2.Adriana Flores — Proffer (Part 1)
112 linesAndriana Flores, being first duly sworn, testified as follows:
COURT CLERK: Have a seat, please, ma'am. State your full name, spelling your last, please.
ADRIANA FLORES: My name is Dr. Adriana Flores, A-D-R-I-A-N-A, last name, F, as in Frank, L-O-R-E-S.
PROFFERED DIRECT EXAMINATION BY MR. YOUNG:
BOYD YOUNG: Good morning, Dr. Flores.
ADRIANA FLORES: Good morning.
BOYD YOUNG: Can you tell Judge Griffith a little bit about yourself, your educational background, your training as a forensic psychologist?
ADRIANA FLORES: Certainly. I have a Bachelors in Psychology from the University of Wisconsin in Milwaukee. That was in 1990. I went on to pursue a PhD in clinical psychology from University of Ohio. And I have a Masters in 1996 and a PhD in 2000. As part of PhD requirement in clinical psychology, I had to complete a 2000 hour internship that was American Psychological Association. So I went to Emory University School of Medicine to complete an internship. I completed that in the year 2000. I stayed on one year, additional post-doctoral fellowship year at Emory School of Medicine, completed that in 2001. I am currently an Adjunct at Emory School of Medicine. They have psychiatry in the law department and I have been Adjunct -- Assistant Professor, sorry, there since 2012. Part of my responsibilities are that I am one of three primary supervisors of psychologists that are now seeking to specialize in forensic psychology.
So I train them and supervise them on competency to stand trial and criminal responsibility evaluations, in turn, insanity evaluations, mitigation, assessing for malingering, assessing for diagnostic purposes and other competencies, such as competency to consent to sexual contact. And that's education and professional. In terms of clinical experience, I worked for the State of Georgia for ten years. I worked at Georgia Regional Hospital at Atlanta, and that is one of the State psychiatric hospitals. For six years, I was the inpatient forensic psychologist on a unit that had 42 individuals who had been adjudicated either incompetent to stand trial or not guilty by reason of insanity. I was responsible for one-hundred percent of the evaluations that were required for diagnostic purposes or to assess for malingering. Part of my responsibilities were also to do psychotherapy groups and also to offer testimony on my findings.
Over the years, at Georgia Regional, I probably -- I mean, I had contact with about 750 individuals who had either been adjudicated not guilty by reason of insanity or incompetent to stand trial and were there for restoration. So I was at Georgia Regional from 2001 to 2011. Six of those years were as an inpatient forensic psychologist. After six years, I was promoted to be on the executive team of the hospital. So I was responsible for developing programming for what was then a 320-patient bed inpatient psychiatric hospital, but at the time had two forensic units, three adult mental health units and some developmental -- some units for individuals with developmental disabilities.
BOYD YOUNG: Have you testified as an expert in forensic psychology?
ADRIANA FLORES: I have.
BOYD YOUNG: And do you know how many times you've been declared an expert in forensic psychology?
ADRIANA FLORES: I am about 90.
BOYD YOUNG: Your Honor, at this time, the Defense would offer Dr. Flores as an expert in forensic psychology.
THE COURT: Any voir dire?
RICK HUBBARD: No voir dire, Your Honor.
THE COURT: All right. She will be so qualified.
BOYD YOUNG: Dr. Flores, have you testified for the State in death penalty cases?
ADRIANA FLORES: I have.
BOYD YOUNG: Can you explain to the Court how it is that you came to be involved in this case?
ADRIANA FLORES: Certainly. Dr. Julie Dorney and I worked at the hospital, Georgia Regional Hospital, for -- we overlapped for ten years. Six of those years, when I was the inpatient forensic psychologist, she was the attending physician at the same unit. So that's how we came to know each other. I currently sublease an office from her practice. My company is completely independent. We don't overlap. I have my own patients, my own client referral source. I was aware she was involved in this case, that she was coming to South Carolina for the last number of years. On the day that she finished her testimony, I recall it was a Friday, she contacted me in the afternoon and said that she was finished and next up would be Dr. Kruse, who would be called, I believe, that Monday, that she would be called. I believe she said -- I believe she said that could I take a look at her testimony because -- and I believe what she said was that during some of the testimony that had been offered so far, there had been some indication toward malingering was coming out and that this was actually not directly stated on Dr. Kruse's report and yet, there had been some alluding to that. So I said, Sure. I said, send me the report. So I believe she contacted you all, got authorization, my understanding was, to release the report. I received Dr. Kruse's report and then I contacted her.
BOYD YOUNG: Why did you contact her after looking at Dr. Kruse's report?
ADRIANA FLORES: What struck me the most, not having looked at the raw data, I didn't know whether her findings were real, not real, but what was readily apparent is that in the report, there is a section that is -- she cut and pasted, which we can, cutting and pasting is fine. The concern that I had was that with regards to one specific instrument, it's called PAI, Personality Assessment Inventory, it was readily apparent to me, because I do this routinely, that she had omitted a validity section on it. So let me explain. This is a test that has what we call validity and disease. It has an ability to assess an individual's response style and determine whether the individual is likely to be what we call underreporting problems. And by that, I mean trying to make themselves look in a better light or healthier than they may be. Or whether they are overreporting problems, which means attempting to make themselves look like they have more problems that they may actually have.
And that, typically, is what we would call malingering. So it has these scales. And when you enter the individual's responses onto the computer and you print out the report, the report spits out, if you will, the findings with response of what we call positive response style, which is the, I'm trying to make myself look better than I actually may be. Like we might see, for example, in divorce, custody cases. And then followed up by that, the next paragraph would address negative response style. So you have positive response style and then it gives you the negative. By negative, it would tell you whether there was any indication of the person attempting to portray themselves as worse off than they may actually be. And then after that, it gives you additional information with regards to scale findings and whatnot. But it always gives those two response styles, the positive and the negative and then the rest of the report. And what I saw in Dr.
Kruse's report is that she provided the paragraph, if you will, that has the information with regards to positive response style. But the next paragraph that she would have cut and pasted was not there, which is the negative response style. And then after that, then she went ahead and provided more. So when I saw that that was missing, it concerned me. It had the feeling that something was being hidden from that report. So I contacted Dr. Dorney and I said, this doesn't feel right. I said, I think there's something that's not right here that's being hidden, but I'm not sure. I would need -- I mean, I was sure about that. I knew that should have been there, but I didn't know what the response style -- what the report would have said. So I said, let me look at the raw data.
BOYD YOUNG: The paragraph that you're talking about that was missing was with respect to negative impression management. There is no evidence to suggest that the respondent was motivated to portray himself in a more negative or pathological light than the clinical picture would want?
ADRIANA FLORES: Correct. And that would allude to potential malingering. The other thing that I saw in the report beyond that, but an issue that also concerned me, is her interpretation of, I believe it was the L scale, the way that she described the L scale on the MMPI. The L scale is very similar to the positive response style indexing the PAI. And by that, I mean it informs the evaluator as to whether or not the individual attempted to portray themselves in a better light. But her wording, the wording she chose to use on the report, it didn't seem like that's what it said. It seemed like there was -- I would have to look at her report. If I may very quickly?
THE COURT: Just be careful not to pit the witnesses.
BOYD YOUNG: Yes, sir.
THE COURT: Because that seems like where we're getting. She can give her opinion, but you can't pit one against the other.
BOYD YOUNG: Yes, sir. A Implying dishonest test taking or extreme defensiveness. It does -- the L scale does, in fact, indicate some defensiveness. But the dishonest test taking in conjunction with the missing negative response style concerned me in terms of the wording.
BOYD YOUNG: So what did you do after looking at that report?
ADRIANA FLORES: I asked for the raw data. And by raw data, I mean the actual testing measures that were administered to Mr. Jones, his responses, whatever he filled out and then, also, any computerized printout reports. And so, I received those.
BOYD YOUNG: Let me show you what's been marked for ID as Court's number 124 and ask you if you recognize that?
ADRIANA FLORES: Some of this is what I received and some of this is from my actual rescoring.
BOYD YOUNG: Okay. And these are your notes on the raw data?
ADRIANA FLORES: Correct.
BOYD YOUNG: Your Honor, we would offer Court's 124 --
RICK HUBBARD: I object --
BOYD YOUNG: -- as a Court's Exhibit.
RICK HUBBARD: I object to that coming in. She's remarked and rescored it and I object to that. If they're attacking Kruse and that's not what Kruse had, I object to that. That's, basically, testifying through an exhibit. I object to it.
BOYD YOUNG: It's her notes on the raw data and rescoring the raw data. It's not an attack on Kruse. The data is what it is.
THE COURT: If she took the raw data and scored it herself, that's rescoring the data. But if she's going to testify to the mistakes Dr. Kruse made, that's pitting witnesses. So characterize your question properly. Do you understand?
BOYD YOUNG: Yes, sir.
THE COURT: Okay. I'm not -- I don't understand that document. Tell me again what it is.
BOYD YOUNG: It's her notes on the raw data that she used in preparation of her affidavit.
THE COURT: Is it notes of her, I'm going to characterize it as criticism of Dr. Kruse's report, or is it her restoring the data and coming up with her own findings based upon the raw data. That's my question to you.
BOYD YOUNG: Dr. Flores, is this your notes coming up with your own findings or is this just criticizing what Dr. Kruse did?
ADRIANA FLORES: So that packet, I believe, has a combination of things. It has a combination of her actual raw data with my comments of my concerns of misscoring.
THE COURT: All right. That, I won't allow. That's pitting witnesses. Her misscoring is pitting a witness. She can score herself independently and give her professional opinion as to what she would take the raw data and present. But I don't think it's proper for her to come in and say Dr. Kruse misscored. I don't think that's proper. So that document -- I mean, it can be a Court's Exhibit, but I wouldn't allow it into evidence if she were testifying.
BOYD YOUNG: At this time, we're just offering it as a Court's Exhibit.
THE COURT: Okay. Well, remember, I want to go forward from this point forward with her opinion as opposed to her pitting, criticisms. Okay?
BOYD YOUNG: Yes, sir.
BOYD YOUNG: Dr. Flores, I'm going to move this forward. Once you got the raw data and looked at that, the first test I want to talk to you about is the SIMS test. Did you look at the raw data for the SIMS, the SIRS and M-FAST?
ADRIANA FLORES: I did.
BOYD YOUNG: Now, can you tell the Court a little bit about these test, what their purpose is and what the proper use of them is?
ADRIANA FLORES: Sure. The M-FAST and the SIMS are both considered screeners for malingering, for an individual overreporting psychological problems that they may not have or exaggerating the level of severity. So those are screeners. By screeners, I mean, they're administered, but you don't arrive at a conclusion of whether somebody is malingering based on either one of those because they're just screeners. If the individual, upon completing either one of these measures, scores what we call above the cut off, in other words, above the number where other individuals have been classified as real malingers or real dishonest people making themselves look worse score, then protocol calls -- the actual measures actually say then you should follow-up with a more comprehensive measure of malingering, which is SIRS, Structured Interview of Reporting Symptoms. And we are in the second edition at this point. Beyond that, in order to -- in order to -- and even if somebody scores high on the SIRS, the SIRS manual says you don't just classify them as malingering even then. You look at other data to see if the clinical picture actually all matches. And other data would include things such as the validity indicators on the MMPI or the PAI and any other relevant data that can inform the individual as to whether or not the individual may or may not, in fact, be malingering.
BOYD YOUNG: Are these tests about whether somebody's malingering today or are, do these tests tell you anything about how somebody was doing on August the 28th of 2014?
ADRIANA FLORES: No. They are about the present. They are all -- when you look at the wording, the malingering, the three malingering tests are all verbed in the present. You can ask the person -- that when they answer these questions ask about the last week or two or last maybe month. But, certainly, they would not -- they were not normed on identifying retrospectively whether somebody being interviewed now with these measures is malingering symptoms of the distant past. So the answer is, we don't have any measures that we can use to prove whether somebody is malingering, making up or exaggerating symptoms that they are reporting occurred years ago. No such measure exist.
BOYD YOUNG: So if somebody came to you, and in your expert opinion, somebody said well, I don't experience -- I'm not experiencing any symptoms right now, I'm on medications, would it be appropriate to give these malingering instruments?
ADRIANA FLORES: No, generally, I don't. If the person is saying I'm not experiencing any problems, I don't have any problems, unless I am going to diagnosis them with a condition, there is no reason to give a malingering inventory.
BOYD YOUNG: Now, on the SIMS test, Mr. Jones, I believe, scored as 12, is that right?
ADRIANA FLORES: That is correct.
BOYD YOUNG: And what is the cut off for determination of whether or not somebody is malingering or how is it appropriately phrased?
ADRIANA FLORES: Right. So the cut off is greater than 14. So a 14 would not necessarily indicate to the SIRS. A 15 is where -- that's where kind of the red flag goes on, that's a -- the cut is greater than 14. So anything 15 and above is more suggestive of potentially malingering in this particular screener.
BOYD YOUNG: Now, the SIMS has subscales on it, right? There's like five different subscales on it?
ADRIANA FLORES: Correct. It has subscales that assess different areas in which the individual may or may not be overreporting symptoms. So, for example, it has an amnesia, whether the individual is reporting some amnesic symptoms that just may or may not make sense, depending on how many points they get. Neurologic impairments. Low intellectual functioning. Sometimes you have individuals that are malingering or making up they actually have a lower intelligence than they may actually have. And there is also an affected one. So looking at whether somebody is reporting mood symptoms, that would be atypical and likely a malinger. And there is a psychotic scale and that, obviously, is looking at things like paranoia and hallucinations, those types of things.
BOYD YOUNG: So the fact Mr. Jones scored a six on the psychosis scale, what does that tell you with regard to the SIMS and whether or not he's malingering?
ADRIANA FLORES: Well, what it tells me is that the score is elevated and that means that it is suspect for the individual reporting on that particular subscale potentially some symptoms that may not exactly be genuine with regards to psychosis. However, just because a person elevates one, again, A, it's a screener and two, if a person elevates one, the error rates -- and I'll explain that in a second, is too high to call somebody a malingerer. So the SIMS manual actually states, it actually has some data, and it indicates very clearly that the best indicator of a potential malingering would be to look at the total score, not at any individual scale. And it has some statistical information. And the reason for that, it says, is because when this test was developed and tested, what they found is that if you use any one of the scales -- and it has different statistics per subscale like psychotic or effective, those have a higher error rate of misclassifying an honest responder as a malingerer. So if you go by one on any one of those scales, they're not going to be as accurate as the cut off score of 14 or higher than 14 in properly and adequately identifying a true malingerer, a true faker.
BOYD YOUNG: Next, I want to talk about the M-FAST test. In the M-FAST test, on that raw data, you actually -- you had -- Dr. Kruse had actually written down what Tim had told her?
ADRIANA FLORES: Correct.
BOYD YOUNG: Were there problems with the M-FAST test and the M-FAST score?
ADRIANA FLORES: Yes, there were.
BOYD YOUNG: Okay. In what manner?
ADRIANA FLORES: Mr. Jones, for example, reported that he was not experiencing voices, that they had improved with medication. And so there were some scores that were scored as a one. And a one means affirming the individual is reporting this issue, but, in fact, he had -- his response per what she wrote did not justify the one. He was actually denying the problem, so it should have been zero. And that occurred four times.
BOYD YOUNG: So after rescoring the M-FAST test, what was your conclusion with regard to that score?
ADRIANA FLORES: So the cut off score for the M-FAST is six. Six and higher is possible malingering. He scored an eight. When I looked at his actual responses, it should have been a four.
BOYD YOUNG: It should have been a four?
ADRIANA FLORES: It should have been a four.
BOYD YOUNG: Which would have been below the cut off?
ADRIANA FLORES: Which would have been below the cut off, right. Typically, what you do with these tests is you give a screener, like a SIMS, or you give the M-FAST because those are two tests that you can actually score fairly quickly on the spot. And if those scores are elevated, then that is when you would then administer the more comprehensive measure, which would be the SIRS. So based on that score, I did not see a need to -- I mean, I see why it was administered because it was an eight. So yes, that would be suspect for potential malingering. But in reality, it should have been a four, which means the SIRE then would not have needed to be administered.
BOYD YOUNG: With regard to the ease of administration, is the SIRS more or less difficult than the M-FAST to follow instructions, do what you're supposed to do?
ADRIANA FLORES: It's more complex. It has different ways to administer different portions. And so in training my trainees, I have found that it definitely -- that they catch onto the M-FAST really fast because it's pretty self-explanatory. But with the SIRS, it's one of the measures that I routinely will have them actually give to each other and practice with each other and then we look at the scoring to see if they, in fact, got it right. Because you can get it wrong. You can get it wrong fairly easily.
BOYD YOUNG: Did misscoring on the M-FAST cause you concerns about the reliability of the scoring on the SIRS?
ADRIANA FLORES: It did. Given that the errors that I perceived on the M-FAST, I was concerned about the validity of the SIRS in terms of its administration scoring.
BOYD YOUNG: On the M-FAST where Mr. Jones' responses were written, were they similarly written on the SIRS testing?
ADRIANA FLORES: No. So that's what made it difficult to discern whether or not it had been accurately scored. Because the SIRS, for example, has a number of two-prong questions. So if a person says yes to the first question, then you follow it up with a second. And what I do with my protocols, for example, if a person says, yes, I will put yes, and then I will follow it up with the follow-up question and then I will put whether they said yes or no. So if you have two yes's, then it's a yes, you give the score. But if the person says no for the second question, like, do you experience this problem. And then the next is, was it only because you were on drugs and the person says yes, right, then it's not a malinger problem. And so it -- but those answers were not on Dr. Kruse's SIRS, so I couldn't really tell whether or not she misscored or didn't correctly score that test.
BOYD YOUNG: You talked about the other tests -- some of the others tests that were given, the PAI and the MMPI, as having their own validity scores. Can you tell the Court about that and what was the result of those testing as to whether or not Mr. Jones was malingering or not malingering?
ADRIANA FLORES: Sure. So on both of those tests, they have -- as I alluded to, I think, earlier, they have different indices that inform the evaluator as to whether or not you can really consider the individual's responses to be true of how they actually are functioning. So both of them have a way to discern whether the individual is actually being more defensive in the way that they take the test. And by this, I mean -- a really good example would be like if you do the PAI and you give the MMPI to somebody going through a custody battle, what we tend to see in those individuals is that they want to present -- generally, they want to present themselves as problem-free, as not having any hallucinations, not having any personality issues, so you tend to see -- in the PAI case, you tend to see what's called the positive response style, you tend to see a higher score there because they're trying to make themselves look more positive, less problematic, more problem-free than they actually may be.
On the MMPI, you have a similar scale, you have the L scale. It's called a life scale, but the L scale, and that one is such an individual in a custody battle, you would expect that one to be a little elevated because they're trying to make themselves seem like they're, perhaps, more fit and better than they actually may be. You also have the opposite. You have scales that inform you of whether an individual is attempting to make themselves look worse than they are in terms of problems. And so, the PAI scale, you have a negative response and on MMPI scale, you have the S scale and you have some other scales. And those are the ones that in forensic criminal cases, we tend to focus more on are we seeing those scores by way of the negative response score and, for example, the F scale. You look for those in cases in which there is some potential secondary gain, criminal matters, civil lawsuits in which there's money to be made, social security dependence in which they can make more money if they are sick. And so it has these scales in performance. Now, let me say this, those tests give scores with regard to both scales. And what you're looking for is which of those scales is tipped on one direction and how much is it tipped. Because the greater the elevation on whether it's the overreporting of symptoms or the underreporting of symptoms, the greater the number is the less likely that information that you have is really accurate in terms of the person's true presentation.
BOYD YOUNG: Overall, was the information that was perceived through those tests accurate and consistent?
ADRIANA FLORES: Both of those tests had -- two different tests, similar concepts, two different tests and they were fairly mirror images. And by that, I mean that -- on the MMPI, you had the F scale was fine. There was no indication of overreporting or malingering of problems. The PAI, the equivalent would be to look at the negative response style and the paragraph that you read, in fact, there was no indication that the respondent was making himself look worse than we are. And then you also have -- on the opposite scale, which would be the L scale on the MMPI and that is the underreporting of symptoms. And was one of 74, so it was a little higher, but not so high that it would invalidate the data. And on the PAI, we have positive response. And as Dr -- as the report, I think, indicated there was some indication of defensiveness. So interpreting both of those, there is no indication of malingering. And on the contrary, there's an indication that the respondent was actually attempting to make themselves look as less -- as having less problems as they actually would. The other thing that was the same in both scales is that -- in both tests, sorry, is that even these are two different tests, they assess in similar constructs. And both of them had the highest scores being in the same two scales, which is schizophrenia and the paranoia scale. So both of them have those scales and both of those are where you see the higher scores.
BOYD YOUNG: Can you explain the statement that the L score is 74 -- and I think you just did, combined with his normal limits TRIN score reflects a rather unsophisticated pattern of faking good?
ADRIANA FLORES: Correct. Right. So you don't just look at the L scale. You look at the L scale and see sort of the pattern of how it was they arrived at raising up that score. And that's exactly what it is. But there was an attempt for the person to fake good. There's fake bad, which is the F, and there's fake good, which is the L scale. But that it was not a great attempt.
BOYD YOUNG: Does the F scale T score of 67, does that mean he's malingering or not malingering?
ADRIANA FLORES: Not malingering. What you tend to see is somebody that -- that is very clear malingering, you will see that F in the 80s and the 90s. I've had people spike it up to 100. And that is when it's like okay, this person is definitely reporting some stuff that is just not making sense and is not the same -- is not information that's being recorded by real people with those problems.
BOYD YOUNG: So across those tests, was there real evidence of genuine evidence of mental illness?
ADRIANA FLORES: I believe there was. I believe that when you take the MMPI and you take the PAI and you see that there were some elevations in schizophrenia and paranoia scale. In light of the fact -- well, in light of two facts and in light of the fact that there was no indication of malingering, it means that those are likely problems the person has experienced at some point. And also in light of the fact that there was some indication on the reporting that it means, potentially, those scores could actually really be a little higher.
BOYD YOUNG: One of the items that was omitted in the MMPI was the question about how often you hear voices without knowing where they come from, right? And what does that say to you about the fact that he didn't answer true or false to that question?
ADRIANA FLORES: Well, I would expect malingers will tend to say to that kind of question because that's just a very clear symptom that individuals know that people who are experiencing something like schizophrenia or just a psychotic, in general, will endorse that. And so if somebody is attempting to make themselves look like they have psychosis, that's an easy one. The general public knows that that question is one that a person who has a real schizophrenia or a real psychosis will say yes, I hear these voices. With Mr. Jones, he left that one blank, which would be consistent with no malingering.
BOYD YOUNG: Do patients with traumatic brain injuries generally -- how does that affect their reporting of symptoms or whether or not they report strange or unusual symptoms?
ADRIANA FLORES: There's a whole body of literature, of neuropsychology literature that has found individuals with traumatic brain injury, a couple of things, one, they are at higher risk of experiencing psychosis. And two, when they do experience hallucinations, they tend to be hallucinations that are more what we call atypical, less likely to be seen in individuals, for example, with schizophrenia. So olfactory, tactile, visual hallucinations. And that is because it's an organicity. Those are similar symptoms that you tend to see the hallucinations, olfactory, smelling things that are not there, tactile, feeling things that are not real. Those are hallucinations that we tend to see in organic brain symptoms. So you see it more in traumatic brain injury, you see it more in people with Parkinson's, people with Alzheimer's. You don't see those as much in people with schizophrenia. They do occur, but they're not as typical. But they're not all that atypical in somebody with a traumatic brain injury.
BOYD YOUNG: Your conclusion with regard to all the data across the board, was Mr. Jones malingering or was he not?
ADRIANA FLORES: Just looking at the data, I don't think there's enough information there to say that he was malingering.
BOYD YOUNG: Let me show you what's been marked for ID as Court's number 122 and ask you if you recognize that?
ADRIANA FLORES: That is my CV.
BOYD YOUNG: And Court number 123 and ask you if you recognize that?
ADRIANA FLORES: That is my affidavit that I submitted to you.
BOYD YOUNG: Your Honor, at this time, I make Court's Exhibits 122 and 123 part of the record. Dr. Flores, please answer any questions the State may have.
RICK HUBBARD: Did that come in or not? I object to it. I object --
THE COURT: This is Court's Exhibit, so, I mean --
RICK HUBBARD: If it's a Court's Exhibit, that's fine.
THE COURT: Yeah, it's coming in as a Court's Exhibit, 122 and 123, and then the other lengthy thing, was it, 121?
COURT REPORTER: 124.
THE COURT: 124?
COURT REPORTER: Yes, sir. (WHEREUPON, Court's Exhibit numbers 122 through 124 were marked for identification.)