A Day in the Life of a Clinical Psychologist Expert Witness

Jane Duff is a Consultant Clinical Psychologist, Head of the National Spinal Injuries Centre Psychology Service, and an Expert Witness. Here, she tells us what she loves about her work and how her clinical and medicolegal roles come together to complement one another.

Psychology and Expert Witness work are both like a jigsaw puzzle.

With psychology, you think around a person’s difficulties and why they might be experiencing them at that moment in time. It’s very evidence based and informed by research.

Expert Witness work is the same. You’re trying to put the pieces together and explore the reasons why someone/something might be presenting the way they are.

It tells a narrative that makes clinical sense to me in terms of the person’s history and what I know from the literature base. 

The cases I get involved in are predominantly about spinal cord injury.

I’ve worked in spinal cord injury rehabilitation for around 30 years, so it’s my area of expertise. I mainly get instructed on clinical negligence or personal injury cases. These cases are normally very high value, which drives litigation costs up significantly, so they usually settle out of court.

I sometimes work on cases about other catastrophic injuries, such as limb loss. The psychological adjustment, adaptation processes, and associated societal challenges can be similar to those resulting from spinal cord injuries.

Very few Expert Witnesses specialise in clinical psychology and spinal cord injury.

It’s not unusual for me to be booked up 18 months in advance. I would encourage other clinical psychologists working in spinal cord injury to consider becoming an Expert Witness and play a vital role in the justice system.

It’s really important to have current clinical expertise as an Expert Witness. 

Working clinically for the length of time that I have, I’ve seen a wide spectrum of needs associated with spinal cord injury. When I’m assessing someone medicolegally, I can think where I would put them on that range because of my clinical experience.

I form my opinion from a comprehensive assessment of psychosocial issues and by drawing on my experience, looking at the person’s needs in relation to other medico-legal clients and patients I’ve worked with. 

As well as the common areas of assessment — like mood, anxiety and trauma — I consider a range of secondary health conditions, such as sleeping difficulties, fatigue and pain. I also look at personal aspects, like resilience and self-efficacy.

All these factors influence how a person might manage the lifelong regimen of health monitoring that results from many spinal cord injuries. 

From a professional satisfaction point of view, I like the depth I can go into with a client in my medicolegal work.

Most people I see in my inpatient NHS role have very complex needs. Psychological stabilisation after sustaining a spinal cord injury can take up to five years, with about 30% of people having long term adjustment difficulties. 

Many people wouldn’t get the amount of psychological therapy on the NHS that they need to lead a good quality of life.

As an Expert Witness, I can recommend longer treatment duration, intensity and different treatment modalities than would be available through community resources. 

Talking therapy is the general NHS community offer, but it is time limited.

Complex spinal cord injury adjustment often requires a transdiagnostic and integrated therapy approach, such as using elements of Acceptance and Commitment Therapy or Compassion Focused Therapy alongside specific and targeted interventions common in cognitive behavioural therapy skills. 

This approach can be particularly important for psychological issues like adjustment and where therapy protocols have yet to be developed, as well as for newer therapy modalities. 

People tend not to be able to access this multi-modal approach and the longer treatment duration needed for complex physical health in community settings on the NHS.

I have published some of my clinical work to help promote a broader knowledge about delivering psychological therapy and demonstrate use of the appraisals model that I and my colleague Paul Kennedy developed.

I learn something from every case I’m instructed on.

Years of experience have taught me that when you work in physical health, you need a broad holistic psychosocial based assessment. In my assessments, I include things like fear of falling, cognitive fatigue and other secondary health conditions.

Anxiety and depression, for example, are often underdiagnosed following spinal cord injury. It could be that symptoms present differently or are specifically associated with spinal cord injury.

There can be a tendency for psychology Experts to focus only on the dominant elements —for example, diagnosing mood or PTSD — and not give sufficient weight to more holistic and lived experience concerns — such as incontinence worries, perceived stigma and negative societal judgements to disability, and any consequent impact on the person’s identity following physical disability. In my experience, these can be some of underlying issues that exacerbate mood and require a more multi-modal treatment approach.

I’ve also found that non-spinal cord injury clinicians who are Experts often don’t consider sex and intimacy needs, and don’t make a treatment recommendation for psychosexual therapy, or for the common associated secondary health conditions if needed.

Being independent isn’t difficult for me.

While I’m normally instructed by the claimant, as an Expert Witness I have to be independent. And as a psychologist, I always hold a curious, inquiring position. It’s a key part of our clinical training: to start with a blank slate and see what emerges from the difficulty that someone is describing. Applying this approach to my Expert Witness work came naturally.

To be a successful Expert Witness, you need to have the ability to say no.

Deadlines are important, so if you know you can’t commit to a certain timeframe it’s important to be honest and turn work down. I approach my Expert Witness work with the same degree of thoroughness and professionalism that I approach my clinical work.

I’ve learned not to commit to too many cases.

As well as my clinical job and Expert Witness work, I speak at conferences and am Chair of the European Spinal Psychologists Association. I dedicate one day a week to medicolegal cases. It’s very important to me to keep it as a distinct part of my working week, so I have the headspace I need to think comprehensively about a person’s needs.

I’ve learnt to limit my medico-legal commitments ahead of speaking at the significant spinal cord injury conferences. It does contribute to my waiting list, or means that I turn down cases, but enables me to be fully present and bring my best self to whatever I am working on.

It’s not unusual for me to receive 2,000 – 3,000 pages of clinical notes to go through for a case.

In my experience there can be some duplication, but I’m fortunate to receive well organised notes from most of the solicitors I work with.

When I review notes, I create a chronology of the person’s history. It helps if, for example, I come across clinical notes from a GP that were not present in the earlier hospital notes. I cross reference the chronology with the page and reference for the clinical notes, which helps with report writing.

My advice for anyone new to medicolegal work is to set aside more time than you think to go through the notes and make sure you receive them well in advance of doing an assessment.

I need to feel confident that I can defend my opinion on the witness stand.

Thinking time is really important. When I’ve drafted my Expert Report, I go away and come back to look at it with fresh eyes. It can take time to weigh up the diagnosis and form a final opinion.

I carry out psychometric tests as part of my assessment. When you put these together with the client’s opinion and your own expertise, the jigsaw starts to come together.

Taking time and using a range of psychometric measures, particularly those associated with broader psychosocial concerns, alongside a clinical interview and the person’s history helps augment my initial clinical impression. It also provides a gauge that I can use to compare a client’s responses with others I’ve assessed.

I enjoy the rigour and evidence base required from being an Expert Witness.

My clinical practice has definitely benefitted from being an Expert, as it helps me to be up to date in terms of literature and research.