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VOLUME 15 • NUMBER 1 • SPRING 2006

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Continuing Education Articles

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06

Who Can Best Catch a Liar: A Meta-Analysis of Individual Differences in Detecting Deception

By Michael G. Aamodt, PhD, FACFEI, DSPCP, and Heather Mitchell, MS

12

Disability, Dysfunction, or Deception: Explaining Acquired Occupational Disability

24

By Jasen Walker, EdD, CRC, CCM, and Fred Heffner, EdD

Preparing for the Worst: Using Modeling to Determine Medical Supply Requirements for Terrorism Response

32

Forensic Physiatry: A Case Study

By Martin Hill, BA, CHS-III, Mike Galareau, MA, Gerry Pang, MA, and Paula Konoske, PhD

By E. Franklin Livingstone, MD

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Case Studies/Current Issues

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Faith, Fanaticism, and Fear: Aum Shinrikyo—The Birth and Death of a Terrorist Organization

By Erica Simons, BS

46

Tragic Task: Dental Identification After the Thai Tsunami

50

Death’s District: The Motivation Behind the Body Farm

54

The Piltdown Man: Not “The Missing Link”

By Megan Augustine

56

The Pleasure of Pain

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By Jules Kieser, BSc, BDS, PhD, DSc, FLS, FDS RCSEd

By Leann Long, BS

By Bruce Gross, PhD, JD, MBA, FACFEI, DABPS, DABFE, DABFM, DAPA

Also in This Issue

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36 ACFEI and The Forensic Examiner Logo Products 62 CE Test Pages: 4 Continuing Education Credits in This Issue 64 ACFEI’s 2006 National Conferences 65 ACFEI’s 2006 National Conference in Orlando, FL, September 22-23, 2006 66 ACFEI’s Certification Conference in Las Vegas, NV, July 18-19, 2006 69 Books by ACFEI Members 71 Falsely Accused: Profiles of Individuals Wrongly Accused or Convicted of Crimes Spring 2006 THE FORENSIC EXAMINER

A Meta-Analysis of Individual Differences in Detecting Deception

THE FORENSIC EXAMINER Spring 2006

This article is eligible for CE credit in the following categories: CFC, CMI, ACFEI, APA, NBCC. See page 3 for a key to these CE abbreviations and complete CE approval statements.

By Michael G. Aamodt, PhD, FACFEI, DSPCP, and Heather Custer, MS Key Words: deception, meta-analysis, lying, individual differences

Abstract A meta-analysis was conducted to determine if there were individual differences in the ability to detect deception. On the basis of 108 studies covering 16,537 subjects, the results indicated that confidence (r = .05, K = 58, N = 6,315), age (r = -.03, K = 72, N = 2,025), experience (r = -.08, K = 13, N = 1,163), education (r = .03, K = 4, N = 522), and sex (d = -.03, K = 53, N = 6,023) were not significantly related to accuracy in detecting deception. The study also found that “professional lie catchers� such as police officers, detectives, judges, and psychologists (M = 55.51%, N = 2,685) were no more accurate at detecting deception than were students and other citizens (M = 54.22%, N = 11,647). There were not enough available studies to investigate the relationship between personality dimensions and accuracy in detecting deception.

Spring 2006 THE FORENSIC EXAMINER

There are many forensic contexts in which detecting deception is important. For example, detectives interview suspects, accusers, and witnesses; psychologists interview defendants pleading not guilty by reason of insanity (NGRI), applicants applying for law enforcement positions, and employees thought to pose a danger through workplace violence; jurors and judges listen to witness testimony; and parole board members interview inmates.

Even though electronic methods such as the polygraph, brain fingerprinting, and brain mapping detect deception at well above chance levels, most forensic decisions about deception are not made using these methods. Instead, most decisions are made by subjectively analyzing the verbal content of a message and the paralanguage and body language of the person communicating the message.

Unfortunately, the research literature suggests that, in general, people are not highly skilled at using communication cues to detect deception and only slightly exceed chance levels in detecting deception (Vrij, 2000). Research is also fairly clear that success at detecting deception can be improved somewhat through training, using patterns of cues rather than single cues, comparing communication behaviors to a baseline of behavior, and listening rather than participating in the interrogation or interview (Vrij). What is not clear from the literature is if there are individual differences (e.g., sex, experience, personality) in the ability to detect deception. That is, are certain types of people better than others at detecting deception? It is the purpose of this study to conduct a quantitative review of the literature (a meta-analysis) to determine if there are individual differences in the ability to detect deception.

Meta-Analysis Meta-analysis is a statistical method for combining research results. Since Gene Glass published the first meta-analysis in 1976, the number of published metaanalyses has increased tremendously, and the methodology has become increasingly complex. In the forensic psychology arena meta-analyses have been conducted on a wide variety of topics, including the validity of techniques used to select law

enforcement personnel (Aamodt, 2004), the communication cues related to deception (DePaulo et al., 2003), and the relationship between the confidence of eyewitnesses and the accuracy of their statements (Sporer, Penrod, Read, & Cutler, 1995).

The most influential meta-analysts have been Frank Schmidt and the late John Hunter. Almost every meta-analysis uses the methods suggested in their 1990 book Methods of Meta-Analysis and clarified in the book Conducting Meta-Analysis Using SAS by Winfred Arthur, Winston Bennett, and Allen Huffcutt (2001). Though metaanalyses vary somewhat in their methods and purpose, most try to answer two main questions: 1) What is the mean correlation found in the literature between two variables? In the current meta-analysis, we are interested in the mean correlations between accuracy in detecting deception and a variety of individual difference variables (e.g., education, confidence, sex, and experience).

2) Can we generalize the meta-analysis results to every situation, or are individual difference variables better predictors in some situations than in others?

Our Meta-Analysis Finding Studies. The first step in our meta-analysis was to locate studies correlating an individual difference variable with accuracy in detecting deception. The active search for such studies was concentrated on journal articles, theses, and dissertations published between 1970 and 2004. Studies published prior to 1970 and more recently than 2004 were included when found, but inclusion outside of the years 1970-2004 would not be considered exhaustive. To find relevant studies, the following sources were used: • Dissertation Abstracts Online was used to search for relevant dissertations.

Interlibrary loan was used to obtain most of the dissertations. When dissertations could not be loaned, they were purchased from the University of Michigan dissertation service. There were a few dissertations and theses that could not be obtained because their home library would not loan them and they were not available for purchase.

• WorldCat was used to search for relevant

THE FORENSIC EXAMINER Spring 2006

Table 1. Characteristics of Studies Used in the Meta-analysis Characteristic Source Journal article Doctoral dissertation Master's thesis Unpublished Book chapter Study Decade 1960s 1970s 1980s 1990s 2000s

# of Sources 94 9 1 3 1 2 10 23 35 37

master’s theses, dissertations, and books.

WorldCat is a listing of books contained in many libraries throughout the world and is the single best source for finding relevant master’s theses.

• PsycInfo, InfoTrac, OneFile, ArticleFirst, ERIC, Periodicals Contents Index, Factiva, Lexis-Nexis, Google Scholar, and Criminal Justice Abstracts were used to search for relevant journal articles and other periodicals.

• Hand searches were made of the Journal of Police and Criminal Psychology, Journal of Applied Psychology, Journal of Criminal Justice, and Law and Human Behavior.

• Reference lists from journal articles, theses, and dissertations were used to identify other relevant material.

Keywords used to search electronic databases included combinations of words involving deception (e.g., deception, lying, lies), words relating to individual differences (e.g., confidence, sex, experience), and words related to the task (e.g., detecting and accuracy).

The literature search yielded 206 studies from 108 relevant sources covering 16,537 subjects (the number of studies is greater than the number of sources because some journal articles and dissertations contained more than one study). A summary of sample characteristics can be found in Table 1.

To be included in the meta-analysis, an article had to report the results of an empirical investigation and had to include a correlation coefficient, another statistic that could be converted to a correlation coefficient (e.g., t, F, X2), or tabular data

or raw data that could be analyzed to yield a correlation coefficient. Articles reporting results without the above statistics (e.g., “We found no significant relationship between accuracy and confidence”) could not be included in the meta-analysis.

Converting Research Findings to Correlations. Once the studies were located, statistical results that needed to be converted into correlation coefficients (r) were done so using the formulas provided in Arthur et al. (2001). In some cases, raw data or frequency data listed in tables were entered into an Excel program to directly compute a correlation coefficient.

Cumulating Validity Coefficients. After the individual correlation coefficients were computed, the validity coefficient for each study was weighted by the size of the sample and the coefficients combined using the method suggested by Hunter and Schmidt (1990) and Arthur et al.

(2001). In addition to the mean validity coefficient, the observed variance, amount of variance expected due to sampling error, and 95% confidence interval were calculated. All meta-analysis calculations were performed using Meta-Analyzer 5.2, an Excel-based program written by Dr. Michael Aamodt. The integrity of the formulas in Meta-Analyzer 5.2 were validated using datasets and meta-analysis results provided in Arthur et al. and in Hunter and Schmidt. Copies of the Meta-Analyzer 5.2 template can be obtained without cost from Dr. Aamodt (maamodt@radford. edu).

Searching for Moderators and Generalizing Results. Generalizing metaanalysis findings across similar organizations and settings (validity generalization) is an important goal of any meta-analysis.

In this meta-analysis, when variance due to sampling error accounted for less than 75% of observed variance, the next step was to remove outliers. Outliers were defined as correlation coefficients that were at least three standard deviations from the mean correlation. Outliers are removed from meta-analyses because a study obtaining results that are very different from those found in other studies is

due to such factors Table 2. Are Professionals Better at Detecting as calculation errors, Deception than Students? coding errors, or Studies/Groups Group N Accuracy % the use of a unique sample. In a meta- Teachers 1 20 70.00 analysis, the removal Social workers 1 20 66.25 1 52 of outliers typically Criminals 65.40 1 34 64.12 reduces the variance Secret service agents 4 Psychologists 508 61.56 but not the mean 2 Judges 194 59.01 correlation or effect Police officers 12 655 55.30 size. After removing Customs officers 3 123 55.30 outliers, if the vari- Federal officers 4 341 54.54 156 11,647 ance accounted for Students 54.22 7 758 50.80 by sampling error Detectives 1 Parole officers 32 40.42 was still less than 193 TOTAL 14,379 54.50 75%, a search for such potential moderators as the year, research indicates that law enforcement study, and sample type (e.g., students ver- professionals are likely to believe that sus law enforcement) was conducted. cues such as gaze aversion are indicators Results Are Professionals More Accurate in Detecting Deception Than Students? As shown in Table 2, local and federal law enforcement agencies have levels of accuracy in detecting deception similar to students. The accuracy rate for students in this meta-analysis (54.22%) is similar to, but a bit lower than, the 57% reported in an earlier and much smaller meta-analysis

by Kraut (1980). Criminals were one of the most accurate groups in detecting deception. Although based on only one study, that finding is consistent with the findings

by Granhag, Andersson, Strömwall, and Hartwig (2004) who found that criminals have more insight than students and prison personnel regarding the cues that, according to research, are the best to use when detecting deception.

Though criminals, secret service agents, psychologists, social workers, teachers, and judges seem to be the best and parole officers seem to be the worst at detecting deception, the small number of studies involving these groups strongly suggests that further research is necessary before concluding any of these groups to be different from students or law enforcement personnel.

The fact that law enforcement officials were no more accurate than students at detecting deception may at first appear to be a surprising finding. However, previous

of deception, when research is clear that such cues are not related to deception (Akehurst, Köhnken, Vrij, & Bull, 1996; Strömwall & Granhag, 2003; Vrij, 1993; Vrij & Semin, 1996) Is Confidence Related to Accuracy? The next question we addressed was whether a person’s confidence in his or her ability to detect deception was related to his or her actual accuracy in detecting deception. As shown in Table 3, on the basis of 58 studies, the average correlation between confidence and accuracy is only .05. Although this correlation is statistically significant because the confidence interval does not include zero, it is of such a low magnitude that it would probably not have much practical significance. Because 76% of the variability among studies would be expected due to sampling error alone, these results can be generalized across situations.

That confidence was not highly related to accuracy in detecting deception is not surprising. Not only are these results consistent with an earlier and smaller metaanalysis on the subject (DePaulo, Charlton, Cooper, Lindsay, & Muhlenbruck, 1997), but they are also consistent with research indicating that confidence and accuracy are not highly related in many areas. For example, a meta-analysis by Sporer et al.

(1995) found only a small correlation (r = .28) between eyewitness confidence and

Spring 2006 THE FORENSIC EXAMINER

accuracy. Three studies suggest that there is an insignificant relationship between confidence and the accuracy of interpersonal judgments (Iizuka, Patterson, & Matchen, 2002; Patterson, Foster, & Ballmer, 2001; Patterson & Stockbridge, 1998). Thus it appears that people are not good judges of their own skill levels.

Are Experienced Lie Catchers More Accurate Than Novices? The next question we looked at was whether “experienced lie catchers” were better able to detect deception than naïve or less experienced people. We used three strategies to answer this question. The first strategy was to look at correlations between years of law enforcement/forensic experience and accuracy in detecting deception. The second strategy was to look at correlations between age and accuracy, assuming that with age came more opportunity to encounter and detect deception. The third strategy was to compare accuracy rates for novices (students) with accuracy rates from people who detect deception for a living (e.g., law enforcement personnel, judges, parole officers). As shown in Table 3, neither age nor years of experience was significantly related to accuracy in detecting deception. As shown back in Table 2, people who detect deception for a living (police, detectives, psychologists, secret service agents, parole officers, and judges) have an accuracy rate (M = 55.51%, N = 2,685) that is only slightly higher than novices (M = 54.22%, N = 11,647).

Are Educated People More Accurate in Detecting Deception? As shown in Table 3, only four studies investigated whether more highly educated people or people with higher cognitive ability are better at detecting deception than their counterparts. On the basis of these four studies, education and cognitive ability do not appear to be related to accuracy in detecting deception. With only four studies, this conclusion is tenuous, and more research is necessary.

Are Some Personalities Better Than Others at Detecting Deception? Though several studies investigated this question, few personality traits had been addressed

Table 3: Meta-Analysis Results Individual difference

K

N

r

Confidence Age Experience Education/cognitive ability Neuroticism Extraversion Self-monitoring

58 17 13 4 3 5 4

6,315 2,025 1,163 522 439 653 251

.05 -.03 -.08 .03 .00 .00 .14

95% Confidence Interval

Lower

Upper

SE%

Qw

.02 -.07 -.14 -.05 -.09 -.12 .01

.08 .01 -.03 .12 .09 .12 .26

76% 100% 100% 100% 100% 41% 74%

75.22 4.76 7.37 1.51 0.61 12.24* 5.39

K = # of studies, N = sample size, r = mean correlation, and SE% = percentage of variance explained by sampling error.

in enough studies to conduct a metaanalysis. As shown in Table 3, the most promising personality trait seems to be self-monitoring (Snyder, 1987). High selfmonitors are people who scan the environment to determine how others are behaving and then adjust their own behavior accordingly. Thus it is not surprising that such individuals would be good at detecting deception because their behavior is based on their ability to read the verbal and nonverbal cues of others.

Are Women Better Lie Detectors Than Men? To determine if there are sex differences in the ability to detect deception, d scores rather than correlations (r) were used. D scores are computed by taking the mean accuracy rate for men, subtracting the mean accuracy rate for women, and dividing by the overall standard deviation. There were several studies, such as Feeley, deTurck, and Young (1995) that indicated that there were no significant sex differences in accuracy but did not include the necessary statistics to be included in the meta-analysis. Many studies did not include information about sex differences, but when contacted, several authors (Elaad, 2003; Garrido, Masip, & Herrero, 2004; Masip, Garrido, & Herrero, 2003a; Masip, Garrido, & Herrero, 2003b; Hartwig, Granhag, Strömwall, & Andersson, 2004; Hartwig, Granhag, Strömwall, & Vrig, 2004a; Hartwig, Granhag, Strömwall, & Vrig, 2004b; Leach, Talwar, Lee, Bala, & Lindsay, 2004; Strömwall, Granhag, & Jonsson, 2003) were kind enough to provide means and standard deviations for men and women so that their studies could be included in the meta-analysis.

As shown in Table 4, contrary to popular belief, men and women are not significant-

10 THE FORENSIC EXAMINER Spring 2006

ly different in their ability to detect deception. This is surprising given a previous qualitative review that found that women are better at interpersonal perception than men (Hall, 1985). Because the percentage of variability due to sampling error in the meta-analysis was less than 75%, we searched for moderators. As shown in Table 4, after separating the samples into law enforcement and non-law enforcement groups, the results indicate that women are slightly more effective than men in detecting deception in non-law enforcement samples and men slightly more effective than women in detecting deception in law enforcement samples. These differences, however, are not statistically significant.

Conclusions The results of this meta-analysis suggest that such individual differences as age, education, law enforcement experience, confidence, and sex are not related to the ability to detect deception. There are two interpretations of these findings. It could be that, in general, people are not good detectors of deception regardless of their age, sex, confidence, and experience. Or, it could be that the artificial situations and tasks used in the studies do not allow for the proper detection of deception. In “real world” situations, judgments about deception are often made on such factors as the story not making logical sense, a person not directly answering the questions being asked, and inconsistencies with previous statements or the statements of others. With the tasks used in most studies, such factors could not be used by the subjects attempting to detect deception.

Furthermore, deception is best detected when there is a baseline of behavior, responses are spontaneous, and there is a

consequence for getting caught (e.g., going to prison, not getting a job). In most, if not all, of the studies in this meta-analysis, such conditions were not met. Thus, it is imperative that in future studies more realistic situations be used.

The authors of this article had hoped to explore the relationship between personality and accuracy in detecting deception.

However, there were not enough studies to conduct a meta-analysis. Thus, this might be an excellent area for future research.

References Aamodt, M. G. (2004). Research in law enforcement selection. Boca Raton, FL: Brown Walker Press.

Akehurst, L., Köhnken, G., Vrij, A., & Bull, R. (1996). Lay persons’ and police officers’ beliefs regarding deceptive behaviour. Applied Cognitive Psychology, 10, 461-471.

Arthur, W., Bennett, W., & Huffcutt, A. I. (2001). Conducting meta-analysis using SAS. Mahwah, NJ: Erlbaum.

DePaulo, B. M., Charlton, K., Cooper, H., Lindsay, J. J., & Muhlenbruck, L. (1997). The accuracy-confidence correlation in the detection of deception. Personality and Social Psychology Review, 1, 346-357.

DePaulo, B. M., Lindsay, J. J., Malone, B. E., Muhlenbruck, L., Charlton, K., & Cooper, H. (2003). Cues to deception. Psychological Bulletin, 129(1), 74-118.

Elaad, E. (2003). Effects of feedback on the overestimated capacity to detect lies and the underestimated ability to tell lies. Applied Cognitive Psychology, 17, 349-363.

Feeley, T. H., deTurck, M. A., & Young, M. J. (1995). Baseline familiarity in lie detection.

Communication Research Reports, 12(2), 160-169.

Garrido, E., Masip, J., & Herrero, C. (2004).

Police officers’ credibility judgments: Accuracy and estimated ability. International Journal of Psychology, 39(4), 254-275.

Granhag, P. A., Andersson, L. O., Strömwall, L. A., & Hartwig, M. (2004). Imprisoned knowledge: Criminals’ beliefs about deception. Legal and Criminological Psychology, 9(1), 103-119.

Hall, J. A. (1985). Male and female nonverbal behavior. In A. W. Siegman & S. Feldstein (Eds.), Multichannel integrations of nonverbal behavior (pp.

195-225). Hillsdale, NJ: Erlbaum.

Hartwig, M., Granhag, P. A., Strömwall, L. A., & Andersson, L. O. (2004). Suspicious minds: Criminals’ ability to detect deception. Psychology, Crime & Law, 10(1), 83-95.

Hartwig, M., Granhag, P. A., Strömwall, L. A., & Vrij, A. (2004). Police officers’ detection accuracy: Interrogating freely versus observing video.

Police Quarterly, 7(4), 429-456.

Hartwig, M., Granhag, P. A., Strömwall, L. A., & Vrig, A. (2005). Detecting deception via strategic disclosure of evidence. Law and Human

Table 4: Differences Between Men and Women 95% Confidence Interval

Individual difference

K

N

d

Lower

Upper

Overall Law enforcement Students/other

53 13 40

6,023 833 5,190

-.03 .10 -.06

-.33 -.33 -.30

.26 .52 .18

SE%

Qw

62% 85.88* 58% 22.39* 68% 59.12*

K = number of studies, N = sample size, d = mean effect size, and SE% = percentage of variance explained by sampling error. Note: a positive d indicates that men were more accurate at detecting deception than women.

Behavior, 29(4), 469-484.

Hunter, J. E., & Schmidt, F. L. (1990). Methods of meta-analysis: Correcting error and bias in research findings. Newbury Park, CA: Sage Publications.

Iizuka, Y., Patterson, M. L., & Matchen, J. C. (2002). Accuracy and confidence on the interpersonal perception task: A Japanese-American comparison. Journal of Nonverbal Behavior, 26(3), 159-174.

Kraut, R. E. (1980). Humans as lie detectors: Some second thoughts. Journal of Communication, 30(3), 209-216.

Leach, A. M., Talwar, V., Lee, K., Bala, N., & Lindsay, R. C. L. (2004). Intuitive lie detection of children’s deception by law enforcement officials and university students. Law and Human Behavior, 28(6), 661-685.

Masip, J., Garrido, E., & Herrero, C. (2003a).

Facial appearance and judgments of credibility: The effects of facial babyishness and age on statement credibility. Genetic, Social, and General Psychology Monographs, 129(3), 269-311.

Masip, J., Garrido, E., & Herrero, C. (2003b).

Statement length and credibility judgments: Questioning the truth bias. Paper presented at the Psychology & Law-International, Interdisciplinary Conference, Edinburgh, UK Masip, J., Garrido, E., & Herrero, C. (2003c).

When did you conclude she was lying? The impact of the moment the decision about the sender’s veracity is made and the sender’s facial appearance on police officers’ credibility judgments. Journal of Credibility Assessment and Witness Psychology, 4(1), 1-36.

Masip, J., Garrido, E., & Herrero, C. (2005).

Observers’ decision moment in deception experiments: Its impact on judgment, accuracy, and confidence.

Unpublished manuscript, University of Salamanca, Spain.

Patterson, M. L., Foster, J. L., & Bellmer, C. D. (2001). Another look at accuracy and confidence in social judgments. Journal of Nonverbal Behavior, 25(3), 207-219.

Patterson, M. L., & Stockbridge, E. (1998).

Effects of cognitive demand and judgment strategy on person perception accuracy. Journal of Nonverbal Behavior, 22(4), 253-263.

Snyder, M. (1987). Public appearances, private realities: The psychology of self-monitoring. New York: W. H. Freeman.

Sporer, S., Penrod, S., Read, D., & Cutler, B. L. (1995). Choosing, confidence, and accuracy: A meta-analysis of the confidence-accuracy relation in eyewitness identification studies. Psychological

Bulletin, 118, 315-327.

Strömwall, L. A., & Granhag, P. A. (2003).

How to detect deception? Arresting the beliefs of police officers, prosecutors and judges. Psychology, Crime & Law, 9(1), 19-36.

Strömwall, L. A., Granhag, P. A., & Jonsson, A. (2003). Deception among pairs: “Let’s say we had lunch and hope they will swallow it!” Psychology, Crime & Law, 9(2), 109-124.

Vrij, A. (1993). Credibility judgments of detectives: The impact of nonverbal behavior, social skills, and physical characteristics on impression formation. The Journal of Social Psychology, 133(5), 601-610.

Vrij, A. (2000). Detecting lies and deceit: The psychology of lying and the implications for professional practice. Chichester, England: John Wiley & Sons, Ltd. Vrij, A., & Semin, G. R. (1996). Lie experts’ beliefs about nonverbal indicators of deception.

Journal of Nonverbal Behavior, 20(1), 65-80.

About the Authors

For the past 22 years, Michael G. Aamodt, PhD, FACFEI, DSCPC, has been a professor of psychology at Radford University in Radford Virginia. He is the author of many journal articles and several books including Research in Law Enforcement Selection and Applied Industrial/Organizational Psychology. Dr. Aamodt frequently consults with and provides training programs to law enforcement agencies.

He is a past president of the Society for Police and Criminal Psychology.

Heather Custer, MA, earned her master’s degree in counseling psychology from Radford University in 2005. She has worked as a communications officer for a police department and is currently an emergency services assessment clinician at the New River Valley Community Services Board.

Earn CE Credit To earn CE credit, complete the exam for this article on page 62 or complete the exam online at www.acfei.com (select “Online CE”).

Spring 2006 THE FORENSIC EXAMINER 11

CME

This article is eligible for CE credit in the following categories: CFC, CMI, ACFEI, APA, CME, NBCC. See page 3 for a key to these CE abbreviations and complete CE approval statements. The author of this article has nothing to disclose for CME purposes.

By Jasen Walker, EdD, CRC, CCM, and Fred Heffner, EdD

Abstract Acquired disability following trauma is an area that is in dire need of discussion and explanation. Unless an expert is fully informed of the multitude of pre- and post-injury medical and psychosocial dynamics that surround an individual’s claim of occupational disability, he or she may not be in a position to make absolute judgments regarding residual employability, pre- and post-work capacity, or the causal attribution of vocational disability.

Causal attribution is critical in determining disability chronicity following trauma, as the host of contributing psychosocial dynamics effecting unproductive states are often overlooked when investigating the most obvious reason for work absence, a so-called explanatory event. A thorough and accurate history-taking is necessary when assessing pre-injury work longevity, determining residual employability, and causally ascribing occupational disability to a particular event. Acquiring a complete and reliable history through various sources places the expert in a better position to offer a professionally certain opinion.

Key Words: medical impairment, occupational disability, attribution theory, disability proneness, work perception Background Central to most personal-injury lawsuits are the issues of vocational disability and lost earning capacity. When injured people begin losing time from work, they inevitably attribute the vocational disability to the most recognizable event preceding the unemployment—the accident. In a purely temporal analysis, most observers would agree with the injured party. That is, a documented event or accident took place and caused subsequent lost time. However, post hoc, ergo propter hoc (after this, therefore on account of it) is frequently a fallacy and too often constitutes a failure in the cause-and-effect analysis of vocational

12 THE FORENSIC EXAMINER Spring 2006

disability. The way acquired disability is explained can affect how chronic it might become.

Confusion exists in our medical and legal systems as to who is best qualified to describe vocational capability and disability and delineate the various factors to which occupational disability might be accurately ascribed. Thus, not only does acquired disability have a personal meaning to be explained by the individual, but also a larger social context in which professionals attempt to determine who is vocationally disabled and why. This article will reflect on who is best qualified to professionally describe occupational disability

and its causes.

Over the past 25 years thousands of injured people have been examined to determine vocational rehabilitation.

Vocational disability is as much a function of psychosocial dynamics as medical impairment and resultant functional limitations. When an individual considers not only a medical impairment, but also the constellation of psychological and social forces that are at play both before and after an accident (and work injury in particular), he or she generally comes closer to defining the true cause-and-effect of lost productivity that may occur following an industrial accident or injury. Also,

thorough and detailed history-taking is the key element in the skilled assessment of vocational disability.

Multiple Factors in Disability Analysis It has been our experience that in the disability equation, one needs to account for the following: • Worker’s general health preceding the event in question.

• Work conditions preceding and at the time of the event at issue.

• Employer-employee relationship.

• Employee’s self-esteem and psychological strength.

• Psychosocial factors outside of the work-

place.

• Social-economic alternatives to remaining productive.

Each of these factors influences the losttime analysis.

Worker Health and Wellness. Minds and bodies are the vehicles that collectively fuel productivity at both the individual and the organizational level. When mental and physical abilities are not maintained with proper health practices, they naturally deteriorate, and under stress these vehicles can actually break down. Some organizations have started to recognize the importance of health and wellness among their worker populations. The institutionalization of prevention and early intervention includes such initiatives as smoking cessation plans, obesity reduction plans, employee assistance programs, and exercise facilities available to all workers in particular companies; however, these types of programs are neither universally available nor commonly accepted as means by which employees can remain healthy and productive.

The degenerating musculoskeletal system, an unavoidable aging phenomenon, eventually becomes prone to injury and disability, particularly in industrial settings. Workplace mortality rates for longshoremen, transportation workers, and steelworkers, for example, are generally higher than those for accountants, lawyers, and schoolteachers, although more sedentary employees are by no means immune to mental stressors that can precipitate occupational illnesses. Without a focus on worker health and wellness, aging employees within an organization can become susceptible to lost time not as a result of a particular event, but as a result of the degenerative process that makes any body and/or mind vulnerable to occupational stress.

Working Conditions. Workplaces are not always conducive to employee health and wellness regardless of the efforts of human resources managers and others in leadership positions. Many industrial plants are more like dungeons than production facilities. Workers can encounter hazardous chemical exposures, run antiquated and dangerous machinery, and function in generally unsafe working conditions,

Spring 2006 THE FORENSIC EXAMINER 13

whether in non-unionized or unionized workplaces. Not infrequently, employees who recognize unacceptable conditions surrounding them initiate workers’ compensation claims and associated lost time because the existence of such environments becomes intolerable—particularly as the workers age and eventually perceive no other exit strategy.

Several years ago, upon considering the issues of worker health, working conditions, and the employer-employee relationship, the metaphor of a “toxic tort” was coined to represent some workers’ compensation claims. That is, in some instances, workers filed claims not because they had been injured or become ill, but because they considered the occupational environment so potentially harmful or “poisonous,” literally and/or figuratively, that filing a compensation claim was a preferred means of economic survival.

Employer-Employee Relationship.

Everyone who toils under supervision has perceptions of leadership, sometimes good, frequently bad. The relationship between the boss and the subordinate has received more attention than any other relationship in books on management, and no relationship has received greater scrutiny in labormanagement agreements. The employeremployee relationship is invariably susceptible to conflict. Unresolved conflict is often the precipitator of workplace stress, tension buildups, and resultant lost time.

Employee Self-Esteem and Psychological Strength. When an individual experiences a sense of self-worth and realizes personal power, he or she is able to be assertive and make his or her needs known to others. Personal power is the goal for most individuals, but unfortunately, many people have not been afforded the building blocks necessary to develop a strong sense of self and self-worth.

Criticized and invalidated by significant others in their early lives, most individuals become workers with tenuous egos and defensive self-concepts, more often focusing on what they do not want to happen to them rather than helping create the environments and relationships they desire.

Personal power in the workplace can be diminished by performance circumstances and/or low productivity. When this hap-

pens, individuals can become susceptible to workplace injury and/or illness.

With reduced productivity concomitant to lowered self-esteem, an employee may find it easier to leave the workplace with a face-saving injury or illness rather than confront the actual problems that led to feeling helpless and depressed in a work environment that seems to lack compassion, understanding, and support. Feeling abandoned in a group of your workplace peers is far more anxiety provoking than becoming absent from work after the onset of injury or illness. The latter clearly vindicates the “honorably” disabled employee who, in his or her mind, has sacrificed personal health and well-being for the company.

Psychosocial Factors External to Work.

Everyone experiences social demands and psychological pressures outside of work.

When those pressures and demands exceed our tolerance for stress, we are susceptible to illness and/or injury. Disability proneness is a concept built on the idea that certain individuals are more vulnerable than others to the customary pressures of life outside of work. Personal and financial changes and losses such as relocation, separation/divorce, and other situations that are difficult to adjust to can lead to maladaptive behaviors affecting job performance and even work attendance.

Experience has shown that individuals with inordinate psychosocial stressors and limited coping skills may very well be prone to disability. Moreover, the literature on work dysfunction reveals that certain personality types interacting with social and occupational demands are more likely to succumb to these pressures, learn helplessness, and claim vocational disability.

Social-Economic Alternatives to Remaining Productive. For years, experts have recognized that a construct parallel to learned helplessness is the phenomenon known as learned laziness. Once deemed the welfare pigeon paradigm, learned laziness is the expectation that certain individuals and personality types will quickly abandon motivational achievement behaviors for non-conditional rewards, sometimes in the form of workers’ compensation indemnity benefits and/or Social Security Disability Insurance. With most

14 THE FORENSIC EXAMINER Spring 2006

benefits (e.g., workers’ compensation and/ or long-term disability) paying at rates of at least 66.6% of the employee’s pre-accident wages, once-productive workers soon find it difficult to risk losing benefits by returning to the unknown consequences of gainful activity, particularly in an environment that may no longer welcome them.

Often employers perceive injured workers with mistrust, and too often employers treat injured employees as damaged goods, or worse, as pariahs. With perceived employer disdain following occupational injury and/or disease, the injured worker quickly searches for alternative methods of financial survival.

There is much at stake when an individual claims to be vocationally disabled following accident and/or injury. There are various ways of explaining how an individual’s disability occurred and why it might become chronic, but in all cases, regardless of the explanation, the nonproductive consequence of people being displaced from work following an accident and/or injury is very expensive to individuals, companies, and our nation’s economy in general.

The Mercer Human Resources Consulting and Marsh, Inc., 2002 Survey of Employers’ Time-Off and Disability Programs revealed that time-off and disability program costs averaged 15% of payroll in 2001. More specifically, for an employee earning $40,000 annually, companies surveyed paid $6,000 for time away from work associated with sick days, workers’ compensation costs, short- and long-term disability programs, salary continuation programs, etc. For years, socalled acquired occupational disability, an inability to work following injury or illness, has cost our economy billions of dollars each year ($170.9 billion, according to one 2002 estimate), and yet little attention has been given to the concept of how individuals explain vocational disability.

Causal Attributions of Occupational Disability Attribution theory seeks to understand how individuals interpret events and how explanatory thinking and behavior tends to correlate with human motivation.

Attribution theory considers how people

make sense of their worlds and what causeand-effect inferences they make about the behaviors of themselves and others. For years the potential role of attribution theory in the cause-and-effect beliefs that people create and maintain when they acquire vocational disability has been explored.

It has been postulated that healthcare providers, specifically physicians, trained in assessing impairment are generally ill equipped to determine the cause of disability in others. The authors of this article have hypothesized that vocational disability tends to be temporary or become fixed depending on an individual’s attributional style. This article will again review the difference between medical impairment and vocational disability and discuss the multitude of issues surrounding causal attribution of occupational disability.

Medical Impairment v. Occupational Disability. Medical impairment, an alteration of an individual’s health status, is what is wrong with a body part or organ system and its functioning (American Medical Association, 1990). Permanent impairment should be determined only at the end of the normally accepted healing period or when maximum medical improvement has occurred. Impairment does not determine the impact on the person’s capacity to meet social or occupational demands; disability defines the impact of impairment on occupational functioning. Medical impairment is evaluated and treated by healthcare personnel. Disability is assessed by non-medical means, generally by vocational experts and disability evaluators. What causes occupational disability is often more complex than simply a decrease in physical or mental functioning secondary to a particular impairment.

Occupational disability is often caused by pre-existing medical problems, social dynamics, psychological issues, the lack of work skills that might be utilized in alternative or perhaps less demanding work, and/or economic factors such as the availability of appropriate employment given a medically impaired individual’s residual employability. Nonetheless, how people explain acquired disability is very much a function of the attributions they create.

Attribution Theory. Attribution theory, what Weiner (1986) called naïve

psychology—the cause-and-effect analysis of behavior made by the person-in-thestreet—attempts to explain the mechanisms by which people construe the causes of behavior and arrive at their beliefs about success and failure. Attribution theory has been linked with achievement-related behavior, such as learning and working, and mental health concepts (e.g., optimism, pessimism, anxiety, and depression). Attribution theory helps explain not only how individuals perceive their own successes and failures, but also how they causally ascribe the achievement of others.

The authors of this article postulate that individuals who have medical impairments can attribute occupational disability to an accident or injury for no other reason than a temporal connection—that is, the person became unemployed after a trauma. Since the injury allegedly resulting in impairment came at the time of or after an accident, it is implied that the accident caused the disability. It can be argued that a timebased explanation in the determination of what causes occupational disability is often inadequate in explaining disability given the multitude of other factors, including pre-existing medical conditions, that can cause unemployment subsequent to, but not necessarily as a consequence of, the indexed traumatic event.

For example, a 38-year-old female who sustained a whiplash injury in an automobile accident stopped working as an outside sales representative 5 months after the accident and claims that her chronic regional pain syndrome, diagnosed after the accident, was the cause of her occupational disability. Careful investigation, however, revealed that she was previously treated for rheumatoid arthritis and fibromyalgia. Her theory as to why she was unemployed with a loss of economic power was that her occupational disability was directly and causally related to the whiplash injury. A physician treating her declared that her chronic pain complaints were directly linked to the whiplash injury that had become the basis for the patient’s personal injury lawsuit. In reality, her chronic complaints of pain and concomitant allegations that she could not work were multifactorial at least. Further investigation revealed that this sales representa-

tive was being disciplined at work for low production. Additionally, the company for which she worked was being purchased by another entity, and rumors were circulating that layoffs of sales representatives would occur as a result of the acquisition.

Causal attributions of occupational disability are best made by trained observers or evaluators who fully appreciate the psychosocial context in which causal attributions of acquired disability are made.

Occupational disability has been studied from numerous social and psychological perspectives. Important constructs have been offered to help better understand and explain the non-medical antecedents and consequences of vocational disability. The concepts of disability without disease and the disability process, learned helplessness (and laziness), co-malingering, locus of control, loss of self esteem, disability induction, disability proneness, illness behavior, and the meaning of work help us understand some of the underlying principles of disability causation.

Disability Without Disease and the Process of Disability After spending many years treating injured autoworkers, Behan and Hirschfeld set forth their idea that injured employees can exhibit disability without disease or accident (1966). Borrowing on this concept, Weinstein delineated the process of disability in 1978.

Weinstein (1978) graphically portrayed the stages of the disability process. He reasoned that the troubled worker, when faced with negative feedback regarding his or her performance, would eventually reach a stage where tension build-up would become overwhelming and viewed as an unacceptable disability. Weinstein argued that an accident or illness, seen retrospectively as an explanatory event, would allow the unacceptable disability to become acceptable and stabilize with medical explanations, diagnostic studies, and eventually unnecessary interventions, such as surgery or chronic pain management involving crippling medications. Behan and Hirschfeld (1966, p. 659) concluded, “This remarkable capacity of disability to seize an accident as its apparent cause results in terrible chronicity.”

Spring 2006 THE FORENSIC EXAMINER 15

Learned Helplessness (and Laziness) Walker (1992) offered the concept of learned helplessness as a useful framework in understanding how injured workers perceive loss of control in the workers’ compensation system—a system that simultaneously rewards and punishes injured workers. Learned helplessness is caused by repeated experiences of aversive, uncontrollable situations. The person caught in a learned-helplessness syndrome exhibits passive, resigned, and inflexible behavior associated with dysphoric feelings of depression. Walker described how the workers’ compensation system breeds conditions ripe for injured worker helplessness. However, he also pointed out that the very same system often financially rewards people non-contingently, thereby also inducing learned laziness by making a return to work financially impractical or disadvantageous for the workers’ compensation claimants. Walker argued that injured workers, trapped in the quagmire

of workers’ compensation systems as they are designed (i.e., to make a person whole), generally manifest amotivational behaviors and surrender their will to work. After proposing learned helplessness as a model for depression and motivational disturbances, Seligman (1975) reformulated the learned helplessness model to include the concept of attributional style. That is, individuals with particular attributional styles are more susceptible to learning helplessness.

Co-Malingering Lost time from work may be a function of either medical restrictions that are related to impairment as determined by physicians or dysfunction associated with behavior and social relationships that develop both before and after the accident/injury. At times, injured workers are accused of malingering, the falsification of symptoms to avoid responsibility, including work.

Only 10% of compensable lost time is due solely to medically imposed restrictions (Mitchell & Leclaire, 1993). “All other

16 THE FORENSIC EXAMINER Spring 2006

reasons for lost time are due to employerand employee-controlled impediments for return-to-work, such as inflexible supervisory decisions, poor injury management practices, breakdowns in communications, and/or employer failures to make reasonable work accommodations.”

These employment situations may represent a form of co-malingering that Kenneth Mitchell, who coined the term, described as “the mutual actions of employers and employees that extend [the] disability duration and impede early return to productive employment” (Mitchell & Leclaire, 1993).

Co-malingering is also sometimes referred to as negotiated disability. “Employees incur 100% of lost time; employers control 90% of it” (Mitchell & Leclaire).

However, for many years now, we have recognized that other members of the lost-time community can also function in relation to the injured employee as co-malingerers, and those other parties include physicians, lawyers, and family members. Co-malingering appears to be

much more common than malingering in lost-time cases.

Locus of Control Locus of control is a useful construct in terms of vocational rehabilitation. At its simplest, locus of control is an individual’s perception of the cause of events in one’s life: either one believes he or she controls his or her own destiny (internal), or one believes that others, luck, or fate control one’s outcomes (external).

Locus of control is closely related to the concept of attribution. An attribution is an explanation of what happens to one’s self and/or others. In general, an internal locus of control is seen as being more desirable.

Consider the following descriptions of internality and externality: • It is an internal attribution about oneself when one succeeds (I did it myself ).

• It is an internal attribution about others when they fail (It was their fault).

• It is an external attribution about oneself when one fails (Something/Someone else made me fail).

• It is an external attribution about others when they succeed (They got lucky).

Research (Mamlin, Harris, & Case, 2001) has shown the following trends: • Males tend to be more internal than females.

• As people get older, they tend to become more internal.

• People higher up in the organizational structure tend to be more internal.

Although these trends are not absolute, they may serve as a starting point for vocational counselors working with clients. It is generally agreed that locus of control is largely a learned condition. For a client who is resisting vocational counseling and incidentally exhibiting an external locus of control, it may be a useful strategy to work toward reversing that bias. There are a number of questionnaires that are designed to determine internal and/or external locus of control. Rotter’s original “29-item Locus of Control Questionnaire” is still used, and newer questionnaires are also available.

The value of starting with knowledge of the client’s locus of control bias is that an external locus of control can lead directly to the loss of control. The important research

in respect to loss of control is Seligman’s learned helplessness (1975). Since locus of control is learned as opposed to innate, clients drift toward learned helplessness as a maladaptive outcome of having no control over what is happening to them. Moving from what may have been an internal locus of control to an external locus of control is a maladaptive adaptive response that may be reversed by sharing knowledge of the condition with the client and devising reversal strategies. Counselors need to be cautioned against simplistic judgments derived from an over-reliance on the locus of control concept, but sharing knowledge about a reality can seldom be injurious.

Acknowledging personal responsibility is an important first step for clients resisting return-to-work actions.

Loss of Self-Esteem Another significant factor in resisting a return to work after an illness or accident is rooted in psychological issues such as depression, anxiety, and low self-esteem.

Frese and Mohr (1987) stated, “Depressed persons who are inactive and pessimistic in their outlook will be unemployed much longer or will become unemployed more readily.”

Weinstein (1978) pointed out that a worker’s loss of self-esteem taking place simultaneously with decreased productivity are two key factors in unacceptable disability that requires an explanatory event, such as a future accident or injury in order to justify continuing dysfunction and ultimately a prolonged period of lost time from work. In other words, Weinstein believed that a worker’s loss of self-esteem is a key predictor to future vocational disability even before the accident that will be labeled the cause of lost time.

Furthermore, Weinstein pointed out that following the explanatory event, medical, psychological, and social factors may actually work to restore the individual’s self-esteem and allow for him or her to be declared “honorably disabled,” thereby signaling a stabilization and chronicity to the disability.

In the final analysis, intractable cases of depression and/or personality dysfunction will need to be referred to competent mental health professionals who understand

behavioral medicine and the importance of vocational rehabilitation. Of course, most rehabilitation counselors are not trained as clinical psychologists, but there are interventions that vocational counselors can and should utilize. Basic interventions that can be applied in counseling clients who are resisting return-to-work would include the following: • Discussing the importance and the value of work with the client.

• Identifying and discussing psychological issues, especially depression, the loss of self-esteem, and the need to find ways to overcome them.

• Discussing locus of control and causal attributions and their significance to motivation and productive return-to-work efforts.

• Recognizing learned helplessness and planning a way to achieve countervailing strategies to prevent helplessness from establishing itself.

• Setting realistic goals with clients and helping them work to achieve goals.

• Supporting the client throughout the counseling and behavioral change processes.

Kelly (1955) said of vocational development, “It is one of the principal means by which one’s life role is given clarity and meaning.” Vocational rehabilitation counselors hold a significant responsibility to assist clients in understanding the obstacles to personal fulfillment through work and to provide the professional guidance to help their clients achieve clarity and meaning.

Disability Induction Occupational disability and lost productivity can often be explained by understanding that acquired disability can be encouraged, prompted, influenced, and solicited. That is, vocational disability can be induced. At least four separate methods of disability induction have been identified: iatrogensis, beaurogenesis, litogenesis, and psychogenesis.

Iatrogenic. Iatrogenic disability occurs more frequently than the casual observer might suppose. Low-back surgery, for example, is well known to resolve less often in the injured-worker population. Indeed, for many years, a successful neurosurgeon

Spring 2006 THE FORENSIC EXAMINER 17

in Philadelphia would not treat compensable back injuries surgically because of the dramatically different “success” rates in the occupationally injured versus non-occupationally impaired populations.

Iatrogenic disability need not be the result only of surgical intervention.

Physician induction of disability can often result from mere suggestion. The susceptible, or all-too-vulnerable patient can hear, or think he or she heard, the physician say that the patient is “unable to work.”

Physicians unknowingly underestimate or consciously abuse the power invested in them by the generally naïve health care recipient.

Disability induction through iatrogenic means is sometimes a function of the employer not insisting that its health care providers stay within their disciplines and avoid making vocational decisions.

Employers and employees make vocational decisions; physicians diagnose and treat disease.

Beaurogenic. Work disability is often caused by the bureaucracy that surrounds occupational injury and non-occupational disease. Organizational policies and personnel decisions often ignore the consequences of shortsighted and antiquated return-to-work practices. From “you cannot return to work until you are 100%” to “light duty for workers’ compensation recipients only,” light duty programs seldom serve both employee and employer.

Although the rising costs of workplace disability and the Americans with Disabilities Act led to some reevaluation of these return-to-work standards in the 1990s, the beaurogenic induction of disability remains a significant problem for most work organizations and our country at large.

Some self-insurers of both workers’ compensation and long-term disability have failed to realize that, as work organizations, they create disincentives for employees to return to work following the onset of injury or illness. With employees able to receive nearly 70% of their income in wage-replacement benefits, the employer has introduced secondary gain as a factor that the injured or ill worker would find difficult to overcome despite a strong work ethic. The Social Security

Administration has recognized that most recipients of Social Security Disability Insurance are of working age, yet few take advantage of the trial work period available to them. The widespread use of managed care organizations in the treatment and rehabilitation of injured workers raises a legitimate question regarding the possibility that managed care adds a layer of bureaucracy to the already complex social and political systems that induce disability in the workplace. Bureaucracies can foster disincentives to get well and return to work.

Litogenic. When representing injured or ill employees (or people pursuing economic damages through personal injury litigation), legal advocates hope to demonstrate that their clients have lost their

“

Physician induction of disability can often result from mere suggestion. The susceptible or all-too-vulnerable patient can hear, or think he or she heard, the physician say that the patient is “unable to work.” Physicians unknowingly underestimate or consciously abuse the power invested in them by the generally naïve health care recipient.

”

potentials to work and earn a living.

Lawyers, in their advocacy of injured employees, pursue economic recovery in claims such as personal injury, workers’ compensation, Social Security disability, and long-term disability. These litigations almost always induce or encourage an argument of disability. Even the most ethical lawyers believe that their clients have more to gain if they can prove economic damage secondary to vocational disability.

Psychogenic. Psychogenic disability

18 THE FORENSIC EXAMINER Spring 2006

suggests the inability to work because of symptoms caused or produced by mental or psychological factors rather than organic problems. Depression, substance abuse, personality disorders, and psychosis can lead to psychogenic disability.

Unfortunately, health care professionals often legitimize symptoms manifested following the diagnosis of a disease or disorder that is not necessarily disabling.

Psychogenic disability can arise when workers blame symptoms secondary to stress on an external cause rather than taking responsibility for reducing the stress.

Psychogenic disability is often precipitated by work dysfunction. For an excellent text on psychogenic disability and its causes, see Psychiatric Disability: Clinical, Legal and Administrative Dimensions, published by the American Psychiatric Press, Inc. Disability Proneness Some employees have predispositions toward disabling diseases or illnesses.

Disability proneness is a real and significant phenomenon antecedent to and at times a cause of many cases of chronic vocational disability. Individuals with particular work dysfunctions are more prone to occupational disability and claims of incapacity. It is believed by the authors that the workers’ compensation system in particular breeds the requisite conditions for learned helplessness and laziness, and that particular attributional styles make individuals more prone to developing chronic disability than others with different styles of causal attribution.

Illness Behavior Illness behavior is frequently exhibited by individuals who are indeed sick. However, some individuals exhibit illness behavior that is abnormal or inappropriate to the situation. According to Pilowski (1978), abnormal or inappropriate illness behavior is “the persistence of an inappropriate or maladaptive mode of perceiving, evaluating, and acting in relation to one’s own state of health,” even though available evidence suggests that this illness behavior is unexpected or inappropriate. In other words, inappropriate illness behavior is thought to be exhibited if individuals are convinced that an organic disease is caus-

ing their pain or other symptoms but no evidence of organic disease exists or the illness behavior is inappropriate to the organic disease that does exist.

Illness behavior as a concept provides a framework for understanding the observed differences among pain patients. According to the Institute of Medicine (1987), “Illness behavior is a process that includes a perception of one’s own symptoms, and attribution of meaning to them (from something trivial to an ominous indicator of serious illness), and the way in which one seeks help in dealing with the symptoms. Such behavior is influenced by the person’s personality and coping style and by the surrounding culture and society.

The fact that such factors can be strong influences on the pain or other symptoms that people experience does not, however, make pain any less real.”

The meanings a patient gives to an accident, sickness, personal suffering, or the relentless presence of pain affect sub-

sequent illness behavior and help order experience in several ways. Patients form causal attributions to account for their perceived circumstances. Limitations imposed on a patient’s lifestyle by chronic pain may be significantly attenuated if the patient believes that he or she can control the pain or can, despite the pain, undertake activities without harm. In contrast, it has been observed that patients who believe they have little or no control over their health and well being (learned helplessness) endeavor less effectively to achieve rehabilitation (Pilowski, 1984). Finally, personal meaning of an illness or symptom may affect self-esteem either positively or negatively. Becoming an invalid, even briefly, can be a blow to a person’s selfesteem. Similarly, being unemployed or forced to accept employment at a lower wage or job status because of pain can be demeaning. However, for some patients embracing the sick role is seen as an elevation in status (i.e., honorably disabled).

These people value the nurturance and special consideration of friends, family, and neighbors that follow injury and the development of chronic pain. Personal meanings are likely to be influenced by the shared meanings of the group to which the individual belongs (Institute of Medicine, 1987).

At the same time, the meaning of work held by the individual and/or the group to which this individual belongs can be a powerful influence on the individual’s capacity or willingness to overcome illness behavior. When work is a central theme in the injured person’s life, chances are illness behavior and associated dysfunction will not lead to total vocational disability.

The Meaning of Work During research at New York University, Wrzesniewski (2003) determined that individuals experience work in one of three distinct ways: • Job—the individual is primarily con-

Spring 2006 THE FORENSIC EXAMINER 19

cerned with the financial rewards of work.

• Career—the individual is focused on advancing within the occupational structure.

• Calling—the individual works not for financial gain or career advancement, but for the sense of fulfillment that work brings.

Usually individuals who view their work as just a job prior to the onset of injury or illness are less likely to return to work than individuals who consider work a career. In contrast, individuals who perceive work more or less as a calling are eager to return to work following illness or injury.

Employees who believe that work is a calling are not representatives of esteemed professions only. Just as many longshoremen, waitresses, custodians, and landscapers fully invest in their vocations as callings as do teachers, lawyers, and physicians. The meaning of work is an experience unique to the individual and not necessarily a function of how society in general might perceive the job title and the employee’s day-to-day responsibilities.

When organizational leaders can imbue every member of a work team, from the least skilled to the most highly trained, with the belief that each employee is highly valuable and important to the organization’s success, the organization will probably have fewer problems with lost time. Take for example the camaraderie of a hospital maintenance staff. The members of the maintenance staff were encouraged to wear surgical garments to work. The maintenance manager felt that without his crew’s involvement, the hospital could not operate and effective health care could not take place, no matter how skilled the staff physicians. This simple but clever gesture was, of course, designed to remind the maintenance staff members of their critical contribution to the hospital’s daily functioning. That particular hospital maintenance staff had few instances of occupational injury/illness/lost time.

The development of occupational disability or the onset of acquired vocational disability may result traumatically from a single event (i.e., the above the knee amputation in a professional football player), but as we have shown above, acquired total disability is often a process

that involves numerous contributions that are not only medical in nature, but also psychosocial. Because acquired disability is heavily weighted by psychosocial dynamics, we believe that professionals trained in determining impairment (medical authorities) should defer to vocational counselors for a total picture—or explanation—of acquired disability.

Causal Attributions of Acquired Disability: Who Is “Qualified” to Make the Call?

The difference between medical impairment and occupational disability is not only a significant distinction, but one that must be recognized in the proper adjudication of damages in personal injury claims.

As noted above, the American Medical Association recognizes that impairment refers to an alteration of an individual’s health status and is assessed by medical means. Disability is an alteration in an individual’s capacity to meet personal, social, or occupational demands and is assessed by non-medical means.

In personal injury cases involving multiple impairments, for example, the vocational expert may be the most qualified professional to speak to both the occupational disability and the actual cause of that disability. Until recently, the misconception has been that physicians are trained and qualified to offer opinions with medical certainty as to why an individual can or cannot work. This article suggests that this is an error in professional judgment on several levels, and if the legal community wishes to pursue accurate disability determinations it must continue to educate its members as to which professionals are best qualified to testify as to the cause of occupational disability in an individual who has multiple impairments.

In order to arrive at a point in vocational/disability analysis where informed and detailed assessment of future employability can take place, one must know the subject’s past. Not only is educational and occupational history relevant, but the subject’s past medical history can be critical in accurately determining the potential for future work, particularly occupational longevity or worklife expectancy.

Worklife Expectancy. This term is

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commonly used in determining how long an individual is likely to participate in the workforce given factors such as age, race, gender, and disability. Although they are hardly a data set without controversy, various vocational experts, to argue disability frequently, cite the Bureau of Census information on individuals absent from the workforce because of health-related problems. Gamboa (1998) introduced the concept of work-life expectancies for persons defined as severely disabled, disabled, not severely disabled, and non-disabled.

Gamboa’s hypothesis is that people with various (pre-incident/accident) medical problems are already disabled with some level of severity. The issue then becomes one of determining the level of severity. If the Gamboa hypothesis is correct, then how does a 54-year-old Certified Nursing Assistant (CNA), who is 5’4” tall and weighs 350 pounds (morbid obesity) claim that absent her lower back trauma (incurred from falling on a slippery floor, for which she is suing the floor cleaning contractor and the floor wax manufacturer), she would have worked until age 65, all the while lifting, bathing, and otherwise caring for geriatric patients, most of whom were non-ambulatory? Moreover, post-injury x-rays of the CNA’s hips and knees show significant degenerative changes. Nonetheless, with the support of a vocational expert, she is claiming that she cannot work and had she not slipped on the floor, she would have continued working full-time in direct patient care until normal retirement age.

Obviously, there is a need for reasonableness in these arguments of disability causation. However, even competent vocational experts can find themselves perplexed when faced with evaluating an individual who has multiple, and often compounding, medical problems pre-existing those specific injuries for which the individual is claiming vocational disability.

What is abundantly clear from evaluating thousands of people who claim they cannot work is that thorough history taking is a crucial step in gathering sufficient information in order to determine the cause(s) of lost time following an observable change in a worker’s health status.

Only a detailed and complete history

can assist trained observers in identifying the causes of unproductive occupational states.

What is also clear is that in most cases the vocational expert, who is trained and experienced in disability analysis, is generally better prepared than a medical expert, who may not fully appreciate the exertional and non-exertional demands of specific jobs, or more importantly, how those demands might be reasonably reduced by job accommodation. Although it is true that medical experts have greater training than vocational professionals in understanding physical and/or mental diseases, the critical factor in disability assessment is whether an individual with physical and/or mental impairment can function in relation to a particular set of job demands.

A Case in Point: The Electrician A 56-year-old industrial electrician fractured his back while operating his son’s trail bike. The electrician attempted to return to his customary work after spinal surgery and rehabilitation, but persevered no longer than 8 weeks after medical rehabilitation, and subsequently claimed total vocational disability and absolute loss of earning power in his personal injury lawsuit against the motorcycle manufacturer.

The electrician’s lawyer hired a vocational expert who interviewed the electrician, performed no vocational testing, and opined that the electrician could not work in any capacity and had lost all power to earn money based on the interview information and medical records, including statements from the treating physician that his patient, the electrician, was totally disabled. Meanwhile, the industrial plant in which the electrician had worked for 25 years closed down. Nonetheless, the plaintiff ’s vocational expert opined that through the union, the electrician could have continued to work as a journeyman, work involving medium and heavy physical demands, had he not been injured in the trial bike accident.

The defendant hired an orthopedic surgeon to examine the plaintiff ’s back complaints. The consulting physician found and stated with certainty that the electrician did have exertional limitations and that his spinal impairment prevented him

from lifting more than 10 pounds and performing more than sedentary work.

The defendant also retained a vocational expert. The vocational expert reviewed the plaintiff ’s complete medical records, studied the electrician’s employment/personnel file, interviewed the electrician, and performed a battery of standardized tests measuring abilities, aptitudes, temperament, and interests. The testing showed that the electrician possessed the linguistic capabilities and vocational aptitudes sufficient to perform sedentary desktop positions, such as maintenance scheduler,

“

What is abundantly clear from evaluating thousands of people who claim they cannot work is that thorough history taking is a crucial step in gathering sufficient information in order to determine the cause(s) of lost time following an observable change in a worker’s health status.

”

production scheduler, and motor vehicle dispatcher. The electrician expressed greater interest in communication work than in his prior employment of craft technology. The defendant’s vocational expert also found that medical documentation showed that the electrician had chronic left, dominant upper-extremity impairments, including a rotator cuff tear and chronic shoulder bursitis secondary to a work-related accident caused when he tried to lift a 65-pound fiberglass ladder 5 years before the motorcycle accident.

The defendant’s vocational expert also reviewed the electrician’s personnel and occupational health records, which revealed that the plant physician had con-

sistently restricted the electrician to lifting no more than 30 pounds with his left upper extremity occasionally and 10 pounds frequently. For the last 4 years of the electrician’s employment, the company had maintained him on restricted duty, working exclusively in the maintenance shop. Finally, company records revealed that the plant closed down, as noted, 1 year after the electrician stopped working. The defendant’s vocational expert opined that the electrician was disabled from the full range of physical activities associated with his craft by his pre-existing upper extremity impairments, which had obviously limited the electrician for several years prior to the personal injury event. Moreover, the defendant’s vocational expert declared that the electrician could not have functioned as a journeyman electrician in the open labor market (as alleged by the plaintiff ’s vocational expert) absent the spinal injury because of pre-existing upper extremity limitations and medically established lifting restrictions.

The Outcome. Who is right? What should a judge decide about these opinions and arguments? Does the determination of what constitutes occupational disability remain with the medical expert? Does the vocational expert possess the knowledge and skill to make a causal attribution of occupational disability when he or she knows that certain pre-existing or unrelated medical conditions would in all probability make certain physical demands as an electrician impossible to execute? Is not the vocational expert compelled to take a thorough medical history and consider all health-related issues that might otherwise affect an individual’s employability?

The plaintiff ’s medical expert stepped outside the confines of her expertise and offered a vocational opinion of total disability. The medical opinion of disability, for all intents and purposes, nullified the purview of the vocational expert, and perhaps the plaintiff ’s vocational expert perceived little choice but to follow suit and also opine that the plaintiff was totally vocationally disabled. Incidentally, in his opinion, the plaintiff ’s vocational expert declared that the Social Security Administration had found the plaintiff totally disabled, and therefore, he agreed.

Spring 2006 THE FORENSIC EXAMINER 21

What the plaintiff ’s vocational expert failed to recognize is that Social Security disability determinations are not accident or injury specific; disability is determined on numerous factors, including the individual’s residual functional capacities without taking into account the cause of the impairment(s) or other dysfunctions (limitations) at issue. Neither of the plaintiff ’s experts considered the totality of the electrician’s medical history, especially his preexisting upper extremity limitations and their occupational relevance in terms of the plaintiff performing the medium and heavy work of the journeyman electrician’s trade, notwithstanding the effects of the spinal impairment.

The defense medical expert was told to examine the plaintiff ’s injury-related complaints, including his spinal impairment and associated lower extremity symptoms, but did little investigation into this man’s prior upper extremity medical history.

The defense vocational expert, supplied with sufficient information to understand the plaintiff ’s employability both before and after the accident in question, could attribute the plaintiff ’s vocational disability from journeyman electrical work to a pre-existing upper extremity disorder, notwithstanding the effects of the musculoskeletal injuries sustained in the motorcycle accident.

Case 2: The Lawyer A lawyer suffered a stroke, and on the way to the hospital the ambulance was involved in an accident. The lawyer was trapped under the wreckage and miraculously survived. However, when he arrived at triage, he presented with a significant compound fracture, and although the fracture was repaired, an infection set in. As a consequence, the lawyer lost his leg above the knee. The stroke, for its part, resulted in cognitive and language deficits.

Through rehabilitation, the recovering man struggled with using his prosthesis and ultimately decided that life was easier in a wheelchair. He tried to return to his profession but struggled with neuropsychological impairment. A lawyer representing the man in court argued that the motor vehicle accident resulting in the compound fracture and resultant amputa-

tion caused the lawyer occupational disability and lost earning power. Which of the medical impairments, the neuropsychological deficits or the post-amputation ambulation problems, caused disability in the practice of law?

Although causal attribution of occupational disability in the case of the lawyer may be more evident than in the case of the electrician, both scenarios represent a potential problem for those who do not fully appreciate the difference between medical impairment and occupational disability in the adjudication of monetary damages associated with lost work capacity. When the injured lawyer was neuropsychologically evaluated by a consultant retained on his behalf, the neuropsychological examiner explained that the lawyer’s cognitive deficits were not secondary to the stroke, but rather a result of reactive depression linked to the loss of the limb. However, the defendant retained both a neuropsychological expert and a vocational expert. Both tested the lawyer with objective personality measures and found that the lawyer was indeed anxious, but not depressed. Moreover, the defendant’s neuropsychologist found a pattern of neuropsychological deficits that were directly associated with brain injury in an area of the cerebrum shown by the MRI to be damaged by the stroke. The vocational expert opined that based on all of the information gathered and reviewed, the lawyer’s vocational disability was a result of the stroke and not the post-MVA amputation. Had he not had a stroke, the attorney could still be practicing law.

The vocational expert or occupational disability analyst is frequently confronted with the problem of assessing the employability of individuals with a history of multiple medical impairments. More often than not, the expert is asked to opine as to the effect of trauma/injury on the occupational capabilities of an individual who has a pre-existing impairment or co-morbidity. The disability analyst’s challenge is to determine the effect of pre-existing impairments, and with thorough medical information, perhaps the differential functional effect of co-morbidities and how those affect an individual’s capacities to work.

22 THE FORENSIC EXAMINER Spring 2006

Case 3: The Teacher In still another example, a teacher who had a long history of mental disorders, specifically a so-called manic depression that had not been well controlled, claimed that because of a motor vehicle accident (MVA) and an associated whiplash injury, he suffered from chronic neck pain, dominant upper extremity radiculopathy, and headaches. It could be argued that the MVA injuries alone could constitute disability in classroom instruction. However, what effect would the uncontrolled bipolar disorder have upon the teacher’s capacities to work? It would be difficult to resolve this issue on a logical basis. Moreover, the history of this specific claimant’s pre-existing mental disorder may be legally eliminated as a factor because it might have produced prejudice for a fact finder or a jury.

The authors of this article believe a vocational expert is better able to attribute occupational disability to a particular cause and to determine residual employability in individuals who are impaired. This is because the vocational expert is more knowledgeable in the actual demands of particular jobs throughout the world of work and should be in a position to thoroughly analyze the injured person’s vocational options in light of medical impairment, whether singular or multiple.

Certainly, the medical professional is better qualified to identify and describe medical impairment (physical and/or mental) and, in some cases, the injured person’s residual functional capacities. But it is the vocational expert (knowledgeable of medical impairments, their general effects on functioning, and how dysfunction might interact with job demands) who remains far better suited than medical professionals to state with certainty whether a particular individual possesses the ability to work (residual employability) or the capacities to perform gainful activity. More to the point, both medical experts and vocational experts possess unique training and skills that require the assistance of the other in fully determining whether an individual can work gainfully and in clearly determining what particular health problem may be occupationally disabling.

Obviously, whatever the training and experience of the individual evaluator,

thorough histories are critical in understanding the entire picture of the injured worker and how that history relates to acquired disability. It is important to recognize that a lack of adequate history-taking can lead to unnecessary or inadequate medical treatment, which is sometimes a contributing factor or indeed a cause of acquired disability.

Conclusion Acquired disability following an accident or injury begs to be explained. Disability is explained by the person who experiences lost time and by a host of others in the injured person’s social and professional networks. Based on our experiences and the contributions of informed others, disability can be explained by numerous psychosocial dynamics independent of the actual injury or impairment, forces that can precipitate, cause, and stabilize unproductive states following trauma or any change in one’s health status. Too frequently, these dynamics are overlooked in consideration of what appears to be the most obvious reason for the absence from work, a so-called “explanatory event.” We have also concluded with certainty that a thorough and accurate history is necessary to assess pre-accident work longevity, determine residual employability, and causally ascribe occupational disability to a particular event. Possessing a complete and reliable history (preferably from documentation of various sources) places the expert charged with disability analysis in a better position to offer a professionally certain opinion.

What Behan and Hirschfeld (1966) call disability without disease or accident does exists. We recognize the importance of attributional style in an individual’s effort to explain disability. Causal attribution of occupational disability remains a major issue that often challenges all rehabilitation personnel in forensic vocational/disability assessment matters and occupational rehabilitation of those who have become injured or ill. The more detailed and reliable a picture one can construct and the more information provided about the injured worker’s personal constructs and tendencies to explain cause-and-effect, the more accurate the examiner can be in

not only assessing vocational disability but its actual cause(s). Solutions can be found through explanations and finding causes.

The question, “Who is qualified to make the call on occupational disability?” is not yet answered. Neither expert, medical nor vocational, may be in an absolute position to make judgments regarding residual employability, pre- and post-capacity to work, or the causal attribution of vocational disability unless the expert is fully informed of the multitude of medical and psychosocial dynamics that surround an individual’s claim of occupational disability.

Causal attribution and attribution theory are critical determinants in disability chronicity following accident and injury.

The literature on pain in disability offers substantial insight into the multiple factors that can cause one to claim total vocational disability. Medical, rehabilitation, and legal professionals are encouraged to recognize the complexity of occupational disability claims. There needs to be more frequent and thoughtful research in the areas of psychosocial antecedents to vocational disability, illness behavior in situations of claimed disability, and attribution theory as determinants of vocational disability.

References American Medical Association (1992). Guides to the evaluation of permanent impairment (3rd ed. revised). Chicago: Author.

Behan, R. C., & Hirschfeld, A. H., (1966).

Disability without disease or accident. Archives of Environmental Health, 12(5), 655-659.

Frese, M., & Mohr, G. (1987). Disability, community, and rehabilitation, prolonged unemployment and depression on older workers: A longitudinal study of intervening variables. Social Science Medicine, 25, 173-178.

Gamboa, A. M., Jr., Tierney, J. P., & Holland, G. H. (1989). Work-life expectancy and disability. Journal of Forensic Economics, 4, 29-32.

Osteweis, M., Kleinman, A. & Mechanic, D. (Eds.). (1987). Pain and disability: Clinical, behavioral and public policy perspectives. Washington, DC: National Academic Press.

Kelly, G. A. (1955). The processes of causal attribution. American Psychologist, 28, 107-128.

Mamlin, N., Harris, K. R., & Case, L. P. (2001). A methodological analysis of research on locus of control and learning disabilities: Rethinking a common assumption. Journal of Special Education, 34(4).

Mitchell, K., & Leclaire, S. W. (1993).

Negotiated disability in the health care industry: The invisible bond between worker and employ-

er. Columbus, OH: National Rehabilitation Planners, Inc. Pilowski, I. (1978). A general classification of abnormal illness behavior. British Journal of Medical Psychology, 51, 131-137.

Pilowski, I. (1984). Pain and illness behaviour, assessment and management. In P. D. Wall & R. Melzack (Eds.), Textbook of pain. New York: Churchill Livingstone.

Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, 80(1), 1-28.

Seligman, M. E. (1975). Learned helplessness: On depression, development, and death. San Francisco: W. H. Freeman.

Walker, J. M. (1992). Injured worker helplessness: Critical relationships and system levels appropriate for intervention. Journal of Occupational Rehabilitation, 2(4).

Weiner, B. (1986). An attributional theory of motivation and emotion. New York: SpringerVerlag.

Weinstein, M. R. (1978). The concept of the disability process. Psychometrics, 19(2).

Wrzesniewski, A., Dutto, J. E., & Debebe, G. (2003). Interpersonal sensemaking and the meaning of work. Research in Organizational Behavior, 25, 93-135.

About the Authors Jasen M. Walker, EdD, CRC, CCM, is the president of Corporate Education and Consultation (CEC) Associates, Incorporated, a multi-service organization with the mission of preventing and managing human risk factors in the workplace. He has written numerous articles and, along with his colleagues at CEC, has compiled a text entitled Managing Workplace Disability. He also maintains a private practice as a disability analyst and vocational expert and provides forensic services to both plaintiff and defense lawyers and their clients. Dr. Walker is a Diplomate with the American Board of Vocational Experts, is a vocational expert for the Social Security Administration Bureau of Hearings and Appeals, and has been a member of the American College of Forensic Examiners since 1996.

Fred Heffner, EdD, is a program development Consultant for Corporate Education and Consultation (CEC) Associates, Incorporated. Dr. Heffner is a semi-retired teacher and adjunct professor (MBA Program, St. Joseph’s University). He has contributed to the research and writing of a number of articles written by Dr. Walker and other associates.

Earn CE Credit To earn CE credit, complete the exam for this article on page 62 or complete the exam online at www.acfei.com (select “Online CE”).

Spring 2006 THE FORENSIC EXAMINER 23

Key Words: terrorism, medical, response

Photo Courtesy of the U.S. Army

By Martin Hill, BA, CHS-III; Mike Galarneau, MA; Gerry Pang, MA; & Paula Konoske, PhD

Preparing for the Worst: Using Modeling to Determine Medical Supply Requirements for Terrorism Response This article is eligible for CE credit in the following categories: CHS, CMI, ACFEI. See page 3 for a key to these CE abbreviations and complete CE approval statements.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. Approved for public release; distribution is unlimited. This research has been conducted in compliance with all applicable federal regulations governing the protection of human subjects in research.

Abstract The Marine Corps Chemical Biological Incident Response Force (CBIRF) was established in 1996 in response to Presidential Decision Directive 39 to outline the nation’s plan for responding to terrorist acts at home and abroad. CBIRF’s mission subsequently expanded from biochemical response to the full scope of chemical, biological, radiological, nuclear, and explosive responses. The objective of this study was to determine the medical supply requirements for CBIRF’s expanded mission.

In November 2003, preliminary research on injury types and medical interventions seen at previous terrorist incidents was presented by the Naval Health Research Center (NHRC) to a subject-matter-expert (SME) panel consisting of military medical and logistical experts. The SME panel identified the clinical tasks that CBIRF needed the capability to perform. NHRC’s method of modeling supply requirements was then applied to those tasks, establishing the clinical requirements for CBIRF’s Authorized Medical Allowance Lists (AMAL). This study was able to identify weaknesses in the existing CBIRF AMALs and strengthen the unit’s field medical capabilities with the addition of new technologies and modularization that allows greater flexibility in responding to terrorist disasters.

24 THE FORENSIC EXAMINER Spring 2006

Photo courtesy of Win Henderson / FEMA photo

Introduction The massive terrorist bombings that struck the World Trade Center in New York in 1993 and the Alfred P. Murrah Federal Building in Oklahoma City in 1995 proved that the United States was not immune to the kind of terrorism often seen abroad. The 1995 sarin attack on the Tokyo subway also raised the specter of terrorism to a new level of mass horror, one in which weapons of mass destruction (WMD) such as chemical and biological agents could be used to spread death and terror. In response to these attacks and others, then-President Bill Clinton signed Presidential Decision Directive 39 (PDD-39), the United States Policy on Terrorism, in 1995.

PDD-39 laid down the strategy for combating both domestic and international terrorism in all its forms (U.S. Department of Defense [DoD], 2001).

In response to PDD-39, then-Marine Corps Commandant General James Jones ordered the establishment of a

self-contained unit that could respond to chemical and biological terrorist attacks within the United States and its territories, as well as abroad. This unit would provide agent identification, rescue response, and consequence management, including medical treatment to victims. On April 4, 1996, the Marine Corps established the Chemical Biological Incident Response Force (CBIRF) as an immediate terrorism response force capable of deploying anywhere in the world on short notice and remaining deployed for up to 3 weeks if responding outside the Continental United States (CBIRF, 2003). Under the U.S. Government Interagency Domestic Terrorism Concept of Operations Plan, CBIRF can be deployed domestically if requested by the lead federal agency overseeing an incident and if the request is approved by the Secretary of Defense (U.S. DoD, 2001). The unit is currently attached to the 4th Marine Expeditionary Brigade (Anti-Terrorism).

Since its inception, CBIRF’s mission has continued to evolve, adding responsibilities for responding to toxic industrial materials, as in a massive chemical accident; high-yield explosive incidents, such as the Oklahoma City bombing; and radiological incidents, such as the detonation of a “dirty bomb” containing radioactive elements (also known as a radiation dispersal device) or a nuclear device. Its original operational requirements document was canceled, and a new one was developed calling for the additional capabilities (C. E. Puckett, personal communication, November 4, 2003). CBIRF’s original complement doubled in size to nearly 500 Marines and sailors by the summer of 2004.

CBIRF now operates as two 200-person incident response forces (IRFs) capable of responding independently to two simultaneous terrorist events covering the full-range of chemical, biological, radiological, nuclear, and explosive (CBRNE) events (Temerlin, 2003).

As part of this change, a new medi-

Spring 2006 THE FORENSIC EXAMINER 25

cal concept of operation (CONOPS) was written.

Each of the two IRFs have a medical contingent consisting of 11 Navy medical personnel, including one physician, one nurse or physician’s assistant (PA), one hospital independent duty corpsman (IDC), and eight regular corpsmen. Fewer would respond if deploying to a nearby incident by helicopter (Temerlin, 2003).

The duties of the medical unit include casualty collection and stabilization, spot decontamination, and emergency medical intervention.

The new medical CONOPS establishes a generic method of deployment for the CBIRF medical section in the event of deployment. The medical section of each IRF will be deployed in three sections: the Casualty Collection Point, with four corpsmen and the seniormost clinician to perform triage; the Nonambulatory Decontamination Line, with two corpsmen to oversee victims as they undergo decontamination, if necessary; and Patient Stabilization, with either a nurse or PA and two corpsmen. An IDC will be stationed at the incident command post as a liaison with the mission commander. This concept of deployment can be collapsed, as needed, according to the type of terrorist incident to which CBIRF responds.

Due to CBIRF’s quick establishment and evolving mission, its medical inventory never received a formal review and analysis, leading to questions of whether its series of six medical supply blocks, called Authorized Medical Allowance Lists (AMALs) in the Navy and

Marine Corps, were adequate for the unit’s expanded CBRNE mission (U.S. General Accounting Office [GAO], 2001; U.S. GAO, 1999). Marine Corps Systems Command tasked the Naval Health Research Center (NHRC) with reviewing CBIRF AMALs with the intent of developing an inventory based on appropriate research. It was the objective of this study to conduct a systematic assessment of the clinical requirements needed to support CBIRF’s missions.

Method The existing CBIRF medical supply inventory was divided among 6 separate allowance lists: AMAL 8400, Casualty Search; AMAL 8401, Casualty Clearing; AMAL 8402, Airway Management; AMAL 8403, Casualty Evacuation; AMAL 8404, Force Protection; and AMAL 8405, Organic Support (C. E. Puckett, personal communication, December 11, 2000). CBIRF officials stated early in the study that this arrangement was unsatisfactory. Despite the indicated use for each AMAL, they did not correspond to any medical function within CBIRF. The six separate AMALs also made both routine maintenance of the inventory and its deployment in the field difficult. Prior to training and actual deployments, CBIRF medical personnel had to pull individual supply items from the various AMALs to put together the inventory with which they actually deployed (W. B. Cogar, personal communication, August 21, 2003).

For the purpose of this study, the six CBIRF AMALs were consolidated on paper and the supply amounts aggregated. An early NHRC analysis showed weaknesses in the area of medications for biological and radiological response, crush syndrome, and medical conditions that might be encountered in extreme environmental conditions.

Recommendations for filling these gaps were submitted for review by a SME panel that convened November 18-20, 2003, at CBIRF headquarters in Indian Head, Maryland. The panel consisted of 15 military and civilian experts in military

26 THE FORENSIC EXAMINER Spring 2006

medicine, medical logistics, and the treatment of WMD victims, including medical officers from two National Guard WMD Civil Support Teams. At the conclusion of the SME panel, the following assumptions were agreed upon for the development of the new CBIRF medical inventory: • CBIRF will have only one AMAL with individual modules for flexibility in responding to various disaster scenarios.

• Each IRF will have 1 CBIRF AMAL. A third will be kept at CBIRF headquarters for quick resupply.

• The CBIRF medical section will provide basic emergent care according to Advance Trauma Life Support protocols to stabilize patients prior to transport to more definitive care. Facilities will include a patient stabilization tent with four treatment stations.

• Patient holding will be limited to 12 hours for a domestic response, 24 hours for outside the United States.

• Sick call for 250 persons (200 CBIRF personnel and a 50-Marine security detachment) for a deployment lasting up to 3 weeks would be provided by a standard Marine Corps battalion aid station sick-call block (AMAL 699) issued to each IRF, with a third in reserve. In addition, hot-cold climate modules will be added to the CBIRF AMAL for responding to areas with weather extremes.

• Medical supplies are needed for a maximum of 100 nonambulatory trauma patients—the extreme upper range of what repeated training showed CBIRF could treat in a 1- to 2-day period.

• Nerve agent antidotes should be included for 500 patients, plus personal protection for up to 250 CBIRF members.

• Medications for treatment of exposure or ingestion of radiological isotopes would be included for 500 patients, plus force protection for 250 CBIRF members. Oral medications are preferred. No chelating agents will be used.

• Cyanide treatment kits would be provided only for the unit’s search-and-rescue entry team, totaling 10 members. Due to the poison’s fast-acting effect, CBIRF would probably not deploy in time to pro-

vide medical treatment to victims.

• In the event of a biological incident, CBIRF’s medical section will probably not provide more than force protection.

Therefore, medications such as antibiotics for biological attacks are limited to force health protection.

• To conserve deployment weight, oxygen use will be limited. An oxygen generator will be deployed instead of a large number of tanks.

In addition to these assumptions, CBIRF’s new medical concept of employment required that all supplies and equipment be capable of being moved and set up by as few as six corpsmen and be capable of being loaded, unloaded, and set up with minimal effort and delay.

The SME panel decided that the CBIRF AMAL should be modularized as much as possible to allow the greatest flexibility and speed in responses. Table 1 lists the various treatment modules as identified

by NHRC and approved by the SME panel.

Results Trauma Supplies. NHRC’s method of modeling medical supply requirements, developed to establish and review AMALs for various levels of care in the Navy and the Marine Corps, was used to determine the type and amount of trauma supplies and equipment CBIRF needed to accomplish its mission. The NHRC modeling method ensures military clinicians get the proper type and amount of medical equipment and supplies they need to successfully complete their field missions. The method involves a four-step process that usually begins with the identification of the patient types that are likely to be encountered, including those with combat wounds, nonbattle injuries, and illnesses. These are identified from the Defense Medical Standardization Board (DMSB) patient treatment briefs, which establish the military treatment protocols for more than 400 injuries and illnesses, called patient conditions (PC), which the DMSB has

Photo courtesy of Win Henderson / FEMA photo

identified as the most likely to be seen on military operations. The treatment briefs identify the treatment to be given for each PC at all levels of care in the military medical system—from the combat medic through the field hospital—and are commonly used by the armed forces for training and modeling manpower requirements.

NHRC’s usual process involves producing a patient stream using a casualty generation program such as the Marine Corps CASEST program, or the NHRC FORECAS program. Both of these programs use historical combat casualty statistics applied to the DMSB patient conditions to predict casualties in a variety of battle scenarios using both conventional and non-conventional weapons. The selected patient conditions are matched with appropriate clinical tasks, and those tasks are then mapped to the necessary supplies. This process produces an audit trail identifying those necessary supplies and avoids stocking AMALs with needless items.

Figure 1 provides an abbreviated illustration of the NHRC modeling process as applied to a combat medical scenario.

Shown is a sample task profile for providing emergent care to a patient with a trauma brain injury (PC 005) in the

triage section of a Level 2 surgical field hospital. Not shown, but also used in the calculation of materiel, are the number of patients with that type of injury (or patient condition code), their average length of stay, the number of times a clinical task is expected to be performed on each patient in a 24-hour period, and the quantity of each supply needed for performing each task.

At the time of this study, NHRC research found no reliable means of projecting a casualty stream for terrorist-related events or studies identifying and quantifying likely terrorist-related injury patterns. Attempts to produce a terrorism-related trauma casualty stream using the combat-oriented CASEST and FORECAS patient generators proved unsatisfactory. However, CBIRF’s intense training efforts had shown that the unit was capable of treating up to 100 serious, nonambulatory trauma victims over a 1- to 2-day period (Temerlin, 2003).

Therefore, the SME panel agreed that a casualty stream of 100 patients would be appropriate for calculating trauma supplies.

Since a reliable stream of patient types could not be developed, the SME panel reviewed a list of clinical tasks produced by NHRC and identified those

Spring 2006 THE FORENSIC EXAMINER 27

that would be necessary capabilities for the CBIRF medical section. These tasks were culled from task descriptions developed by DMSB and NHRC for medical modeling purposes. The tasks selected by the SME panel are listed in Table 2.

As noted, NHRC research found few studies identifying the specific types of traumatic injuries incurred in terrorist attacks. A study of survivors who received medical treatment after the collapse of the World Trade Center reported generic categories of injuries, but not interventions (Boodram et al., 2002). A study of the impact of the Oklahoma City bombing on local medical facilities showed similar injury categories, but also provided a list of the types and numbers of field and emergency room medical interventions performed on survivors (see Table 3; Gonzalez, 2002).

The SME panel agreed that using these interventions and their percentages on a casualty stream of 100 patients was appropriate.

These interventions were mapped to the DMSB/NHRC clinical tasks identified by the SME panel. In doing so, one intervention in the Oklahoma City list might become two or more tasks in the SME panel list. This was due to breaking down some DMSB/NHRC interventions into smaller steps than those identified in the Oklahoma City bombing. In some cases, the percentage of patients receiving a task was reduced to reflect the belief that a particular task would not be performed as often as others would in the same grouping. Examples of the intervention/task mapping can be seen in Table 4.

Quantities of Table 1. Chemical Biological Incident Response Force mannitol and Authorized Medical Allowance List Modules sodium bicar- CBIRF AMAL Modules bonate injec- Corpsman Trauma Bags (x11) Purpose Trauma tion-medications Corpsman Airway Bags (x11 Trauma, chemical commonly used Patient Stabilization) Trauma, chemical, radiation in the treatment Radiological Response dispersal device Radiation exposure of crush syn- Biochemical Chemical, nerve agent, biological drome as seen force protection in building col- Sick Call Outside U.S. Hot Weather/Tropical lapses like those Outside U.S. created by high- Cold Weather Outside U.S. Set-Up Equipment Tentage, power yield explosions were calculated rhage; and the introduction of the pelvic for the CBIRF mission using data providsling to replace the use of military antied by the Federal Emergency Management shock trousers for stabilizing pelvic fracAgency (FEMA). FEMA estimates disaster tures. crush casualties at between 5% and 40%, Another addition was the use of predepending on the cause of the disaster, packed medical “roll-down” bags in the with 20% as the average (Dickson, 1998; Patient Stabilization area. These bags, Pennsylvania Emergency Management made by Iron Duck (Chicopee, MA), are Agency, 2003). Therefore, the amounts of long, hanging multipocket bags packed these medications were calculated on the with medical supplies. Designed to speed assumption that crush syndrome injuries the setup of field medical facilities, they would occur in 20% of the casualties are similar to the prepackaged bags used so encountered by CBIRF. successfully in the Marine Corps Forward Next, task profiles were created linking Resuscitative Surgery System (FRSS), a each task to the supplies and equipment sort of one-bed trauma center on wheels required to perform it, plus the amount of that has been widely used in the war each supply needed to perform the task, in Iraq. Also adapted from the FRSS is as well as the percentage of patients who the Base-X tentage system (Base-X, Inc., would likely receive the procedure. Once Lexington, VA), which includes built-in the profiles were complete, the amount lighting and a portable electric generator of each supply was calculated using the to give the CBIRF medical section operNHRC modeling method, then totaled. ating capability in various lighting and This study also attempted to identify climate extremes that it did not previously new technology and products that would have. enhance CBIRF medical capabilities yet Biochemical Response. Medical supremain within unit weight and cube restricplies for injuries caused by pulmonary tions. As previously noted, a decision was agents or vesicants are largely the same as made to use an oxygen generator instead those trauma supplies used for respiratory of carrying a large number of oxygen distress and burns and, therefore, were not tanks. The added portable oxygen generacalculated separately (U.S. Army Medical tion system (POGS 10) provides 10 liters Research Institute of Chemical Defense per minute of oxygen through two patient [USAMRICD], 2000; Battlebook Project outlets, weighs 70 pounds, and comes in Team, 2000). CBIRF’s major concern in its own wheeled case. Also added were the area of chemical attack is the potenportable ultrasound equipment to detect tial use of nerve agents such as sarin. unseen internal injuries; automated exterCBIRF medical officers estimate they can nal defibrillators; QuikClot (Wallingford, decontaminate and treat up to 500 nonCT), a thermogenic powder pioneered ambulatory nerve agent patients in a 10by the Marine Corps to control hemorhour period, the maximum amount of

28 THE FORENSIC EXAMINER Spring 2006

Table 2. List of Medical Tasks* Required by CBIRF Task 001 002 006 007 011 017 019 022 024 038 049 050 070 071 073 075 079 084 085 086 092 096 098 103 108 121 123

Task Description Triage Assessment & Evaluation of Patient Status Establish Adequate Airway Emergency Cricothyroidotomy Stabilize Neck (Collar/Spine Board) Suction (Oral/Trach/Endo) Emergency Control of Hemorrhage O2 Administration Set-up Vital Signs Maintain on Ventilator Start/Change IV Infusion Site Administer IV Fluid Bowel Sounds Assess Insert NG Tube Perform NG/OG Suction Irrigate NG Tube Catheterization, Foley Shave and Prep Wound Irrigation Clean and Dress Wound Apply Ace Bandage Apply Sling Apply Splint/Immobilize Injury Circulation Check Minor Surgical Procedure (Debride/Suture/Incision) Eye Irrigation Eye Care (Dressings/Eye Patch)

time CBIRF team members can operate in full Level-A protective gear before requiring relief. Therefore, calculations for nerve agent antidotes were based on the requirements for treating 500 patients, plus force protection for up to 250 CBIRF members. (The latter included Mark I personal nerve agent kits to be carried by all CBIRF members in the cargo pockets of their pants, or in thigh rigs duct-taped to their chemical suits.)

Calculations for biochemical medications were based on dosage information that NHRC developed to calculate the required amount of medications for the Marine Corps Surgical Company’s nuclear, biological, and chemical warfare supply block, which underwent an NHRC SME review in 2002 (Hill, Galarneau, Pang, & Konoske, 2003). The requirements for atropine, pralidoxime chloride, and diazepam were calculated on a worstcase maximum dosage of 12 mg of atropine per person. The per-person dosage for pralidoxime chloride was calculated on the basis of 600 mg per 2 mg of atro-

Task 126 145 128 129 197 248 359 748 1012 A6 Z014 Z027 Z037 Z042 Z083 Z094 Z103 ZZ02 ZZ42 ZZ64 ZZ72 ZZ76 ZZ77 ZZ87 ZZ92 ZZ94

Task Description Seizure Care/Precautions Administer Appropriate Medication Patient Restraint (Combative Patient) Perform Restrained Patient Control Charting & Paperwork - Patient Specific Force Fluids (via NG tube) Induce Local Anesthesia Assemble Material/Clean Up Amputation Apply Tourniquet Intubation Cardio Arrest Resuscitation Bag Valve Mask Set-up Insert Chest Tube Expose Patient for Exam Extremity Traction, Application/Adjust Re-Establish IV Access (Intraosseous) Stain Eyes (Fluoroscein Stain/Woods UV Lamp) Active Patient Rewarming (Chillbuster or Similar) Sedate Agitated Patient Monitor/Assess/Manage SpO2 Manage/Secure Lines & Tubes (Incl CV Lines) Assess Airway/Breathing Maintain Dry Dressings Reverse Narcotic-Induced Respiratory Depression Emergent Escharotomy

pine. Diazepam dosage was calculated at a rate of 10 mg per 6 mg of atropine.

These doses were based on military ruleof-thumb suggestions for field treatment of nerve agent poison (USAMRICD, 2000; Battlebook Project Team, 2000).

In reality, some victims would require less while others would require more, depending on their exposure.

Due to cyanide’s fast-acting effect, CBIRF probably would not deploy in time to provide medical treatment to victims. Therefore, cyanide treatment kits were provided only for members of the CBIRF initial entry team, those 10 members who would be working the closest to the hot zone in the event of a cyanide attack. In the event of a biological incident, CBIRF’s medical section would probably not provide more than force health protection for CBIRF Marines. Therefore, antibiotics for biological attacks were limited to amounts needed to provide prophylactic treatment to CBIRF’s 250-member response force.

Radiological Response. Recommended emergency field treatment for radiologi-

Table 3. Medical Interventions Performed at Bombing Sites* Interventions Spinal immobilization Wound care/debridement Field dressing IV placement/fluids Pulse oximetry Analgesics (IV, PO, IM) ET intubation Fracture care Foley catheter Antibiotics (IV, PO, IM) ACLS resus/meds Eye care Central venous line Tourniquet Antihypertensive Field amputation Tube thoracostomy CPR Blood transfusion Chest decompression

% of Patients Receiving Intervention** 72 62 45 40 8 7 6 5 5 5 4 3 3 3 2 2 1 1 1 0

*Data from studies of survivors from Oklahoma City bombing (Gonzalez, 2002). **Numbers rounded up to whole numbers.

cal casualties—whether from nuclear detonation fallout, nuclear accident, or dispersal from a radiation dispersal device or “dirty bomb”—is limited to decontamination, treatment of trauma and/or burns, and pain medication and antiemetics as needed (DeLorenzo & Porter, 2000). However, some medications may be of value in treating radiation victims in the field. These medications, if administered quickly after exposure, aid in eliminating some radioactive elements from the body, thus limiting exposure effects (American College of Radiology, 2002; Battlebook Project Team, 2002; DeGarmo, 2003). A list of recommended medications for radioactive agents can be seen in Table 5. In addition, antacids and laxatives can be useful in preventing absorption and assisting the elimination of radioactive elements from the body (DeGarmo, 2003).

The NHRC review of existing CBIRF AMALs found little ability to treat radiation exposure. The proposed CBIRF radiological response module included all of the medications listed above except

Spring 2006 THE FORENSIC EXAMINER 29

for zinc and trisodium calcium diethylenetriaminepentaacetate, which at the time were investigational drugs in the United States.

In addition, aluminum hydroxide antacid, calcium carbonate antacid, and magnesium citrate oral laxative solution were included. In all cases, oral medications were chosen to simplify distribution, and amounts were calculated to treat 500 patients, plus force protection for 250 CBIRF members.

Additional Supplies. CBIRF’s expanded mission role could find it responding to extreme climates throughout the world. However, its original medical inventory provided little or no capability for treating the type of environmentally related medical conditions that can be found in weather extremes. To correct this, two supplemental modules—one for hot weather, another for cold—were created, allowing CBIRF to carry only those supplies dictated by need. The hot-cold weather supplies are based on the existing Marine Corps Surgical Company environmental supply block originally devised using NHRC’s modeling method, this time scaled down to CBIRF needs.

Though primarily focused on force protection (population at risk = 250 personnel), these supplies can also be used to treat victims of terror attacks if harsh weather produces environment-related medical complications.

As previously stated, the SME panel selected the standard battalion sick-call supply block to provide a sick-call capability for CBIRF during prolonged deployments.

This will allow CBIRF to

Table 4. Mapping of Oklahoma City Interventions to Military Medical Tasks Oklahoma City Interventions IV Placement/Fluids

Eye Care WoundCare/ Debridement

Patients (%) 40

Mapped to Task(s) 49 50 248 Z103 ZZ76

Task Description Start/Change IV Infusion Site Administer IV Fluid Force Fluids (via NG tube) Re-Establish IV Access (Intraosseous) Manage/Secure Lines & Tubes (Incl CV Lines)

Patients (%) 40 40 20* 20* 40

3

121 123

Eye Irrigation Eye Care (Dressings/Eye Patch)

3 3

62

85 86 108

Wound Irrigation Clean and Dress Wound Minor Surgical Procedure (Debride/Suture/Incision) Maintain Dry Dressings

62 62 62 62

*Patient percentages were reduced for some tasks when the task was not expected to be performed as often.

respond with this supplemental capability only when deemed necessary, such as during an overseas deployment lasting for weeks. Using a standard sick-call supply block will also provide convenient resupply, if needed.

Conclusion CBIRF’s evolving mission, growing from biochemical response to include the full range of CBRNE responses, outstripped its original medical inventory. This study afforded the first opportunity to analyze clinical supply needs of the unit’s medical section in light of its increased responsibilities. In doing so, the study was able to identify weaknesses in CBIRF medical capabilities due to deficiencies in its authorized medical blocks, particularly in the areas of radiological response, the treatment of crush syndrome, sick call for prolonged deployments, and medical conditions that might be encountered in extreme environmental conditions.

As a result of this study, these “capability gaps” were closed. In doing so, the study showed that NHRC’s method of analyzing and modeling battlefield medical requirements can also be utilized to determine the medical supply requirements for field medical units responding to terrorist attacks. Such modeling can be useful in ensuring disaster responders have not only

30 THE FORENSIC EXAMINER Spring 2006

the equipment that is correct and necessary to respond to WMD attacks, but also have it in adequate amounts.

References American College of Radiology. (2002). Disaster preparedness for radiology professionals: Response to radiological terrorism. Retrieved October 10, 2003, from http://www.acr.org/s_acr/index.asp The Battlebook Project Team (2000). The medical NBC battlebook (USACHPPM Tech.

Guide 244). Aberdeen Proving Ground, MD: U.S. Army Center for Health Promotion and Preventive Medicine.

Boodram, B., Torian, L., Thomas, P., Wilt, S., Pollock, D., Bell, M., et al. (2002). Rapid assessment of injuries among survivors of the terrorist attack on the World Trade Center-New York City, September 11, 2001. CDC Morbidity and Mortality Weekly Report, 51(1), 1-5.

Chemical Biological Incident Response Force (CBIRF). (2003). Retrieved August 4, 2003, from the Global Security.org website: www.globalsecurity.org/military/agency/usmc/cbirf.htm DeGarmo, B. (2003). Radiological terrorism: Primary care preparedness. Retrieved November 15, 2003, from http://www.bioterrorism.slu.edu/ bt/products/ahec_rad.htm DeLorenzo, R. A., & Porter, R. S. (2000).

Weapons of mass destruction emergency care. Upper Saddle River, NJ: Brady.

Dickson, J. R. (1998). Crush injury (Disaster Medical Assistance Team training document).

Washington, DC: U.S. Department of Homeland Security National Disaster Medical System.

Gonzalez, M. S. (2002). The impact of mass casualties on the health care delivery system—conventional injuries. Retrieved October 14, 2003,

Table 5. Medication Available for Field Treatment of Radiation Exposure Radionuclide Iodine

Medication KI (potassium iodide)

Rare earths, plutonium, transplutonics, yttrium

Zn-DTPA, CaDTPA

Uranium Bicarbonate

2 ampules sodium bicarbonate

Cesium, rubidium, thallium

Prussian blue (ferrihexacyanoferrate [II])

For Ingestion/Inhalation Principle of Action 130 mg (tabl) stat, followed by 130 Blocks thyroid depomg qdx7 if indicated sition

1 g Ca-DTPA (Zn-DTPA) in 150-250 Chelation ml D5W IV over 60 min

(44.3 mEq ea; 75%) in 1000 cc normal saline @ 125 cc/hr; or oral admin of two bicarb tabl q 4 hr until urine pH = 8-9

Alkalinization of urine; reduces change of acute tubular necrosis

1 g w/ 100-200 ml water po tid for Blocks absorption several days from GI tract and prevents recycling

from www.vch.state.va.us Hill, M., Galarneau, M., Pang, G., & Konoske, P. (2003). Marine Corps NBC warfare: Determining clinical supply requirements for treatment of battlefield casualties from chemical and biological warfare (NHRC Tech. Rep. No. 03-13). San Diego, CA: Naval Health Research Center.

Pennsylvania Emergency Management Agency (PEMA). (2003). Medical aspects of urban search and rescue. Retrieved August 4, 2003, from http://www.pema.state.pa.us/pema/ Temerlin, S. (2003). CBIRF medical concept of employment (CBIRF report). Indian Head, MD: U.S. Marine Corps Chemical Biological Incident Response Force.

U.S. Army Medical Research Institute of Chemical Defense (2000). Medical management of chemical casualties handbook (3rd ed.).

Aberdeen Proving Ground, MD: USAMRICD. U.S. Department of Defense. (2001).

CONPLAN: United States Government interagency domestic terrorism concept of operations plan (Joint Agency Rep. No. A583783). Washington, DC: U.S. DoD. U.S. General Accounting Office. (1999).

Combating terrorism: Chemical and biological medical supplies are poorly managed (Rep. No. GAO/HEHS/AIMD-00-36). Washington, DC: U.S. GAO. U.S. General Accounting Office. (2001).

Combating terrorism: Accountability over medical supplies needs further improvement (Rep. No. GAO-01-463). Washington, DC: U.S. GAO.

About the Authors Martin Hill is a research analyst with the Naval Health Research Center in San Diego, CA, specializing in operational field medicine for the Marine Corps. Mr. Hill has 16 years of

military experience in Navy counter-insurgency operations, and in Coast Guard search-and-rescue and maritime law enforcement operations, including counter-narcotics and homeland security operations. He has served as a tactical and rescue medical specialist with the San Diego County Sheriff ’s Department Search and Rescue detail and is a medic and security specialist with a federal Disaster Medical Assistance Team. He is Certified in Homeland Security at Level III (CHS-III) by the American Board for Certification in Homeland Security.

Michael Galarneau, MA, a research psychologist, has been involved in the research and development of medical information systems, health care products, and modeling simulations for the U.S. Navy Fleet Marine Force since the mid-1990s.

He has received a patent for his work at the Naval Health Research Center (United States patent 5,995,077, November 1999). He currently oversees the Navy-Marine Corps Combat Trauma Registry at NHRC. Mr. Galarneau is a Nationally Registered Emergency Medical Technician-Basic.

Gerry Pang, MA, is a computer specialist whose responsibilities at the Naval Health Research Center include both hardware and software support for research and development of medical information systems, health care products, and modeling

simulations for the U.S. Navy Fleet Marine Force. Mr. Pang designs, develops, debugs, evaluates, analyzes, and implements new medical software and provides database and programming support for research projects.

Paula Konoske, PhD, received her doctorate in social psychology from Wayne State University, Detroit, MI. Prior to coming to the Naval Health Research Center in 1994, she was a research psychologist at the Navy Personnel Research and Development Center, San Diego. Her research experience includes the design of interactive technical training, survey design and development, program evaluation, Total Quality Leadership implementation, and the application of statistical process control. Dr. Konoske is currently the Program Manager for the Modeling and Simulation Group. Dr. Konoske has authored numerous technical reports and journal publications and has presented research results at professional meetings and conferences.

Figure 1. Abbreviated Example of NHRC Medical Requirements Model PC = Patient Condition. More than 400 PCs have been identified by the Defense Medical Standardization Board as the most likely injuries/ diseases to be seen on various military operations.

Earn CE Credit To earn CE credit, complete the exam for this article on page 63 or complete the exam online at www.acfei.com (select “Online CE”).

Spring 2006 THE FORENSIC EXAMINER 31

By E. Franklin Livingstone, MD

CME

This article is eligible for CE credit in the following categories: ACFEI, CME, CBRN, CFN. See page 3 for a key to these CE abbreviations and complete CE approval statements. The author of this article has nothing to disclose for CME purposes.

T

he medical specialty of physical medicine and rehabilitation (physiatry), encompasses the diagnosis and treatment of a wide range of medical and physical problems. The problems can be as minor as a sore shoulder or as complicated as a spinal cord injury. The focus of this specialty is on restoring function and quality-of-life to individuals with disabling illnesses or injuries. Physiatrists diagnose and treat acute and chronic musculoskeletal pain disorders as well as disorders of the nervous, muscular, and skeletal systems. They study the appropriate use of various physical medicine modalities, such as heat, cold, exercise, traction, and electrical stimulation for motor development

and pain control. Physiatrists are trained to lead a multidisciplinary team of medical professionals in the comprehensive and holistic treatment of illness and injury related disability. Indeed, the specialty of physical medicine and rehabilitation was the first to promote and develop a holistic medical team based on the interdisciplinary treatment of often complex medical, physical, and psychological problems.

Many physiatrists receive extensive training in the subspecialty of Electrodiagnosis: electromyography of nerves and muscles and nerve conductivity testing.

The purpose of this article is to emphasize the physiatrist’s role as a clinician and as a forensic expert. Physiatrists are able to diagnose, evaluate, and provide a prognosis to the wide-ranging impact of disability on clients and their significant others. Physiatrists are also able to develop a comprehensive rehabilitation treatment program with short and long term goals and then oversee the progression of interdisciplinary treatment to optimize

32 THE FORENSIC EXAMINER Spring 2006

functional outcome and quality-of-life.

Physiatrists are valuable consultants and expert witnesses in forensic cases, particularly cases involving injury or disease related disability with its pervasive effects and residuals.

The physiatrist is often the most qualified to determine the extent to which a disability exists, its relationship to illness or injury, and its overall impact upon the present and future life of the client.

The overall analysis might include comprehensive life care planning: a study of potential and actual economic loss, a prognostication of future employability or under-employability, and cost analysis of the rehabilitation treatment program and its implementation.

Life care planning in complex cases requires multidimensional analysis. This comprehensive planning will take into account the current medical and impairment status along with progressions and secondary complications that are possible and likely to occur. Current treatment,

“

Life care planning is complicated by severe physical impairment and multiple complex and progressive medical disease processes.

Figure 1. With the body supine on a flat surface, the coccygeal area is protected from significant pressure distribution as a result of the curvature of the sacrum. Note the curvatures: cervical lordosis, thoracic kyphosis, lumbar lordosis, and sacral kyphosis.

In general, behavioral traits (particularly poor compliance) factor strongly into past progression, current status, and prognostic speculation.

”

beneficial treatment alternatives, and the likely need for future treatment must also be delineated. Specialized equipment or home modifications, transportation needs, measures in the prevention of secondary medical and physical complications, and educational and vocational considerations must be thoroughly detailed in the life care plan. In addition, emotional adjustment issues may require periodic or ongoing intervention and may have pervasive effects in functional outcomes and quality-of-life.

The determination of causation may often require multifactorial investigation.

Medical and physical problems may be a composite result of illness; injury; or anatomical, physiological, congenital, or behavioral factors. Often the relative importance of the various contributing determinants must be quantified, requiring appropriate justification for any speculation. This, of course, may be quite complex, requiring a broad base of training and experience and the ability to clearly communicate and often educate those involved.

Case Study A 62-year-old man with a history of arteriosclerosis and peripheral vascular disease was admitted to a cardiology institute for evaluation because of worsening heart failure that had been treated with diuretic medication. His medical history was com-

plicated by adult onset diabetes and T-9 level paraplegia resulting from a motor vehicle accident 20 years previously.

Complications relating to his paraplegia included recurrent urinary tract infection and an ischial pressure ulceration approximately 2 years prior to this admission that had healed completely with conservative care. An echocardiogram the prior month revealed aortic stenosis, aortic insufficiency, and an ejection fraction of 40%. He was admitted for right and left heart catheterization, coronary angiography, and evaluation of his aortic heart valve.

The cardiac catheter evaluation was complicated by his severe and advanced arteriosclerosis, causing the evaluating physician to be unable to advance the catheter through the femoral arteries.

As a result, catheterization through the brachial arteries was performed, which allowed completion of the evaluation but extended the total time that the patient was lying supine on the examination table to approximately 3.5 hours. The results of the evaluation were severe aortic stenosis with calcification, mild to moderate aortic regurgitation, and severe arteriosclerosis with single vessel coronary artery arteriosclerosis. He was immediately transferred to a large, acute-care hospital for open-heart surgery for coronary artery bypass and aortic valve replacement. On admission, he was noted to have a small reddened area at the midline in his gluteal cleft, which by the next day had progressed to a small blister. During this hospitalization he also developed skin irritation and redness at both heels. These skin problems improved after they were treated conservatively, and the patient was discharged with family care and home health nursing with

a small, healing, partial skin thickness ulceration at the midline in the gluteal cleft.

At home, the gluteal cleft ulcer gradually worsened, spreading to the sacral area, and prolonged pressure on the heels from mostly supine positioning resulted in ulceration of the skin over the heels, bilaterally. Eventually the sacral wound, having continued to progress, was treated with surgical debridement and a “flap” closure. Continued convalescence, mostly at bed rest per the patient’s request, led to further skin problems, including nonhealing, ischemic ulcerations at several toes that became infected and eventually required bilateral below-knee amputations.

The case arose out of the alleged failure of the defendants to take necessary and proper precautions to properly cushion, pad, protect, and treat the plaintiffs’ sacral/buttocks region and heels during and after the heart catheterization procedure and during and after the open-heart surgery procedure. As a result, the plaintiff claimed he developed pressure sores on his coccyx and heels that required further hospitalization and surgery (flap repair and bilateral below knee amputations due to pressure ulcers on the buttocks and heels).

Forensic Considerations Life care planning is complicated by severe physical impairment and multiple complex and progressive medical disease processes. In general, behavioral traits (particularly poor compliance) factor strongly into past progression, current status, and prognostic speculation. Current medical care with extrapolation to future care

Spring 2006 THE FORENSIC EXAMINER 33

“

The physiatrist, in these cases, is an educator for the involved attorneys, court, and jury, explaining the often complex progressions and interactions involving anatomical structures, physiological processes, and psychological considerations in terms that can be easily understood by non-medical professionals and lay-people.

needs, in light of the progressive nature of the disease processes involved, must be as clearly delineated as possible with coherent justifications. Durable medical equipment needs will also change over time based on the progression of physical impairment somewhat in parallel with disease progression and should be anticipated in the life care plan. Given the somewhat dismal prospects in this case, quality-oflife considerations for the clients and their significant others should be given as much forethought as ongoing medical needs.

Plans for optimizing physical function will be primarily concerned with equipment and environmental modifications as well as prevention of secondary complications including progressive debility.

Periodic and ongoing therapeutic intervention for the latter should be anticipated and may require comprehensive services from multiple providers and professional disciplines. The treatment management of these cases requires consideration for continuity, thoroughness, and flexibility in order to respond to the ever-changing medical and physical needs of each individual.

In this day and age, family care or participation may not be an option in patient care. Financial needs over the predicted life span of the client should take into consideration long-term care placement versus home nursing/attendant care and may account for a lion’s share of anticipated

costs. Actual needs will depend upon disease and impairment progression, which are also affected by behavioral factors, client and caregiver training, and compliance to treatment recommendations.

Worst-case scenarios will be presented, but other less-than-worst-case alternatives should also be considered and planned for.

Vocational issues are not a significant concern in this situation, but many times they are primary issues with respect to damage claims. Potential and actual economic losses are often substantial. Any study of future employability or underemployability needs to include appropriate goals for vocational rehabilitation, costs involved, and a cataloging of available resources. A vocational rehabilitation consultant is recommended to be part of the multidisciplinary team for clients of appropriate vocational age.

There are two separate causation issues in this case. First, did the progression of medical problems leading to bilateral below-knee amputations stem directly from the progression of the sacro-coccygeal ulceration? And second, did the coccygeal skin breakdown result from negligence on the part of the medical staff at the cardiology institute or the acute care hospital where surgery and post-surgical convalescence occurred?

This is a complex case with multiple disease processes, the natural history of

34 THE FORENSIC EXAMINER Spring 2006

�

which result in progressive problems and secondary complications. The client was discharged to his home with a small, healing coccygeal (actually, lower sacral, S4S5, and coccygeal) skin breakdown, grade II, with partial skin thickness ulceration.

This generally heals with simple conservative wound care and pressure relief. He received home health nursing care.

Healing was thwarted by many factors.

The client had a history of poor compliance with positioning changes. He preferred the reclined and supine position, leading to inadequate pressure relief in the area of the skin breakdown. He was on medications that interacted to cause nausea, resulting in inadequate nutrition to facilitate healing. His two significant progressive disease processes (diabetes with associated angiopathy and arteriosclerosis with severe peripheral vascular disease) combined to result in poor blood flow to the area of the skin wound. In this case, too much pressure, inadequate blood flow, and poor nutrition were a recipe for skin ulcer progression. The small lower sacral and coccygeal ulcer gradually progressed, developing a large, deep sacral skin ulceration that eventually required extensive surgical debridement and a skin-flap closure procedure.

The development of skin breakdown at the heels resulted from nearly continuous pressure where the heels rested on the bed mattress (as well as from those factors

described previously). However, the ischemic wounds at the toes were not caused by the skin breakdowns but by progressive insufficiency of blood flow to the feet, aided by poor nutrition and a lack of physical activity. This resulted in the death of the skin and subcutaneous tissues along with wound formation that eventually became infected, leading to the necessity of below-knee amputations. While there is a temporal relationship and commonalities in terms of aggravating factors, a causal relationship is not presumable.

With respect to the causation of the initial skin breakdown, which was first noted at admission to the acute care hospital after the evaluation at the cardiology institute, the complaint of “failure to take proper precautions to properly cushion, pad, and protect” the client was not supported by facts. First of all, the client was lying on a flat, padded examination table for about 3.5 hours for the complicated angiographic procedures. This positioning, in the absence of significant physical deformity at the sacrum, would place the client at risk for pressurerelated skin breakdown over certain boney areas: the back of the skull, the prominences over the back of the shoulder blades, the heels, perhaps the lateral ankle prominences (if there was significant external rotation of the hip joints), and the upper sacral area.

The area involved, the lower sacral and coccygeal area, would be protected from pressure and its detrimental effects under these circumstances by the normal spinal curvatures (see Figure 1). Therefore, on a more probable than not basis, the lower sacral and coccygeal skin breakdown did not occur as a result of any treatment, or lack there of, by the defendants in this case.

That of course begs the question, what caused the initial skin breakdown? On a more probable than not basis, this skin breakdown was, in fact, present at the time of the admission to the cardiology institute, running an indolent course. Its presence and slow development due to inadequate attention to skin care and pressure relief was further facilitated by the client’s poor health and his progressive diabetes and peripheral vascular disease.

In addition, the client drove himself to the cardiology institute, a drive of over 3 hours. The position he maintained in

his automobile while driving would have caused, more or less, continuous pressure at the lower sacral and coccygeal area. This would have been enough pressure-related impedance to blood flow to cause a subclinical area of skin breakdown to become clinically apparent, as in this case. This timing of progression fits very well into the clinical findings.

In this situation, the physiatrist was able to work with the defense attorney on an ongoing basis, providing periodic updates (written and verbal), helping in trial preparation, providing the attorney with insight into the presentation of evidence at trial, and ensuring that the testimony preceding his testimony set the proper foundation and support for the opinions of the experts involved. The physiatrist was involved in many aspects of the trial casework. He was able to determine the extent and causation of disability; provide support and guidance in all aspects of the life care plan, including beneficial treatment, present and future; and he was able to present evidence that successfully refuted the plaintiffs’ contentions.

The physiatrist will usually have many ideas to offer the attorney regarding the strengths and weaknesses of the case and can help the attorney decide how best to present evidence and testimony to emphasize the strengths of the case based on historical information, injuries, progression of recovery and/or disability, and medical and scientific information sources. The physiatrist, in these cases, is an educator for the involved attorneys, court, and jury, explaining the often complex progressions and interactions involving anatomical structures, physiological processes, and psychological considerations in terms that can be easily understood by non-medical professionals and lay-people. During trial proceedings, the physiatrist is also one of the most qualified witnesses to present objective testimony with respect to non-economic damages, including but not limited to psychological trauma and its consequences, difficulty adapting to specific disabling conditions, and the pervasive effects of chronic pain and its residuals.

As a physiatrist and new member of the American Board of Forensic Medicine within the American College of Forensic

Examiners, I would like to increase awareness and understanding of the medical specialty of Physical Medicine and Rehabilitation and the role of the physiatrist in forensic medicine.

References Burke, W. H. (1995). Forensic rehabilitation.

Houston, TX: H.D.I. Publishers.

Deutsch, P. M. (1990). A guide to rehabilitation testimony: The expert’s role as educator. Orlando, FL: P.M.D. Press.

Weed, R. O. (1999). Life care planning and case management handbook. Boca Raton, FL: C.R.C. Press.

Livingstone, E. F. (2004). Current issues in the field of forensics: An introduction to forensic physiatry. The Forensic Examiner, 13(4), 62-63.

About the Author E. Franklin Livingstone, MD, was born and raised in Seattle, Washington.

His interest and passion for rehabilitation medicine developed after his own experience in rehabilitation. At the age of 18 and 2 weeks before graduating from high school, Livingstone was injured in an automobile accident. He was thrown out of one car and landed on the front bumper of another, fracturing his lumbar vertebrae and damaging most of the nerves in his legs. He spent 5 months recovering in the University of Washington Hospital, attended to by a very special physiatrist, Dr. Donald Silverman. Dr. Livingstone’s desire to pursue a career in rehabilitation medicine developed over the next 6 years, and he subsequently matriculated through his undergraduate, medical school, and residency education at the University of Washington. He graduated as a rehabilitation patient in 1967, and he graduated his training as a physiatrist in 1983 from the same rehabilitation program. Currently, Dr. Livingstone is the Director of Rehabilitation Medicine at Havasu Regional Medical Center where he is living out his dream of being a rehabilitation doctor and connecting with patients as Dr. Silverman did with him. Visit his website at www.doctor-livingstone.com.

Earn CE Credit To earn CE credit, complete the exam for this article on page 63 or complete the exam online at www.acfei.com (select “Online CE”).

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Asahara Shoko, Leader of the Aum Shinrikyo Cult

By Erica Simons, BS Introduction n March 20, 1995, Japan, a nation recognized for its remarkably low crime rate, was struck by a devastating terrorist attack on its busy Tokyo subway system. The attack left 12 dead and as many as 5,500 injured and opened the world's eyes to the dangerous possibilities of terrorist attacks involving chemical weapons. The attack was eventually linked to a religious cult known as Aum Shinrikyo, which had amassed a very large following and millions of dollars worth of assets within Japan and other nations. Investigations following the subway attack revealed the deadly mission that drove this group and uncovered several previously unknown terrorist attacks it had attempted, as well as a web of criminal activity ranging from kidnapping and murder to the manufacture of weapons, illicit drugs, and deadly chemical agents.

Spring 2006 THE FORENSIC EXAMINER 37

About Aum Aum Shinrikyo was founded by Chizuo Matsumoto, a partially blind Japanese man who gained a small group of followers while teaching yoga classes.

Matsumoto’s true religious fervor began in 1986, when he claimed to have received divine enlightenment while traveling in the Himalayan Mountains of India. It was at this time that Matsumoto changed his name to “The Holy” Asahara Shoko and launched a modest group of followers that he named Aum Shinrikyo (Aum meaning the powers of destruction and creation in the universe, and Shinrikyo meaning the teaching of the supreme truth).

Asahara used Aum Shinrikyo to spread his self-created religious teachings, which were based on an eclectic mix of Buddhist, Hindu, Taoist, and Christian belief systems. The group gained followers slowly at first and then much more rapidly after Aum gained official recognition as a religious organization by the Japanese government under the nation’s Religious Corporations Law. Japanese officials were initially hesitant to grant Aum this status, largely due to a number of protests and complaints that had been filed by many of the families of existing Aum members over the group’s requirement that followers sever all ties and communication with the outside world, including with their relatives and acquaintances. Aum responded to the Japanese government’s reluctance with a fervent series of lawsuits and public demonstrations, a practice that the group would successfully employ many times in future years. Aum’s campaign was victorious, and in 1989 it was granted official legal status as a religious organization. Under this status Aum would be free to pursue its activities without oversight from Japanese authorities, as the Religious Corporations Law provided the group with special shelters and privileges including tax benefits, the right to own property as an organization, and most importantly, protection from all state and other external interference. The law specifically prevents authorities from investigating a group’s religious activities or doctrine, a stipulation that is widely interpreted to include any activities an

organization is involved with, including those raising revenue for the group or other private corporations.

Under its new official status as a legitimate religious organization, Aum’s wealth and number of followers expanded rapidly. From 1992 to 1995, Aum membership increased from approximately 10,000 to 50,000 worldwide. The cult established facilities and branch offices in six countries, and their net worth grew from around 430 million yen to more than 100 billion yen. Aum amassed this wealth through a variety of legitimate and fraudulent activities, including donations and tithing by cult members, the sale of cult-related paraphernalia such as videotapes and books, the manufacture of illegal drugs, the hosting of seminars and training courses, and various commercial endeavors, including a chain of restaurants and computer and software manufacturing companies. Additional income was generated through bribes made to the group by local Japanese officials; in these instances Aum would reportedly threaten to establish new cult operations in cities if the officials in those areas did not pay the bribes Aum demanded. Aum also established a working partnership with the Japanese mafia involving illegal activities such as murder, theft, and extortion for profit.

While Aum grew and expanded, Asahara’s teachings became more radical and Aum leaders gained increasing power over cult members. Aum leaders reportedly kept cult members docile and cooperative using various mind control techniques such as sleep and food deprivation and the administration of illicit drugs.

Aum members, who donated everything they owned to the cult when they became followers, were financially dependant on the group, making it extremely difficult to break away from the group if they wanted to escape. Those who did attempt to leave the cult were often tracked down and forced to rejoin, many times through outright kidnapping.

Aum’s Involvement in the Sakamoto Family Disappearance One of the earliest examples of Aum’s

38 THE FORENSIC EXAMINER Spring 2006

murderous criminal activities occurred in May 1989, when the group allegedly kidnapped and killed attorney Tsutsumi Sakamoto and his wife and infant son.

This family became Aum’s targeted enemy when Tsutsumi began working with the families of several Aum members in lawsuits against the cult. At the time that the family went missing, Sakamoto was working on 23 of these cases, which were aimed at forcing Aum to release key followers who wanted to leave the cult.

The Sakamoto family seemingly disappeared overnight. When concerned family members entered the Sakamoto home, they found the residence empty. The family was gone, and the couple’s and infant son’s bedding had also disappeared.

Besides that, the home seemed to be untouched. It was Sakamoto’s mother who discovered what appeared to be a glaring piece of evidence linking Aum to the family’s disappearance: a badge inscribed with the insignia of the Aum cult, which was found on the floor of the family home.

It would seem to many observers that this piece of evidence and Sakamoto’s previous involvement with Aum would clearly link the cult to the family disappearance. However, the area police involved in the case denied that the cult was suspected and were reluctant to investigate the matter further. Police officials even went so far as to suggest that Sakamoto himself had organized his family’s disappearance as a tactic to discredit the cult.

When the media learned the police were avoiding an investigation into the link between Aum and the Sakamoto family disappearance, the story made major headlines, placing increased pressure on the police force to investigate the matter. Some 16 days after the family went missing, the police finally took action by approaching Aum representatives and requesting interviews with the group’s leaders. Aum denied these requests, and Asahara went underground to avoid questioning on the matter until several days later, when he called a press conference in which he denied Aum’s involvement in the incident. During the press conference Asahara also claimed that the discovery of the Aum badge at the Sakamoto family

Aum Gains Powerful Presence in Russia In 1992, Aum spread its activities into Russia with great success. Here the cult undertook a major recruiting campaign strengthened by positive media coverage and a strong new relationship with the Russian government. A weekly television program was even broadcast across the country in support of Aum. Many top Russian officials, including the then-chairman of the Russian security council, welcomed Aum into the country after the group gave more than $14 million in cash donations along with computers and various supplies to the leadership of the Russian government.

These political relationships gave Aum leaders valuable new contacts within the Russian ruling society, providing easier access to the nation’s weapons stocks and scientific community. Using these new ties, Aum leaders attempted to purchase a range of powerful military weapons from the Russians, including a fighter aircraft, a rocket launcher, and a helicopter. Their requests for the fighter plane and rocket launcher were denied, but Aum was allowed to purchase the helicopter. The cult also gained many new Russian Aum operatives with scientific and technical backgrounds that would contribute greatly to its terrorist missions.

home could easily have been a coincidence, and stated that more than 40,000 of those badges had been produced and distributed to the public. In reality, less than 100 of these badges existed.

Even with this conflicting statement and the clear connection between the Sakamoto family and the Aum cult, the police did not pursue the case further and the media eventually stopped covering it. Six years later, in 1995, the bodies of Sakamoto, his wife, and their infant son were discovered at three separate remote mountainous locations.

Aum Enters the Japanese Political Arena In 1989, Aum’s activities took a new direction as Asahara and 24 of his followers entered various political elections in Japan.

This new initiative was launched after Asahara proclaimed that political involvement would be necessary if Aum was to accomplish its ultimate goal, which at that time was to save the world from destruction resulting from an Armageddon-like battle between Japan and America. These Aum political candidates thought that by gaining seats on various political agencies they would be able to publicize the group and Asahara’s teachings and thereby provide salvation to more people.

Aum’s political campaign was marked with unethical practices carried out by both Aum candidates and supporters, such as the destruction of opposition party posters, spying on opponents, and voter intimidation. Even with these fraud-

ulent activities, all 25 Aum candidates were defeated.

It is believed that this resounding political defeat brought about a major change in the aim and ideology of Aum. Originally Asahara’s teachings were based on the prevention of the apocalypse; he claimed that 30,000 people had to be saved through his teachings in order to save the world.

After the political defeat, however, the cult’s new aim was simply to protect its followers, as they now thought they could no longer save the world. With this new ideal, the group began building secluded communes equipped with nuclear shelters, places where they could live together self-sufficiently away from the influence of nonbelievers.

Early Terrorist Attacks Attempted by Aum Aum initiated its campaign to create chemical weapons around 1993. It is believed the cult invested an estimated $30 million into the effort, which involved many scientists and skilled workers and extensive facilities equipped with computer-controlled reactors and industrial packaging capabilities. Aum scientists experimented with various deadly toxins, including mustard gas, VX, and hydrogen cyanide, but sarin, a powerful nerve agent, eventually became the group’s focus, and Aum leaders set a goal of producing 70plus tons of sarin at one of its facilities in Kamikuisiki.

One of Aum’s earliest attempted terrorist attacks using a toxic substance was

“

Aum scientists experimented with various deadly toxins, including mustard gas, VX, and hydrogen cyanide, but sarin, a powerful nerve agent, eventually became the group’s focus, and Aum leaders set a goal of producing 70-plus tons of sarin at one of its facilities.

”

carried out in central Tokyo in the area around the Japanese parliament. Aum’s plan was to use a truck specially outfitted with a spraying device to spread Clostridium botulinum, the basis of botulism. The attack was aimed at destroying Japan’s government by killing as many leaders as possible, with the goal of leaving the country in a panic and in need of a new government leader—who according to the cult’s plans would be Asahara. The truck-mounted spraying devices that the Aum attackers used to disperse the toxin worked successfully, but luckily the toxin itself failed and the attack was ineffective.

Another unsuccessful attack was carried out soon after at one of the Aum facilities in Tokyo. In this attack Aum operatives

Spring 2006 THE FORENSIC EXAMINER 39

About Sarin Sarin is colorless, odorless, and tasteless; it is highly toxic in both liquid and vapor states. It mixes easily with water, making it an especially dangerous threat if mixed with drinking water. Sarin is created through the combination of several chemicals, which may be purchased commercially with little difficulty, in a particular sequence. It was developed in Germany in the 1930s as a pesticide, and was later used in gas chambers at Nazi death camps.

According to the U.S. Environmental Protection Agency, sarin can lead to death within 1 to 10 minutes of inhalation. It is 20 times more deadly than cyanide, and even a tiny dose of sarin can be deadly. Sarin prevents the body from regulating nerve impulses, which leads to continuous stimulation of glands and muscles and eventually system fatigue and a loss of bodily functions. Early signs and symptoms of sarin exposure include runny nose, difficulty breathing, pinpoint pupils, eye irritation, and blurred vision. Later symptoms include drooling, sweating, coughing and chest pain, diarrhea, confusion, drowsiness and weakness, headache, nausea, and vomiting. Those exposed will convulse, fall into coma and paralysis, and suffocate if intervention is not provided very quickly. Antidotes for sarin exposure exist, including atropine and oximes, but they must be administered quickly to be effective.

used a high-powered fan installed on the building roof to disperse anthrax into the air and spread it over the surrounding community. While no citizens were injured by the attack, many did report a terrible odor, illnesses within the pet population, and damage to plants and greenery. These were later determined to have been caused by exposure to a toxic agent.

Police investigating the strange occurrence eventually linked the Aum facility to the release of the toxin. However, the group claimed the substance released was a mixture of perfumes and oils that had been burned to cleanse the building.

The investigators accepted this reasoning, but before leaving the scene they took a sample of a strange fluid that was leaking from pipes in the Aum facility. This fluid was later found to contain high levels of active anthrax bacilli. Scientists eventually explained why the toxic agent released in the incident had not caused illness in the surrounding population; a veterinary vaccine anthrax strain had been used in the creation of the toxin emitted, and that particular strain was not capable of causing sickness in humans. Even with this finding, the police did not carry out additional investigations into the incident, and the matter was eventually forgotten.

These are just a few examples of Aum’s early attempts at using toxic agents in attacks against innocent civilians and Japanese leaders. Luckily, Aum failed in these initial attempts and no known human injuries or fatalities were linked

to the events. Unfortunately, however, these test attacks went largely unnoticed or uninvestigated by Japanese authorities, which allowed Aum operatives to refine and improve the deadly techniques with the aim of creating true havoc and destruction in the near future.

Aum Attacks Aimed at Judges in Matsumoto On June 27, 1994, Aum operatives carried out their most successful attack attempt in Matsumoto, Japan. This attack targeted three judges who were about to rule on a lawsuit over the legality of one of Aum’s many land purchases.

For this attack, Aum operatives drove a specially converted refrigerator truck into the Matsumoto neighborhood where the three targeted judges resided. These operatives parked the truck and initiated a computer-controlled system designed to release a cloud of sarin gas into the air.

This sarin was successfully released, and as planned a cloud of the dangerous toxin traveled on the breeze to a group of nearby homes, apartments, and dormitories where hundreds of citizens, including the targeted judges, were settling in for the evening. Since the weather was pleasant at the time of the attack, many of these residents had their doors and windows open to the night breeze, which allowed the sarin gas to easily enter their homes.

These citizens quickly began falling ill, suffering from symptoms ranging from eye irritation, darkened and tunnel vision,

40 THE FORENSIC EXAMINER Spring 2006

nausea, vomiting, headache, sore throat, and shortness of breath. Police and emergency officials were called to respond, and 500 affected residents were taken to local hospitals, where seven later died.

The judges targeted by Aum’s attack were not killed by the attack but were sickened enough to delay a ruling on the Aum case, meaning the cult’s goals had ultimately been accomplished.

Emergency responders called to the attack scene were also affected by the released toxin. Eighteen of the 50 rescue workers involved in the operation fell ill, one seriously enough to require hospitalization.

Initially the police investigating the event and the physicians treating those affected by Aum’s attack did not know what had caused the outbreak of illness in the Matsumoto area. These physicians based their treatments on the afflicted patients’ symptoms, which were consistent with poisoning by an organophosphate substance. About a week later an official report was released revealing the illnesses had been caused by sarin exposure. This cause was determined when forensic specialists identified the agent through gas chromatography-mass spectrometry on a water sample retrieved from a pond in the affected area. These findings revealed that the area had been targeted with an intentional attack, but officials had no solid leads on who could have carried out such an operation. In fact, a local gardener was falsely accused of having released the

toxin and lived under intense scrutiny for several months while he was investigated; officials suspected the gardener had accidentally created the poisonous gases that injured so many while mixing fertilizers in his garden. The man was finally cleared of any connection to the event.

On July 9, only weeks after the Matsumoto incident, a major gas leak occurred in one of Aum’s facilities. Aum members were witnessed fleeing from the facility wearing gas masks, and damage appeared on trees and grass in the surrounding area. After launching a minor investigation into the event, area police officially declared a tentative link between the gasses that had been released during this accident and those used in the Matsumoto attack. However, it wasn’t until March of 1995 that police took action and raided the Aum facility in response to the connection, and even this measure did not lead to any arrests directly linked to the Matsumoto attack.

Instead, three Aum members were arrested for an unrelated alleged kidnapping of one of their fellow members who had tried to escape the cult. No further action was reportedly taken by officials against the group in response to the attack.

Events Leading Up to the Tokyo Sarin Gas Attack In the months leading up to Aum’s attack on the Tokyo subway system, Japanese authorities were growing more suspicious of Aum’s activities and had began to collect increasing evidence that the cult was involved in the creation of chemical weapons. Still, due to the nation’s laws protecting Aum as a religious organization, the police were unable to take action based on their suspicions.

A break came to these officials when the cult was directly linked to a kidnapping.

At this time, Aum was losing hold over many of its followers despite the control and subversion tactics used to keep them subdued. One of these members was a 62-year-old woman who decided to flee the cult after devoting several years and her life savings to the group. When this woman escaped and went into hiding, Aum operatives searched but were unable to locate her. Finally, in an attempt to

force the woman to come out of hiding and rejoin the group, cult members kidnapped and killed her 68-year-old brother.

This kidnapping, which was clearly tied to Aum on many levels, finally provided Japanese police with an undeniable reason to investigate the cult’s activities. These police agents launched preparatory measures to initiate a raid on Aum facilities, the largest operation of its kind to take place in the nation at that time. While the planned raid was kept highly secret, word leaked out to Aum leaders about the operation. It is suspected that undercover Aum operatives working within the Japanese police force released the information to the cult.

Armed with the time, date, and location of the planned police raids on Aum facilities, cult members went into action to cover up, hide, or destroy any evidence that could be used against them, including chemicals they had manufactured, equipment they had amassed, and various records revealing past cult activities. Many Aum members and leaders then went into hiding, including Asahara, who would continue to direct the group from a secret location for several months.

But Aum wasn’t satisfied with protecting itself from police interference and was determined to take further action against the Japanese police force and government to delay or halt the planned raids. With this mission, Asahara and his top followers hastily planned a deadly attack to be carried out on the Tokyo subway system, with the goal of killing and injuring thousands of innocent civilians.

Terror On the Tokyo Subway System Aum’s deadliest attack was carried out on Tokyo’s subway system during the busy morning rush hours of March 20, 1995.

The attack was centered on Kasumagaseki station, which is located under several government offices, including the National Police Agency headquarters. This segment of the subway serves many of the officials working in Japan’s leading government agencies, as well as thousands of civilian passengers. Aum knew an attack at this location could result in a great number

of deaths and injuries and extensive panic within the nation.

The attack was carried out by 5 Aum operatives who delivered sealed packages camouflaged with newspaper onto separate subway cars, where they punctured the packages using sharpened umbrella tips. The operatives then departed from the trains while the pierced packages leaked their deadly toxic substance: liquid sarin. This sarin vaporized and spread into the air, dispersing quickly among the innocent passengers aboard.

Although sarin is odorless, many passengers first noticed a strong solvent-like odor throughout the trains targeted in the Aum attack. Quickly after, these passengers began suffering initial symptoms of sarin exposure, including severe eye irritation; coughing, choking, and labored breathing; vomiting; and convulsions.

Some passengers with more extensive exposure lost consciousness. Those who could struggled to escape the subway to reach fresh air outside.

More than 100 ambulances and 1,364 emergency medical workers were dispatched to the subway system. Overall more than 600 people were taken to area hospitals by emergency medical and fire vehicles, and more than 4,000 reached medical facilities on foot, in private automobiles, and in public taxis.

Confusion and panic spread quickly among those directly involved in the attack, including affected subway passengers and first responders. Fear also spread throughout the public as mixed messages and erroneous and limited information was released through subway officials, police, and the media. For example, initial reports blamed a gas explosion for the passengers’ ailments.

While Aum’s attack did not create the massive amount of death and injury that cult leaders had hoped, 12 lives were lost and as many as 5,500 people were injured as a result of the terrorist act. Luckily, the subway’s powerful air exchange system was effective in removing the toxin from the air in the station, which substantially cut down on the number of casualties. Unfortunately, several factors related to insufficient preparation and response capabilities worsened the effects of the

Spring 2006 THE FORENSIC EXAMINER 41

Aum Operatives Who Carried Out the Tokyo Subway Attack The devastating Tokyo sarin gas attack was carried out by 10 Aum operatives; five men served as getaway drivers and five others actually delivered the packages containing the deadly toxin onto the subways and released the chemicals.

Those operatives are profiled below.

Hayashi Ikuo Before becoming an Aum follower, Ikuo was a respected senior physician with the Japanese Ministry of Science and Technology specializing in heart and artery medicine. He graduated from one of Japan's leading universities and held several prominent hospital positions before joining the cult. Ikuo grew to be one of Aum's leading members, and was appointed Minister of Healing within the group.

Hirose Kenichi Kenichi was known as a bright and well-educated physicist before joining Aum. Within the cult, Kenichi rose to the ranks of Aum's Chemical Brigade, and was a key operative within the group's Automatic Light Weapons Development arm.

Toyoda Toru Toru, a highly educated physicist, joined Aum just before he was set to begin his doctoral program. Toru became a leading member in Aum's Chemical Brigade.

Yokohama Masato Masato, a physicist who worked for an electronics firm before resigning to become an Aum follower, was made undersecretary of the cult's Ministry of Science and Technology, and was a leading member of their Automatic Light Weapons Manufacturing arm.

Hayashi Yasuo Yasuo, a specialist in the field of artificial intelligence, held the third-highest position in Aum's Ministry of Science and Technology.

subway attack, including lack of communication between agencies involved in the rescue operations, lack of protocols for emergency response measures involving chemical agents, lack of quarantine of effected areas and people, lack of protective equipment for first responders and hospital workers, and poor informationsharing with the public and hospital staff.

Also, the first responders working at the attack site did not have adequate training and education on agent identification and how to deal with such threats, and there was a lengthy delay before officials fully understood the nature of the attack. Even after the subway control center learned that an emergency had taken place within the rail line, many of the trains continued along their scheduled routes without delay, and station managers and workers were not notified of the situation. These shortfalls complicated recovery measures and allowed contamination to spread beyond the subway systems that were initially targeted in the attack.

Most of the emergency response personnel called to the Tokyo subway attack were not equipped with the protective gear needed in an environment where toxic chemicals were present. This led to secondary contamination, which sickened many EMTs, firefighters, police officers, and medical workers. Since most hospital staff were unaware that the incident had involved toxic agents, few decontamination measures were taken for patients transported to medical facilities, which resulted in many nurses and physicians becoming ill themselves. If the sarin used in the attacks had been more potent, this effect would have been far more devastating.

Difficulties also complicated the medical community’s response to the subway attack. For example, few hospital personnel were aware of what types of toxins had been involved in the attack. Information was limited for these workers, sometimes coming from unexpected sources, including at least one physician who contacted hospitals in the affected area to share what he had learned while treating patients who had been injured in the earlier Matsumoto sarin gas attack. A hospital that had treated the Matsumoto victims also faxed

42 THE FORENSIC EXAMINER Spring 2006

treatment information to Tokyo hospitals, and when one Japanese manufacturer of a medicine used to treat sarin-exposed patients learned of the attack through news reports, the manufacturer promptly shipped stocks of the medication to Tokyo hospitals without waiting for requests from officials.

At the time of the subway attack, most hospitals in Japan did not have set plans in place for handling disasters causing mass casualties. This was illustrated in the medical community’s lack of decontamination for the sub-

way victims.

E v e n when hospital staff began decontamination efforts, they were hindered by a lack of facilities and training on the decontamination process.

Another problem within the medical community’s response to the attacks was their staff organization and placement.

When calls for assistance came through to the hospital, many physicians and nurses volunteered to provide aid at the subway stations. Unfortunately, once these aid workers arrived at the attack scene, the worst of the wounded had already been transported to the hospital. As a result,

the hospital was overwhelmed with the critically ill and was faced with a severe shortage of physicians and nurses.

Technical problems in communications systems arose in several agencies called to respond to the Tokyo sarin gas attack. The Tokyo Metropolitan Ambulance Control Center experienced a system overload due to the overwhelming number of calls it received; as a result EMTs lost radio contact with headquarters, leading to a lack of hospital availability information and directions regarding emergency patient c a r e .

Wi t h o u t their communication systems, these EMTs had to rely on public phones or simply guesswork to get any information they could. This resulted in delayed treatment for several critical patients, overloaded hospitals, and an inability to track the location, number, and medical status of patients affected by the attack.

Hospital communication systems also failed due to overwhelming use during the hours following the attack. Without the use of telephones, paging systems, and other communication devices, many physicians, nurses, and other hospital

staff were forced to share information by shouting to one another from room to room, often having to search out a person just to share or request vital information.

Communication was also poor among various agencies due to other factors. Area police officials were aware that sarin had been used in the attacks within hours of the toxin’s release, but hospitals and other leading response agencies were not notified of this finding until much later.

The public was also largely left in the dark in the hours following the attack.

This lack of effective information sharing with the public led to panic within the Tokyo area, which led to a mass of “worried well,” citizens who had in no way been affected by the sarin gas attack who went to hospitals anyway, thinking they were suffering symptoms. This influx of patients who didn’t actually require treatment caused additional pressure on area hospitals, which were already over capacity with those injured in the subway attacks. For example, more than half the patients treated at St. Luke’s, one of the most overloaded hospitals following the attack, did not exhibit symptoms at all.

The situation was further worsened since many medical workers were unaware of exactly what symptoms the Tokyo attack victims were suffering, making it difficult to distinguish which patients to prioritize.

Investigations Following the Tokyo Sarin Attack Less than 2 days after the Tokyo subway attack, Japanese police carried out intensive raids on many of Aum’s facilities across the nation. One of the facilities targeted was Satyan 7, which Aum had claimed was a shrine to one of the entities that the cult worshiped. When investigators entered this facility they found it actually housed a massive chemical production operation that was capable of producing thousands of kilograms of sarin per year.

Although the facility was equipped for this purpose, it was not operating at the time of the raids, as it had been closed down following an accident that had occurred there the previous summer.

Even with the extensive cover up that Aum members had carried out in various

Aum in the United States Two days after Aum's attacks on the Tokyo subway system, the U.S. Federal Bureau of Investigation (FBI) launched an intensive investigation into the cult. Their concerns were reasonable, since Aum had established a substantial presence in the United States. Aum even had an office located only blocks from Times Square in New York City, although when police searched this facility no illegal activities were apparent at the site.

Aum facilities before the raids took place, Japanese police discovered more than 200 forms of deadly chemicals and the equipment needed to disperse those toxins. It is estimated that millions of people could have been killed if these items had been successfully used in terrorist attacks. Also uncovered during the raids were millions of dollars worth of cash and gold, large stocks of weapons, fully stocked hospital facilities, and several torture chambers and prison cells, some still holding former Aum followers.

More than 200 Aum members were arrested following the Tokyo subway attack for various crimes. However, even with extensive evidence uncovered during the raids, investigating police did not make any immediate arrests directly linked to the cult’s previous terrorist attacks. Aum attorneys responded to the police raids by denying any wrongdoing and claiming that the toxins and equipment located during the facility searches had been intended for the manufacture of legal products, including fertilizers and consumables. These attorneys then sued the city in retaliation for the raids, claiming damages.

Meanwhile, Asahara remained at large until he was discovered hiding in a secret room near Aum’s main facility in Kamikuishiki. When Asahara was located he had in his possession a large amount of cash and gold bars.

New Terrorist Attacks Follow

Spring 2006 THE FORENSIC EXAMINER 43

the Tokyo Subway Incident Several attacks believed to have been carried out by Aum members followed the Tokyo subway terrorist attack, holding the nation in the grip of terror. The first occurred in late March 1995, when an unsuccessful assassination attempt was carried out against Chief Kunimatsu, the head of Japan’s National Police Agency.

Kunimatsu was shot and critically injured, but survived the attack. At the time of his near-assassination, Kunimatsu was heading up the Japanese police investigation into the Tokyo subway attacks.

Several minor gas-related attacks also followed on subway systems in the TokyoYokohama vicinity, including one carried out on May 5 at one of Tokyo’s highesttraffic subway stations, Shinjuku. At this station, a burning bag was located in a restroom. Fire officials were able to put the fire out, but not without difficulty.

When the item was later examined, it was found to contain two condoms, one containing sodium cyanide and the other holding sulfuric acid. These items were

meant to mix to create the deadly gas hydrogen cyanide, which would have dispersed throughout the station, killing as many as 20,000 commuters.

Weeks later a letter bomb exploded at the office of Tokyo’s governor. Following that incident, four additional devices designed to spread deadly toxins were found in Tokyo subways, luckily located before they were detonated. It is believed that if successfully detonated, these devices each could have taken thousands of innocent lives.

Information Uncovered Through Trials Following the Tokyo Attack Several Aum members provided chilling testimony during the trials following the Tokyo subway attacks, revealing that the cult had made several attempts at creating and spreading such biological agents as anthrax, botulism, cholera, and Q fever.

A group of Aum physicians and nurses had even traveled to Zaire under the guise of a medical mission with the goal of returning with samples of the Ebola

44 THE FORENSIC EXAMINER Spring 2006

virus, which they intended to use as one of their many weapons. Although the cult had actively carried out nine attacks using these biological weapons, those attacks were unsuccessful because the agents they had attained weren’t virulent enough to cause serious harm to the people who were exposed.

Computer Software Developed

by Aum Used by Leading Japanese Agencies Investigations following the Tokyo sarin gas attack uncovered the troubling revelation that several leading Japanese agencies, including the Defense Agency and police departments, had purchased computer systems that used software developed by Aum operatives working for one of five software companies that the cult operated. Many top Japanese companies were also found to have purchased or used the Aum-created software. This raised concerns that the Aum followers who developed the software could have created hidden capabilities within the programs that would allow Aum operatives to

“

Today Aum is believed to have around 1,650 members and 28 facilities actively operating in Japan. While the group is currently under strict police surveillance, the court order allowing this surveillance ends in January 2006.

”

infiltrate key agency and company computers, which could lead to the unlawful release of vital sensitive information. The Tokyo police admitted that at least 90 government agencies and private organizations had purchased such software created by Aum followers, including the Japanese Telecommunications Ministry, Construction Ministry, and Education Ministry. These systems are no longer used, and investigations are ongoing as to whether any damage could still result from their previous use.

Convictions and Trials of Aum Members Many Aum followers, including most of the cult’s leaders, have now been tried and charged with various crimes related to their many violent and illegal activities. Asahara was charged with a range of unlawful actions, including murder through the Tokyo subway sarin gas attack, murder through the Matsumoto sarin gas attack, the kidnapping of the Sakamoto family, the production of several illegal drugs and substances, and the kidnapping and murders of several other individuals, including at least 33 Aum members who are believed to have been killed after attempting to flee the cult. Although Asahara maintained his innocence throughout the process, many Aum members confirmed his guilt when they confessed to being involved in the

crimes, claiming that they were working under Asahara’s direct orders.

Asahara and 12 of his leading followers have been sentenced to death for their crimes, but to date none have been executed. Asahara’s attorneys have appealed his sentence on the basis that the former Aum leader was unfit to stand trial, claiming that he should be hospitalized due to his deteriorating mental condition.

Psychiatrists engaged by Asahara’s legal team have testified that their client may be suffering from a brain disorder and is incompetent. The Tokyo High Court has engaged another psychiatrist to conduct an additional mental evaluation on Asahara; in the meantime he remains in prison.

Aum Today and Into the Future In the months following the Tokyo subway attack, Japanese courts ordered the dissolution of Aum’s religious status. This opened the group to close scrutiny by the police and removed the group’s substantial tax shelters. Still, the cult is able to practice its faith and the businesses it has established.

In the years following the sarin gas attacks and subsequent trials and convictions of many Aum members, the cult has taken many steps in an effort to remake its image in the eyes of the public. One of these measures was the renaming of the group to Aleph, which means to start anew. Even with these changes, Aum followers still reportedly believe and live by Asahara’s teachings. Today the group organizes yoga and computer classes to raise money and attract new followers. They also reportedly have plans to establish a new software company in Tokyo.

Today Aum is believed to have around 1,650 members and 28 facilities actively operating in Japan. While the group is currently under strict police surveillance, the court order allowing this surveillance ends in January 2006. The Japanese Public Security Intelligence Agency has requested a 3-year extension on this courtmandated surveillance, but at the time of this article’s publication the measure had not yet been approved.

The Tokyo Subway Attack Victims Today One of the shortfalls of Japan’s response to the Tokyo subway sarin gas attack was a lack of psychological intervention following the incident. Few of the passengers and response workers affected by the attack received any mental health assistance after the traumatic event, and today many are believed to suffer symptoms related to post-traumatic stress.

Additionally, the victims of the Tokyo sarin gas attack were injured financially as well as physically and emotionally.

Under Japanese law, Aum is responsible for compensating its victims for the damages its actions caused. However, the group’s funds were depleted long before its victims were fully compensated. As a result, most victims had to pay their own medical bills resulting from the injuries they sustained during the attack.

New Laws and Regulations Established in Japan The Tokyo sarin gas attack led to several changes in Japan’s laws and regulation systems. A new law was established prohibiting the creation, possession, and use of sarin and other toxic agents, and the laws that had strictly prohibited police intervention into religious organizations’ activities were modified. For example, the Group Regulation Act passed in 1999 was specifically designed to monitor groups that had committed mass murder. Efforts have also been undertaken to better prepare the Japanese medical and first-responder community to handle terrorist attacks and other major catastrophes through specialized training and equipment, although such resources have to date been limited.

Note: Due to space limitations the references for this article have not been included. For a complete list of references, please visit www. acfei.com (click “Online CE” and then “Read Articles”).

About the Author Erica Simons, BS, is the senior writer for The American College of Forensic Examiners.

Spring 2006 THE FORENSIC EXAMINER 45

46 THE FORENSIC EXAMINER Spring 2006

1

Tragic Task: Dental Identification After the Thai

SUNAMI

By Jules Kieser, BSc, BDS, PhD, DSc, FLS, FDS RCSEd The Asian Tsunami of Boxing Day, 2004, was the result of 1000 kilometres of a tectonic fault that ruptured beneath the sea west of Sumatra, creating an earthquake that measured 9 on 2 the Richter scale. It claimed over 250,000 lives, including more than 5,500 in southern Thailand (Stone, 2005). In response to this disaster, the Thai government issued an urgent request for assistance from the international community. Within a day an initial dental disaster victim identification (DVI) team consisting of two Australian forensic odontologists arrived in Phuket; they were joined 48 hours later by two New Zealand colleagues. Over the next few months these numbers swelled enormously as individual volunteers and national teams arrived from Thailand and over 30 other countries.

Photographs in this case study are courtesy of Royal New Zealand Police.

Figure 1. Massive destruction of a coastal resort in Phuket, Thailand.

Figure 2. Unbagged human remains covered in dry ice to prevent further decomposition.

Spring 2006 THE FORENSIC EXAMINER 47

Figure 3. The start of a dental post-mortem in a temporary morgue at Wat Yan Yao.

Initial mortuary sites were established at three Buddhist temples or Wats: Site 1 at Wat Yan Yao, Site 2 at Mai Khao, and Site 3 at Krabi. Given the overwhelming casualty rates, the large numbers of tourists who had been killed, and the high temperature and humidity, the top three priorities were security, disease containment, and cooling the bodes with dry ice, followed by tagging, bagging, and storing bodies in refrigerated containers. A temporary mortuary was set up at Site 1, and work began under Interpol DVI standard operating procedures. Although the design of the morgue was primitive and consisted of locally available materials, the identification process started with the flow of bodies through four sequential phases: fingerprinting, photographing and having pathologists examine bodies, performing full dental post-mortems and collecting DNA specimens, and maintaining quality control, which was directed by a forensic odontologist.

Standard Operating Procedures While operating under an overall Interpol protocol, dental standard operating procedures were established on day 3 after consultation between the Australian and Dutch teams (James, 2005). First, it was decided to work in two-dentist teams within each mortuary line, with a ‘super dentist’ to oversee quality assurance. The latter proved to be highly successful, especially once the multinational teams arrived and the pace of work became frenetic. It was crucial having a ‘super dentist’ in overall charge of quality control when large numbers of different national teams were working together and also when inevitably, fatigue set in.

Second, the teams resolved to avoid full mouth radiographs and limit radiography to a pair of posterior bitewing radiographs and X-rays on any other feature of interest. In retrospect, this may have been a poor decision. Forensic dentists conducting post mortems were

48 THE FORENSIC EXAMINER Spring 2006

Figure 4. The use of Polaroid images proved to be crucial to quality assurance.

confronted with the problems posed by tooth-colored restorations. These were difficult to detect at autopsy, especially given the limited lighting available in the makeshift morgue at Wat Yan Yao. This, together with the fact that they are often radiolucent or vaguely radio-opaque, suggests that additional radiographic views would have been ideal.

Third, a set of Polaroid photographs of the anterior dentition in edge-to-edge view, as well as the occlusal tables of the

left and right posterior teeth were taken.

This proved to be a useful decision, as the photographs were an essential aide to interpreting unclear dental chartings and/or radiographs. They were also useful in the identification of tooth-colored fillings, especially when these were radiolucent or vaguely radio-opaque (Sholl & Moody, 2001).

Finally, a pair of unrestored posterior teeth was extracted for DNA profiling.

This protocol was later changed to anterior teeth, then to the collection of a bone sample from the iliac crest, and finally to the removal of a piece of rib.

Lessons from the Post-mortem Procedures In addition to discovering that having a ‘super dentist’ and taking photographs were crucial to the identification process, there were three other major lessons to be learned from this experience: • There needs to be an overall dental DVI commander in charge of a site and under whose direction regular debriefs are held to address problems and issues as they arise.

• All operators, and especially commanders, need to be fully aware of the negative effects that can result from inexperience and burnout, as over-confidence in inexperienced operators as well as the effects of burnout can easily lead to false positive or false negative (exclusion) identifications (Dailey, 1997).

• As there are a host of standards used to dentally age children in different parts of the world, each with its own unique set of determinants, a single method needs to be adopted on evidence-based principles, and this method needs to be made available to all operators.

Ante-mortem Data Collection Both ante-mortem data entry and subsequent reconciliation were performed at the Thai Tsunami Victim Identification Information Centre in Phuket. As usual this phase proved to be highly challenging, with ante-mortem record collection dependent upon respective countries of origin, coordinated by Interpol. As Sakoda et al. (2000) noted, the three main factors

involved in successful dental identification are the availability of recent dental records, the accuracy of the ante-mortem dental data, and the alteration of dental status after the last clinical examination.

Unfortunately, half of all ante-mortem records received had to be returned for additional information (Kieser, Laing, & Herbison, 2005). One of the clearest messages to come from this exercise is that dental ante-mortem data needs to be collated in the country of origin by forensically trained dentists. An example of this was the leadership role taken by the Bureau of Legal Dentistry (BOLD) in Canada, which received and processed all dental records of missing Canadians.

High quality digital data with adequate radiographic records and forensic dental chartings proved to be invaluable.

The value of dental data in reconciliation is absolutely beyond doubt. Six months after the Thai Tsunami, 1,474 bodies had been identified, 90% of them based on dental data (James, 2005).

Conclusion After 9/11 it seems as though there has been an acceleration of terror attacks, airplane crashes, and natural disasters worldwide. Each of these underscores the value of having dedicated, trained teams of forensic odontologists who can be applied wherever they are needed. Each disaster also underscores the importance of having adequate standard operating procedures that are well-known by the forensic odontologist and the importance of coordinated ante-mortem data collation.

Acknowledgement This article acknowledges the huge effort of the large number of volunteers in Phuket, Thailand, and is dedicated to all those who lost their lives as a result of the Boxing Day Tsunami.

tification—overview to date. Journal of Forensic Odonto-Stomatology, 23, 1-18.

Kieser, J. A., Laing, W., & Herbison, P. (in press). Lessons learnt from large-scale comparative dental analysis following the South Asian Tsunami of 2004. Forensic Science International.

Sakoda, S., Zhu, B. L., Ishida, K., Oritani, S., Fujita, M., & Maeda, H. (2000). Dental identification in routine forensic casework: Clinical post-mortem investigations. Legal Medicine, 2, 7-17.

Sholl, S. A., & Moody, G. H. (2001).

Evaluation of radiographic identification: An experimental study. Forensic Science International, 115, 165-169.

Stone, R. (2005). A race to beat the clock.

Science, 307, 502-504.

About the Author

Jules Kieser, BSc, BDS, PhD, DSc, FLS, FDS RCSEd, is a professor and the head of the Department of Oral Sciences at the Faculty of Dentistry, University of Otago, New Zealand.

He was drafted as part of the Royal New Zealand Police response to the Asian Tsunami of December 26, 2004, and spent a month in Phuket, Thailand, performing dental disaster victim identification (DVI) with odontologists from more than 30 countries. Dr. Kieser has published widely and continues to conduct forensic research, particularly in the fields of the evidentiary reliability of bite mark analysis, dental anthropology, and more recently, craniofacial blood spatter analysis.

References Dailey, C. J. (1997). Charting errors in mass disaster dental records: Incidence, issues, and implications. In C. M. Bowers & G. L. Bell (Eds.), Manual of forensic odontology (pp. 250257). Saratoga Springs, NY: ASFO. James, H. (2005). Thai Tsunami victim iden-

Spring 2006 THE FORENSIC EXAMINER 49

50 THE FORENSIC EXAMINER Spring 2006

By Leann Long, BS

A Tragedy Unfolds

On the morning of February 2, 2002, the parents of Danielle van Dam were forced to face their worst nightmare when they discovered the empty bed of their 7-year-old daughter. Danielle was last seen the night before when Damon van Dam put his beautiful blue-eyed daughter to bed.

The distraught parents immediately reported Danielle as missing, and an extensive search involving hundreds of volunteers began.

Authorities assumed that the innocent young child was abducted from her bed while she slept on the night of February 1, 2002.

Only 4 days after the young victim disappeared, police began keeping a 24-hour surveillance of their main suspect, Daniel Westerfield, a 50-year-old self-employed engineer and twice-divorced father of two.

Westerfield lived two doors down from the van Dam family. Police quickly focused in on him when they learned he had left for a solo camping trip to the desert the same morning Danielle was discovered missing.

As soon as Westerfield returned from his camping trip, police began investigating his activities.

While under investigation, Westerfield was reported as being extremely cooperative. Police obtained warrants to search Westerfield’s home, RV, and car. The searches turned up valuable evidence, including the following: • Child pornography on Westerfield’s computer • Danielle’s fingerprints in Westerfield’s RV • A drop of Danielle’s blood in Westerfield’s RV • A drop of Danielle’s blood on Westerfield’s jacket • Fibers similar to Danielle’s bedroom carpet in Westerfield’s RV • Dog hairs that could have come from the van Dam’s dog in Westerfield’s RV • Blond hairs that could have belonged to Danielle in Westerfield’s RV and house Although Danielle was still missing by February 22, 2002, it was assumed that she was no longer alive and might never be found. Westerfield was presumed to be responsible for her alleged death and was arrested. On February 26, 2005, he was arraigned on charges of kidnapping, murder, and misdemeanor possession of child pornography.

On February 27, 2002, almost a month after she was reported missing, the body of Danielle van Dam was discovered 25 miles away from her home along a desert road east of San Diego. The evidence found during the investigation of Westerfield and his suspicious alibi provided a convincing case for the prosecution during the trial.

However, his defense lawyers presented a significant amount of evidence to raise doubts in the minds of the jurors.

Uncertainly Guilty The prosecution could not present any evidence that directly linked Westerfield to Danielle. There were no traces of evidence that Westerfield had been in the van Dam’s house. No one saw Westerfield and Danielle together, and none of his DNA was found on her body. The defense asserted that only someone who was familiar with the van Dam’s house could have been able to sneak in and take Danielle undetected.

The lifestyles of Brenda and Damon van Dam, Danielle’s parents, were also brought into question during the trial. The two admitted to smoking marijuana the night before Danielle was abducted and also to openly having sex with other people. The night Danielle was taken from the house, the van Dams, as they often did, had many guests over at their house until the early hours of the next morning. The defense claimed that the van Dam’s reckless and wild behavior put their daughter at risk and that any of their past guests could have been responsible for Danielle’s kidnapping and death.

The night Danielle was kidnapped, several witnesses reported seeing Brenda

Spring 2006 THE FORENSIC EXAMINER 51

dancing closely with Westerfield at a local bar. The defense suggested that hairs, from both Danielle and the van Dam’s dog, could have been transferred onto Westerfield while they were dancing, consequently ending up in his home and RV. Brenda also testified that she and Danielle had visited Westerfield’s house the week Danielle disappeared to sell Girl Scout cookies. During the trial, it was confirmed that Westerfield kept a pile of laundry near his front door.

Westerfield’s defense argued that the blood on his coat and Danielle’s hairs that were found in his house could have been left during that visit.

Various neighbors also testified that the van Dam children were often left to play unsupervised and could have gotten into Westerfield’s RV. If Danielle had been playing in the RV, she easily could have deposited her hair, her fingerprints, her blood, dog hairs, and carpet fibers from her bedroom in the RV. Despite all of the previously mentioned factors, the defense case mostly hinged on bugs.

Creepy-Crawly Contradictions The prosecution claimed that Danielle was killed within the first few days after she was kidnapped, as it would not have been possible for Westerfield to kill and dump her body once he was under police surveillance, which began on February 5, 2002.

However, the defense argued that the state of Danielle’s remains indicated that she was killed after Westerfield was under surveillance. Proving this in court would clear Westerfield’s name.

Initially, the defense brought to the stand forensic entomologist David Faulkner.

Forensic entomologists study insects, and when a body has been decomposing for more than 48 hours forensic entomologists can give a more precise estimation of time of death than medical examiners.

Entomologists are able to calculate an estimated time of death by determining when a body was colonized by bugs.

Dead bodies immediately start attracting thousands of flies and other insects.

Flies are used most often to determine time of death. They feed on the corpse and lay eggs that quickly turn into maggots,

which also feed on the decaying body. A fly’s lifespan, and consequently the speed of a body’s decomposition, is dependent on the temperature. Entomologists have to consider temperature when trying to determine how much time has elapsed since death.

Falkner testified that Danielle’s body was not outside and available to insects until February 16 through 18, weeks after Westerfield was placed under police surveillance. The defense brought in additional entomologists to offer their own expert testimonies. Entomologist Neal Haskell reported that Danielle’s body was infested with insects between February 12 and 21, and entomologist Robert Hall claimed her body was initially infested between February 12 and 23.

The prosecution then had entomologist Madison Lee Goff offer his expert testimony. He testified that insect infestation occurred between February 9 and February 14, but also claimed that other factors may have resulted in a delay in bug arrival.

There were a few non-entomologist forensic experts whose proposed time frames included the first few days after Danielle’s disappearance—before Westerfield was under police surveillance—but each of the entomologists offered a time frame confirming the body was dumped after Westerfield was being monitored by police.

However, the entomologists’ inconsistent timetables also depicted the unreliability of determining the time of insect infestation, and the prosecution was able to convince the jury that the field of entomology was inexact.

Reasonably Doubting the Death Penalty Although the jury, with large support from the community, turned over a guilty verdict in the case based on the evidence presented, it cannot be known for sure whether or not Westerfield was truly guilty. After Westerfield’s sentence was given, some people felt the death penalty was too harsh with there being so much evidence to question—especially the evidence about the bugs.

It would have been invaluable if the testimonies and findings of the forensic experts had not varied so much. If the

52 THE FORENSIC EXAMINER Spring 2006

forensic entomologists would have been able to consistently and accurately pinpoint Danielle’s time of death, they would have been able to shred most of the doubt that accompanied the case.

This is not the first case where the study of a decomposing body has offered critical information about a victim’s time of death, and unfortunately, nor will it be the last. It will be extremely valuable if in the future, forensic experts are able to narrow the time of death of a decomposing body to a smaller and more definite time frame.

How can this be accomplished without studying decomposing bodies? It can’t, which is why the body farm was created.

Examining the Expired In Knoxville, Tennessee, there is a threeacre wooded plot surrounded by razor wire and wooden fences where about 40 lifeless bodies are currently decomposing. One is lying out in the open where it can sunbathe each day, while another is refrigerated in darkness. A headless corpse might be decaying in the woods while a dismembered cadaver lies buried in mud.

Of course, all of this is done in the name of science.

While teaching at the University of Tennessee, forensic anthropologist Bill Bass was repeatedly faced with the challenge of informing detectives how long a victim had been dead. After coming up short when consulting the literature, he realized the only way to be able to analyze the time of death of badly decayed bodies would be to study bodies as they decompose. In the early 1980s he was granted land to begin the University of Tennessee Forensic Anthropology Facility, or as it has been nicknamed, the body farm.

The meager beginnings of the body farm consisted of just one body, corpse 1-81, in a 16-square-foot chain-link enclosure.

Experiencing temperatures in the 80s, Bass and his graduate students watched and carefully observed corpse 1-81 go through all four of the broad stages of decomposition—the fresh stage, the bloated stage, the decay stage, and the dry stage—in a matter of 2 weeks.

The time that each stage of decomposition lasts varies, as the stages are greatly affected by the environment and tem-

perature. The fresh stage of decomposition begins immediately following death and continues until the corpse begins to bloat.

The bloated stage is a result of bacteria consuming the stomach and intestines.

Microbes release waste gases that cause the abdomen of a body to inflate. The decay stage begins once the abdomen collapses because it is no longer bloated with gases.

During this third stage, the remains are comparatively dry. When only small bits of tissue remain on a body and it is little more than a skeleton, the body has entered into the dry and final stage of decomposition.

Corpse 1-81 gave observers a lot of information during the short amount of time they had to observe it, and the skeletal remains of the corpse were the first of many used by Bass to help teach students how to identify human bones by their size, shape, and texture. However, the studies done at the body farm have greatly advanced over the past 25 years.

Most of the initial research performed on Bass’s self-proclaimed “death acre” concentrated on observing and recording the basic succession and timing of decomposition. They were seeking the answers to basic questions that would help in investigations, such as the following: • How long before limbs start to fall off?

• In what environment did the body decay?

• Was the body in shade or direct sunlight during decomposition?

• Was the body clothed during decomposition?

• Where was the body during decomposition (indoors, outdoors, car)?

• Did the body decompose in land or in water?

• From how far away can humans detect the odor of decomposition?

The answers to those questions are much less of a mystery today, but when it comes to decomposition and analyzing human remains, there is not a formula that works 100% of the time. For that reason, graduate students from the university continue to record and analyze each stage of decomposition, constantly adding to the information available to law enforcement officials, medical examiners, crime scene investigators, and other forensic experts.

As climate and insects are the two most influential factors on how quickly a body will decompose, the bodies that are studied are still put in a variety of situations.

Hoping to encompass most conditions, the students study corpses in various settings—from being locked in the trunk of car to being submerged under water. The researchers analyze the soil as well as the bodies, as byproducts of decomposition seep into the ground and can provide valuable information about how long a body has been laying a particular spot. Data that has been taken from the body farm has helped solve many cases around the nation and continues to advance what is known about human decomposition.

Eager to enhance science, over 300 people have donated their bodies to be observed at the body farm. Each body is allowed to decompose for about a year before it is replaced with a new body to study.

Plentiful donors will be very beneficial for Tyler O’Brien if he receives the grant he is seeking in the amount of $400,000 to $500,000. If all goes as he hopes, the biological anthropology professor at University of Northern Iowa will start another body farm. Bodies in a body farm in Iowa would be exposed to many different types of weather, including wind, rain, sun, snow. There would also be different rodents, plants, and bugs than in Tennessee. O’Brian believes it is very important to study how bodies react in different environments. Although his request has been denied in the past, many in his community are in favor of the research.

There is still a lot to be learned about the rates at which dead bodies decompose, but the research collected at the body farm during the past 25 has provided crucial information in several murder investigations. If O’Brian’s grant is approved, even more will be learned about the rate at which human bodies decompose in various environments.

Hopefully, in the future forensic experts will be able to accurately pinpoint the time of death of human remains so that in cases where a victim’s time of death is crucial to a verdict, justice can be served.

References Bass, B., & Jefferson, J. (2003). Death’s acre.

New York: G. P. Putman’s Sons.

Baum, M. D., & Tolley, T. (2000). Pastoral putrefaction down on the body farm. CNN. com. Retrieved November 30, 2005, from http://archives.cnn.com/2000/HEALTH/ 10/31/body.farm/ Courttv.com. (2002). Danielle van Dam murder case. Retrieved November 20, 2005, from http://www.courttv.com/trials/ westerfield/timeline/time_of_death.html Dvorak, T. (2005). Iowa scientist seeks funds for body farm. Associated Press. Retrieved November 30, 2005, from http://www.cnn. com/2005/TECH/science/11/28/body.farm. ap/ Epler, K. (2002). Defense begins case in Westerfield trial. North County Times. Retrieved November 30, 2005, from http://www.nctimes. com/articles/2002/07/03/ export13362.prt Epler, K. (2002). Expert: Fingerprints are Danielle’s. North County Times. Retrieved November 30, 2005, from http://www.nctimes. com/articles/2002/03/13/ export4969.prt Epler, K. (2002). Hair in Westerfield home similar to Danielle’s. North County Times.

Retrieved November 30, 2005, from http:// www.nctimes.com/articles/2002/06/25/ export12739.prt Epler, K. (2002). Many in community support jury’s decision. North County Times.

Retrieved November 30, 2005, from http:// www.nctimes.com/articles/2002/08/22/ export16664.prt Epler, K. (2002). Three DNA experts link blood, hair to Danielle. North County Times. Retrieved November 30, 2005, from http://www.nctimes.com/articles/2002/06/21/ export12485.prt Epler, K. (2002). Westerfield’s defense worked to raise a reasonable doubt. North County Times. Retrieved November 30, 2005, from http://www.nctimes.com/articles/ 2002/08/09/export15808.prt Ramsland, K. (2005). The body farm. The Crime Library. Retrieved November 20, 2005, from http://www.crimelibrary.com/criminal_ mind/forensics/bill_bass/4.html Weiss, M. (n.d.) Forensic entomology.

Retrieved January 9, 2006, from http://www. ndsu.nodak.edu/enomology/topics/forensic. htm Wikipedia.com. (2005). Body farm. Retrieved November 30, 2005, from http://en.wikipedia. org/wiki/Body_Farm

About the Author Leann Long, BS, is the Assistant Editor of The Forensic Examiners and a staff writer and editor for the American College of Forensic Examiners.

Spring 2006 THE FORENSIC EXAMINER 53

THE PILTDOWN

MAN: “The Missing Link”

By Megan Augustine, BS Science is the system of acquiring knowledge, of uncovering truth. However, pranks, hoaxes, and outright frauds have been perpetrated under the guise of “science,” leading mankind not to truth, but away from it. In the case of the Piltdown hoax, that is exactly what happened. This anthropological hoax, reported in science books as truth for nearly 40 years, is perhaps the most famous scientific fraud in history.

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In 1912, archeologist Charles Dawson and Sir Arthur Smith Woodward, keeper of geology at the Natural History Museum, presented an amazing discovery to the public, a discovery that shook the very foundations of science at the time. What they presented was a reconstructed skull that they claimed was the “missing link” between apes and humans.

The reconstruction, dubbed “Piltdown Man,” consisted of a piece of skull and a jawbone. Named after the Piltdown quarry in Sussex, England, where a laborer discovered the fragments, the Piltdown Man had the noble brow of the Homo sapiens and a primitive jaw.

Then, in 1915, more remains turned up in the Piltdown quarry: a second partial skull and an odd-looking bone artifact that resembled a cricket bat. Now even those who had been skeptical of the first finding were convinced: the Piltdown Man discovery was real.

The Hoax Unravels Over Time As time passed, scientific discoveries in other countries, including the “Taung Child” in South Africa and “The Peking Man” in China cast doubt on the Piltdown Man by illustrating contradictory evidence in the pattern of human evolu-

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tion. However, Piltdown Man supporters remained loyal and rebuffed arguments against its validity.

But by the late 1930s, the Piltdown Man was marginalized and by the 1940s and 1950s ignored. The truth began to unravel with a new dating technique in 1949, the fluorine absorption test, which dated the Piltdown fossils as relatively modern.

Then, in 1953, after further testing, the fraud was exposed. A group of scientists lead by Kenneth Page Oakley revealed that the skull’s fragments were from a modern human and the teeth and jawbone were actually from an orangutan. The teeth had been filed down (microscopic examination revealed scratch marks), and the bones had been stained with an iron solution and chromic acid to make them appear ancient.

The “missing link,” the answer to human evolution, and the work of Dawson and Woodward was all a hoax! But who was the perpetrator?

The Perp The perpetrator of the Piltdown Hoax has never been uncovered. Theories abound, but no one really knows who was behind the largest anthropological hoax in history.

Some theories include the following:

• Martin A. C. Hinton: later the keeper of the zoology collection at the British Museum. A trunk, found in the loft of the museum, bore Hinton’s initials and contained a set of bones stained in the same way as the Piltdown Man fragments.

Motive? Some say Hinton developed the hoax to embarrass Woodward, who had previously refused Hinton a salaried job at the museum. Others say it began as a practical joke, but after the large amount of publicity the jokester (Hinton) kept quiet.

• Sir Arthur Conan Doyle: author. Conan Doyle lived near the Piltdown quarry and frequently played golf just a few miles away. As an amateur bone hunter who participated briefly in the digs, he had the opportunity to plant the bones; however, he had no way of guaranteeing the bones would be discovered. But, it has been said that he left clues and references to the hoax in his book The Lost World. Motive?

Some argue that Conan Doyle was out for revenge on the British scientific community for ridiculing his spiritualist research.

• Sir Arthur Smith Woodward: keeper of geology at the Natural History Museum.

Woodward stood to gain great recognition as the Piltdown Man’s co-discoverer.

Additionally, he had access to the fragments, so why did he not perform any scientific examinations? On the other hand, after Woodward retired from the British Museum, he spent the remaining years of his life searching for more Piltdown finds.

Why would a man waste his life digging for something he knew was a hoax?

• Charles Dawson: amateur archeologist and Piltdown-Man discoverer. Dawson chose to search the Piltdown Quarry and was the one who made the original discovery, with no confirmation from another individual. After his death in 1916, several forgeries created by Dawson were exposed, and no further objects related to Piltdown were ever found. Motive? With this find Dawson would go down in history as the archeologist who found the “missing link.”

How Forensics Exposed the Hoax Why did it take so long to discover the

Piltdown Man forgery? With today’s scientific and forensic resources, hoaxes such as the Piltdown Man would quickly be revealed. But in the time of the Piltdown Man, forensic techniques were not what they are today. Additionally, the Piltdown Man affirmed many scientists’ theories of human evolution. They wanted to believe the “missing link” had been found. Perhaps scientists did not put the findings under careful scientific examination in fear they’d discover they were wrong; they did not want to confront (and possibly disprove) the evidence that proved their theory.

The lack of scrutiny could also be the result of national pride. English scientists wanted to have a hand in unraveling human evolution. Neanderthal was found in Germany in 1856 and Cro-Magnum in France in 1868. Maybe the British wanted a piece of the fame, and this desire overshadowed the search for truth.

In the end, forensics led the search for truth. A variety of forensic experts and their techniques aided in exposing the Piltdown hoax.

First, Dawson and Woodward dated the bones with the help of index fossils they found at the site of the discovery. More recently, radiocarbon dating showed that the human bones were less than 1,000 years old, which dated Piltdown Man at least 100,000 years after the first “modern” humans were on earth.

Second, skull reconstruction in the days of Dawson and Woodward was open to different interpretations. It was not an exact science; two different individuals could reconstruct two completely different models. Today, a 3D laser scanner can photograph skull fragments and a computer-modeling program can accurately piece the fragments together, leaving only one reconstruction.

Third, the teeth in the Piltdown jaw felt smooth and flat. This was much different than the rough, pointed teeth of an ape.

Dentist Arthur Underwood took an X-ray of the Piltdown jaw and compared it to that of a chimpanzee’s jaw. He concluded that the roots of a chimpanzee jaw looked much straighter than those in the Piltdown jaw. Today, however, X-ray machines are

much more sophis2 ticated and are of higher quality.

A modern X-ray would lend critical information to Piltdown’s origins. Additionally, scanning electron microscopes clearly revealed the scratch marks on the teeth, making it obvious the teeth had been filed down by hand.

Although modern forensics would have uncovered the hoax in no time, one question still remains: would modern forensics have been able to nail down the individual responsible for the largest anthropological forgery in history? Unfortunately, we will never know.

References Harter, R. (1996-1997). Piltdown Man: The Bogus Bones Caper. The Talk.Origins Archive. Retrieved November 11, 2005 from http://www.talkorigins.org/faqs/ piltdown.html Monty White, A. J. (2003). The Piltdown Man Fraud. Answers in Genesis.

Retrieved December 12, 2005 from http:// www.answersingenesis.org/docs2003/ 1124piltdown.asp?vPrint=1 Natural History Museum (2005).

Piltdown Man. Retrieved November 9, 2005 from http://www.nhm.ac.uk/natureonline/life/human-origins/piltdown-man Wikipedia.com. (2005). Piltdown Man. Retrieved December 12, 2005 from http:// en.wikipedia.org/wiki/Piltdown_Man About the Author Megan Augustine holds a bachelor of journalism degree, and she is the Chief Association Officer for the American College of Forensic Examiners.

Captions 1. The jaw of the Piltdown Man. 2. Charles Dawson.

Spring 2006 THE FORENSIC EXAMINER 55

56 THE FORENSIC EXAMINER Spring 2006

Pain

By Bruce Gross, PhD, JD, MBA, FACFEI, DABFE, DABPS, DABFM, DAPA

Of all the paraphilias—exhibitionism, sexual sadism, sexual masochism, frotteurism, fetishism and transvestic fetishism, voyeurism, and pedophilia—the least researched are sexual sadism and sexual masochism. Known collectively as “sadomasochism” to professionals, those who practice this alternative sexual lifestyle tend to use the term bondage-dominationsadism-masochism, or BDSM.

Recently, BDSM has entered the plotline in episodes of several popular primetime television series, made-for-TV movies, and motion pictures. This increased focus on BDSM by the entertainment industry may have been sparked by the national news coverage surrounding the trial of the BTK serial killer in 2005, primed by the prior arrest and conviction of John Edward Robinson, the first known cyber serial murderer who attracted his victims through a shared interest in BDSM (Gross, 2005). The increased focus on BDSM may be the natural byproduct of increased prevalence in the general population, increased openness within the BDSM community, and/or increased societal curiosity regarding more extreme alternative sexual practices. The near absence of empirical research on BDSM makes it impossible to know the exact factor(s) underlying the thematic trend.

The Basics of BDSM A key difficulty in researching BDSM is the lack of formalized, uniform definition of terms, agreed-upon by scholars and practitioners of this alternative form of sexual expression (American Psychiatric Association [APA], 1994; American Psychiatric Association [APA], 2000). In the late 1890s, sexologists considered human sexual masochism a natural evolution of that evidenced in lower mammals. Over 40 mammalian species have been identified that bite while mating;

among humans, approximately 25% of both men and women report having been sexually aroused by a partner’s bite (Ellis, 1927; Weinberg, 1995). Masochism became defined as sexual algophilia, or the “fondness or love of pain” during sex (Féré, 1899). To incorporate sadism in this construct, Schrenck-Notzing developed the term “algolagnia,” determining the attraction to sadomasochism was lust rather than love (Schrenck-Notzing, 1893). Unlike algophilia, the word algolagnia reflects both the active (algo-/pain) and passive (-lagnia/lust) components of sadomasochism. It was not long before the meaning of algolagnia was expanded to include not just acts, but also the fantasies of sadomasochism that are necessary and sufficient to achieve sexual gratification (Eulenberug, 1911).

There is evidence of BDSM occurring across time and cultures, with perhaps the most widely known example being the Kama Sutra, written by Vatsysayana in 450 AD as a guide to maximizing sexual pleasure (Vatsysayana, 1964). As suggested by the Kama Sutra and as raised by Ellis in 1927, “pain” may not be an appropriate term or applied concept in the context of sadomasochism, in which (regardless of the underlying reason) pain is experienced as pleasure resulting in sexual gratification (Eulenburg, 1911). This paradox led to a paradigmatic shift away from a singular focus on pain, as pain itself is not perceived as erotic for every practitioner of

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Scholars and practitioners alike accept that sadomasochism exists in the context of an extreme psychological imbalance of power between partners, in which one is submissive and the other dominant.... This power differential is played out in many different roles ...

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BDSM and may be included in only one of many BDSM rituals practiced by those who do. As BDSM includes the desire or need for submission, domination, and humiliation for sexual gratification (often without requiring pain), the definition of BDSM shifted to a focus on the construct of an erotic power exchange.

Scholars and practitioners alike accept that sadomasochism exists in the context of an extreme psychological imbalance of power between partners, in which one is submissive and the other dominant (APA, 2000; Ellis, 1927; Weinberg, 1995). This power differential is played out in one of many roles, such as master-slave, teacherstudent, or parent-child. It is also generally accepted that sadomasochism involves the fantasy or urge to inflict (sadism) or receive (masochism) physical pain and/or humiliation during sex; urges that may or may not be acted upon. Bondage refers to the use of physical restraints and/or psychological restraint (through controlling commands) during sex. However, sexual domination and submission do not require either restraint or the infliction of pain.

The sexual behaviors encompassed by sadomasochism range from harmless (such as gentle biting and spanking or being blindfolded) to comparatively bizarre (such as being required to mimic animals, or being defecated and/or uri-

nated upon) to fatal (through self-strangulation to induce arousal consequent to oxygen deprivation or accidental/negligent/intentional murder) (Masters, Johnson, & Kolodny, 1995; Reinisch, 1990; Weinberg, 1995). As with the intensity and severity of behaviors, there is a wide range in the frequency with which BDSM is practiced by those who enjoy it. For some, BDSM is part of every sexual interaction, while for others it is occasional. Most sadomasochists, as differentiated from rapists, seek willing partners where limits are clearly defined and respected, while a few realize sexual pleasure by intentionally pushing past consent.

The Beginnings of BDSM A range of theories exists as to the etiology and attraction of BDSM (APA, 2000; Masters et al., 1995; Weinberg, 1995).

Clinical and lay views on the practice of BDSM range from its being a form of normal, healthy sexuality, to being reflective of issues related to vulnerability and intimacy, to its being synonymous with mental illness. While dominance and submission are generally accepted as normal aspects of the continuum of sexual behavior, sadism and masochism are less so. In light of the fine line between pleasure and pain, it has been hypothesized that BDSM is associated with an atypically high pain threshold. As endorphins

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are autonomically released in response to both pleasure and pain, it has also been suggested that BDSM is associated with abnormally high levels of endorphins reinforcing an initial experimental or accidental experience with BDSM. In terms of psychological theories of etiology, psychoanalytic theory purports BDSM is the result of childhood sexual trauma; psychobiological theory asserts BDSM is the result of hormonal influence on the central nervous system; and behavioral theory suggests the practice is acquired through early exposure to BDSM (through experience and/or observation) that is imitated and reinforced.

Learning theory contends that BDSM represents a form of conditioning; specifically, when a young boy becomes aroused while being spanked over his mother’s lap.

The pain is associated with arousal resulting in patterned masochism. (Of note, BDSM cyber-serial killer John Edward Robinson was the middle of five children born to a binge-drinker alcoholic father and a mother who was an excessive disciplinarian.)

Based on self-report, men tend to prefer BDSM more than women do. Among men, it is especially enjoyed by those who are well-educated and employed in highstatus and/or high-authority positions (Masters, Johnson, & Kolodny, 1985; Masters et al., 1995; Reinisch, 1990; Weinberg, 1995). This observation has

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Between 5-10% of the population in both the United States and the European Union practice some sort of mild, pain-free BDSM sex-play on a regular basis .... males typically report having enjoyed the behavior since childhood, while females characteristically report first finding the behavior pleasurable in adulthood after being introduced to BDSM by a partner.

led to a “psychodynamic” interpretation of the individual’s preference for the submissive/bottom or dominant/top role in a BDSM sexual encounter or scene. That is, which role the given person plays out in a scene is determined by the nature of the role he or she has assumed or been assigned in his or her public life. A publicly dominant person would be given to assume the submissive/masochistic role in BDSM, while a person who feels (or is) powerless and/or inadequate in his or her public life would assume the dominant/sadistic role in sex. Acting-out in the opposite role allows for a sense of balance, a release of tension or repressed rage, or the practice of self-confidence.

Between 5-10% of the population in both the United States and the European Union practice some sort of mild, painfree BDSM sex-play on a regular basis (APA, 2000; Masters et al., 1985; Master et al., 1995; Reinisch, 1990; Weinberg, 1995). It is, however, extremely rare for sadomasochism to be an individual’s only means of sexual satisfaction (paraphilic sadomasochism is seen almost exclusively in males, at a ratio of 20:1). Of those adults who find BDSM pleasurable, males typically report having enjoyed the behavior since childhood, while females characteristically report first finding the behavior pleasurable in adulthood after being introduced to BDSM by a partner.

A Perfectly Normal Perversion?

In the late 1970s and early 1980s, those who participated in the alternative lifestyle associated with BDSM had become increasingly visible to the public through the adoption of the leather trend in dress started by gay men and the emergence of BDSM clubs where people with like interests could meet. As a result of this normalization through familiarity, by the mid-1980s BDSM was no longer considered inherently indicative of mental illness. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) included Sexual Masochism and Sexual Sadism in the category of Sexual and Gender Identity Disorders, diagnosable only if the sexual fantasies, urges, and/or behaviors persisted for at least 6 months and caused clinically significant distress or impairment in functioning (APA, 1994).

With the revisions made to the DSMIV in 2000, sexual sadism/masochism can be diagnosed if the fantasies or urges are acted upon, even if the individual does not suffer consequent distress or impaired functioning (APA, 2000). As noted by Masters et al., there are individuals with sadistic or masochistic fantasies that, while ego-dystonic, do not result in a level of distress sufficient for diagnosis and do not meet the criteria for obsessive-compulsive disorder (Masters et al., 1995). They also note that while sadomasochistic fantasies

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are common, most of those who find such fantasies sexually arousing have no desire to experience the acts in real life.

For some individuals fantasies and urges for violence during sex and the possible negative consequences of acting on these urges results in those individuals experiencing a level of fear and anxiety that may lead to voluntary participation in psychotherapy. Others may seek mental health services to aid in the resolution of issues related to coming out. In general, individuals who have embraced the culture of BDSM seldom feel the need for help and usually do not voluntarily seek treatment unless/until their behavior results in conflict with a partner, an arrest, or conviction for sexual assault (APA, 2000; Weinberg, 1995). Even those with diagnosed sexual sadism or sexual masochism seldom perceive themselves as having a sex-related problem needing professional intervention. In the event of involuntary treatment, several options exist, including pharmacology (medications that decrease circulating levels of testosterone), surgery (stereotactic neurosurgery and castration), and psychotherapy (aversive conditioning and traditional psychotherapy).

Cyber-Sadism The BDSM clubs that emerged in the 1980s were a tremendous advance for BDSM, providing a safe social environ-

Spring 2006 THE FORENSIC EXAMINER 59

ment where those with shared interests could meet more easily. Yet, that was nothing compared to the opportunity for worldwide connections provided by the advent of the Internet in the 1990s.

Internet newsgroups allowed for open education and discussion regarding issues related to BDSM, while chat-rooms and email lists dramatically increased the ability of those interested in BDSM to find one another and to experience a broad sense of social inclusion. The Internet is a unique venue for interpersonal interactions due to its accessibility and immediacy; anonymity and disinhibition; premature intimacy; potential blurring of male/female identities; the assumption of new, false, or fantasy-based personas; and the fine line between what’s real and what’s virtual. These very characteristics are also descriptive of BDSM, making for a perfect match.

With the move into the Internet those interested in BDSM gained easy connection but at the same time lost the safety and protection afforded by real-world close-knit communities. Verbal and visual cues to behavior, which are key indicators of potential threat, are absent in cyberspace, heightening both the thrill and the risk when picking a BDSM partner online. Perhaps the greatest risk is for those women who are nurturing by nature, feel lonely and disconnected, believe they can find fulfillment of their intimacy needs online, and express a curiosity or interest in BDSM. These women are tremendously vulnerable to victimization, as exemplified by every one of cyber-serial killer John Edward Robinson’s victims (Gross, 2005).

Safety Net Just as there is an absence of research on BDSM in general, there is an absolute void of research on the more extreme forms of BDSM such as mutilation and lust-murder. A very superficial online search resulted in a surprising number of sites dedicated to the more bizarre and seemingly violent BDSM behaviors, which at least suggests a greater interest (if not practice) than one might expect. (A Google search for the keywords “BDSM

bulletin boards” returned over 89,500 sites, while a search for “BDSM chatrooms” returned just under four million sites.) While serious injury is rare in sexual sadomasochism, it is certainly a reasonable fear, especially for those new to the practice. Researchers and those who practice BDSM uniformly agree that once a participant’s “comfort-line” has been crossed and consent withdrawn, any continuation or escalation of behavior by the other partner is a criminal action (as is so with any other sex act).

Within the BDSM subculture, there exists a division in thought (and in practice) related to safety measures (Masters et al., 1995). On one side are those who believe BDSM requires heightened risk to achieve heightened pleasure. The requisite imbalance of power becomes illusory when the interaction is negotiated and scripted, drawing emphasis to the difference in authenticity between playing a sexual sadist/masochist and being one.

On the other side of the ongoing controversy are those who are adamant that the transfer or surrender of power and control should always be negotiated in advance.

Within themselves, each party should be clear about their psychological and physical limits, as well as in what activities they are willing to engage. That self-knowledge should be fully shared with and understood by the other party before starting a scene.

The social and legal expectation for all sexual encounters is that each party has given informed consent and that each will respect and behaviorally conform to the other’s “no.” Without both elements a sexual act becomes a punishable crime.

Unfortunately, many men and some women often have difficulty hearing or properly interpreting the “no,” especially when the verbal and nonverbal messages are inconsistent or conflict. Compared to more traditional or vanilla sex, the potential for missing or misreading a partner’s “no” is far greater in BDSM, given that the identifying power imbalance is manifested in signs of servitude, acts of blind obedience, desperate begging, vigorous resistance, and complaints of pain.

Those who advocate safe, sane, consen-

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sual (SSC) BDSM—also known as riskaware-consensual-kink (RACK)—recommend establishing safe-words (other than “no” or “stop”) that once spoken by either party will immediately stop the scene. If gagging is part of the sexual experience, a safe-sign should be created as well. Safe calls should be pre-arranged whenever meeting with an unknown partner. The overriding goal is to find and maintain a balance between risk and safety.

Bending and Beating the Law Ideally, those persons who participate in BDSM do so in the context of mutual trust, open communication, and informed consent. Yet BDSM involves a range of acts that include varying degrees of expressed intent, physical contact, and potential for bodily harm. Having gray areas can easily lead to the possibility of civil and/or criminal action being taken against either or both parties.

Those persons who assume the dominant or top role in a BDSM encounter may fear being charged with assault and/ or battery. While the exact definition of these crimes may vary by jurisdiction, a brief assault is the crime of threatening and having the ability to inflict harm resulting in fear of such in the intended victim, while battery refers to the crime of intentionally or recklessly causing physical contact that is offensive or harmful and to which the victim did not consent.

Depending on the specifics of the act and its context, charges of assault can be filed in civil and/or criminal court; as a tort, misdemeanor, or felony; and as simple assault, assault with intent (to commit another crime), or aggravated assault (which includes the intent to cause serious bodily injury and the use of a dangerous weapon, or an assault occurring in association with another felony charge). Perhaps of greatest concern is the possibility of being charged with indecent assault and sexual assault. Indecent assault has been generally defined as “intentional offensive sexual contact that does not amount to sexual intercourse or involve penetration and that is committed without consent of the victim and without the intent to commit rape” (Garner, 2004;

Merriam-Webster, 1996). Sexual assault is generally defined as “sexual contact that is forced upon a person without consent or inflicted upon a person who is incapable of giving consent or who places the assailant in a position of trust.”

As with assault, battery charges can range from simple, which is generally a misdemeanor and does not include the use of a weapon or other factors in aggravation, to aggravated battery (which is generally filed as a felony offense). An increasing number of states are enacting mandatory arrest laws in situations of domestic violence that could potentially result in the arrest of one party (most likely the top) if for any reason the police are called to the location of the BDSM scene.

Most of the possible charges of assault and battery include the element of the lack of or inability to consent on the part of the victim. While most BDSM encounters include implied or expressed consent by both parties, if charged with BDSM-related assault and/or battery the defendant may be prohibited from using consent as an affirmative defense.

Jurisdictional restrictions aside and despite appearances, consent may not have been freely or fully given. This can occur if the person consenting lacks the capacity to do so (independent of the person’s belief regarding his or her own ability), if his or her ability to consent was impaired at the time, or if consent was obtained through fraud. The misrepresentation of one’s experience with specific acts or ability to use specific BDSM tools or toys may invalidate the consent given by the other, as would engaging in any behaviors that exceed the scope of the given consent.

Other charges that might arise in the context of BDSM and that are typically filed against the dominant party include sodomy, kidnapping, or unlawful imprisonment (especially when using bondage).

Wearing costumes is a component of fulfilling and sexually satisfying BDSM for some practitioners. Typically this only presents a problem when the publicly worn costume is so revealing it meets the standard of indecent exposure or too closely resembles that worn by law

enforcement officers, potentially resulting in charges of impersonating an officer.

Some BDSM clubs employ women who provide domination services to interested clients. If the pro dom’s behavior includes sexual contact or the direct acceptance of a fee, the club owner can be charged with pimping or pandering and the dominatrix with prostitution. These same charges can be filed against individuals who host BDSM parties in their homes if there is sex activity at the party and guests are required to pay an entrance fee. In all states but Nevada prostitution is illegal, with most states limiting the definition to the exchange of sex for a fee. In some states (like Arizona), laws related to prostitution include sadomasochistic acts and in others (like California) sexual contact must be made to be charged. Under California’s law, paid BDSM that includes only humiliation, physical punishment, and/or violent acts would not constitute prostitution even though those acts are for the purpose of sexual gratification.

Club owners who offer bondage and torture equipment for use by patrons can be sued for negligence in the event the equipment fails and causes someone physical or psychological injury. The same is true for private owners of such equipment. It should be noted that liability insurance (or even a liability waiver) might not offer protection (or an affirmative defense) if a suit is filed.

When Love Hurts Regardless of the degree of involvement, people who engage in BDSM are vulnerable to attack on many fronts. In addition to potential civil suits and criminal charges, BDSM practitioners might find their sexual preferences being used against them in the context of disputed child custody, or as a means of blackmail in general. Aside from the range of obvious physical injuries that might result from BDSM rituals, practitioners are at increased risk of contracting those diseases that are transmitted by blood, especially if proper health precautions are not taken. While BDSM is considered normal (with the exception of extreme manifestations), it seems patently abnormal for a

person to willingly consent to assault. All healthy relationships are characterized by mutual trust and respect and include the negotiation of roles and boundaries. Yet for those drawn to BDSM, these interpersonal values are literally of potentially life-threatening importance.

References American Psychiatric Association. (1994).

Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2000).

Diagnostic and statistical manual of mental disorders (4th ed. text revision). Washington, DC: Author.

Ellis, H. (1927). Studies in the psychology of sex.

New York: Random House.

Eulenburg A. (1911). Sadism and masochismAlgolagnia: The psychology, neurology and physiology of sadistic love and masochism (2nd ed.) (H. Kent, Trans.). New York: Bell Publishing.

Féré, C. S. (1899). L’Instinct sexuel: Évolution et dissolution. Paris: Felix Alcan.

Garner, B. A. (2004). Black’s legal dictionary (8th ed.). Pittsburgh, PA: West Publishing Company.

Gross, B. G. (2005). eDanger.com. The Forensic Examiner, 14(4), 58-62.

Masters, W. H., Johnson, V. E., & Kolodny, R. C. (1985). Human sexuality (2nd ed.). Boston: Little, Brown & Co. Masters, W. H., Johnson, V. E., & Kolodny, R. C. (1995). Human sexuality. Boston: Little, Brown and Company.

Merriam-Webster. (1996). Merriam-Webster’s dictionary of law. Springfield, MA: Author.

Reinisch, J. M. (1990). The Kinsey Institute new report on sex. New York: St. Martin’s Press.

Schrenck-Notzing, A. (1893). Therapeutic suggestion in psychopathia sexualis (pathological manifestations of the sexual sense): With especial reference to contrary sexual instinct. Philadelphia: Davis.

Vatsysayana. (1964). Kama sutra. New York: Lancer Books.

Weinberg, T. S. (Ed.). (1995). S&M: Studies in dominance and submission. Amherst, NY: Prometheus Books.

About the Author Bruce Gross, PhD, JD, MBA, is a fellow of the American College of Forensic Examiners Institute (ACFEI) and is an executive advisory board member of the American Board of Forensic Examiners.

Dr. Gross is also a Diplomate of the American Board of Forensic Examiners, the American Board of Forensic Medicine, and the American Board Psychological Specialties. He has been an ACFEI member since 1996 and is also a Diplomate of the American Psychotherapy Association.

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CE TEST PAGE: FOUR TOTAL CREDITS AVAILABLE (WITH THE COMPLETION OF ALL 4 CE TESTS) To receive CE credit, please do the following: 1.) Read the CE article. 2.) Complete the exam by circling the chosen answer for each question. 3.) Complete the evaluation form. 4.) Mail or fax the completed form, along with $15 for each CE exam taken. A certificate of completion for one CE credit will be sent for each exam passed with a grade of 70% or above. Those who do not pass the exam are notified and will have a second opportunity to complete the exam.

Direct any questions, grievances, or comments to the ACFEI CE Department (phone 800-423-9737; fax 417-881-4702; email cedept@acfei.com

Learning Objectives for “Who Can Best Catch a Liar? A Metaanalysis of Individual Differences in Detecting Deception”

Learning Objectives for “Explaining Acquired Occupational Disability”

After studying this article, participants should be better able to do the following: 1.) Identify the extent to which people are able to detect deception.

2.) Identify which individual difference variables are related to accuracy in detecting deception.

3.) Understand the complexity of sex differences in the ability to detect deception.

4.) Understand how a meta-analysis is conducted.

After studying this article, participants should be better able to do the following: 1.) Recognize that the essential starting point in successful vocational rehabilitation is the identification of the specific cause of a workplace injury.

2.) Explain the event (the injury) in terms of cause and effect reasoning.

3.) Formulate a position as to who is qualified to determine the validity of an occupational disability claim and the basis of the claim.

Article 1: CE test for “Who Can Best Catch a Liar? (See page 6 for article).

Article 2: CE Test for “Explaining Acquired Occupational Disability” (See page 12 for article.)

2.) Compared to students, police officers are: A. Much better at detecting deception.

B. Much worse at detecting deception.

C. At approximately the same level in detecting deception.

D. More confident but worse at detecting deception.

2.) The individual employee may find it easier to leave the workplace with

1.) Which best describes people’s ability to detect deception?

A. People are no better than chance at detecting deception.

B. People detect deception at slightly above chance levels.

C. People are able to detect deception at levels exceeding 75%.

D. The research is unclear on this issue.

3.) What is the relationship between confidence and accuracy in detecting deception?

A. The relationship is statistically significant but not practically significant.

B. The relationship is both statistically and practically significant.

C. The relationship is practically significant but not statistically significant.

D. The relationship is neither statistically nor practically significant.

4.) Are women better able to detect deception than men?

A. Yes B. No C. Women from law enforcement samples were more accurate than men, but men from student samples were more accurate than women.

D. Men from law enforcement samples were slightly more accurate than women, and women from student samples were slightly more accurate than men, but these differences are not statistically significant.

5.) Which of the following personality traits is most related to accuracy in detecting deception?

A. Self-monitoring B. Extraversion C. Agreeableness D. Conscientiousness Evaluation for Article 1: (1-3 rating section) Please circle one (1=Poor 2=Satisfactory 3= Excellent) 1. The author presented material clearly. 1 2 3 2. The stated learning objectives were met. 1 2 3 3. New knowledge or technique was gained. 1 2 3 4. Additional comments:

Payment Information: $15 per test

1.) Unresolved conflict in the workplace is often the precipitator of: A. Stress.

B. Tension buildup.

C. Loss time.

D. All of the above.

a face-saving injury rather than: A. Confront the actual problem.

B. Deny the existence of a difference of opinion.

C. Blame the supervisor.

D. Endure the humiliation.

3.) Attributional theory helps to understand how individuals: A. Signify dissatisfaction.

B. Incur the supervisor’s wrath.

C. Interpret events.

D. Are labeled troublemakers.

4.) True or false: Attributional theory helps explain how individuals perceive their successes and failures.

A. True B. False 5.) Wrzesniewski’s research has shown that individuals experience work in three distinct ways, which include all of the following EXCEPT: A. As odious and undesirable.

B. As a calling.

C. As a career.

D. As a job.

Evaluation for Article 2: (1-3 rating section) Please circle one (1=Poor 2=Satisfactory 3= Excellent) 1. The author presented material clearly. 1 2 3 2. The stated learning objectives were met. 1 2 3 3. New knowledge or technique was gained. 1 2 3 4. Additional comments:

(Identifying information: Please print legibly or type the following:)

Name:

Fax Number:

Address:

City:

Phone Number: State:

Zip:

E-mail:

Credit Card #

Signature

Circle one:

Statement of completion: I attest to having completed the CE activity. Please send the completed form, along with your payment of $15 for each test taken. Fax: (417) 881-4702, or mail the forms to ACFEI Continuing Education, 2750 E. Sunshine, Springfield, MO 65804. If you have questions, please call (417) 881-3818 or toll free at (800) 423-9737.

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62 THE FORENSIC EXAMINER Spring 2006

Date

CE TEST PAGE: FOUR TOTAL CREDITS AVAILABLE (WITH THE COMPLETION OF ALL 4 CE TESTS)

Learning Objectives for “Using Modeling to Determine Medical Supply Requirements for Terrorism Response” After studying this article, participants should better understand the following: 1.) The use of modeling in determining medical supply requirements for military operations and terrorism response.

2.) The medical capabilities and skills required of terrorism medical responders.

3.) The need for regularly scheduled reviews of medical inventories for terrorism response to ensure required capabilities are properly supplied.

1.) A physiatrist is a medical specialist who: A. Diagnoses and treats physical impairment resulting from illness or injury.

B. Uses primarily conservative treatment modalities.

C. Directs an interdisciplinary team of rehabilitation professionals.

D. Is directed to decrease functional impairment and increase quality of life.

E. All of the above.

1.) Modeling medical supply requirements ensures that clinicians: A. Do not spend over their budgets.

B. Get the needed type and amount of medical equipment and supplies.

C. Know what each piece of equipment does and how it is used.

D. Are restricted to only those supplies authorized by military leaders.

2.) Historical data of combat injuries are used to determine: A. Which soldiers or Marines will get higher combat pay.

B. When to send a medic or a qualified doctor with a patrol.

C. The best way to perform surgical procedures under austere field conditions.

D. Likely patient types to be encountered under different battle conditions.

3.) Although the CBIRF mission had expanded in scope, NHRC’s modeling showed: A. CBIRF medical manpower had stayed the same.

B. CBIRF training had been inadequate.

C. Deficiencies in CBIRF medical supplies in the areas of radiological response and the treatment of crush syndrome.

D. CBIRF medical supplies were bloated, overweight, and too expensive.

4.) The Chemical Biological Incident Response Force was established in response to: A. Presidential Decision Directive 39, signed by then-President Bill Clinton.

B. The Al-Qaida attacks on the World Trade Center and the Pentagon on September 11, 2001.

C. An order of then-Marine Corps Commandant General James Jones.

D. Both answers A and C. 5.) NHRC’s study of CBIRF medical inventory: A. Showed that NHRC’s method of modeling medical requirements can be used to determine clinical needs for terrorism response.

B. Showed that modeling can be used to thwart terrorism attacks.

C. Suggested we are terribly unprepared for another Al-Qaida attack.

D. Indicated CBIRF requires additional doctors and corpsmen.

Payment Information: $15 per test

(Identifying information: Please print legibly or type the following:) Fax Number:

Address:

City:

Credit Card # check enclosed

Name on card:

2.) A physiatrist’s training includes: A. Medical school.

B. Internship training.

C. Residency training specializing in physical medicine and rehabilitation.

D. Specialized neuro-muscular and electrodiagnosis training.

E. All of the above.

3.) Life care planning in this case includes all of the following EXCEPT: A. Present and future medical care needs.

B. Reasonable prognostication of medical and physical impairment progression.

C. Present and future durable medical equipment requirements.

D. Long-term view of potential need for attendant or nursing home care.

E. Vocational rehabilitation.

4.) With regard to forensic medical concerns, a physiatrist may be required to: A. Delineate extent, causation, and impact of physical impairment.

B. Specify treatment to minimize secondary complications and progression of disability.

C. Develop or critique life care planning.

D. Assist the attorney in planning the presentation of evidence and testimony.

E. All of the above.

5.) In the case presented, which of the following is true?

A. Pressure ulcerations occur most often due to prolonged pressure on the skin and subcutaneous tissues over a boney prominence.

B. A sacral area pressure ulceration always leads to more severe medical problems in the lower extremities.

C. Temporal association of two medical processes does not necessarily indicate a causal relationship.

D. A and C are correct.

E. All of the above are correct.

Evaluation for Article 4: (1-3 rating section) Please circle one (1=Poor 2=Satisfactory 3= Excellent) 1. The author presented material clearly. 1 2 3 2. The stated learning objectives were met. 1 2 3 3. New knowledge or technique was gained. 1 2 3 4. Additional comments:

Name:

Circle one:

After studying this article, participants should better understand the following: 1.) The physiatrist’s role as a clinician and forensic expert.

2.) The areas of medical training that encompass the medical specialty of physical medicine and rehabilitation.

3.) The main objectives of life care planning.

4.) In medical forensics, temporal association does not always imply causation.

Article 4: CE Test for “Forensic Physiatry: A Case Study” (See page 32 for article).

Article 3: CE test for “Using Modeling to Determine Medical Supply Requirements for Terrorism Response” (See page 24 for article).

Evaluation for Article 3: (1-3 rating section) Please circle one (1=Poor 2=Satisfactory 3= Excellent) 1. The author presented material clearly. 1 2 3 2. The stated learning objectives were met. 1 2 3 3. New knowledge or technique was gained. 1 2 3 4. Additional comments:

Learning Objectives for “Forensic Physiatry: A Case Study”

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Statement of completion: I attest to having completed the CE activity. Please send the completed form, along with your payment of $15 for each test taken. Fax: (417) 881-4702, or mail the forms to ACFEI Continuing Education, 2750 E. Sunshine, Springfield, MO 65804. If you have questions, please call (417) 881-3818 or toll free at (800) 423-9737.

Spring 2006 THE FORENSIC EXAMINER 63

Regional Certification Conference Las Vegas, NV • MGM Grand • July 18-19, 2006 This will be the only chance for qualified professionals to earn a new certification at a live course through ACFEI in 2006! Choose from any of the following certification review courses: The Certified Medical Investigator®, CMI, Course The Certified Forensic Nurse, CFNSM, Course The Certified Forensic Consultant, CFCSM, Course The Certified Forensic Accountant, Cr. FA®, Course Register for this conference by April 15th and save $50!

ACFEI’s 14th National Conference Orlando, FL • Buena Vista Palace in the WALT DISNEY WORLD® Resort • September 22-23, 2006 This exciting conference is a must-attend event for anyone passionate about forensics. The conference will feature dozens of exciting and cutting-edge forensics presentations, plus this year’s keynote address will be delivered by Barry Scheck, co-founder of the Innocence Project. The Innocence Project is a non-profit legal clinic and criminal justice reform organization that handles cases in which people’s convictions can be challenged via DNA testing. To date the Innocence Project has helped exonerate 172 people, including 14 who were at one time sentenced to death.

Register for this conference by April 10th and save $100!

Register now for either of these conferences!

Call toll free (800) 423-9737, ext. 156, email carlye@acfei.com, or visit www.acfei.com.

64 THE FORENSIC EXAMINER Spring 2006

★ ★ SAVE 30% when you register for both the CHS Conference and the ACFEI, APA, or AAIM Conference! ★ ★

2006 NATIONAL CONFERENCE

Celebrate...Escape...Educate!

Orlando, Florida • Buena Vista Palace • September 2006 (Please type or print your name as you would like it to appear on your badge.)

Name Designation Member ID # Address City State Zip Phone ( ) Fax ( ) Email ❑ The American College of Forensic Examiners (ACFEI) 2006 National Conference ❑ The American Psychotherapy Association (APA) 2006 National Conference ❑ The American Association of Integrative Medicine (AAIM) 2006 National Conference September 22-23, 2006

Please check which of the above three associations’ conferences you wish to attend. (Check only one.) Registration with ACFEI, APA, or AAIM grants you full access to the sessions of ALL three associations. However, you will only receive the complementary conference merchandise for the association with which you register.

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$240 $270 $300 $330 $360 $ Student Non-Member (save 40%) $300 $330 $360 $390 $420 $ $300 $350 $400 $450 $500 Spouse/Guest $ Circle one: Spouse Guest Name: (Spouse/Guest registrants cannot earn CE.) Banquet Tickets: $50 ($75 if purchased onsite)

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❑ The Certified in Homeland Security (CHS) National Conference September 20-21, 2006

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All requests for cancellation of conference registration must be made to Association Headquarters in writing by fax or mail. Phone cancellations will not be accepted. All cancelled/ refunded registrations will be assessed a $50 administrative fee. All refunds will be issued in the form of credit vouchers and are pro-rated as follows: cancellations received four or more weeks prior to the conference = 100% refund (less $50 administrative fee); cancellations received less than four weeks but more than one week prior to the conference = 50% refund (less $50 administrative fee); cancellations received one week or less prior to the conference = no refund. For more information on administrative policies, such as grievances, call (800) 423-9737, ext. 157. The performance of this conference is subject to the acts of God, war, government regulation, disaster, strikes, civil disorder, curtailment of transportation facilities or any other emergency making it impossible to hold the conference. In the event of such occurrences, credit vouchers will be issued in lieu of cash. Conference schedule is subject to change. Please be prepared to show photo identification upon arrival at the conference.

❑ Check here if you require special accommodations to participate in accordance with the Americans with Disabilities Act. Attach a written description of your needs.

FAX YOUR REGISTRATION FORM TODAY to (417) 881-4702 MAIL TO Association Headquarters, 2750 E. Sunshine Springfield, MO 65804; PHONE toll free (800) 423-9737

H H H H H H Earn up to 14 continuing education credits! H H H H H H

ACFEI’s 2006 REGIONAL CONFERENCE Las Vegas, NV

•

MGM Grand

•

July 18-19, 2006

(Please print your name as you would like it to appear on your badge.)

Last Name First Name M.I. Office Phone Home Phone Fax Email Street Address City State Zip Code Designation, Primary Areas of Expertise

Date

I certify that the information provided in this application is true and correct. I may be asked to provide additional documentation. If I misrepresent my credentials, refuse to provide documentation at a later time if asked, or allow my membership with the American College of Forensic Examiners Institute to lapse, I understand and agree that my certification status will be revoked and my membership terminated. I affirm that all of the information that I have provided to ACFEI is true, correct, and complete, and I agree to hold harmless and indemnify ACFEI and its officers, directors, employees, and agents for any misrepresentation of my credentials and for all claims, loss, judgment, or expense. I understand that ACFEI reserves the right to verify any and all information on this application.

I certify that I have not been convicted of a felony. I have not been­ disciplined for an ethical violation in the last 10 years, nor am I under investigation by any legal or licensing board. The American College of Forensic Examiners Institute (ACFEI) does not endorse, guarantee, or warrant the work or opinions of any individual members. Membership does not imply licensing or registration by the organization of a member’s qualifications, abilities, or expertise. The objective of ACFEI’s publications and the activities that it sponsors are for informative and educational purposes. The views expressed by the authors, publishers, or presenters are their own views and do not necessarily reflect those of ACFEI. ACFEI does not assume any responsibility or liability for its members or subscribers’ efforts to apply or utilize the information, suggestions, or recommendations made by the organization, publication resources, or activities.

Signature

Date

I. ACFEI Membership Categories

Check one of the following categories of membership. (International members, please add $25 to annual dues to cover additional postage.)

Requirement – A complete résumé and license (if applicable) documenting background and experience must accompany your application, as well as three professional references. q Current Member Member Identification Number: q Member: $145 for 1 year’s annual dues q Life Member: $1,850 (Never pay dues again. Payment plan available—call 800-423-9737 for information.) $

II. Conference Certification Review Course Registration

Applicants for these courses must be ACFEI members in good standing; have appropriate credentials for their profession, current and unrestricted, with no history of revocation or suspension; have records of compliance with all applicable local ordinances, state laws, and federal regulations for their professions; and not be under investigation by any law enforcement agency, licensing board, professional association, or other entity. Some of these courses have prerequisites; you may be asked to provide additional information at a later date.

Please check the course that you wish to attend. You must select only one.

❑ The Certified Forensic Consultant, CFCSM, course

Early Bird (Until 4/15)

$445

Regular (After 4/15) $495

❑ The Certified Forensic Nurse, CFNSM, course

$300

$350

❑ The Certified Medical Investigator®, CMI, course

$445

$495

$445

$495

Please check your anticipated level: ❑ CMI-I ❑ CMI-II ❑ CMI-III ❑ CMI-IV ❑ CMI-V

❑ The Certified Forensic Accountant, Cr.FA®, course

III. Payment Information Payment must accompany application. o MasterCard Card Number:

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All requests for cancellation of conference registration must be made to ACFEI headquarters in writing by fax or mail. Phone cancellations will not be accepted. All cancelled/refunded registrations will be assessed a $50 administrative fee. All refunds will be issued in the form of credit vouchers and are pro-rated as follows: cancellations received 4 or more weeks prior to the conference = 100% refund (less $50 administrative fee); cancellations received less than 4 weeks but more than 1 week prior to the conference = 50% refund (less $50 administrative fee); cancellations received 1 week or less prior to the conference = no refund. The performance of this conference is subject to the acts of God, war, government regulation, disaster, strikes, civil disorder, curtailment of transportation facilities, or any other emergency making it impossible to hold the conference. In the event of such occurrences, credit vouchers will be issued in lieu of cash. Conference schedule is subject to change. Please be prepared to show photo identification upon arrival at the conference.

❑ Check here if you require special accommodations to participate in accordance with the Americans with Disabilities Act. Attach a written description of your needs.

fax to (417) 881-4702 • mail to: ACFEI, 2750 E. Sunshine, Springfield, MO 65804 www.ACFEI.com • call toll free (800) 423-9737, ext. 156 • email carlye@acfei.com

Mountain State University (MSU) *ACFEI members save 20% MSU is a private, non-profit university with North Central accreditation. It offers a variety of internet, distance learning, and on-site programs at both the bachelor’s and master’s levels. These degree programs are focused A grave dig is part of MSU’s forensics program. on high-demand professional fields as well as the humanities and sciences. Thanks to an educational strategic partnership between ACFEI and MSU, ACFEI members can save up to 20% on tuition and related fees!

For more information on MSU visit www.mountainstate.edu or send an email to Dr. Harvey Stone at hstone@mountainstate.edu.

What part do I play in the spiritual lives of my friends, relatives, co-workers, and clients?

The 7 Steps to The Cure of Souls Written by the Founder of the American College of Forensic Examiners, Robert O’Block, MDiv, PhD, DMin

To order, visit www.cureofsouls.com or call (800) 423-9737.

Offer Continuing Medical Education (CME) through your organization by jointly sponsoring an activity with the American College of Forensic Examiners International (ACFEI). By jointly sponsoring activities with ACFEI, a nationally accredited provider of Continuing Medical Education, you can offer Continuing Medical Education to physicians in practice anywhere in the United States.

For more information about how your organization can offer CME by jointly sponsoring an activity with ACFEI, call toll free (800) 4239737 or send an email to cedept@acfei.com.

“In addressing the important subject of spiritual healing, this book is a valuable tool for those who are interested in the care of the whole person. This is a fresh and interesting approach to an important topic in the development of the spiritual life.”

- Robert W Hotes, PhD, DACC, Bishop, Counselor, and Psychological Researcher

www.acfei.com Spring 2006 THE FORENSIC EXAMINER 67

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The Forensic Investigation Handbook is one of the most comprehensive forensic science texts available today. It outlines the general principles of forensic science including an overview of the history of forensic science, an introduction to ballistics, crime scene investigation techniques as well as evidence gathering, processing and documentation procedures. The Forensic Investigation Handbook presents valuable information on advanced forensic topics as well. These areas include criminal profiling, fingerprints and DNA as identification, the forensic autopsy, pharmacology, toxicology, and biohazard risks for the forensic investigator. The handbook also provides the reader with information on the American criminal justice system and how it relates to forensic science. The handbook also features one of the most detailed and extensive forensic glossaries ever assembled. It includes more than 600 pertinent forensic terms with definitions that will serve as an invaluable desk reference for forensic novices and seasoned veterans alike. The Forensic Investigation Handbook was written by Dr. Michael Karagiozis - a physician with fifteen years experience in the field of medicine and criminal justice and Richard Sgaglio, a professional with experience in both medical administration and hands-on investigation. In addition to writing, consulting and speaking nationally, Dr. Karagiozis is the lead instructor for the Certified Medical Investigator courses offered through the American College of Forensic Examiners Institute.

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Current Perspectives: Working With Sexually Aggressive Youth and Youth With Sexual Behavior Problems

By Robert E. Longo, DABFC, and David S. Prescott, MSW, LICSW, DABFSW

Robert E. Longo

The field of evaluating and treating sexual abusers is young and represents the junction between psychology, criminology, medicine, sexology, and other diverse professions.

David S. Prescott With the increasing emphasis on evidence-based methods for assessment and treatment and an emerging body of literature, professionals are obligated to stay up-to-date with a field that is changing rapidly. This is especially important with juveniles, as research demonstrates they are a different population than their adult counterparts.

Robert E. Longo and David S. Prescott have assembled the current findings and thoughts of numerous professionals from North America, Europe, and Australasia in Current Perspectives: Working With Sexually Aggressive Youth and Youth With Sexual Behavior Problems. Through 29 chapters the authors (many of whom are undisputed leaders in the field) provide a thorough review of literature regarding such topics as typology, etiology, interviewing, and understanding special populations (e.g., female adolescents,

families, and the developmentally delayed) and discuss strategies for assessment, understanding, and treatment. The authors place a special emphasis on the need for a holistic perspective and for an understanding of sexual abuse from a public health perspective. Given the extraordinary needs of youth, their families, and their communities, this work will benefit all who attempt to rise to the challenge.

Robert E. Longo is a pioneer in the assessment and treatment of sexual abusers. He was instrumental in founding the Association for the Treatment of Sexual Abusers (ATSA), the world’s largest organization for professionals in this field, and is the only recipient of that organization’s “Founder’s Award.” Mr. Longo also helped bring the Safer Society Press (and its associated foundation) to national prominence as one of the first companies to produce books for professionals working with sexual abusers. He is in charge of publishing at New England Adolescent Research Institute (NEARI) Press, which publishes books for professionals working with youth who have been sexually abused. He provides consultation and training around the world and in recent years has run programs for youth who have been sexually abused. Mr. Longo is the author of several workbooks for adults and youth attempting to come to terms with their harmful sexual behavior.

He is a Diplomate of the American Board of Forensic Counselors and has been a member of the American College of Forensic Examiners since 1999.

David S. Prescott, LICSW, is the treatment assessment director at the Sand Ridge Secure Treatment Center in Mauston, Wisconsin.

Prescott has published articles on risk assessment, interviewing, and providing residential treatment to youth, and he has edited books on youth who have been sexually abused. He has presented on these topics around North America and in Europe. Prescott is a member of the Executive Board of Directors of the Association for the Treatment of Sexual Abusers (ATSA) and edits that organization’s

newsletter, The Forum. He is a Diplomate of the American Board of Forensic Social Workers and has been a member of the American College of Forensic Examiners since 2000.

The Expert Witness Handbook

By Dan Poyner, BS, DACFEI

Dan Poyner

Before appearing in court, expert witnesses are often concerned about what questions they are going to be asked and what they should say. As they will learn by reading The Expert Witness Handbook: Tips and Techniques for the Litigation Consultant by Dan Poyner, experts should not feel intimidated by the court system. The text explains how to prepare for testimony, how to act at a deposition and in court, how to make testimony more effective, how to handle difficult questions, and much more. The book is filled with thorough sample questions and answers that have been taken from actual courtroom experiences. The clever replies are not only very educational, but also a delight to read.

This book contains knowledge gained from the author’s vast experiences in the courtroom and wisdom he has picked up from other expert witnesses, litigation attorneys, law professors, and judges. The text has been written to help experts perform professionally and successfully in the courtroom.

The Expert Witness Handbook is a valuable

Spring 2006 THE FORENSIC EXAMINER 69

reference and will make an important addition to the library of any consultant.

Dan Poynter, BS, has served as an expert witness and litigation consultant in the fields of parachutes and skydiving since 1973. He has worked on more than 100 cases and has testified numerous times. He is also a frequent speaker on litigation consulting and has written over 70 books and more than 500 magazine articles. His work as an author over the last 35 years has allowed him to study his subjects in detail while validating his expertise. He is a Diplomate of the American College of Forensic Examiners and has been a member since 1996.

The 7 Steps to The Cure of Souls

By Robert L. O’Block, MDiv, PhD, PsyD, DMin

Dr. Robert L. O’Block

Providing spiritual guidance, as a Curate (or spiritual counselor) would, to help others obtain spiritual wholeness is an underlying theme of a new book, The 7 Steps to The Cure of Souls. There is a long history of the Cure of Souls that can be described as the spiritual healing of humankind. The concept has been around for many years, but with the diminishing authority of the church this concept has been largely forgotten.

The Cure of Souls is not a band-aid approach to overcome personal emotional problems. Neither is it another self-improvement course. Nor is it a journey down life’s pathway where we attempt to find ourselves or learn who we really are so we can enjoy life more. Rather, the Cure of Souls goes much deeper—it provides the tools and guidance to help readers achieve peace in their lives, with God, with themselves, and with others.

While the book is not Scripture, it does complement the Bible, and extensive passages of Scripture are quoted to provide a

Godly foundation for the 7 steps the reader will experience. The definition of Cure of Souls is explained in the first chapter; then, the 7 steps are outlined: • Step 1 is the rejection of sin.

• Step 2 takes readers through the process of confessing sin to God. Confession is defined simply as acknowledging sin.

• Step 3 is receiving forgiveness and forgiving others.

• Step 4, faith, is closely tied to trust and truth.

• Step 5 is love.

• Step 6 is prayer.

• The final step, Step 7, is holiness. Living with God in holiness is living near to God’s heart, communicating with Him, and hearing from Him. As readers progress through the 7 steps, they will come to better understand how to reject sin, confess any sin in their lives, receive and offer forgiveness, have faith, learn how God loves them and how to love others, pray without ceasing, and achieve the place of living in holiness with their Creator, with a cured soul.

Additionally, spiritual counselors and members of the clergy will find this book particularly useful as a tool to help others understand the Bible and form closer, more meaningful relationships with God. This book is ideal for all types of believers because it isn’t about religion; it is about forming a unique, fulfilling, and lasting relationship with one’s Creator.

Robert O’Block, MDiv, PhD, PsyD, DMin, is the founder of the American College of Forensic Examiners, the American Psychotherapy Association, the American Association of Integrative Medicine, and the Society for The Cure of Souls.

When “I Love You” Turns Violent: Recognizing and Confronting Dangerous Relationships

By Scott A. Johnson, MA, LP, DACFEI In the newly revised, updated, and expanded When “I Love You” Turns Violent: Recognizing and Confronting Dangerous Relationships, psychologist Scott A. Johnson offers insightful, proven facts, and strategies that readers need to identify, handle, and hopefully heal or, if necessary, end relationships filled with conflict. With real-life examples, checklists, charts, and diagrams, Johnson teaches couples to recognize the signs and symptoms

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of emotional, psychological, physical, and sexual abuse.

This clearly written guide offers effective solutions, with 19 rules for problem resolution, and provides partners with a productive plan to deal with conflicts that turn into major emotional and/or physical confrontations. Couples will learn the features essential to healthy relationships (and how to develop them in their troubled unions) as well as the three factors for healthy sexual behavior.

Johnson also reveals patterns of thinking that make some people more likely to abuse or be victimized and explains to readers the necessary steps to change those patterns.

There are several new chapters, including a chapter containing intervention strategies for readers who have friends and loved ones trapped in abusive relationships, a chapter focused on alcohol’s role in abuse, and a chapter devoted to military families. The vital information, tools, and tips within this book are essential when confronting violence and developing happy, healthy relationships.

Scott. A. Johnson, MA, is a licensed psychologist who specializes in relationship issues and forensic psychology. In addition to his private practice, Johnson is an adjunct instructor at Saint Mary’s College Graduate Center and has conducted forensic evaluations on sexual offenders for the state of Minnesota. He is a Diplomate of the American Board Psychological Specialties and has been a member of the American College of Forensic Examiners since 1998. He is also a Diplomate of the American Academy of Certified Consultants and Experts.

Falsely Accused DNA Evidence Frees Man Whose Confession Put Him Behind Bars for 17 Years On August 26, 2002, Eddie Joe Lloyd was exonerated after DNA tests proved he could not have committed the crimes for which he was convicted.

On the cold winter morning of January 24, 1984, Michelle Jackson went to a bus stop in a town in Michigan and failed to return home that evening. Her worried parents went around the neighborhood that night, asking if anyone had seen their 16-year-old daughter. Alarmed, the neighbors organized a search party and, to their horror, found Michelle Jackson strangled to death in an abandoned garage.

Months went by after Michelle’s death and the police hadn’t arrested anyone.

Then one day, 8 months after the crime, police received a letter from Eddie Joe Lloyd, a patient who had been involuntarily admitted to a mental health hospital after having a dispute in a welfare office.

Lloyd wrote to the police to request a file on the case and to give them tips about how to catch Michelle’s murderer and solve other murder cases. Police immediately narrowed in on Lloyd as a suspect in

the case of Michelle Jackson and started visiting the hospital and interrogating him. Soon, police had a written and recorded confession from Lloyd.

In his confession Lloyd provided the police with many specific details that were not released to the public. He knew the location of the body, the exact date of the crime, what type of jeans and earrings the victim was wearing, what type of knife was used to threaten her, that longjohns were used to strangle her, and that a green bottle was used to assault her.

At his hearing Lloyd pled not guilty and claimed the police tricked him into confessing to the murder, revealing to him all of the unreleased information.

He maintained the story that during interrogation they convinced him that his confession would help “smoke out” the real killer. Lloyd testified that he confessed to the murder of Michelle because he wanted to help.

The jury was not convinced though.

There was semen and other biological evidence presented during the trial, but no testing connecting Lloyd to that evidence was offered. Even with no conclusive DNA evidence to support the decision, and after deliberating for less than an hour, the jury found Lloyd guilty based on his confession. He was convicted of Michelle’s rape and murder in 1985 and was sentenced to life in prison without parole.

Lloyd contacted the Innocence Project 10 years after his conviction, desperate for the project to test the biological evidence that was found at the scene. It took several years for students to finally find the evidence they needed.

The Forensic Science Association (FSA) and the Michigan State Crime lab both found that the spermatozoa on the mouth of the green bottle, the spermatozoa found on a piece of paper stuck to the bottle, the spermatozoa on the long johns that were used to strangle the victim, and the spermatozoa on the anal slides that were gathered at the autopsy all matched each other. When tested, the only spermatozoa that didn’t match were the spermatozoa of the man who had spent 17 years in prison for the rape and murder

of the victim. In 2002 Lloyd became the 110th person in the United States to be exonerated thanks to DNA evidence.

Luckily, there is no death penalty in the state of Minnesota; otherwise an innocent man would have likely been executed. False confessions have been behind around 20% of DNA exonerations. In a number of those cases, the falsely accused person has been mentally retarded or mentally ill.

Many believed that the investigation and trial that sent Lloyd to prison should have been scrutinized, saying that his case illuminated a national problem with false confessions, especially with those who are mentally ill. It is hard to believe that anyone would trick a mentally-ill person into confessing to the murder of a teenager, but how else would Lloyd have known all of the undisclosed details that he provided in his confession? If responsible, the police who interrogated him not only caused an innocent man to suffer in prison, but let the perpetrator, who has yet to be found, go free.

References The Innocence Project. (2001). Eddie Joe Lloyd. Retrieved January 11, 2006, from http://www.innocenceproject.org/ case/display_profile.php?id=110 After 17 years, DNA frees man who confessed to murder. (2002). The Sydney Morning Gerald. Retrieved January 13, 2006, from http://www.smh.com.au/ articles/2002/08/27/1030053060280. html Wilgoren, J. (2002). Confession had his signature; DNA did not. The New York Times on the Web. Retrieved January 11, 2006, from http:// www.truthinjustice.org/eddie-lloyd.htm

Has your work on a case helped to exonerate someone who was falsely accused? Send your story to editor@ acfei.com or write to Editor, 2750 E. Sunshine, Springfield MO, 65804

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