Abstract
Competent forensic practice has required continued training and professional practice in differentiating between genuine and malingered presentations, especially within the spectrum of psychotic disorders. Historically, practitioners valued racial, ethnic, and cultural differences but often considered them as peripheral matters. In contemporary forensic practice, however, language and culture play preponderant roles. This commentary is focused on core features of malingering via a cultural lens. Three core, race-informed principles, such as biases against the African American Language, are highlighted and discussed. Related subjects for forensic practice include relevant clinical constructs such as malingering bias and “imposed etics,” specifically, the imposition of mainstream values and discounting of cultural differences.
Momentum has continued to build in forensic psychiatry1,–,3 and psychology4 to recognize cultural differences and their roles more fully in forensic practice. From a legal perspective, the criminal courts began to grapple with cultural competency in the context of competency to stand trial. As summarized by Bergkamp and colleagues,5 the Washington Supreme Court underscored the importance of cultural competency in two separate cases.6,7 In the latter case, it affirmed the trial court's discretion when it weighed the cultural competency of a Spanish-speaking neuropsychologist without forensic training more than a seasoned forensic evaluator. A pivotal question in many court cases was whether the defendant from a diverse cultural background was malingering.
Ratkalkar and colleagues8 have advocated for broad principles to be applied to race-informed forensic assessments that address potential evaluator bias, systemic racism, and cultural humility. But scholars have continued to debate the wisdom of including race, ethnicity, and culture in forensic reports and whether it should be counterbalanced with similar information about the forensic evaluator.9 On this latter point, Griffith provided a compelling personal example regarding his own ethnic journey with a singular sense of authentic representation and belonging.10 Disparate patterns based on racial-ethnic identity have raised questions about fundamental fairness and implicit biases. For example, odds ratios (OR) for insanity acquittals in California have ranged sharply from miniscule for Hispanic and Latinx (OR = .14) to exceptionally large for European Americans (OR = 5.54).11
Scholarship has focused squarely on cultural differences with an emphasis on ethnic-racial identities (i.e., between-group differences). Yet the within-group differences are equally important. As a salient example, Asian Americans are often lumped indiscriminately into a single marginalized group. In addressing racism, for example, Cheng and colleagues described the rich diversity of Asian Americans, “including different languages, ethnicities, and cultural practices” (Ref. 12, p 628). From an international perspective, profoundly important variations occur between Asian regions, including east (e.g., China and Japan), south (India and Afghanistan), southeast (e.g., Vietnam and Indonesia), and southwest (Iran and Turkey). Unfortunately, these crucial discrepancies are often entirely missed in forensic practice and research.
Given the complexity of forensic assessments, it may certainly be tempting to de-emphasize within-culture variations. Indeed, this approach was widely adopted for traditional cross-cultural studies, where such variations were dismissed as measurement error and “treated as noise in the data” (Ref. 13, p 184). Nonetheless, seasoned forensic practitioners can easily appreciate how this lumping together has been, at best, construed as an ill-considered perpetuation of inaccurate stereotypes. Thus, forensic practitioners should take seriously within-culture variations and protect their conclusions and opinions from unnecessary vulnerabilities when faced with vigorous cross-examinations.
From a criminal forensic perspective, psychosis frequently has formed the basis of competency and insanity referrals.13 The same study found that attorneys for nonwhite (their terminology) defendants were much more likely (odds ratio of 1.65) than their White counterparts to be focused on competency alone and omit general pretrial referrals entailing both competency and insanity. This large odds ratio in a forensic sample with its very large number of pretrial defendants (N = 2,655) has raised questions of racial bias. In addition, the investigators lumped together remarkably different racial-ethnic identities as nonwhite: “Black, Hispanic, Native American, Asian, Middle Eastern and Other” (Ref. 13, p 299). They also appeared to omit the multiracial category entirely. Although hampered by small ethnic representations, these investigators could still have included preliminary data for the 85 Hispanic and Latinx defendants.
This article focuses generally on genuine or feigned psychotic presentations as informed by racial-ethnic identities. In the next section, it emphasizes the race-informed principles outlined by Ratkalkar and colleagues.8
Race-Informed Principles and Communication
In the context of forensic evaluations, Ratkalkar and colleagues8 provided the following description of race and ethnicity: “Race is a social construct referring to physical traits that groups and cultures consider socially significant; ethnicity refers to shared cultural identity, characteristics (e.g., language, beliefs, ancestry) and cultural expression” (Ref. 8, p 1). For specific cases, nine race-informed principles were promulgated for forensic assessment. Three are highlighted here.
For legal standards, competency to stand trial may have few racially informed implications for factual or rational knowledge, with much larger effects for the capacity to consult with counsel (e.g., racial distrust).
For legally relevant behavior such as sentencing, practitioners were asked to consider the examinee’s background (e.g., racial trauma and adverse experiences) and beliefs (racial injustice and healthy cultural paranoia).
For forensic evaluations, practitioners may have unintentionally expressed bias against African American Language (AAL) and other culturally informed patterns of English speaking.
These race-informed principles for forensic assessments, at least in our minds, were thought provoking and should be considered seriously on a case-by-case basis. On the first point, for example, lived experiences with different legal systems (e.g., minimal due process) may lead to superficial treatment rather than true understanding of both factual and rational understanding. For instance, rational understanding of competency may have a completely different meaning in a criminal justice system that appears, in the mind of the defendant, to suffer from widespread corruption.
On the second point, from a consequentialist perspective, some forensic practitioners might well consider the different effects of sharing such matters as racial injustice, particularly, the intended and unintended consequences for the examinee as well as the practitioner. Oh and colleagues14 highlighted that African Americans have high rates of race-related trauma such as police misconduct, and this was associated with increased likelihood of psychotic experiences. Knowing this information, forensic practitioners can better understand legally relevant behavior and how it relates to the examinee’s background.
The third point appeared the most compelling in raising directly how discrimination may play a biasing role. While rarely found in medical or psychological literature, the educational search engine (Educational Resources Information Center or ERIC) documented more than 800 peer-reviewed articles on African American Language (AAL). When compared with White Mainstream English (WME), AAL has been linked to anti-Black linguistic racism.15 As a further concern with communication, European Americans, including forensic practitioners, may espouse presumably egalitarian views toward African Americans yet unintentionally perpetuate racist views.16 On this point, forensic practitioners may want to spend more time listening, especially in the beginning of the assessment process, than directing the interview. This way, two complementary goals can sometimes be achieved. First, the forensic practitioner is less likely to jump to preconceived notions about the examinee’s background and beliefs. Second, the examinee may respond positively to the practitioner’s openness and willingness to learn about the examinee’s cultural background.
More broadly, a fourth principle addressed how “worldview differences between evaluator and examinee can affect appraisal” (Ref. 8, p 4). For example, Chinese Americans17 generally report fewer psychotic symptoms, but they may describe their experiences differently than Western individuals because of language differences and cultural beliefs.
On the other hand, African Americans have been found to disclose significantly more positive symptoms such as hallucinations and suspiciousness.18 For the assessment of malingering, examiners who harbor mainstream biases without a full awareness of cultural differences might be predisposed to view African Americans as potentially overreporting and Chinese Americans as underreporting psychotic symptoms.
Racial-Ethnic Differences in Psychosis
This section summarizes racial-ethnic differences in general and clinical samples in the United States. Similar analyses should be pursued within different countries and be sensitive to language differences and cultural issues.
Psychotic-Like Symptoms in the General Population
Earl and colleagues19 conducted a large-scale investigation of nationally representative samples for four minoritized populations in the United States: African Americans, Caribbean Blacks, Asian Americans, and Latinx. The focus centered on psychotic-like symptoms within the general population, thus providing valuable insights regarding subjects’ culturally informed experiences. Of particular interest, the common culturally informed themes were also identified.
Visual hallucinatory experiences were the most common in these four racial-ethnic groups with prevalence rates ranging from five to nine percent (see Table 1). Asian American and Hispanic and Latinx groups often reported supernatural or ghost-like experiences. Interestingly, auditory hallucinations were typically of unidentified voices, especially for Caribbean Blacks (59%), for whom spirituality or religion and family matters are secondary themes.
Percentages of Psychotic-Like Symptoms Adapted from Earl et al.19 Research on Nationally Representative United States Samples of Four Minoritized Groups
In contrast to hallucinations, the prevalence rates for delusional material remain consistently low (0 to 2%). Regarding persecutory thoughts, the suspected motives and actions of others represented the primary concern with concerns regarding one’s own personal safety lagging far behind (see Table 1). Spiritual and religious themes varied substantially with in delusions of reference, being the most prominent in Caribbean Blacks (53%) but only infrequently present for Hispanic and Latinx (12%).
Positive Psychotic Symptoms in Clinical Samples
This section emphasizes the Positive and Negative Syndrome Scale20 (PANSS), a widely used clinical measure with systematic ratings of psychotic symptoms. The term “positive” in the PANSS title refers to the exhibiting of new symptoms and behaviors (e.g., hallucinations), whereas “negative” describes the losses of abilities and behaviors (e.g., blunted affect). An important feature of the PANSS involves its reliable scoring for severity of psychotic symptoms: one = absent, two = minimal, three = mild, four = moderate, five = moderate severe, six = severe, and seven = extreme. Clear descriptions are supplied to anchor the seven different ratings for each item. Our focus is centered on the Positive Scale and Negative Scale, each with seven items.
A combined MEDLINE and PsychInfo search, accessed on April 21, 2023, used the following search terms: “psychotic,” “Positive and Negative Syndrome Scale,” and “PANSS.” It yielded 3,648 peer reviewed articles. They covered many translations and adaptations to different cultures. For example, 59 articles specified “Spanish” in their abstracts.
U.S. Racial Differences in Psychotic Symptoms
Barrio and colleagues,18 in an outpatient study, compared African Americans, European Americans, and Hispanic and Latinx Americans on the English-language PANSS. For the Positive Scale, African Americans received significantly higher ratings than European Americans on Suspiciousness (# P6) and Hallucinatory Behavior (# P3), whereas European Americans rated the highest on Excitement (# P4). For the Negative Scale, no significant racial-ethnic differences were found. Nonetheless, Poor Abstract Thinking (# N5) consistently averaged in the upper mild (3.6 to 3.7) to moderate (4.0) range. Passive and Apathetic (# N4) followed next in the lower mild range (3.0 to 3.3). As later noted, the presence of negative symptoms may assist in confirming a genuine psychotic disorder. Hispanic and Latinx persons were rated higher on Somatic Concerns (# G1) than the other comparison groups.
Mark and colleagues21 studied psychotic disorders in a primarily community sample and found the slight majority of Black men (52%) were diagnosed with paranoid schizophrenia surpassing non-Black men (42%) and more than doubling the rate of Black women (24%). Gender differences were also remarkable for schizoaffective disorders, especially for Black persons, with twice the prevalence for women (42%) than men (21%). Despite these pronounced diagnostic differences, average PANSS scores were unexpectedly low and very consistent. Even the highest average score (2.8) was at the upper end of minimal level, which is reserved for questionable pathology. As a further disparity, these outpatients, despite such minimal evidence on the PANSS, demonstrated serious symptoms or impairment in overall functioning. In sum, this study raised more questions than answers about cultural differences in psychotic presentations.
Chang and colleagues17 found that Chinese Americans with diagnoses of schizophrenia had fewer positive symptoms compared with African Americans and Hispanic and Latinx, substantially differing from Barrio et al.18 Specifically, Chinese Americans had an average Positive factor score of 9.17 in contrast to 11.36 for African Americans and 11.97 for Hispanic and Latinx. Moreover, African Americans had significantly higher Negative factor scores (M = 17.03), while Chinese Americans and Latinx averaged about 4 points lower. Overall, Chinese Americans exhibited significantly lower symptoms than the other ethnic groups in diagnosed cases of schizophrenia.
Psychosis and Adverse Racial Experiences
According to Oh et al. (Ref. 14, p 277), 44.5 percent of African Americans had experienced one or more of “nine major racist events” (e.g., being prevented from moving into a desirable neighborhood). Police misconduct was the most common (22%), which was characterized as “unfairly stopped, searched, questioned, physically threatened or abused by the police” (Ref. 14, Supplementary Table 2). Being subjected to such police actions was associated with about a 50 percent increased likelihood for lifetime psychotic experiences. This increased likelihood remained even when controlling for relevant factors, such as substance use and poverty.
Whaley and colleagues22 undertook more than a decade of research on cultural mistrust and confluent paranoia (i.e., interactive effects of cultural and clinical paranoia) among African Americans. Race-related content was correlated with overall delusions. While low in frequency (7%), items related to the oppression of African Americans must be carefully evaluated on a spectrum from nonclinical to clearly delusional.22
Psychosis and Racial-Ethnic Differences
Besides its valuable findings, Table 1 can serve as an initial template for asking culturally informed questions about psychotic-like experiences for different racial-ethnic identities. Clearly, spirituality and religious beliefs predominate as a theme, while being highly variable among cultural experiences. For hallucination-like experiences, large percentages were not identified with specific themes, but this could have resulted from a lack of detailed questioning. Themes related to premonitions, warnings, and communication with deceased persons deserved close attention with detailed inquiries. Open-ended questions could be asked in a family or other interpersonal context. Consider the following example: “During your youth, please tell us about spiritual experiences that happened to you or someone in your family.” By broadening the perspective beyond the individual examinee, the forensic practitioner may gain insights regarding to what extent, if any, it was a shared experience. In addition, direct access to these same collateral sources may assist in confirming or disconfirming the examinee’s culturally informed beliefs, as well as provide insights into possible delusions.
Delusions of control, which have often been associated with thought insertion and thought withdrawal,23 may be of particular interest in both general and clinical populations. Despite very low prevalence rates, delusions of control may play substantive roles in Asian American and especially Hispanic and Latinx general populations (see Table 1). For clinical cases, delusions of control can affect both the sense of agency and ownership24 which should likely be considered via a cultural lens. For forensic referrals, the relationship of these delusions to command hallucinations has continued to deserve close examination.
An important variation related to delusions of control is termed “delusions of possession.”25 Patients with delusions of possession and the diagnosis of schizophrenia often seek faith-healing, even exorcisms in the case of satanic possessions, rather than mental health interventions. Clearly, the roles of religion and culture are core to the delusional expressions, which fundamentally vary across African traditionalism, paganism, and organized faiths (e.g., Buddhism, Hinduism, and Judaism).26 It is crucial to grasp the context surrounding delusions of possession. In forensic assessments, these delusions might sometimes be wrongly dismissed as feigning, even though they could stem from cultural influences within the individual.
Specifically for insanity evaluations, Rogers and Shuman27 provided detailed outlines of psychotic symptoms and their potentially different effects on criminal responsibility. For example, delusions entailed 14 separate considerations that include “religious denominations and recognized subcultures” (Ref. 27, p 171). Other considerations include the permanence of the beliefs, the severity of delusions of control, the defendant’s behavioral responses, and the specific timing of the alleged criminal behavior. Such a detailed approach should provide forensic practitioners with a full understanding of psychotic symptomatology, and where appropriate, its cultural context.
Negative Psychotic Presentations
The PANSS has been recommended for its detailed coverage of both positive and negative psychotic symptoms. Forensic evaluations have tended to emphasize the positive symptoms, which are potentially more problematic in retrospective cases such as insanity evaluations. But negative symptoms may play a predominant role that requires ongoing participation. The first author (R.R.) evaluated a competency case in Hawaii involving international conspiracies and a change in world order. Persecutory and nihilistic delusions were eventually managed, at least superficially (i.e., no longer disclosed), with medication. But severe to extreme negative symptoms compromised his ability to consult with counsel. While trying to appear well-adjusted, his simulated minimization of negative symptoms failed to be maintained after only several minutes.
Negative symptoms have also played a valuable role in determinations of malingering. The absence of negative symptoms should raise important questions about the genuineness of the psychotic presentation.13 In general, malingerers have been mostly invested in the creation or exaggeration of positive symptoms, such as command hallucinations or extreme behavioral reactions to supposed visual hallucinations. The idea of faking the absence of psychological functioning is rarely contemplated. Consider for the moment the cognitive effort of faking alogia and blunted affect especially for a sustained period, where professional interactions are expected.28
Besides the PANSS, cross-cultural research and practice has also involved the Brief Negative Symptom Scale (BNSS)29 with 13 items of which several items (e.g., avolition) accurately differentiate observed behavior from internal experiences. A 12-item BNSS successfully achieved the same factor structure when tested across the United States, Europe (e.g., Italy, Spain, and Switzerland), and China in their respective languages. As summarized, “5 domains reflect core processes inherent to the diagnosis that are not dependent on language or cultural influences” (Ref. 30, p 311). These factors consisted of anhedonia, avolition, asociality, alogia, and blunted affect. Forensic practitioners are likely to see the BNSS as either a complementary measure or an alternative to the PANSS.
As a cautionary note, forensic practitioners should always evaluate whether psychotic-like experiences may be better explained via ethno-cultural context. One current author (R.R.) evaluated an African American defendant who attributed his current predicament to the “5 percent nation network” offering the following observation of the population: gods (5%), fallen stars (10%) and “deaf and dumb” (85%). According to his avowed beliefs, he “proved” the superiority of African Americans by the relative weights of their brains (seven and a half ounces for Blacks versus six ounces for Whites). Considering his bizarre-sounding statements (e.g., the moon appearing brighter when reflecting off White persons), it would be understandably tempting to dismiss such beliefs as entirely delusional. But a Microsoft Bing search (accessed on May 30, 2022) of “5 percent nation network” produced more than 50,000 cites. According to Collins,31 Clarence 13X, originally a disciple of Malcolm X, founded the Five Percent Nation of Islam that focused on a Black God and the religious empowerment of Africans. It later separated itself from Islam and is sometimes referred to as the “Nation of Gods and Earths.”
Cunningham32 emphasized the importance in distinguishing between delusions and culturally sanctioned extreme beliefs in his proposed Model of Analysis for Differentiating Delusional Disorder from the Radicalization of Extreme Beliefs-17 Factor (MADDD-or-Rad-17). Unlike many radicalized beliefs, delusions often emphasized internalized experiences such as grandiose identification with the intended actions, disorganization, and gross lapses in critical thinking. A New York City woman was evaluated by a current author (A.A.C.) whose criminal charges involved behaviors similar to individuals in the Sovereign Citizen movement.33 This movement employs the use of symbols and coded messages with convoluted reasoning to justify their beliefs. This defendant also espoused additional delusions that were not culturally affirmed, such as government weather-control machinery and a secret cyborg manufacturing plant in New York. She met criteria for delusional disorder, not because of her sovereign citizen beliefs, but because of the nonculturally sanctioned delusions that severely impaired her behaviors, leading to her arrest.
Stigma of Severe Mental Disorders
Stigma surrounding mental health and mental disorders can pose a significant obstacle to individuals disclosing symptoms of psychosis. Such stigma often stems from societal norms, typically defined by the majority culture. A 2016 systematic review noted that “cultural factors may be viewed as key in determining the fundamental capacities that shape stigmatization among different populations” (Ref. 34, p 73).
The same systematic review evaluated 26 articles related to mental health stigma in Latin America and the Caribbean. Although stigma was measured in various ways, public stigma stood out as notably prevalent. For instance, one mentioned study35 in Argentina noted 44.4 percent of community members believed that people with schizophrenia have multiple personalities and exhibit “bizarre or inadequate behavior” (Ref. 35, p 285). Furthermore, the same sample reported social discrimination against people with mental disorders.
These public perceptions of mental disorders are echoed in the Asian community. Prior literature has found that some Asian persons hold stigmatizing beliefs against those with mental disorders, such as believing that people with mental disorders may be possessed by supernatural beings (i.e., demons).36
These perceptions of mental disorders can pose a challenge for forensic evaluators, as people may be influenced by their cultural backgrounds and choose not to disclose their mental health status. This could be detrimental to the client, as minimizing symptoms could affect the evaluation and the client’s freedoms.
Spanish-Language Test Adaptations
The MMPI-3 ushered in a new generation of multiscale inventories with English and Spanish versions being codeveloped and copublished. Spanish norms were developed based on 275 men and 275 women.37 With bilingual undergraduates, the correlations of Spanish and English versions ranged from .68 to .87 evidencing moderate to strong correlations that were similar to the Spanish test-retest reliabilities (.61 to .84).38 For civil forensic applications, the Spanish MMPI-3 has been investigated in the context of parental fitness evaluations.39 The revised clinical scales exhibited acceptable to strong scale homogeneities with the single exception of RC2: Low Positive Emotions (alpha = .59), which has been traditionally associated with depression.
In 2023, the test publisher of the Personality Assessment Inventory,40 Psychological Assessment Resources, undertook a new Spanish translation. This recent translation improved the understandability via simplified sentences, word choice, and grammar. The new version also incorporated more generalizable Spanish-language words by employing a panel of bilingual psychologists representing different countries of origin and with substantial knowledge of within-country dialects.
Spanish adaptations have included several forensic measures, such as the Spanish Structured Interview of Reported Symptoms, second edition (Spanish SIRS-2)41 and the Spanish Evaluation of Competency to Stand Trial–Revised (Spanish ECST-R).42 For the Spanish SIRS-2, five doctoral-level bilingual psychologists independently followed a detailed translation and back-translation process for the English SIRS-243 that complied with the International Test Commission (ITC) Test Translation and Adaptation Guidelines.44 The interrater reliabilities for the Spanish SIRS-2 primary scales were exceptionally high, ranging from .98 to 1.00. Moreover, the discriminant validity in classifying feigners versus genuine examinees demonstrated close correspondence with the English SIRS-2 Decision Model.41,43 In addressing cultural differences, certain Spanish-speaking countries (e.g., Dominican Republic) typically do not include rhyming in their educational curriculum. Fortunately, the SIRS-2 already considers this; nonresponding to rhyming is not scored in the feigning classification.
The Spanish ECST-R combined an early Puerto Rican translation with a more recent North American version which is based on the original English version. For the ECST-R competency scales, 94.3 percent of its test items evidence the same or virtually the same translations, when compared with the English version.45 For concurrent validity, plans are underway for the Spanish ECST-R to be field tested at Patton State Hospital.42
It is essential to recognize that Spanish-speaking individuals may come from diverse cultural backgrounds and may exhibit linguistic nuances not fully addressed in translated assessments. When using a translated measure in a forensic evaluation, it is important to consider these linguistic and cultural distinctions. Additionally, the evaluators’ own cultural background should be considered, as it can influence their understanding of the client. For instance, if the evaluator is from Spain and the client is from Latin America, differences in cultural perspectives could affect the evaluator’s conclusions.
Concluding Thoughts
The assessment of genuine and feigned psychotic presentations in forensic psychiatry and psychology has continued to require a culturally informed evaluative process. Understanding and appreciating racial-ethnic identities must be considered an ongoing process of learning cultural humility and respecting ethnic differences. According to Ratkalkar and colleagues,8 forensic assessments should include race-informed principles to better evaluate examinees and the intersections of their identities. With this in mind, evaluators can more comprehensively assess genuine and feigned presentations that are relevant to cultural backgrounds in the context of forensic determinations.
Footnotes
Disclosures of financial or other potential conflicts of interest: Richard Rogers, PhD, receives nominal royalties (i.e., less than $200 per year) for his authorship of the Spanish SIRS-2.
- © 2024 American Academy of Psychiatry and the Law
