National Highway Traffic Safety Administration, U.S. Department of Transportation.
Correspondence regarding this article may be addressed to Edward Hickling at ejhickling@gmail.com
