The Non-Disclosing Patient: A Clinician's Guide [1st ed.] 9783030486136, 9783030486143

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The Non-Disclosing Patient A Clinician’s Guide Alexander Lerman

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The Non-Disclosing Patient

Alexander Lerman

The Non-Disclosing Patient A Clinician's Guide

Alexander Lerman Westchester Medical Center New York Medical College Valhalla NY USA

ISBN 978-3-030-48613-6    ISBN 978-3-030-48614-3 (eBook) https://doi.org/10.1007/978-3-030-48614-3 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Contents

Part I DND in the Clinical Encounter 1 A Personal Encounter with Deceit�������������������������������   3 A Question of Relevance�����������������������������������������������   7 2 Deception in the Psychiatric Interview������������������������   9 Fact Collection and “Templating”���������������������������������  10 Assessment Goes Awry���������������������������������������������  11 Psychotherapeutic Literature�����������������������������������  12 Therapeutic Repulsion����������������������������������������������  13 References������������������������������������������������������������������������  16 3 Types of Interviews, Types of Listening�����������������������  17 The Fact-Based Interview����������������������������������������������  17 The Meaning-Focused Interview�����������������������������������  19 Beyond Facts: The Transactional Interview������������������  20 Stratified Listening����������������������������������������������������������  21 Level I: The Subjective Narrative����������������������������  23 Level II: The Emotional Narrative��������������������������  23 Level III: Omissions and Distortions����������������������  24 Level IV: (Formulation-Guided) Listening������������  25 “Hard” and “Soft” DND������������������������������������������������  25 Conclusion������������������������������������������������������������������������  26 Reference�������������������������������������������������������������������������  26

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4 Therapeutic and Anti-­therapeutic Relationships������    27 The Therapeutic Relationship��������������������������������������   29 Therapeutic Relationship and Behavioral Therapy���������������������������������������������������������������������������   30 References����������������������������������������������������������������������   33 5 Engaging Deceit������������������������������������������������������������   35 Four Principles of Engaging Deception and Non-­Disclosure (DND)����������������������������������������   35 Interviewing Charlie�����������������������������������������������������   46 Charlie as Storyteller�����������������������������������������������   46 References����������������������������������������������������������������������   48 6 Deceit and Its Meaning������������������������������������������������   49 Application of the Transactional Interview���������������   49 Transactional Encounters���������������������������������������������   53 Objections to Psychodynamic Principles��������������������   56 Absence of Treatment Frame���������������������������������   56 Failure of Neutrality������������������������������������������������   57 Imbalance of Power������������������������������������������������������   61 Anxiety���������������������������������������������������������������������������   62 Part II Personality Functioning and DND 7 Neurobiology of Deception�����������������������������������������   67 Executive Function and Deception�����������������������������   67 Deception Detection Techniques��������������������������������   69 Polygraph������������������������������������������������������������������   71 Thermal Imaging������������������������������������������������������   72 Electroencephalogram (EEG)�������������������������������   72 Neuroimaging of Deception����������������������������������������   73 Functional Magnetic Resonance Imaging (fMRI)�������������������������������������������������������   74 Connectivity Studies������������������������������������������������   78 Neurochemistry of Deception�������������������������������������   81 Attention�������������������������������������������������������������������   82 Memory���������������������������������������������������������������������   84 Inhibitory Modulation���������������������������������������������   88 Deception and Role of Genetics���������������������������������   89 Conclusion����������������������������������������������������������������������   91 References����������������������������������������������������������������������   92

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8 Shared Consciousness and the Emergence of Mind���������������������������������������������������������������������������   97 The Capacity to Conceal���������������������������������������������� 101 Types of Deception: Concealment, Falsification, and Dissociation������������������������������������� 101 Nondisclosure and the “Moral High Ground”����������  102 Engaging Deceit�������������������������������������������������������  102 Proposition One: DND Manifests as Hopelessness�������������������������������������������������������������  103 Proposition Two: DND Is a Window���������������������������  104 Attributes of Deception�����������������������������������������������  104 Taxonomy of Deception: Nondisclosure and Concealment�����������������������������������������������������������  105 Self-Deception���������������������������������������������������������������  106 DND and Psychopathology�����������������������������������������  106 Clinical Example�����������������������������������������������������������  107 Social Deception and “White Lies”�����������������������  107 Pragmatic Lies����������������������������������������������������������  107 Deception in the Setting of Psychopathology�����������  108 Affect Containment�������������������������������������������������  108 Shame and Guilt������������������������������������������������������  109 Paranoia and Psychopathy��������������������������������������  110 Dissociation and Disorganization��������������������������  111 Type IX: Predatory Deception�������������������������������  111 “Multiple Function”������������������������������������������������������  112 Qualities of DND����������������������������������������������������������  113 Active Falsification��������������������������������������������������  113 Dissociation and Self-Deception���������������������������  113 “Soft” Versus “Hard” DND������������������������������������  113 Dissociation, Disorganization, and Nondisclosure���������������������������������������������������������  118 The Patient as Storyteller���������������������������������������  118 References����������������������������������������������������������������������  119 9 Personality Disorders, Psychopathy, and Deceit��������� 121 A Psychoanalytic Perspective on Personality������������  123 Structural Model������������������������������������������������������������  125 Defense Model��������������������������������������������������������������  126 Motivational and Early Fragmentation Model����������  127

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Fragmentation Model “Borderline Personality Organization”���������������������������������������������  127 Differentiation of “Borderline Personality Organization” from DSM���������������������������������������������  128 “Defensive” and “Malignant Narcissism” Models of DND�������������������������������������������������������������  130 Morality, Self-Esteem, and Descent into Primitive Masochism���������������������������������������������  131 Discussion of the Linda Case��������������������������������������  133 “Structural” Problems or “Nonspecific Ego Weakness”��������������������������������������������������������������  134 “Defensive” Problems���������������������������������������������������  135 Case Studies in Psychopathy����������������������������������������  137 Case 1: Johnny����������������������������������������������������������  138 Case 2: David������������������������������������������������������������  140 Case 3: Lisa���������������������������������������������������������������  143 Case 4: Leon�������������������������������������������������������������  145 Case 5: Carla�������������������������������������������������������������  146 Discussion�����������������������������������������������������������������������  148 References����������������������������������������������������������������������  149 Part III Assessing DND in a “Gated” Simulated Patient 10 “Biggie” Assessing a Deceptive Patient in a “Gated” Simulated Patient Interview������������������� 153 Introduction�������������������������������������������������������������������  153 A Simplified Process�����������������������������������������������  153 Good Patients/Bad Patients������������������������������������  154 Different Challenges�����������������������������������������������  154 Higher Goals for Interview������������������������������������  155 Role of Simulated Scenario—Positive Reports����������������������������������������������������������������������  156 Cautionary Views of Simulated Patient (SP) Exercises���������������������������������������������  157 WMC SP Scenario Goals����������������������������������������  157 The “Biggie” Scenario���������������������������������������������������  158 Development of the WMC Simulated Patient Program�������������������������������������������������������  158

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Method����������������������������������������������������������������������������  159 Scenario Design�������������������������������������������������������  159 Actors and Interview Setting���������������������������������  160 Interview Cohort�����������������������������������������������������  161 Measures�������������������������������������������������������������������  161 Results�����������������������������������������������������������������������������  162 Covariance of Interviewing Competencies����������  163 Discussion�����������������������������������������������������������������������  165 Conclusion����������������������������������������������������������������������  167 Appendix I Definitions of Selected Terms�����������������  168 Therapeutic Relationship����������������������������������������  168 Appendix II: Correlation by Training Year����������������  172 Appendix: III—Biggie Scenario Documents�������������  178 Background Information for Standardized Patient�����������������������������������������������������������������������  178 11 Aggression in the Simulated Case Scenario: Karl Moehller������������������������������������������������������������������ 185 Problems with the “Karl Moehller” Scenario������������  187 Interview with Dr. Choudhury—Transcript���������������  188 Transcript������������������������������������������������������������������  188 Doing a “Dorothy” (i.e., Ignoring Subject’s Aggression)���������������������������������������������������������������  190 Bobbleheading���������������������������������������������������������  190 Pheromones��������������������������������������������������������������  197 Perfection������������������������������������������������������������������  198 Domestic Violence��������������������������������������������������� 200 The Door������������������������������������������������������������������� 201 Longitudinal History�����������������������������������������������  203 Templating����������������������������������������������������������������  210 Founding Fathers�����������������������������������������������������  213 Conclusion����������������������������������������������������������������������  218 Good Intentions, Frustrated�����������������������������������  218 Appendix IV: The “Karl Moehller” Simulation Scenario—Design and Supportive Documents���������  219 Goals of the Interview��������������������������������������������  219 Presenting Problem�������������������������������������������������  219 Karl’s Background���������������������������������������������������  221

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Sandy�������������������������������������������������������������������������  223 Other Background Information�����������������������������  224 Interview Scenario���������������������������������������������������  225 Interview Process�����������������������������������������������������  225 Examples of Karl’s Dialogue���������������������������������  228 If Questioned About Removing the Door�����������  229 Asked About the Bruises on Jenna’s Arms����������  230 LEVEL TWO Behavior During the Interview������������������������������������������������������������  231 LEVEL THREE Behavior During the Interview������������������������������������������������������������  232 LEVEL 4������������������������������������������������������������������  234 References����������������������������������������������������������������������  234 Conclusion�����������������������������������������������������������������������������  235 Index���������������������������������������������������������������������������������������  239

Introduction

The LORD God called to the man, “Where are you?” He answered, “I heard you in the garden, and I was afraid because I was naked; so I hid.” Genesis 3:10

Most books written for professionals on a given subject at least claim to contain facts. This book, by contrast, is about what happens when facts are unknown, irrelevant, or distorted to a point that they are no longer true. It is based on a few simple ideas: • The motivation that drives an individual to withhold factual information is often more important than the facts themselves. • Nondisclosure of important facts, even when undetected or artfully concealed, casts a pall over human relationships. • Sensitivity to the emotional and interactive process of an interview represents a different way of engaging patients, within which the process of distortion and falsification can be understood and integrated into the clinical assessment. The history of deception is as old as humankind. The story of Adam and Eve begins with the corruption of Eve by a serpent, and her consumption of the fruit of the tree of knowledge. This is followed by Eve’s seduction of Adam, and a descent into evasion and finger-pointing as all three parties try to avoid responsibility as the deity questions them about what happened.

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Among the manifold interpretations of this story is the idea that the state of possessing knowledge is inherently problematic, particularly when more than one person is involved. Children naturally turn to adults for protection and information. But when an adult or adolescent human being turns to another for help in acquiring greater knowledge, a host of potential problems arise. Will the information the second party provides be relevant, or correct? Will the “knower” either think less of us for asking a question, or exploit the possession of knowledge as a means of forcing the learner into a child-like position of dependency? What if we are not prepared to reconcile the impact of what we learn on what we previously believed? One solution to the problems associated with knowledge is the regulation of its disclosure and modification of its content  – in other words, distortion, nondisclosure, and varying degrees of deceit. We refer to these three intertwined practices as DND. As many others have discussed, DND serves a variety of psychological and social functions across a range of settings ranging from romantic liaisons to international politics. In this volume, we will be focused on issues of knowledge and un-knowledge in one specific setting, the psychiatric interview. Who would lie to, or withhold knowledge from, a mental health clinician? The answer is at some point in the clinical encounter, almost everyone. This is because the psychiatric interview inevitably takes place within a human relationship, attended by concerns ranging from embarrassment and shame, to anxiety about being diagnosed with a mental illness, to doubts about the clinician’s ability or professional dedication. In a setting of more severe mental illness and the involvement of third parties such as the legal system and governmental agencies, such concerns are often magnified, and the patient’s capacity to discuss them further curtailed. The result is impairment of communication between the patient and the clinician. In some instances, it is bridged in a

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climate of deepening trust; in others it widens  – whether detected or not by the clinician – into an abyss. Clinicians, in other words, face what might be called the “Eden Problem.” The clinician is expected to function as a wise and caring “knower,” while the patient’s real and imagined concerns about the consequences of knowledge lead them to hide. This process of concealment involves distorting the narrative through the practices of distortion (Dt), nondisclosure (ND), and/or deception (Dc). Like the deity in the Eden myth, mental health professionals remain profoundly dependent on patient’s willingness to disclose information; their diagnostic and therapeutic procedures are uniquely vulnerable to breakdown when patients fail to do so. With this comes the danger of producing a psychiatric assessment that is compromised or completely meaningless. We believe that ND is a constant in contemporary practice, and that countless assessments and clinical encounters are compromised by it every day.

Is DND Insignificant? Given that nondisclosure is a nearly universal pattern of behavior, one would expect a voluminous literature on this subject. But, instead, we find very little. Why?

The Nature of Deception One problem arises from the nature of deception itself. Deceit is an inherently elusive quarry; for how are we to know when we are being deceived? For every distortion or evasion we detect, how many do we fail to perceive? How many evaluations are doomed by the omission of critical facts from the initial assessment and subsequent contact, when the clinician is in the dark regarding the omission itself?

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Suppression of Diagnostic Uncertainty A second aspect of the problem reflects the conditions in which modern mental health clinicians practice, which do not favor expression of doubt or diagnostic uncertainty, but reward swift and standardized assessment methods. In the case of a patient suspected of malingering, for example, it is far easier for a clinician to apply an invalid code, along with a correspondingly invalid treatment plan, than to undertake a time-consuming assessment – not least because many thirdparty payers will decline reimbursement in the absence of a medical diagnosis. A third, more general issue is the dictum that governs all academic enterprise: study and report on what can be reliably described and measured. Study of a topic as elusive as DND is unlikely to be rewarded, and indeed threatens the validity of many otherwise well-constructed scholarly endeavor.

Syndromal Diagnosis A fourth problem lies in the degree to which mental health clinicians rely on checklists and rating scales to establish a syndrome will diagnosis according to specified diagnostic criteria. The resultant data is concise, easily quantified, and often of clinical relevance, but it is only as good as the level of motivation capacity and candor of the patient completing it. Rosen et al. [1] described the deleterious impact on treatment alliance of computer use during a mental health visit. With or without a keyboard, many beginning clinicians overrely on fact collection and syndromal templates in their conduct of the evaluation interview, limiting their ability to detect or engage problems the subject may be having in sharing information.

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Good News/Bad News and the Tendency to Withdraw The good news for clinicians confronting a patient engaged in DND is that the same affective anxiety, which accompanies most nondisclosure, and also provides a range of cues that can put the clinician on the path to understanding the patient’s behavior, and the mental process guiding it. Similarly, instances of deception, if perceived as such and engaged, can be mobilized in the service of insight into a patient’s motivation (e.g., as illustrated in “the case of Karl” below).

Human Tendency to Withdraw The bad news, as we will extensively discuss in this volume, is that there is a human tendency to withdraw, emotionally and intellectually, from deceptive people. We will argue that this is the case regardless of whether ND is perceived by the clinician. Indeed, our experience to date demonstrate that nonperceived (by the clinician) ND may have a more profound disruptive effect on subsequent treatment than overt ND that is perceived and understood as such. ND patients tend to be experienced as annoying, confusing, or boring. There is a natural tendency, particularly on the part of a less-experienced clinician, to solve the problem by collecting more facts. As will be extensively discuss later, less-experienced clinicians attempting to engage them display a range of ineffective behaviors during the interview, for example, obsessional collection of irrelevant information, excessive nodding and other propitiatory behavior, and denial of a patient’s noncooperation and the resultant adversarial nature of an interview.

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This is not because clinicians are unconcerned or unmotivated. Indeed, the majority of people who choose careers in mental health treatment are likely motivated by a desire to understand and help other people. But when the clinician’s efforts are stymied by the lack of cooperation on part of the patient, the process of understanding comes to a halt. To engage what is happening in an ND environment, the clinician must be prepared to set aside the logical task of assembling facts and focus instead on the interpersonal situation between the clinician and the subject. Deceit can only occur within the context of the relationship of one human being with another. Deceit is always driven by a reason that governs its creation. Undetected, deceit erodes and invalidates human discourse. Perceived and comprehended, deceit offers a unique window into a subject’s motivation, hopes, and concerns. This study is undertaken in an effort to give what is unsaid, and perhaps more importantly consideration of why certain things remain unsaid, and in so doing offer help to clinicians in understanding patients who may otherwise be beyond our reach.

Conclusion The impulse to share experience represents a critical human need; yet the same is true for the impulse to withhold, conceal, and deceive. This dialectic governs all interpersonal encounters, but few more powerfully than that between a patient and a clinician engaged in a mental health assessment or treatment. The central thesis of this volume is the proposal that the act of engaging in deception and nondisclosure (DND) offers a window into the emotional and mental life of the individual soul observed. Too often in contemporary mental health care, our interactions are driven by template-driven sequences of factual questions, each of which may be important in its own right, yet in aggregate threatened to obscure the interactive process, which underlies every treatment encounter.

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DND spans the entire range of human context, ranging from the exercise of social tact, to acts of aggression, to conditions of aberrant personality functioning in which self-deceit and deceit of others are difficult or impossible to separate. In each instance, exploration of the form and imperatives driving DND offer invaluable insight, which in many instances, as the capacity to rescue a treatment intervention that otherwise may be untenable. Absent successful engagement, the danger of DND is substantial and is derived from two sources: first, there is the impact of false and incomplete information on the successful conduct of the treatment intervention. How many patients failed to take, or abuse the medications physicians prescribe? How many psychotherapy patients withhold critical information, including their actual opinions of the therapists and experience in treatment? The answer to this question is unknown, and likely unknowable  – but undoubtedly negatively affects treatment interventions affecting millions of lives. The second threat is derived from the negative impact of DND on the attitude and conduct of the mental health clinician. Frequently subjectively experienced by the clinician as an experience of boredom, frustration, and self-doubt, breakdowns and patient communication trigger a process of psychological withdrawal that threatens to undermine, and in many instances eradicate, the therapeutic alliance and the prospect for a successful outcome. Once again, the scope of this problem is difficult to measure, but likely blights millions of treatment interventions and the lives they represent. What is the prospect that brain imaging and other forms of biological intervention might transform the level of honest disclosure in treatment contacts, as well as many other encounters? The answer, as best we been able to determine, is that the difference between candor and deceit exists at an advanced level of brain functioning, which at present lives far beyond the scope of our knowledge of neurobiology, and the technology with which we study it. It also seems likely that, for the near future at least, the human genius for deceit and nondisclosure will breed “countermeasures” to match each development in brain science.

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It is in the study and clinical treatment of personality functioning that DND moves to the foreground of clinical practice. Personality disorders are characterized by distortions in self-perception and of other humans in the social field, accompanied by surges of dysregulated affect. In the case of more severe personality disorders, this distorted perception and communication frequently threatens to overwhelm treatment endeavors, raising the spectrum of treatment failure. In such a setting of assiduous attention to DND and the motivations driving it may serve as a source of insight for patients, and a source of orientation for a clinician attempting to ride out the storm. In the final section of this volume, we have described efforts to orient and train early-career clinicians in identifying and effectively responding to DND in challenging clinical situations. Our preliminary findings suggest that interviewing competency to detect and engage falsehood are poorly taught in our training program, which like many others in the United States emphasizes fact collection over the interactive and transactional aspect of the psychiatric interview. It is our hope that these and other studies will advance training and awareness of the fundamental truth: psychiatric assessment and treatment represents a process undertaken by two people. Compassion merged with intellectual discipline can yield an alloy strong enough to reach individuals who in other circumstances may not be easily engaged.

Reference 1. Rosen D, et al. The impact of computer use on therapeutic alliance and continuance in care during the mental health intake. Psychotherapy. 2016;53(1):117–123. Alexander Lerman, MD Hussain Abdullah, MBBS Vishnupriya Samarendra, MD

Part I

DND in the Clinical Encounter

For now we see through a glass, darkly; but then face to face: now I know in part; but then shall I know even as also I am known. I Corinthians 13:12

Chapter 1 A Personal Encounter with Deceit

Clinical Example: Alan’s Suicide Sometimes, death serves as a wake-up call to those who remain. For a relatively inexperienced clinician, the suicide of a patient began a lifetime interest in deception, particularly the means through which patient ND (nondisclosed) seems to induce passivity and ineffectiveness in clinicians who fail to detect it. For example: Alan, a successful, highly educated, middle-aged man, returned to the care of a clinician, who had treated him before, after his wife discovered what appeared to be a draft suicide note among his papers. As previously, Alan reported insomnia, unendurable emotional distress and suicidal ideation. Alan acknowledged feelings of intense distress but insisted he would not harm himself. Neither Alan or his wife brought in a copy of the note. As during the previous episode, the clinician had recommended hospitalization, which Alan declined, citing business obligations and stating that he would refrain from harming himself out of concern for his family. He responded to a course of antidepressant therapy with remarkable speed and successes. After a year of maintenance therapy,

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he tapered and discontinued medication, agreeing to a program of what the clinician termed ‘lifetime vigilance’ and early treatment of recurrent symptoms. This outcome was a source of significant professional and personal satisfaction to the clinician. In the course of teaching duties, the clinician subsequently used the history of Alan’s response to treatment as an instance of a “biologically mediated depression,” in which pharmacotherapy delivered within a collaborative treatment relationship afforded decisive treatment. In the new treatment episode, the clinician again urged hospitalization, and Alan once again declined, citing the same concerns. A friendly and collaborative relationship seemed to be quickly reestablished between clinician and patient, which the clinician interpreted as a protective factor with regard to suicide risk. On his second visit, Alan expressed appreciation for the clinician making time for him on the evening before a major holiday. Alan said he’d forgotten to bring suicide note to the session, but this seemed unimportant at the time. The clinician spent a portion of the session outlining treatment options and the near certainty of a complete recovery. At the conclusion of the assessment interview, the patient hesitated as he was about to leave the office and turned back to ask, “Do you think people who commit suicide suffer in hell?” The clinician equivocated, but the patient said, “Well, I do.” Although oddly timed, the comment was interpreted by the clinician to represent another favorable indicator or ‘protective factor’. Two days later, the patient committed suicide in what was clearly a long prepared and carefully orchestrated plan. Carefully collated legal documents and financial arrangements made clear that Alan had been preparing to end his life for several months. Driving to a remote area, he left a string of voice mails falsely informing family members about his movements and then concealed himself with such effectiveness that his body wasn’t found for many months.

Chapter 1.  A Personal Encounter with Deceit

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Like innumerable other instances of nondisclosed (ND) mentation and behavior, the source of Alan’s motivation to kill himself remains a mystery. His level of deception, however, is clear for all to see. On reflection over the following days, and following years, a number of further facts and impressions had come to light. What the clinician considered Alan’s first episode, that is, 5 years before his death, was actually at least his second. As the clinician knew but tended not to consider, Alan had been psychiatrically hospitalized for 2 weeks for depression in his mid-twenties. At that time, Alan had refused to take medication, and yet—as during his second episode—he appeared to make a full recovery. This history raises questions about the purely “biological” nature of Alan’s depressive diathesis and illuminates a quality of Alan’s personality that affected the treatment relationship, but that the clinician tended not to reflect on, a streak of egocentric stubbornness. Family members described Alan’s description of his childhood as blame-centered, inaccurate, and unfair to other members of the family. They described Alan as obsessionally preoccupied with his appearance and prone to brooding about essentially nonexistent defects in his skin. They described Alan, whom the clinician only knew as affable and kind, as possessing a sharp temper and unforgiving attitude regarding even minor grievances or differences of opinion. Why did this material fail to come to light in either treatment episode? In hindsight, it became clear that there are several reasons: First, Alan restricted and distorted what he disclosed to the clinician. Second, the clinician was uncharacteristically incurious and acquiescent. Third, the clinician’s concessions tended to reduce potential disagreement about the course of the treatment, and with it the likelihood that Alan’s more belligerent personality traits would emerge. Each of the clinician’s concessions—for example, avoiding hospitalization, discontinuing medication, not undertaking psychotherapy—could be defended as a rational treatment decision; yet in aggregate they represent an acquiescent treat-

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ment posture that contributed to diagnostic and treatment failure. Did that failure contribute to the fatal outcome as well? In hindsight, it is clear that Alan was determined to commit suicide and had been so for some time. He engaged in a calculated pattern of preparation and deceit, conducted over a period of at least several months, to achieve his goal. It is far from clear that the clinician, or anyone else, could have prevented his death. But this is not the only standard by which the professional ability of a clinician should be judged. Amid all the uncertainties, what is clear is that the clinician failed to understand Alan’s situation or to understand the degree of risk. It is also clear, in hindsight, that the clinician “bought in” to Alan’s superficial and antipsychological narrative of his lifetime of depressive symptoms. The conceit of a “biologically mediated depression” served as a screen for Alan’s reluctance to discuss his childhood, his first depressive episode, his aversion to psychotherapy, and likely a range of other factors about which he might otherwise have been challenged or engaged. Where does Alan’s final question, Do you think people who commit suicide suffer in hell?—and more saliently the haunted look on Alan’s face as he pronounced these words— fit in this story? Was Alan trying to apologize for his deceit up to that point? Did he, perhaps in the grip of a psychotic affective process, believe himself to deserve perpetual torment? Did his resolve waver in what he knew to be a final moment of farewell? Alan took the possibility to pose these questions with him to his early, lonely grave. What seems clear is that this single moment, whatever it meant, represented a unique moment of honesty in what was otherwise duplicitous relationship. What is also clear is that the clinician wholly failed to grasp its significance, instead perceiving it to represent a “protective factor”; as he left for the holiday. While the effect on the final outcome of the case may not have changed, it seems likely that the clinician might have

A Question of Relevance

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been spared some of his burden of guilt and professional self-­ doubt if he had focused on Alan’s expression, rather than his words, and invited him to come back and explain what he meant.

A Question of Relevance How unusual is Alan’s story? We know that ND is ubiquitous. People considering or preparing for suicide are notoriously secretive, both for obvious practical reasons, that is, the expected effort of others to obstruct the suicidal plan, and due to withdrawal from interpersonal relationships which all too often represents a characteristic precursor of a suicide attempt. Similar levels of secrecy and withdrawal likewise attend depression, substance abuse and eating disorders, compulsive gambling, and a host of other psychiatric disorders. What proportion of patients fail to disclose critical facts about their history and present circumstances? What proportion of patients fail to report their actual experience in treatment, including medication compliance, degree of satisfaction with care, concerns about the clinician, sexual or other intimate problems? The elusive nature of deception and other forms of nondisclosure renders it difficult to quantify, but likely attends every clinical encounter. Indeed, we may come nearer to the mark to regard disclosure and nondisclosure as intrinsically conjoined. In many clinical settings, for every fact disclosed, another is withheld, for a variety of reasons, including embarrassment, mistrust, or difficulties in self-perception. To a greater extent than many clinicians appear to accept, the validity of an assessment rests less on facts than on a transactional process through which a deeper understanding of the truth—at least under favorable circumstances—is achieved.

Chapter 2 Deception in the Psychiatric Interview Leading psychiatric educators cite the ability to conduct a diagnostic interview as an essential clinical skill, albeit one that can be difficult to define, teach, or quantitatively assess. Shea [4] describes collection of information as one of a range of objectives for the interview, the others being the process that includes the establishment of a therapeutic alliance, an “evolving and compassionate understanding” of the patient, and “a deepening partnership between clinician and patient.” Beresin [3] states that “the purpose of the psychiatric interview is to establish a therapeutic relationship with the patient, in order to collect, organize, synthesize data that can become the basis for formulation, differential, diagnosis, treatment plan.” On the other hand, it is hard to escape the conclusion that clinical interviewing occupies a position of diminished importance and declining perceived relevance to modern psychiatry. For example, the conduct of the psychiatric interview is reduced to a sub-competency of “Psychiatric Evaluation” in the “Patient Care” domain of the Accreditation Council for Graduate Medical Education [2]. The American Association of Directors of Psychiatric Residency Training (AADPRT) Clinical Skills Verification worksheet [1] includes empathy and response to nonverbal cues as checklist subcomponents peripheral to the major parameters of the assessment.

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Fact Collection and “Templating” In many instances of modern psychiatric practice, the assessment interview has been streamlined and simplified to a form that bypasses any concern about its process, or the unfolding of the gradient between shared and unshared knowledge between the patient and the clinician. It may be argued that the advent of syndromal diagnosis and, more recently, dimensional rating scales, renders the traditional psychiatric interview obsolete. Nothing could be further from the case. While the collection indeed represents a crucial component of any assessment, critical facts are invariably infused with e­ motional valence and wider psychological significance, which in turn lead to a range of distorting influences on the process through which facts are disclosed. For example, we will argue, with some experimental evidence in support, that the vulnerability of the evaluation interview to nondisclosure (ND) is increased when the clinician is focused on the systematic collection of facts. Excessive “templating,” that is, focus on completion of a series of scripted questions, is frequently observed on the part of clinicians who have lost control of the interview, and are not sure how to proceed. Unfortunately, this process is the norm rather than the exception in many psychiatric treatment settings, and is driven by the growing institutional, regulatory, and reimbursement-driven imperatives. Undetected and unengaged, disclosure–nondisclosure (DND) threatens every aspect of a clinician’s diagnostic and clinical effectiveness. As we will see, unengaged DND can trigger a range of untoward psychological responses in the clinician that can undermine his or her sense of professional identity, and capacity to respond constructively. Successfully engaged, on the other hand, the phenomenon of DND offers a unique window into an individuals’ presuppositions, anxieties, and mental functioning. A clinician who is aware that a patient is both withholding information and comfortable with that awareness may approach the patient while listening for cues that indicate the presence of non-­



Fact Collection and “Templating”

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disclosed material. Even more importantly, he or she can do so with an awareness of psychopathology or other motivational forces driving nondisclosure. The purpose of this book, therefore, is to equip the professional to encounter DND with curiosity, and to perceive and avoid its pitfalls, and study its properties. By doing so, we hope to deepen the capacity of the professional to understand a diverse population of patients who are complex, challenging, and—occasionally—dangerous. Through better understanding, we strive to free our own and our patients’ minds.

Assessment Goes Awry As we will see, ND occurs in many settings, and takes many forms. Sharing emotionally charged material stimulates a range of responses in both parties, as an exchange of banalities does not. Many patients face a range of anxieties, frightening feelings of dependency, or in some instances have specific goals for the interview that candid self-disclosure would compromise. Clinician’s fears include becoming the target of the patients unregulated emotions, exposure of their own vulnerabilities, or simply not knowing what to say. For both clinician and patient, in short, anxieties associated with the interview tend to drive both parties into superficial and incomplete discussion of the problem, with the prospect of a clinical assessment failing to identify critical aspects of the patient’s situation. The resulting assessment is at best compromised, and at worst dangerously divorced from the patient’s actual condition and needs. Nondisclosure or failure in communication comes in many forms (Table 2.1). A wide discrepancy between the patient’s report and the facts as otherwise established is a measure of either the severity of the patient’s underlying psychopathology or the breakdown in the treatment alliance, or both. In hospital settings, the response often consists of administrative procedures that

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Chapter 2.  Deception in the Psychiatric Interview

Table 2.1  Forms of nondisclosure ND Nondisclosure (ND) denotes an instance where a fact is not disclosed, without regard to intent or awareness on the part of the subject. Dc

Deception refers to a specific form of ND consciously undertaken by the subject to disrupt the interviewer’s awareness of the facts as understood by the subject, conducted by either providing false information or withholding relevant facts.

Dt

Distortion refers to ND in the form of incomplete, false, or disorganized information provided by the subject without conscious deceptive intent on the part of the subject.

bypass a patient’s volition (such as involuntary commitment or discharge proceedings). In outpatient settings, the result is ineffective or prematurely terminated treatment (e.g., “The case of Listerine Liz” in Chap. 9). In both settings, we find a tendency of overreliance on medication. A clinician trained solely in the collection of facts possesses few resources to understand or respond to the patient’s disclosure and ND.  The clinician may, or may not, be consciously aware of the problem, but almost invariably experiences an emotional response, ranging from boredom, to emotional withdrawal from the patient, to feelings of anxiety or personal inadequacy.

Psychotherapeutic Literature What of psychotherapeutic literature? The concepts of “resistance” and operation of various defense mechanisms and psychodynamic treatments represent an exception to the general dearth of academic or clinical writing on DND. The problem is that psychodynamic treatment is restricted to a

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small subset of patients engaged within a treatment governed by the “basic rule” under which the patient has already committed himself or herself in theory to unregulated self-­ disclosure. The ultimate candor of the patient is assumed; and failure to attain it is considered a contraindication for psychodynamic treatment. A patient seen in a general psychiatric setting, by contrast, has not agreed to comprehensive disclosure, and is unlikely to engage in the pattern of deepening therapeutic alliance and disclosure intrinsic to psychodynamic care. The concept of defense mechanisms is less restricted to a specific treatment environment and may have more general applicability; but is replete with assumptions and conceptual concepts that many mental health clinicians either do not share, or are unfamiliar with.

Therapeutic Repulsion Lastly, we suspect that the scanty literature on nondisclosure reflects a tendency of clinicians and investigators across all specialties to recoil from deceptive subjects. This repulsion is abundantly evident in clinical practice, and is evident in the language by which such patients are designated as “unreliable historians,” “manipulative,” or “noncooperative,” or by other terms that capture the frustration they engender in those who try to understand and help them. Such a reaction on the part of the professional may itself be regarded as a potentially pathognomonic symptom of DND in the interview (Tables 2.2 and 2.3).

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Table 2.2  Impact of deception Human well-being, purpose, and resilience are grounded in the experience of present and past relationships with other people, and an intrinsic need to share and communicate their experiences with others. The need for communication and shared experience is balanced against an increasing need for privacy over the course of child and adolescent development, and the selective use of dissimulation and deception represents an important means of facilitating and protecting social relationships. Deception in other circumstances threatens social relationships, erodes trust, and, in some circumstances, both reflects and promotes intrapsychic disintegration and vulnerability to psychopathology of all kinds. In treatment settings, this “second kind” of deception obstructs diagnostic assessment and the delivery of effective mental health care. Deceptive behavior is frequently accompanied by nonverbal cues that, if detected and integrated, can provide valuable indicators of what is going on. If this process of integration does not occur, the target of deception is vulnerable to experiences of passivity, wishful thinking, and/or psychological withdrawal. This phenomenon may represent an aversive response to anxiety associated with confrontation or suspicion. If deception is detected and engaged, on the other hand, the deceptive act may provide critical information regarding patient motivation and perception.

Fact Collection and “Templating” Table 2.3  The non-disclosing patient: “the big picture” All patients (and all people) engage in nondisclosure (ND). If an assessment (or any conversation) is viewed simply as a process of collecting facts, nondisclosure of important facts renders the assessment meaningless, and frequently induces apathy, self-doubt, clinical objectification, or some other form of psychological withdrawal on the part of the clinician asking the questions. On the other hand, the clinician can detect that ND is taking place, and begin to entertain hypotheses about why ND is taking place; thus, the process of ND can be transformed into a new channel of communication and understanding. Our method for engaging ND has several components:  “Framing” the patient narrative in the context of the overall clinical presentation, for example, obvious inconsistencies, mental status observations, secondary gain, grossly apparent psychopathology.  “Transactional interviewing” focused on the patient’s affective and motivational state on a moment-to-moment basis, as opposed to the collection of facts.  Close attention to vagueness, omissions, and nonverbal behavior, and to the context within such behaviors that emerge.  Self-awareness on the part of the clinician regarding his or her emotional response to the interview process. Many patients rely on ND to buffer, conceal, and contain symptoms and preserve social functioning. Many patients engage in ND in response to deep feelings of defectiveness and shame. We will look in detail at resident performance on simulated patient interviews of ND patients, and identify common pitfalls. ND manifests differently, and serves different functions, in the setting of different forms of psychopathology. Detecting and understanding the function of ND sharpens diagnostic assessment.

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References 1. American Association of Directors of Psychiatry Residency Training. Clinical skills verification worksheet; 2019. 2. Association Council for Graduate Medical Education. The psychiatry milestone project; 2013. 3. Beresin E, Gordon C. The psychiatric interview. In: Stern TA, editor. The Massachusetts general comprehensive clinical psychiatry. 2nd ed. Boston: Elsevier; 2016. p. 54–72. 4. Shea C.  Psychiatric interviewing: the art of understanding. New York: Elsevier; 2017.

Chapter 3 Types of Interviews, Types of Listening

Many clinicians in training consider the psychiatric interview to represent a process of fact collection, often keyed to the regulatory and reimbursement requirements. Experienced clinicians come to appreciate that there are many forms and types of interviewing styles, which like any other tools are each best suited to different situations and requirements. We will limit our discussion here to three intertwined processes (Table 3.1).

The Fact-Based Interview The process of psychiatric assessment represents a process of collecting data from various sources, and its integration into a diagnostic assessment and treatment plan. As generally conceived, the assessment interview consists of a series of questions designed to obtain whatever factual information needed to complete the evaluation. The contents of such an interview Table 3.1  Three types of interviewing

The fact-based interview The meaning-focused interview The transactional interview

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is then cross-checked with information from other sources, in order to determine its reliability. We refer to this as a “fact-­ based interview.” Within narrow terms of such an interview, the significance of the facts, for both interviewer and patient, is largely irrelevant. Within the bounds of propriety and common courtesy, the interviewer’s presence and bearing during the interview is likewise irrelevant. In a good deal of clinical practice, fact collection is emphasized to the exclusion of all other domains of assessment. A patient’s symptom report is fitted to a template of syndromal criteria to achieve a diagnosis, followed by dispensation of medication and/or symptom-focused counseling. This process works well, as long as the patient’s problem can be satisfactorily reduced to a set of syndromal facts, and the patient is willing to provide a reasonably complete account of them. When these conditions are violated, however, an evaluation interview can quickly become meaningless—or worse, a source of false or incomplete information—and, as we will see, a source of alienation of clinician from patient. Clinical Example: A Frightened Mother A single mother was referred for assessment by a caseworker who observes her tearfulness, social withdrawal, and increasing hopelessness. On evaluation, she denied all symptoms and stated that she was “fine.” On follow-up discussion, the caseworker discovered that the patient mistakenly believed that the purpose of the evaluation was to determine her to be an unfit mother and terminate her custody of her child. In this example, all four conditions were violated: the frightened patient’s symptoms were not evident to the evaluating psychiatrist, nor did the patient trust him enough to provide a coherent account of what was going wrong. The persistence of the caseworker was the only thing that prevented a grave clinical error.

The Meaning-Focused Interview

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The Meaning-Focused Interview The meaning-focused narrative is concerned with the significance of facts, as opposed to their accuracy or information content. Within this frame, nonfacts, including instances of noncommunication, confusion, and outright deceit, may possess as much significance as facts known to be true. But who decides what is significant, and what its significance is? In contrast to facts, which are universal, the quality of significance is established within the mind of a listening and attuned interviewer. Listening, to what? Listening (obviously) to what the patient is saying, but, by inference and other sources, also to what the patient is not saying, and developing a formulation as to why specific material remains un-said. One may object that this process is “subjective,” as indeed it is. Jaspers [1] observed more than a century ago that psychiatric assessment requirement demands a process in which the clinician’s “objectification” of the patient is balanced against empathetic attunement. This posture is of particular importance in engaging the non-disclosing patient. When reliable facts are in short supply, omissions and contradictions may suffice. Clinical Example: A Quarrel in a Residential Home A 16-year-old girl residing in a residential treatment center gives the following account of a violent incident: “I was just standing in the kitchen, minding my own business, and she started with me  – she’s the one who started with me, and I said ‘Bring it, bitch,’ and she run her mouth, and the next thing is that the residences manager is telling the cops that it’s me who started, and that’s just a lie.” An agitated and demanding patient like this frequently elicits eye rolls from emergency service staff. This is a nontrivial phenomenon. Psychological withdrawal and disparagement represent a characteristic response among clinicians confronted

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by a patient engaging in disclosure–nondisclosure (DND), and may even serve as an indicator of nondisclosure and deception. In this case, no great diagnostic acumen is needed to establish the incomplete nature of patient’s narrative. We do not know all the facts, but the gaps “signify” what is missing, indicating either a volitional or avolitional process leading the patient to withhold information. The crude and disrupted syntax of the patient’s statement likewise serves as an indicator either of her cognitive limitations, or a more acutely disrupted mental state.

Beyond Facts: The Transactional Interview The focus of the transactional interview is on the relationship between the interviewer and the subject rather than the content of the discussion. This relationship, with a few modifications, is the same as that described in the mother–infant perception studies cited above: The interviewer asks “tell me your story” and the subject either does so or withholds or distorts their report, in a narrative shaped by the balance between the impulse to share and the impulse to deceive. Seen in the context of the interview, facts represent no more than tokens in an encounter between patient who is governed by emotion and often distorted anticipation of the other’s response, than any aspect of the facts themselves. Consider the following example: Clinical Example: “I Know Better Than to Talk About Suicide with a Psychiatrist” A depressed elderly man interrupted a question by an evaluating clinician by responding “No” in a loud atonal voice as the clinician asked if he had ever considered committing suicide. When asked about his response the patient initially denied any significance, but eventually adds “I know better than to talk about suicide with a psychiatrist.” The patient later went on to describe how an angry family member called the police when he made an oblique suicidal threat during an argument.

Stratified Listening

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In this example, the significance of the factual data—that is, the patient’s history of psychiatric hospitalization and chronic passive suicidal ideation—is secondary to patient’s anxiety that the evaluating psychiatrist will ignore his actual concerns and subject him to involuntary treatment. These concerns mirror his mistrust of, and failure of communication with, other members of his family. Note how the patient signaled his transition to nondisclosure solely by a change in vocal pitch and volume. While the patient’s decision to withhold information reflected his fear of involuntary treatment, it was likely clear to the patient from the context of the discussion that the likelihood of this outcome occurring as a result of the present discussion was minimal. Instead, he seemed to be signaling his bitterness and mistrust of the clinician’s effort to understand him. Even though it occurred in words, his response could be regarded as a fundamentally nonverbal “transaction” through which he demonstrated the depth of his isolation. Note that the facts at issue, including whether the patient intended to commit suicide in the near future, were important, but rendered temporarily inaccessible by the patient’s refusal to cooperate. Even the fact of his refusal was not communicated directly. Yet, as the window of factual discussion closes, that of relational transaction may open, depending in part on the clinician’s awareness and capacity to function in an interview that is no longer based on collecting facts.

Stratified Listening The process of a psychiatric assessment can be stratified into four levels (see also Table 3.2). • Level I: Listening for facts –– This level of listening represents the patient’s subjective account of his or her experiences and understanding of them, as shared with the evaluating clinician. Such accounts vary widely in coherence. They may be detailed

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Table 3.2  Stratified listening Level I The patient’s subjective narrative Level II

Omissions and distortions in the patient narrative

Level III

Emotional valance

Level IV

The patient narrative as assembled in the clinician’s observing mind, guided by knowledge of psychopathology, and scrutiny of the discrepancy between levels I and II.

and highly organized, or chaotic, or tangential to the point of incomprehensibility. Less-experienced clinicians often over-rely on the Level I narrative, and mistake it as a factual entity. In fact, the subjective narrative is a manufactured construction that reflects the patient’s state of mind, self-awareness, and rapport (or lack thereof) with the evaluator. • Level II: Listening for emotions –– Facts aside, every moment of an interaction, even the most casual exchange of greetings, possesses an emotional valance for both parties. • Level III: Listening for inconsistencies/omissions and why they occur –– Includes everything that is omitted, distorted, or out of place in the Level I narrative, along with consideration of why this information might be omitted. • Level IV: Assembling the narrative –– Unlike the first two narratives, Level IV exists only within the evaluating clinician’s mind. It represents the patient narrative as assembled within the clinician’s own mind, including the clinician’s capacity for inference, toleration of contradictory ideas and information, and knowledge of psychopathology. Let’s return to the example of how the concepts of narrative level and stratified listening can be put to use in the interview of a non-disclosing patient.

Stratified Listening

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Clinical Example (a Return) “I was just standing in the kitchen, minding my own business, and she started with me – she’s the one who started with me, and I said ‘Bring it, bitch,’ and she run her mouth, and the next thing is that the residence manager is telling the cops that it’s me who started, and that’s just a lie.”

Level I: The Subjective Narrative In this instance, the Level I factual history might be reconstructed as follows: the patient was in a state of innocence when the other individual initiated some kind of confrontation. The patient responded to the provocation with an invitation to “bring it”, whereupon the other individual responded with further verbal provocation. In consequence, the patient was falsely accused by both the residence manager and the police of initiating conflict. In many instances, a fact-focused clinician may abandon the interview at this point, and try to get information from other sources to determine “what really happened.” Such a course is logical and saves time, but comes at a price of abandoning both the patient narrative and the opportunity to observe the patient’s mental and emotional functioning. Even (or particularly) when subjective listening cannot be relied upon, the other levels of listening can be brought into play.

Level II: The Emotional Narrative Even in retelling her account, the patient’s initial calm surges to one of lability and rage. Such a display should be regarded as the patient’s testament: although unable to reflect or deliver a coherent narrative account, the patient’s flooding emotions tell the story. More can be learned from the emotional trajectory of the rest of the session. Assuming that the

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interviewer is patient and kind, we might expect the patient to respond by calming down. The failure to do so often reflects something intruding into the patient–clinician encounter, in some instances the effect of a major psychiatric illness. In some circumstances, deceitful individuals mobilize intense displays of grief, distress, or anger as a means to control the interview, avoid difficult questions, win the interviewer’s sympathy, or throw the interviewer off-balance. Such displays of emotion may be termed “instrumental” because they are undertaken to achieve something. Clues to an instrumental display include its scripted, repetitive quality, and its resistance to alteration by the interviewer’s response until or unless the instrumental goal is achieved, whereupon the display typically evaporates.

Level III: Omissions and Distortions Note how incomplete and almost incoherent the narrative is. What was the nature of the initial argument? Why were the police on the scene? Why was the patient taken for emergency psychiatric assessment? As frustrating as they may be for the fact-focused clinician, omitted and distorted facts tell their own story. The patient has systematically omitted every instance of her own aggressive conduct, from the initial quarrel, to whatever behavioral escalation led to the police being called. Despite the incomplete facts, this account gives us a rich sample of the patient’s mental functioning as it unfolded in the incident. Why are the facts incomplete? Is the patient engaging in volitional behavior, and if so why? Is the patient exhibiting failings in mental functioning? If so, what? Even if we suspect the patient of intentionally withholding information, the disrupted quality of the narrative offered reflects patient’s affective flooding and egocentricity.



“Hard” and “Soft” DND

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Level IV: (Formulation-Guided) Listening Based on the three other levels of the history, we can infer with some confidence that the patient likely has an extensive history of emotional and behavioral self-regulation problems, impaired social perception, and quick resort to verbal and possibly physical violence. We are also left with questions: the degree to which the patient is volitionally attempting to conceal her own part in the crisis that precipitated the ER visit is unclear. It may be unclear to the patient herself, or the patient’s incoherence may represent a volitional or semi-volitional ruse designed to conceal her responsibility for an aggressive encounter. It is likewise unclear whether the patient’s perceptual limitations reflect a momentary decompensation under stress, or a more sustained incapacity. The interview has sharpened our awareness of the further information we need about the nature of the patient’s grievances with the other residents, her lability in other settings, and evidence of sociopathy and/or calculated deceit. In other words, what is the quality of the patient’s nondisclosure?

“Hard” and “Soft” DND With the preliminary stratified narrative complete, the interviewer is now psychologically and intellectually better prepared to engage the patient. Among other things, the interviewer may offer emotional support, and point out to the patient how incomplete her narrative is. In the case of “soft” DND, one may observe rapid improvement in the therapeutic alliance during the interview, with a corresponding improvement in the quality and completeness of the patient’s narrative. Persistent “hard” DND, on the other hand, suggests either the absence of a treatment alliance, more severe underlying psychopathology, or both.

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Chapter 3.  Types of Interviews, Types of Listening

Conclusion In summary, the accumulation of facts represents only the most basic aspect of a psychiatric interview. The assessment process is deepened by expanding the consideration of facts, to consideration of what facts mean to both clinician and patient, and under what circumstances facts are shared and withheld. All information possesses emotional valance, which is often of greater clinical relevance than the information itself. Within the domains of the “meaning-focused” and “transactional” interviews, nondisclosure can be conceptualized and engaged as clinical data regarding key elements of a patient’s beliefs and motivation.

Reference 1. Jaspers K.  General psychopathology. Baltimore: Johns Hopkins University Press; 1963, 1997.

Chapter 4 Therapeutic and Anti-­ therapeutic Relationships

Insight-directed psychotherapies specifically promote the elaboration and integration of previously nondisclosed perceptions and ideas between both the partners of the therapeutic dyad and within the mind of the patient. In either case, an effective treatment takes place within a relationship based on trust and disclosure. Many early-career physicians can be compared to the deity in the Garden of Eden myth, in that they expect the patient to be candid and forthcoming and experience shock and disappointment when this proves not to be the case. Others give little consideration to the relationship within which questions are asked, and facts distorted or disclosed, and merely focus on completing a formal or informal template. As different as they are, both of these approaches arrive at the same place: a breakdown in the level of trust and rapport between clinician and patient, that is, a breakdown in the therapeutic relationship. How does this breakdown occur? A patient engaged in nondisclosure challenges the clinician’s endeavor to understand and help patients on two levels. First is the problem of working with incomplete or inaccurate information. Second is the disruptive impact of DND on the core human experience and the need to establish contact with one another. The first problem is obvious and triggers a number of immediate responses, such as noting that the patient is either © Springer Nature Switzerland AG 2020 A. Lerman, The Non-Disclosing Patient, https://doi.org/10.1007/978-3-030-48614-3_4

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an “unreliable” or “poor” historian in the medical record, seeking more trustworthy information from other sources. The second problem is both more subtle and more pervasive: a reflexive emotional withdrawal from the patient. Often, the clinician is only minimally aware that this withdrawal is taking place or that the resulting emotional undertone, typically ranging from self-doubt to repulsion, represents a response to the patient’s behavior. This near-universal phenomenon is expertly captured in a brief scene from the film [4] depicting the effort of a physician in a military hospital to interview “Nick,” a soldier after a series of harrowing battlefield experiences. Clinical Example: Interview with “Nick” Physician: Are you Nickonar Chevatorevich? Nick: (No response) Physician: Can you understand me, Nickonar? Nick: (Regards physician, no response) Physician: Are you Chevatorevich? Nick: Yes. (whispers) Physician: Are you sure? Nick: (whispers but physician interrupts) Physician: Chevatorevich, is that a Russian name? Nick: No, it’s American (speaking clearly for the first time) Physician: (Grimaces in annoyance) All right, let me see your name tag. (Examines tag) Is this yours? Nick: (Indicating mutilated soldier) It’s his. Physician: What are your parents’ names? Nick: Lou and my mother’s name is Eva. Physician: And what’s your mother’s date of birth? Nick: Repeatedly attempts to respond, weeps, appears unable to speak Physician: We’re going to have to get him out of here. This vignette depicts an impasse characterized by mounting frustration on the part of the interviewer who, despite his

The Therapeutic Relationship

29

good intentions, is unable to effectively respond to or ­understand the difficulty that prevents his patient from providing a history. As is so often the case in such encounters, the clinician responds by doubling down with repeated requests for factual information, in this case the patient’s identifying information (a behavior we characterize as “templating” in Chap. 5). Note also what the interviewer does not do. He displays no indication that he is considering the patient’s inability to state his name as a symptom of an underlying disorder. He makes no effort to infer what recent combat experiences might be driving the patient’s behavior. When the patient deflects the interviewer’s attempt to draw him out by stating that his name is “American” rather than “Russian,” the interviewer gives up on the subject, possibly overlooking important issues of patriotic or national identity. Instead, the interviewer examines the patient’s name tag, asking suspiciously if it actually belongs to the patient. As Nick decompensates, possibly in part in response to the interviewer’s psychological disengagement, the interviewer then abandons the effort to communicate, altogether, stating “Get him out of here.” It may be argued that this depiction of an assessment in a wartime military hospital is a poor example of a psychiatric interview: there’s minimal time allotted for the interview, no privacy, and an exhausted interviewer under pressure to collect facts and process the patient as quickly as possible. In fact, these are precisely the conditions under which many mental health clinicians are currently trained and expected to work.

The Therapeutic Relationship Many have written about the centrality of a “therapeutic relationship” to the successful undertaking of a psychiatric interview. The precise meaning of this term varies in different hands (e.g., [3]) but is generally understood to represent the establishment of a partnership between the clinician and the

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Chapter 4.  Therapeutic and Anti-­therapeutic Relationships

patient, characterized by consent, trust, and disclosure on the part of the patient and a posture of nonjudgmental beneficence, as well as expertise, on the part of the clinician. Out of this relationship emerges some form of collaborative enterprise, dedicated to improved understanding of the patient with his or her problems. Is it possible to generate empirical evidence for the privileged status, or even the existence, of such a thing as a “therapeutic relationship”? A formidable body of research data indicates the association between treatment alliance and therapeutic outcome [1].

 herapeutic Relationship and Behavioral T Therapy Behavioral psychotherapies tend to de-emphasize the relationship between the clinician and the client but are nonetheless founded on a supposition that the patient is participating candidly and providing accurate data. Insight-directed psychotherapies specifically promote the elaboration and integration of previously nondisclosed perceptions and ideas between both the partners of the therapeutic dyad and within the mind of the patient. In either case, an effective treatment takes place within a relationship based on trust and disclosure [2]. Some patients make this process easy: it takes no more than a few moments to begin a dialogue about the patient’s experience and situation. The resulting process often boosts the clinician’s sense of engagement and professional efficacy. We often consciously or nonconsciously consider these patients to be “good”. But if we accept the concept of a therapeutic relationship, may we not propose the existence of its opposite, an “anti-­ therapeutic relationship”? Such a relationship is characterized by the opposite principles: mistrust rather than trust, deception rather than candor, acting out, and missed sessions. Above all, we see disruption of communication between the

Therapeutic Relationship and Behavioral Therapy

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patient and the clinician, including the patient’s moment-to-­ moment experience in the session. When it occurs in a patient, an anti-therapeutic posture inevitably includes DND as one of its major elements. DND in this setting reflects a variety of factors, including the patient’s anxiety about the prospect of retaliation or rejection by the clinician (and with it mistrust of the clinician’s nonjudgmental posture), distorted mentation and egocentricity reflecting the patient’s underlying psychopathology, or in some instances active psychopathy (e.g., when a patient engages in a sham therapeutic process to satisfy a third party). Table 4.1 contrasts the patient experience in the therapeutic and “anti-therapeutic” situations. The result is a treatment encounter that is typically challenging and unpleasant for the clinician. Early-career clinicians frequently feel anxious, guilty, or dubious about their Table 4.1  Qualities of the therapeutic and anti-therapeutic relationships. Patient experience and behavior Therapeutic Anti-therapeutic Trust Mistrust Disclosure

Deceit/nondisclosure

Consent and motivation by the patient to participate

Absence of consent or motivation

Reliable reports of symptoms and behavior between sessions

Distorted or grossly inaccurate reports of inter-session behavior and experience

Discussion and integration of previously nonconscious or nondisclosed material

Persistent psychological fragmentation

Diminishing symptoms and aberrant behavior as treatment becomes established

Behavioral acting out reflecting unchanged or intensified psychopathology

Planned termination

Withdrawal/unplanned termination of care

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Chapter 4.  Therapeutic and Anti-­therapeutic Relationships

own competence. One of the things that makes anti-­ therapeutic relationships particularly challenging for the clinician is the fact that patients engaged in DND frequently do not share their actual experience in treatment. Sometimes a clinician’s only indication of pervasive DND in the clinical encounter is a subjective experience of apathy (Table 4.2). In our experience, treatment relationships characterized by “hard” DND are doomed to a poor outcome, as both the clinician and the patient withdraw from the clinical encounter. Clinicians are trained to seek information from alternate sources and frequently rely on them as they abandon the clinical encounter. This process can only be arrested if the clinician forcefully intervenes. But what is the alternative? What exists beyond facts? As we examine the transactional interview, let us consider the propositions we have established so far: • All treatment encounters reflect a balance between disclosure and nondisclosure. • Many instances of nondisclosure are “soft” and resolve spontaneously over time, while “hard” instances represent the material that a patient is determined not to reveal. Table 4.2  Qualities of the therapeutic and anti-therapeutic relationships: clinician experience and behavior Therapeutic Anti-therapeutic Engagement Boredom Nonjudgmental posture

Negative or dismissive judgment of patients

Sense of therapeutic method/direction

Confusion about how to proceed

Self-confidence and fulfillment

Anxiety about competence, guilt

Fluent elicitation of clinical material

Regression to template interview questions, excessive nodding, cuing

Fluid fulfillment of the clinical role

Clinician enactments

References

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• Nondisclosure and its impact on the interview process are neither “good” nor “bad” and reflect a range of anxiety and other forces, some of which we have already enumerated (see Table 8.4 in Chap. 8), which reflect a patient’s willingness and capacity to disclose. • A clinician who relies on the establishment of a “therapeutic relationship” as the basis of the patient encounter is likely to encounter difficulty in engaging a nondisclosing patient. Often this manifests in the clinician’s subjective experience of anxiety, confusion, or boredom. • Identification and engagement of DND in the interview process is a critical aspect of the psychiatric assessment and when successfully undertaken contributes significantly to positive therapeutic outcome. • Successful engagement of anti-therapeutic elements requires an active rather than passive posture on the part of the clinician.

References 1. Arnow B, Steidtmann D. Harnessing the potential of the therapeutic alliance. World Psychiatry. 2014;13(3):238–40. 2. Beck J.  Cognitive behavior therapy. New  York: Guilford Press; 2011. 3. Shea C.  Psychiatric interviewing: the art of understanding. New York: Elsevier; 2017. 4. Spikings B. et. al. (Producers) Cimino M (Director). (1978). “The Deer Hunter” [Motion Picture] United States: EMI.

Chapter 5 Engaging Deceit

 our Principles of Engaging Deception and F Non-Disclosure (DND) The psychiatric interview represents a balance between sympathy and objectivity. It should be an effort to understand the patient in the context of his or her personal experience of what is happening, as well as development, life situation, and—not least—the patient’s psychopathology, whatever the evaluating clinician conceives it to be. This involves integrating the interviewer’s subjective experience with all available facts and integrating this data in the context of known principles of psychology and neuropsychiatry. As Karl Jaspers [1] stated, There is a natural way of empathetic listening to others in which we simultaneously keep in touch with ourselves. Every psychopathologist depends on his power to see and experience, and on the range in complexity of such power. This sympathetic tremulation of one psyche with the experiences of another means that, if we are to be scientific, we must objectify experience critically. Sympathy is not the same as knowledge, but from it springs that vision of things which provides knowledge with indispensable material.

The capacity to “objectify experience critically” brings us to the first principle of the formulation-guided interview (Table 5.1).

© Springer Nature Switzerland AG 2020 A. Lerman, The Non-Disclosing Patient, https://doi.org/10.1007/978-3-030-48614-3_5

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Chapter 5.  Engaging Deceit

Table 5.1  Four principles of engaging DND I The clinician can only listen effectively when guided by a developing clinical formulation (i.e., Level III of the stratified interview). II

A clinician’s emotional or “countertransference” response is the most sensitive indicator of unassessed DND in the clinical formulation.

III

The “why” driving DND is almost always more important than the “what” that is being concealed.

VI

“Follow the affect”—A patient’s emotion is a better guide than logic during the interview.

First Principle: Transactional Assessment Depends on Clinician’s Capacity to Develop and Maintain a Clinical Formulation

As noted, many clinicians, particularly those early in training, tend to either over-rely on the patient’s narrative or give up if the patient appears to be dishonest. Both outcomes are undesirable. The naive evaluator will miss clues that a patient may be providing false or incomplete information. The cynic risks abandoning a process that is yielding valuable information, albeit not of a factual nature. In both instances, the interviewer has abdicated Jaspers’ dictum to “objectify experience critically,” that is, develop and maintain a formulation of the clinical case that is related to, but independent of, the patient’s own subjective narrative. Placed in the context of an evolving formulation, the full range of the patient’s behavior can be engaged in the process of seeking a deeper understanding. Second Principle: A Clinician’s Emotional or “Countertransference” Response Is the Most Sensitive Indicator of Diagnostic Failure During the Evaluation Failures on the part of patients to communicate coherently, as well as on the part of clinicians to listen and understand, occur on a moment-to-moment basis in clinical practice. When minor, these problems are corrected as a matter of

Four Principles of Engaging DND

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course when one or the other partner says “I don’t ­understand what you mean” or “I don’t think you’re getting what I’m trying to say.” When more significant forces are limiting disclosure in an interview environment, on the other hand, and a more sustained breakdown of human communication is taking place, correction of the misunderstanding is less likely. In the case of less obvious DND, the problem itself is likely to go unrecognized. In such an event, the clinician’s most reliable warning that the interview is going awry is his or her subjective experience of anxiety, frustration, or boredom and often a series of unproductive errors in handling the interview. In the hands of less experienced clinicians, one may observe a range of behavior patterns reflecting the clinician’s escalating anxiety. • One behavior is a regression to “templating,” that is, abandonment of open-ended questioning and pursuit of linear sequential questions necessary to conclude a factual record of the conversation. • Other behaviors include a range of behaviors that appear to represent an effort to propitiate or reassure the patient, as though it is the patient who is experiencing anxiety, rather than the interviewer. These behaviors include “bobble-­ heading,” that is, excessive nodding, repeated affirmative verbal interjections, such as “uh huh,” or a tick-­ like tendency to repeat the closing words of the patient’s last sentence. • Clinicians under greater stress often engage in “cueing,” that is, narrating the procedures of the interview to the patient or to himself or herself. This includes behaviors such muttering reassuring interjections like “okay” repeatedly or stating to the patient “now I’m going to have to ask you some questions that I have to ask everybody, okay?” These behaviors and others like them should serve as indicators that the clinician is losing control of the interview but often go unrecognized.

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Chapter 5.  Engaging Deceit

A clinician who is prepared to regard his or her subjective experience during the interview as data, on the other hand, may begin to regain control of the interview environment by posing the following questions: • What am I feeling? • What is the patient doing to make me feel this way? • How do I reconcile with my clinical formulation to date? To return to the clinical example of Charlie’s presentation in the emergency room: this young man was superficially cooperative and reasonably polite, but he was depressing and frustrating to talk to. His behavior induced a feeling of pessimism and frustration in the clinician. The clinician’s subjective experience appeared consistent with a clinical formulation that Charlie appeared to be withholding critical information and might in fact be at greater clinical risk than immediately apparent. Third Principle: The “Why” Driving DND Is Almost Always More Important than the “What” That Is Being Concealed In the fact-based interview, we focus on facts. When we suspect that the patient is failing to provide reliable information, we abandon the interview and seek out other informants. In the transactional and formulation-guided interview, on the other hand, we move from pursuit of facts to pursuit of understanding of the patient’s motivation for nondisclosure. To put it more simply: why someone lies is often of greater significance than the point of fact in question. The first step of this process is establishing a shared understanding that the patient is withholding information. The second step is reducing anxiety on the part of both the patient and the clinician that this is the case and instead beginning a conversation. A posture of acceptance towards a patient’s DND behavior diminishes what the patient might otherwise perceive as an adversarial nature in a DND-focused interview. Some patients who are not ready to disclose facts can be engaged in exploration of why they do not wish to disclose.

Four Principles of Engaging DND

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We place our knowledge and conjecture regarding the patient’s motivation in the context of everything else we understand about the patient. While there are often many reasons for nondisclosure, motivation is at its core almost always a matter of emotion, rather than facts. Many patients who are unwilling to share specific facts nonetheless consciously or nonconsciously broadcast their emotional state through nonverbal behavior. Patients who feel an interviewer is sympathetic to their emotional state are much more likely to share both feelings and information. Fourth Principle: “Follow the Affect” In the course of an assessment interview, patients frequently become emotional. Such moments of emotional intrusion range from intense and sustained demonstrations of affect to momentary displays that may seem irrelevant and are easily missed. Less experienced interviewers frequently are observed to attempt to contain or minimize such demonstrations, for example, by handing the patient box of tissues or persisting in a preestablished line of questioning. More experienced interviewers are aware that there is no question one may be about to ask, or issue one is attempting to clarify, then whatever it is that just caused the patient to flood with emotion. Sometimes this is simply a matter of asking the patient what’s going on. Emotional reactions are nonlinear and frequently nonlogical and as such offer a unique means of access to the patient’s motivational state. Clinical Example: The Case of Charlie Charlie is an 18-year-old student with a chronic history of anxiety and dysthymia, who was psychiatrically hospitalized after a behavioral meltdown in the office of his longtime outpatient psychiatrist, a few weeks after he started his freshman year in college. He had sought evaluation in an emergency room the day before for an overdose of acetaminophen that

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Chapter 5.  Engaging Deceit

appeared to have been of no medical consequence, but which had worried his mother enough to bring him home for a therapy session, during which the patient had kicked over furniture and threatened to run from the building. On interview, he was cooperative but tense. He appeared to regard the interviewer as an ally against his outpatient psychiatrist, whom he characterized as incompetent and fixated on prescribing medication. The interview was punctuated by long silences, which the patient explained occurred because he “runs out of things to say,” whereupon he regarded the interviewer with a vacant, bared-teeth smile. When asked why he came home from college, Charlie states “I tried to kill myself.” “What happened?” The clinician asked. “I took an overdose. It was like 3 or 4 Tylenols,” he adds with a grin. “But what happened?” The clinician persisted. Charlie offered a few more details: “I just got upset. I had a fight with my girlfriend, but I don’t think that’s really why I did it. I was just really upset, you know?” Charlie went on to describe at some length various quarrels between the he and his ex-girlfriend, and the vicissitudes of their breakup as he graduated high school and went to college. When asked about the disturbance at his psychiatrist’s office, Charlie stated: “Oh he’s an idiot, he thought that because I had taken an overdose he had to call the police. He really ticked me off. I don’t even know why I see him.” With some prompting, Charlie went on to describe his breakup with his high school girlfriend, whom he described as popular, attractive, and manipulative. Charlie reported that the overdose occurred after he discovered he learned that his ex-girlfriend was dating a mutual friend at his old high school. But he again insisted that he didn’t think that this was his “main problem.” What was his “main problem”? Charlie said he “didn’t know.”

Charlie’s mother provided a detailed chronology of significantly more extensive disruptive conduct at school, including Charlie’s screaming during conversations on the phone with his ex-girlfriend, quarrels with his dormitory resident advisor, and a “suicide attempt” that occurred when he waded into a shallow pond on the campus grounds.

Four Principles of Engaging DND

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Charlie’s case seemed consistent with any number of other instances of minor adolescent self-injury, but on closer examination, it did not make sense. What was the nature of the meltdown in his psychiatrist office? Why did he go to the emergency room after taking only one or two more pills than prescribed? The interviewer attempted to resolve the confusion and discrepancies in Charlie’s account. Eventually, Charlie stated: It’s kind of embarrassing. I didn’t really take Tylenol. I made this drink, out of everything I could find, there was furniture cleaner and mouthwash and liquid soap. I put it in this bottle and drank some of it  – and then I got scared and went to the emergency room.

A narrative of this kind is typical of the incomplete accounts clinicians frequently receive from patients in crisis. Let’s take a look at additional data gained over the course of a 2-month brief psychotherapy: • Charlie’s sense that the breakup wasn’t his “main problem” seemed to be correct. He certainly had suffered from a range of other difficulties. Charlie developed anxiety symptoms and feelings of physical and personal inadequacy from an early age. His father died in an accident when he was 4 years old, and his mother had conducted an active dating life subsequently, including two men with whom she had longer term relationships, and Charlie had regarded them as “father figures” prior to the termination of their respective relationships with his mother. During the same period, Charlie had been subject to verbal denigration and at times violent bullying by his athletic older brother, who repeatedly denigrated Charlie as “gay.” Throughout early and middle childhood, Charlie was subject to violent temper tantrums and mercilessly teased by his brother about them. • Charlie had perceived himself to be a socially awkward misfit in high school, a child of a troubled family, and an academic underachiever. In his senior year, something changed, both his self-esteem and his grades improved, and he found himself included in a circle of talented, wealthy kids. He began a relationship with popular and

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Chapter 5.  Engaging Deceit

attractive in the group, and he pronounced this the ­happiest time of his life. He dreaded the approach of summer and worried that he was not attractive or sexually experienced enough to hold his girlfriend’s interest. He struggled to refrain from obsessively texting her to check on her whereabouts and companions. • When Charlie left for college, he and his girlfriend reached an ostensibly “mutual” decision to end their relationship, but Charlie was miserable, continually contacting his girlfriend for emotional support and reassurance. Two days prior to his hospitalization, when he learned that his girlfriend was “hooking up” with friends, Charlie disintegrated into regret, self-loathing, and rage, repeatedly calling his girlfriend until she blocked her phone. • Charlie then composed a mixture of vodka, liquid soap, and furniture polish and drank a small quantity, whereupon he became frightened and sought care in a local emergency room. Charlie was too embarrassed to confess to the physicians there how he had actually attempted to poison himself and gave the same false history of ingesting “three or four Tylenol” that he later offered the psychiatrist in his hometown. Charlie states he has long detested his psychiatrist, who also treats Charlie’s mother. In that capacity, Charlie feels the psychiatrist has long ignored his mother’s excessive alcohol consumption. Near the end of the reef treatment, accounts of his mother’s incapacitation to do heavy solitary drinking became a more prominent focus. • Charlie reported that he had taken the bottle of furniture polish home with him, stating “I don’t know why” he had done so. Over the course of the initial interview, Charlie engaged in repeated acts of deception regarding the nature and circumstances of his toxic ingestion and his mental state and behavior before and after it. In aggregate, his actions represented a fabric of deceit with the potential to blind any effort to understand him. The individual acts, however, are not uni-

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form in character, method, or even Charlie’s awareness of engaging in deception, as best we can assess it. Table 5.2 itemizes his most significant false statements during the initial interview or index episode along with his level of awareness. (The term “index episode” denotes a subject’s first version of events, against which subsequent accounts and accumulating factual data can be weighed.) With Charlie’s false statements listed in order, one thing that becomes apparent is the range and depth of his nondisclosure during the index episode. We can see that nearly every fact that gained importance in Charlie’s subsequent treatment was initially concealed. Note that only one element on the list of Charlie’s false statements represents an active and deceptive falsehood, that is, his report that he overdosed on “three or four Tylenol” Table 5.2  Charlie’s factual distortions Subject of DND Nature of overdose

Type Deception

Level of awareness High

Continued possession of toxic compound

Nondisclosure

High

Dependence on ex-girlfriend

Distortion (minimized)

Moderate

Outbursts at ex-girlfriend

Nondisclosure

Moderate

“Attempted Drowning” Episode

Nondisclosure

Moderate

History of psychological victimization

Nondisclosure/ distortion

Low

Chronic self-image/self-­ esteem problems

Nondisclosure/ distortion

Low

Maternal alcoholism

Nondisclosure/ distortion

Low

Treatment by mother’s psychiatrist

Nondisclosure

Low

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Chapter 5.  Engaging Deceit

when he in fact consumed a compound of cleaning fluid and other substances. A second, more frequently employed class of falsehoods is the withholding of critical information, for example, the nature of the toxic compound he attempted to poison himself with or the fact that he brought it back with him from college. The fact that these distortions were achieved by the passive means of nondisclosure, rather than through outright false statements, renders them no less deceptive, and the act of deception during the interview no less clinically significant. Even more common is the omission of obviously relevant facts that might reasonably be expected to have surfaced in the index episode, such as the basis of Charlie’s outbursts at his ex-girlfriend or his “drowning attempt” undertaken in the middle of one. Charlie appears to have been somewhat less aware of withholding this material and perhaps simultaneously deceiving himself in the process of doing so. More pervasively still, we find a range of material that appears to remain undisclosed because it lies at the limit of Charlie’s capacity to perceive himself or organize his perceptions into an awareness that can be communicated or shared. Such cognitive limitations appeared to coincide with Charlie’s long-standing symptoms of anxiety, passivity, and identity disturbance, exploration of which leads in turn to his abuse at the hands of his brother and his mother’s alcohol dependency (Table 5.3). It may be argued that we are making too much what Charlie did or did not disclose in the “index episode,” that is, that a process of selective omission represents an inherent limit to the quantity of information that can be transmitted during the initial interview, rather than a process of any psyTable 5.3  Classes of nondisclosure

Deception Omission “Inadvertent” ND Disrupted awareness

Four Principles of Engaging DND

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chological significance. It should be noted, on the other hand, that Charlie withheld the same facts from the clinicians who evaluated him at his college, from his mother, and from a psychiatrist who treated him for more than 4 years. This suggests that the process by which information is selected for disclosure or withheld is nonrandom. A second objection to the validity of the nondisclosure concept could be made based on the argument that at least some nondisclosure reflects a failure of his awareness and capacity, rather than a volitional act. We have already acknowledged this element to be in play with regard to Charlie’s seeming unawareness of pathogenic events development history and their impact on him. It should also be noted, on the other hand, that deception of others and self-deception frequently go hand in hand. Many, if not all, actors report that theatrical verisimilitude depends on convincing oneself that a fictional role is real. The same advice is often offered to those who wish to successfully lie. It is always easier to lie by omission, because passive deception is easily dismissed as a failure of memory. In addition, some facts are genuinely forgotten or half-forgotten. All of us live with facts and memories that we are less ready to remember, and such material is often most vulnerable to more or less genuine “accidental” failures of recollection. This brings us to a complex proposition with a long history, namely, that both volitional and non-volitional distortions of self-awareness represent a means of self-regulation in the human mind, that is, a “defense mechanism” [2]. Distortions of this kind undertaken on a repetitive basis possess the potential to disrupt the mechanisms of consciousness and identity and pave the path to more pervasive mental illness, namely, a “personality disorder.” A complete discussion of these propositions lies beyond the scope of this treatise, but we will return to it again. By any measure, Charlie’s index narrative was stunted, incomplete, and riddled with volitional and semi-volitional

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acts of deception. Affectively, he concealed his actual feelings behind his fixed grin.

Interviewing Charlie Are there clues that can lead an interviewer to perceive that a subject is withholding information?

Charlie as Storyteller For one thing, Charlie was a terribly storyteller. His history, as offered in the initial interview, made no sense. The story was formally disrupted, that is, the salient events, as he reported them, were confused, out of sequence, and often lacking context by which his actions could be understood. It was difficult to understand, for example, why he had gone to the emergency room after a tiny overdose. It was also hard to determine how this led to his decision to leave college, or the nature of his outburst in his psychiatrist office that led that clinician to call the police the next day. Another oddity could be found in the mental status exam, namely, Charlie’s flat affect, and a strange, perseverative grin. When the interviewer commented on his smile, Charlie replied, “This is just my shit-eating grin”—a term that seemed to capture his self-deprecation, denial of his own suffering, and evasion of the effort of others to understand or help him. Subsequent events attested to the “soft” (i.e., malleable) nature of Charlie’s posture of nondisclosure. His pervasive sense of shame quickly became established, and from this followed an increasingly candid nature of his dependence on his ex-girlfriend. In the course of this discussion, he volunteered he had lied about the nature of his overdose, because he was ashamed of “acting like a psycho” in composing and attempting to consume the cocktail with which he did intent to harm himself. (And in this he appears to have been correct: the bizarre nature of the overdose attests to his disrupted mental state at the time.)

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In the ensuing discussion, many of the previously nondisclosed aspects of his life surfaced, and a more coherent picture of his life circumstances and the actual circumstances of his decompensation college began to take form. Particularly troubling was the nature of Charlie’s prior treatment for the outpatient psychiatrist, as it emerged that this clinician also treated the patient’s mother and appeared to share her minimization of alcohol dependency, including its impact on Charlie. In hindsight, it is notable that on presentation Charlie himself was only moderately aware of the extent of his nondisclosure; yet after disclosing the material that he actively withheld, many aspects of his non-volitional disclosure likewise began to unravel. This is a pattern we will see again and again: volitional and non-volitional nondisclosures go hand in hand. Once a subject begins to disclose previously privileged material—and most particularly, as the subject’s motivation for previously withholding information is itself exposed—the rest of the story inevitably follows. But reaching this happy outcome is frequently more difficult than it was in the case of Charlie, and the complexity of many individuals’ resistance to speaking openly is as deep and wide as the nature of humanity itself. Clinical Example: Charlie 2 Charlie presented in the psychiatric emergency room in the setting of what he claimed was a minute overdose and a more significant behavioral outburst at his outpatient psychiatrist’s office. The interview was punctuated by long silences, which the patient explained occurred because he “runs out of things to say,” whereupon he regarded the interviewer with a vacant, bared-teeth smile. In response to this smile, which Charlie later characterized as a “shit-eating grin,” the evaluating clinician experienced a wave of subjective pessimism about the case and a desire to complete the interview quickly. On assessment, the clinician was immediately struck by the laconic nature of Charlie’s account. The minimal factual

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content was mirrored by the patient’s passivity and his statement that he had “run out” of things to say, which seem to foreclose the possibility of any conversation. Another notable feature of Charlie’s presentation was the trivial quantity of his overdose, as reported at the time. Taken in aggregate, this modest quantity of data led to a formulation that guided the rest of the treatment: the best explanation of the available data was that Charlie was withholding critical information. Given this possibility, all of the statements he had made should be likewise regarded as unreliable. The reason that Charlie was behaving in this way was unknown, and understanding why he was doing so became a new and critical assessment of the therapeutic goal.

References 1. Jaspers K.  General psychopathology. Baltimore: Johns Hopkins University Press; 1963, 1997. 2. Vallant G. Involuntary coping mechanisms: a psychodynamic perspective. Dialogues Clin Neurosci. 2011;13(3):366–70.

Chapter 6 Deceit and Its Meaning

Application of the Transactional Interview Let us return to the “first principle” of the transactional interview formulation: the idea that the clinician must be guided by some kind of formulation. In other words, the clinician requires at least a provisional sense of meaning to orient himself or herself and to begin to try to understand and help a patient. Many patients make this easy for us. A sense of meaning is established as the patient offers a history of their problem, along with the hope that the clinician will be able to help. This sense of meaning will be subject to all kinds of revision as the interview, and possibly treatment, proceeds, but is established in its primal form almost at the first moment of contact between clinician and patient. But what about a patient who disseminates falsehoods or withholds information? Can deceit have meaning? If deceit represents a breakdown of communication between two or more people, how is it possible to establish that deceit occurs, let alone reach shared determination of what its meaning might be? If communication is not possible, which of the partners decides what meaning to derive from what has happened? In fact, an environment of deceit is toxic to interpersonal understanding. It is either detected as such and commits both partners to solitude. This toxic property © Springer Nature Switzerland AG 2020 A. Lerman, The Non-Disclosing Patient, https://doi.org/10.1007/978-3-030-48614-3_6

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accounts for a major fraction of the anxiety and frustration that DND arouses among clinicians, and resultant tendency to withdraw from a deceptive subject. The transactional interview represents a method that allows the clinician to regain control of the deceptive environment. The first step in this occurs the clinician creates a formulation to account for what is going on, including the patient’s behavior. Let’s take another look at the example from the film “The Deer Hunter” cited earlier in the book. For example, in the excerpt from “The Deer Hunter” cited above, we see a brief effort by the physician to engage the subject based largely on a series of “template” questions about the patient’s identity. When the subject response sarcastically and then fails to answer these questions, the physician quickly abandons the effort. Guided by the principles of transactional interviewing, the physician in this case, might alternatively have responded first by • Developing a formulation, which might be as simple as “I don’t know what’s going on.” • Making the connection between his own emotional reaction and the patient’s failure to disclose critical information. • Ascertaining the “why” driving the patient’s nondisclosing behavior, likely that the patient is in a state of acute shock. • “Following the affect” to gain an emotional if not narrative account of the circumstances leading to the patient’s distress. So, what makes this a “transactional interview?” The distinction rest with the process that begins as the effort to communicate, as otherwise conceived, breaks down. The subject’s silence is regarded as a “transaction,” rather than a failure to communicate. The initiative passes from the patient to the clinician to develop and test a series of clinical formulations. Note that the patient’s cooperation is not necessary for the

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patient do this. In fact, actively noncooperative or even ­violent conduct on the patient’s part identified as a “transaction” and the engaged in this process. Let’s consider a more extensive instance of an interview characterized by high level of DND. Consider the following case:Clinical Example—“The Pornographer with a Gun” Police and a mobile psychiatric crisis team were called to evaluate a middle-aged man involved in the production and distribution of pornography, after his ex-girlfriend reported that the patient had repeatedly engaged in a game of “Russian roulette” while on the phone with her during a quarrel. She stated she had previously seen him in possession of a revolver. The patient insisted that the report was untrue and denied owning a firearm of any kind. He was unable to offer an explanation for the metallic sounds his ex-girlfriend reported hearing over the phone, stating that she was “pretty hysterical”, and might have confused the sound of a cup he was drinking from banging on the phone. The clinical team had reached a decision to admit him to a psychiatric hospital for further assessment. When so informed, the patient retrieved a nonfunctional starting pistol for a hiding place. He explained that he had indeed threatened to shoot himself over the phone, but neither intention nor capacity to do so, had only intended to intimidate and manipulate his ex-girlfriend. The patient is an individual who under normal circumstances would never see evaluation or treatment. The rigid and categorical nature of his denial of his ex-girlfriend’s account recalls that of the teenager in the residential home who insisted she was the victim of an attack. Might he not be the victim of a false accusation? Perhaps, but there is little sense on the part of the patient of any receptiveness to help, or of hope that a sympathetic listener will understand what actually happened. The smug and irritable nature of his demeanor is more consistent with the posture of an individual who is confident that he will prevail.

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This posture is suggestive although not probative of “hard DND”, that is a fixed and determined effort to deceive that is likely to be impervious to any effort at therapeutic engagement. The breakthrough in the evaluation is achieved through the threat of arrest and hospitalization rather than any consensual process between patient and clinician. The breakthrough achieved, we see a network of deception: first the patient deceives his girlfriend by threatening to shoot himself with what is in fact a toy gun, then he deceives the treatment team by pretending the gun does not exist. It is important for the clinician in these circumstances to examine his or her emotional response to such an individual as data relevant to the assessment, and not to abandon the assessment process. This is not out of charity to the subject, but out of a duty to assess the full register of the patient’s psychopathology. Viewed “transactionally”, we see that the patient has designed a deceptive snare within the assessment encounter to match that which he constructed for his ex-girlfriend. How many other people has he fooled with his toy pistol? What devices has he used to recruit and control models for his pornography business? How manipulative is he to his customers? In short, the “transactional” assessment, that is, a systematic review of his interactions with the interviewer and their possible motivation, reveals the patient to be an insecure and deceitful individual who might even, under some circumstances, represent a danger to the clinician. His use of deception indicates a need to manipulate and control others. At the same time there is a quality of make-believe associated with the toy pistol, the production and sale of pornography, and the patient’s immediate shift from defiance to servility when confronted with the prospect of psychiatric hospitalization. The word “psychodynamic” covers a range of different and at times contradictory ideas and clinical conduct. Some of the shared concepts that unite them include:

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• All thoughts, actions, and impulses have meaning. Different elements of our mental and behavioral lives are related to each other. Sometimes these relationships are obvious, while at other times human beings are oblivious to the origin of their motives and beliefs. • A clinician wishing to explore these relationships must be curious, supportive, and nonjudgmental. • All people engage in behavior and mentation that is nonlogical or self-destructive, with varying degrees of awareness. • The process of discussing self-experience candidly with a clinician can lead to improved self-understanding, along with some other kind of positive outcome. • This process must be governed by absolute confidentiality, and a range of other rules. These concepts are put into practice within an agreed-­ upon set of rules on the between the patient and clinician. There is an expectation of complete openness on the part of the patient, and a nonjudgmental posture on the part of the clinician. There is an expectation that, at times over the course of treatment, which the patient may not understand, or might even be unaware of. Our focus is on the phenomenon of deceit in the clinical interview, not psychotherapy, or any of the deeper questions about the human psyche. Our questions are narrower in scope: Does deceit have meaning? If so, is it possible to apply principles of psychodynamic psychology to the exploration of DND the general psychiatric interview?

Transactional Encounters We propose that every interaction between one human being and another can be seen as a transaction, that is to say, a behavior undertaken in a social setting, which acquires meaning in the minds of one or both parties, and triggers some kind of response.

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Can that actually be true? Consider the act of asking another person their name. Clinical Example: Template Question A patient arrives for a psychiatric evaluation. The receptionist asks his name. This instance in this case is a specimen “template question” that is, an inquiry driven by an impersonal program rather than any interaction between the questioner and subject. Such questions are understood by both parties to be devoid of social or emotional valence. They are asked and answered as a matter of course. Even in such an instance, however, it’s not that simple. Even a template response can be infused with secondary significance. The receptions may communicate disinterest, boredom, compassion, curiosity, or any of a range of other reactions that begin to color the patient’s experience of the clinical contact. Sometimes the significance of a transaction is idiosyncratic and personal. Clinical Example: Extramural Significance A psychiatry resident of middle eastern origin experiences a pang anxiety when a patient says “I can’t pronounce your last name—What’s your first name,” which is “Mohammad.” Afraid that the patient will denounce him as a Muslim terrorist, the resident changes the subject. In this case the source of anxiety is brought to the interview solely within the mind of one participant, reflecting the influence of events and ideas extraneous to the experience of the other. It is nonetheless likely that the resident’s anxiety may be consciously or nonconsciously sensed by the patient, precipitating a range of other responses in turn. For example, independent of the current cultural and political climate, the resident’s response may reflect the resident’s discomfort on being asked a personal question, and possibly his inexperience in tolerating intimacy while in professional role.

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Consider the same question in another setting. Clinical Example—Intimacy Without Context A man and a woman of no prior acquaintance are standing at a bus stop, when the man asks “What’s your name?” For many, such a question asked at the outset of such an encounter would violate conventional social expectations. Why does this person want to know my name? Does the question the possibility of a preexisting relationship? Is it being asked playfully? Or, is this the beginning of some inappropriate effort at intimacy? The object of the question might seek nonverbal cues which may give context or meaning to the request. What is this person’s level of cleanliness and hygiene? How are they positioning their body with respect ours? What does their facial expression reveal about their state of mind? Note that if the question was preceded by even momentary nonverbal contact including some expression of interest on the part of the woman, the meaning of the question would be completely different. In the absence of some form of reassuring contact, many of us approached in this way by a stranger may conclude, consciously or nonconsciously, that the other person is in some way deviant. We then try withdraw, socially and physically, and terminate the encounter. If, on the other hand, the stranger makes an attempt at striking up a conversation at a bus stop in a more “normal” way, the significance of the question would again change. Clinical Example A man and a woman of no prior acquaintance are standing at a bus stop, when the man says “Excuse me, you look familiar. Have we met before?” The woman sees his name tag and replies “Were you at the meeting this morning?” The man answers “Yes, that’s it. What’s your name?” In this example, the questioner begins with “Excuse me,” a politeness that acknowledges the potential the woman will per-

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ceive his initiating a conversation as intrusive. Next, he offers a context for his doing so. The woman has an o ­ pportunity to accept or decline further conversation. When she does, and offers a context within which he has a reason to do so, he asks her name. Irrespective of whether there actually was a meeting or not, or any other subtext to the encounter, the two people have formed the basis to begin at least a temporary relationship. All of these considerations inform an initial psychiatric encounter. Template questions comprise a good portion of many assessment interviews; indeed some of the more-­ structured assessment procedures conducted by psychiatrists-­ in-­training consist of little else.

Objections to Psychodynamic Principles We anticipate a number of objections:

Absence of Treatment Frame Most psychotherapies begin with an independent decision on the part of the patient to seek treatment. This is followed by a negotiation between clinician and patient that includes an agreement about of the conduct and goals of the treatment. The patient accepts his or her responsibility to engage in candid self-disclosure. The clinician, on the other hand, is governed by a nearly absolute responsibility to protect the patient’s confidentiality, and the patient possesses the right to terminate treatment at any time. These principles are often referred to as the treatment “frame.” The psychiatric assessment, on the other hand, many aspects of the treatment “frame” are not present. A diagnostic evaluation is characterized by an implicit imbalance of power, starting with the professional responsibility of the clinician to (hopefully) apply expert knowledge that the patient does not possess, and may be beyond the patient’s capacity to understand. Some evaluations are undertaken with unwilling subjects; including those that involve the prospect of involuntary treatment. Even in the case of a person seeking

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assessment voluntarily, the subject is characteristically in trouble. Some patients are desperate for help. For others, the act of submitting to an evaluation may in and of itself appear to be a frightening concession of weakness or incapacity. It is easy to understand how an individual in the circumstances may be inclined to establish some control of the interview situation by minimizing, distorting, or withholding factual information. Increasing concerns about the security of protected health information, as well as its legal and widespread dissemination under the Health Insurance Portabilitiy and Accountability Act (HIPAA) and related statutes, represents a serious potential breach of a psychiatric treatment frame. Clinical Example David is a 27-year-old military veteran and law enforcement officer, who suffers from recurrent passive suicidal ideation and occasional active suicidal impulses. He states he would never seek psychiatric treatment because “the minute they hear about that, they take my gun away, and my career is over.”

Failure of Neutrality One of the core responsibilities of the psychodynamic therapist is that he or she should be “neutral.” This doesn’t mean a therapist doesn’t care about the patient, or avoids engaging them in a humane and accepting manner. Rather, “neutrality” in its simplest form means adopting an open-minded, and nonjudgmental posture toward the patient. It implies, among other things, acceptance of the possibility that the information the patient is providing might knowingly or unknowingly be less than complete, and a posture of curiosity regarding why this might be. Clinical Example A patient referred to an outpatient mental health clinic for treatment of acute anxiety disorder stated “I went to see a

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psychiatrist, but she wasn’t interested in what was going on. All she wanted to know was what meds I had been on before and prescribe more pills.” Modern psychiatric evaluators are frequently non-neutral in their practice. Many are governed by institutional and reimbursement imperatives that limit the amount of time available for the evaluation on the one hand; and impose mandatory requirements for collecting a range of specific facts on the other. As discussed above, the result is frequently a brief fact-focused interview geared towards identifying and quantifying mentation and behavior that is implicitly labeled as pathological. Clinical Example A clinician in training manages her anxiety in collecting a behavioral history by reading questions directly from the electronic health record (“templating”) including “Have you engaged in unprotected sex in the last year?” and “have you ever consumed alcohol to the point of blackout?” When the patient answers in the negative, the clinician mutters (“cueing”) “Good,” apparently to herself. The clinician may not intend to convey a negative moral judgment, but the use of the template leaves little doubt in the mind of either party that the question is assessing pathological behavior. Enactment Perhaps a more obvious term for this psychodynamic concept is “action statement” referring to a generally nonconscious substitution of action for a process of self-discovery and reflection. Clinical Example: Francine Francine (a simulated patient) is a divorced middle-aged professional who works in highly regarded capacity in a leadership position. She is referred for psychiatric evaluation by her family after her daughter discovered apparent research

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regarding suicide methodology on web browser. On evaluation she minimizes her solitary alcohol consumption. As the evaluating clinician presses her for precise details of her drinking history, Francine maintains that her daughter was manipulated by her ex-husband to make this report. In this vignette, Francine’s nondisclosure is multifactorial, and reflects in part both her sense of shame and her stoic denial of her own distress. The clinician’s effort to quantify her alcohol consumption represented a reasonable pursuit of important factual information, but exacerbated Francine’s sense of alienation from the interviewer, with whom she already enjoyed only a tenuous relationship. In so doing, Francine can be understood to be replicated the same sense of shame-based isolation she experienced with her daughter and other family members. As noted, the patient’s trust of the evaluating clinician cannot be taken for granted. It is necessary for the clinician to project concern, acceptance, and warmth. By so doing, the clinician both provides psychological support, and establishes a reasonably neutral environment, within most patients will become somewhat more comfortable and candid. These are the fundamental criteria of the therapeutic relationship and illustrate how maintaining such a relationship and step in substance to the evaluation. A patient’s resistance to engagement in the course of an affirmative interview is of greater diagnostic significance, then the same behavior in a clinical setting that is cold, distant, or threatening. Note that friendliness on the part of the clinician is not a violation of neutrality; if anything the opposite is the case. Clinical Example Andy, a middle-aged man referred for a professional fitness evaluation was taciturn, guarded, and made several demonstrably false statements during the evaluation interview. In the course of drafting his report, the evaluating clinician contacted the subject to apprise him of the forthcoming

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conclusion that Andy was engaging in deceitful conduct, and offered him another opportunity to speak in a more forthcoming passion. The patient declined the invitation, and subsequently filed a malpractice charge against the clinician, alleging that the clinician had behaved dishonestly on a professionally as the agent of Andy’s now-former employer. After reviewing the evidence, the judge dismissed the case, noting that the record indicated that the evaluating clinician had made an unusual effort to include Andy’s side of the story. Note in this example, the issue is not of an absent “treatment frame”—there is no treatment taking place. The evaluating clinician has no therapeutic role, no burden of confidentiality with regard to the patient’s material, nor any commitment to advance the subject’s (not patient’s) well-­ being, other than making an attempt to determine the truth. These considerations notwithstanding, however, the clinician’s posture of obvious beneficence within his professional role increased rather than decreased the value of the assessment is an objective measure. Nonlinear Process and Transference  The nontherapeutic environment: here the distinction between the evaluation at a psychodynamic treatment environment is less important. Nonlinear process occurs all the time. Patients interrupt their accounts to smile, sigh, change the subject, or engage in a range of other seemingly unrelated behaviors, all the time. This is particularly the case with regard to breakthrough affect and nonverbal cueing. Often, the only modification necessary is opening the mind of the clinician to regard nonlinear material as data and integrate it into the clinical formulation. KARL Clinical Example Karl (a simulated patient modeled on an actual case) is a successful corporate executive who is referred for psychiatric evaluation following allegations that he physically attacked his wife and daughter during a domestic quarrel. During the interview, he strenuously denied these allegations. While

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doing so, Karl engages in a systematic campaign of disparagement against his female, non-American-born evaluator, a clinician in training. As the clinician attempts to interview him, Karl repeatedly interrupts. Although she was speaking normally, he Asked her to slow down, and speak with less of an accent, inquired about the location and nature of her training, and her reasons for moving to the United States. Increasingly frustrated and inhibited, the evaluating clinician made a few ineffectual attempts to redirect the patient, and then effectively yielded control of the interview to him. After the exercise ended, the frazzled clinician commented “I didn’t know how to control him. He made me feel stupid, and I hated him so much—I think I need a therapist now.” In order for this clinician to succeed, she had to contain the intensity of her emotional response to the patient’s psychological assault and mobilize and objectifying posture within which she could begin thinking about the patient within the reference of a clinical formulation. Once this process was initiated, it was possible to search for the source of her emotional reaction, and consider the “why” driving the patient’s motivation to treat her in this way, and to consider the affect writing the patient’s behavior. From this perspective, it became clear that, despite the clinician’s goodwill and therapeutic intent, the patient’s superficial politeness a state masked his deep internal rage— a finding of high significance given the circumstances which precipitated the evaluation. The clinician’s observations, and the resulting formulation, were obviously of great relevance to the diagnostic assessment which would have been of salient evidentiary value in any subsequent legal proceeding.

Imbalance of Power Another respect in which psychotherapeutic treatment differs from psychiatric assessment is that the assessment relationship is frequently attended by a perceived, and often real,

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imbalance of power. Nearly every psychotherapeutic relationship begins with a process of establishing shared concept of the problem between the therapist and patient, as well as shared therapeutic goals. Many psychiatric evaluations, on the other hand, are undertaken with unwilling subjects facing the prospect of involuntary treatment based on the outcome of the evaluation. Even in the case of a voluntary assessment, the subject is characteristically in trouble. The act of participating in an evaluation may in and of itself appear to be a confession of weakness or incapacity. The evaluating clinician to one degree or another possesses expert knowledge. He or she controls the process and direction of the diagnostic assessment, decides what questions to ask, which answers to emphasize, and which to disregard. Hopefully, the clinician is developing a diagnostic schema, testing hypotheses, and applying conceptual tools which the interview subject at best minimally understands.

Anxiety Such a process always involves a level of anxiety on the part of the subject, which under some conditions is shared by the examiner. The nature and form of this anxiety varies in character. Some patients fear being misunderstood, judged, or exposed. Some perceive the diagnostic assessment as arcane and one-­ sided, and fear being labeled “crazy” or being assigned some esoteric diagnosis. Others fear the intensity of their own dependency needs, or intense affective states mobilized by the interview process. More-severe psychopathology is associated with a range of intense anxiety states, sometimes of bizarre character. On examination, such anxieties often reflect conscious or nonconscious attribution or “projection” of the subject’s own attitudes onto the interviewer (Table 6.1).

Anxiety Table 6.1  Common forms of anxiety

Fear of interviewer’s judgment (including projected guilt) Fear of disgust (including shame) Fear of exploitation (dependency needs) Incomprehension Emotional withdrawal Disclosure Unprofessional conduct

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Part II

Personality Functioning and DND

The great enemy of truth is very often not the lie  — deliberate, contrived and dishonest — but the myth — persistent, persuasive and unrealistic.” John F. Kennedy

Chapter 7 Neurobiology of Deception

Executive Function and Deception Executive functions refer to high-level cognitive processes that, by operating on lower-level mental processes, flexibly regulate and control our thoughts and goal-directed behavior. (Ambrosini et al. [5])

In everyday life, we attain control of our behaviors and responses through neurobiological resources constituting cognition. The word “cognition” is derived from Latin word “cognoscere” which means to “get to know.” Cognition is crucial to daily functioning as it enables us to interact with our surrounding environment and react accordingly. Therefore, it is a complex process of perceiving information and reaction formulation, information processing and understanding, storage of information and retrieval, decision-­ making, and appropriate responsiveness [21]. Cognitive control collectively is referred as executive function of the brain, which involves control of behaviors and information, reasoning, planning, and problem solving [21]. Behaviors are developed and modulated necessarily through initiation or inhibition, respectively, rendered by processes involved in executive functioning of the brain. It is argued whether cognitive functioning is a conscious or an unconscious process, although cognitive architecture and associated principles support later but cognition may have access to consciousness [21]. The principal area implicated in cognitive functioning is © Springer Nature Switzerland AG 2020 A. Lerman, The Non-Disclosing Patient, https://doi.org/10.1007/978-3-030-48614-3_7

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pre-frontal cortex (PFC) of human brain, whereas deeper brain regions also contribute in processes involved in cognition. It can also be viewed as higher cortical centers playing an essential role in behavioral adaptation during unconventional circumstances while deeper brain systems performing daily automated tasks. Deception is a complex behavior requiring efficient retrieval and manipulation of information along with regulation of emotional and physical responses for efficient delivery of altered information. These processes are examples of classic executive functions. Hence, deception is a cognitive process involving higher centers of brain for modulation of information and affective response while coordinating with the deeper centers of the brain for associated physical and emotional response regulation. This relative and important concept of long-range connectivity between higher and deeper centers of the brain will be discussed in following sections (Table 7.1). Deception therefore involves cognitive processes as assessment of the situation, retrieval of the memory or information, suppression of information known as true, desired fabrication of the information, and ultimately its delivery. The executive functioning of brain remains involved even after the delivery of the deceptive information for the purpose of reaction assessment of the deceived and one’s behavioral adaptation and emotional modulation in response to either successful or failed outcome. Therefore, inhibition and modulation of emotional and physical responses associated with factual information and maintenance of attention span and working memory are additional cognitive tasks being performed during the entire process. Affective modulation in response to target’s reaction helps fine-tune the deceptive behavior. Deceptive behavior from cognitive neurobiological perspective presents as a process of behavioral control with use of limited cognitive resources. Increased cognitive load interprets as increased response latency. This increased response latency serves as a key variable in the detection of deception. On the other hand, one may ask, is it possible to measure increased cognitive load? If so how much reliable and specific

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Table 7.1  Deception as an executive function Processes Brain regions PFC regions as superior Assessment Memory retrieval frontal cortex (SFC), and maintenance orbitofrontal cortex (OFC), of task set and and middle frontal cortex context evaluation (MFC); anterior cingulate cortex (ACC). Inferior parietal sulcus (IPS)

Preparation and delivery

Others

Social context evaluation

Temporal lobe and temporo-parietal junction (TPJ)

Behavior inhibition and conflict monitoring

Middle frontal gyrus (MFG), inferior frontal gyrus (IFG), and anterior cingulate cortex (ACC)

Reward and benefit processing

ACC, striatum, thalamus, motor cortex, precuneus, inferior parietal lobule (IPL)

Working memory, attention and error codes processing, long-range connectivity

Cerebellum: cerebrocerebellar connections Fronto-parietal and cinguloopercular networks

this information could be for successful deception tracing? These pertinent areas will be discussed in the following sections.

Deception Detection Techniques You can fool all the people some of the time, and some of the people all the time, but you cannot fool all the people all the time. Abraham Lincoln

The notion that humans are not always accurate in detecting deception is supported by the findings of a research study

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reporting that nearly 50% of the people were able to recognize lies as false and nearly 60% were able to recognize truth as non-deceptive [58]. In an effort to fill this gap, man has been trying for ages to develop reliable techniques to measure deception. Historically, it is believed that deceptive behavior due to the associated stress is associated with changes in autonomic activity [16]. In an effort to measure the changes in autonomic activity and its correlation with deceptive behavior, Marston measured changes in blood pressure and muscle tension while lying, carving the foundation work for still acknowledged and utilized lie-detection-­tool [40, 49]. In the early nineteenth century, changes in physiological measures associated with lying were formally studied, and measurement tools were devised for the purpose of lie detection. Later, various other cortical activity measurement techniques such as electroencephalogram (EEG) and even more sensitive modalities such as magnetic resonance imaging (MRI) have been used to study neurological correlates of deception. In this section, outcomes of these ­modalities will be briefly reviewed not only to enhance the understanding of deception as a neural process but also to estimate the rate of success in deception detection as a neurobiological process (Table 7.2). Table 7.2  Deception detection approaches Cognitive or Emotion/ Memory/ neural arousal recognition correlates The polygraph test

Guilty knowledge test using: Autonomic (skin conductance response) Central (ERP, fMRI) Memory, malingering tests

Allen and Mertens [1]

Response conflict Attention and memory load Linguistic analysis fMRI approaches

Future perspectives Neurochemical correlates (HMRS scans) Combined efficacy of polygraph and fMRI-based connectivity studies

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Polygraph Polygraph test records autonomic activity of an individual under investigation in a graphical form measuring blood pressure, heart rate, respiration, and sweating. The first polygraph machine was invented by John Larson [40, 49]. The questioning format for assessment during polygraph testing varies across the studies, but predominantly “The Comparison Question Test” is used. This format consists of control questions intermixed with interrogation-related questions along with which the polygraph recordings are used to measure the changes in the autonomic measures recorded during the pre-­ investigation interview and during the investigation. Reliability of polygraph test – The reliability of polygraph testing remains questioned throughout the course of its development and application. Its application is based on the presumption that subject’s physiological responses will remain consistent and measurable during the investigation. Contrarily, the situation of being under investigation itself is stressful, which can impact the physiological measures read by polygraph regardless of telling the truth or a lie. Therefore, it is argued that polygraph findings potentially measure stress in form of anxiety rather than the guilt of telling a lie and the interpretation of the findings ultimately remain examiner [25]. In addition, there is no reported literature on the effect of confounding medical conditions as, as autonomic dysregulation, and effect concurrent use of medications impacting autonomic activity on the polygraph testing outcome [9]. In controlled settings, the studies have reported reliability of polygraph testing ranging between almost 80% and 90% [40]. Contrary to this lucrative percentage of success, the studies outside the controlled settings have reported up to 50% of false positive rates [57]. In an attempt to enhance the accuracy and reliability of deception detection due to the limitations in the previous tools, rarely researchers used combined modalities. In a recent study, Bhutta and colleagues [7] demonstrated functional near infrared spectroscopy (fNIRS), gathering topo-

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graphic and tomographic hemodynamic responses associated with the neuron behavior, combined with polygraph testing, which indicated higher accuracy of single trial lie detection as compared to the individual modalities alone.

Thermal Imaging In order to address the situational stress of being assessed, researchers tried to address the bias studying noninvasive techniques aimed at measuring physiological changes during lying. Thermal imaging has been reportedly implied in investigations focused at assessing the changes in physiological features such as blood flow with equivocal findings and limitation to be generalized [13].

Electroencephalogram (EEG) EEG-Rhythm of brain underneath the mind

Electroencephalogram (EEG) measures the cortical electrical signals generated during the neuronal activity. It employs scalp electrodes that measure the postsynaptic action potentials and local voltage gradient as a result of synchronous cortical pyramidal neuronal firing [36]. The morphology of EEG changes in response to the stimuli and the replicable change in the cortical electrical activity, which is time locked to the event, is termed as event-related potentials (ERPs) [11]. The most widely studied evoked potential is P300, which is strongly believed to be associated with stimulus processing and categorization [45]. It is hypothesized that the detection of P300 in a subject will predict true recognition of the stimulus as a subject has been exposed to the same stimuli in the past and can be implied as a measure of deception detection. Depending on the nature of the study, accuracy of P300 for detecting deception have been reported in the range of 40–80%, which is potentially subjected to higher false negative rates [47]. One

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potential reason reported by the authors for high false positive rates is subjects exercising countermeasures of distraction such as increasing the significance of distractor data during assessment. In another study, enhanced accuracy was reported using multifaceted electroencephalographic response (MER), employing enhanced analysis, and memory- and encoding-­ related multifaceted electroencephalographic response (MERMER) employing additional electrical measures with superior accuracy than P300 alone. Whether P300 reflects true or false memories? The work of Allen and colleagues [1] is important to consider as they evaluated the difference in evoked potentials predicting truthful and false memories. The results were consistent with most of the previous data with no statistical difference between true and false memory-related findings and inability to generalize results for classifying outcomes for individual subjects.

Neuroimaging of Deception The act teaches you the meaning of the act. Abraham Joshua Heschel

The use of functional MRI (fMRI) for the study of deception began in the early 1990s. Different modalities to detect deception as discussed earlier raised concerns for bias and questioned the accuracy and generalizability of the findings. In order to address these challenging questions, researchers focused on more advanced and sensitive techniques such as fMRI.  The reliability of newer techniques yet faces challenges just as since the times of polygraph testing. Considering deception as a cognitive process, distinct activity in any single brain region might not reflect the level of biological activity required for such a cognitively rich and complex mental process of deception. In addition, these techniques are expensive and also came up with restrictions for use in some individuals such as those with metallic foreign bodies or implants.

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Another associated challenge, as with any deception detection tool, is concern for type-II error introduced potentially by the absence of foci of greater activation during truth telling [53]. Nevertheless, it is reported that these imaging modalities have enhanced specificity and sensitivity for lie detection as compared to the conventional modalities [34].

Functional Magnetic Resonance Imaging (fMRI) Considering the challenges with the conventional deception detection tools such as polygraph, researchers focused on measuring deception-neural footprints by studying the blood-­ oxygen-­level-dependent (BOLD) contrasts by fMRI during truthful and falsifying responses. Majority of the studies relied on using binary questions paradigm and measured the group level changes with a hope of generalizability of the findings to individual level. In the pioneering work, Spence and colleagues [51] focused on the autobiographical and episodic memory of the subjects. They found that when visual and auditory protocols were combined, greater activity was noted in the bilateral ventrolateral prefrontal cortices (VLPFCs), medial prefrontal cortex (mPFC) and premotor cortices, and left inferior parietal and lateral premotor cortices. They also found that bilaterally Brodmann area 47 was more activated; deficits in this region are reported to be associated with loss of inhibition of pre-potent responses, which may elicit perseveration. This deficit model of failure to inhibit has also been hypothesized to account for limitations of autistic subjects to deceive [24]. Several studies later were able to replicate the findings of Spence and colleagues [51] using the similar binary question paradigm as guilty knowledge testing (GKT) [33]. In these studies, the activation level of medial prefrontal cortex (mPFC) and dorsolateral prefrontal cortex (DLPFC) was different by telling a lie and truth. Real life versus laboratory settings – A major challenge in the generalizability of the fMRI studies is the nature of tasks assigned while testing for deception. There is strong evidence suggesting different neuronal responses depending on the

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nature of content being tested [41]. Another challenge, as with binary paradigm testing, is relatively less degree of engagement, emotional attachment, and cognitive load during evaluation tasks in controlled settings as compared to real-life, high-stake situations. Also during study, telling a lie is not the only cognitive task the subject might be performing. To come up with more realistic testing paradigm, Lee and colleagues [31] implied forced-choice memory paradigm in which subjects simulated memory impairment in digital and autobiographical domains. The results were not different for the two memory tasks for simulated memory impairment and accurate recall as they both showed activation in the Brodmann areas 9 and 10, bilateral temporal and parietal cortex, and caudate. Idiographic approach – In further efforts to individualize the findings, Kozel and colleagues [30] implied the idiographic approach and found activations in the region of interest as middle frontal gyrus, inferior frontal gyrus, and anterior cingulate. Their classification accuracy was not much different from that of traditional polygraph testing. In a study, Monteleone and colleagues [20] tried to reexamine the previous data with emphasis on sensitivity, specificity, and generalizability of findings across the individuals. As suggested by Ganis et al., the patterns of brain activation vary depending on the types of lies; Monteleone and colleagues came up with the supportive findings when they found reliable mPFC activation better than chance classification of the individuals but whether it accounts for deception alone? mPFC activation is not specific to deception alone and can be involved in various other cognitive processes. Intention determines the outcome  – In a study, Abe and colleagues [4] implied positron emission tomographic (PET) study to test the hypothesized brain regions implicated not only in inhibition of true responses, a vital function of deception, but also intention of deceiving which is potentially accompanied with emotional feedback for behavioral modulation. They successfully identified the functional dissociation within the prefrontal cortex during deception reporting the association of left dorsolateral and right anterior prefrontal

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cortices with the process of falsifying the truthful responses. While studying the intention to deceive the interrogator, the left ventromedial prefrontal cortex and amygdala were implicated. They also found that the right anterior prefrontal cortex activation was associated with both inhibitions of true response and intention to deceive. Interestingly, they also reported significant activation of cerebellum, left cerebellum in the main effect of lie and bilateral cerebellum in dishonest responses. Reliability and generalizability – A group of researchers have raised questions regarding generalizability of these research findings. Laboratory settings imply limitations and ethical challenges as opposed to the real-life situation, which includes personal relevance, varying levels of emotional associations, and the fact that subjects under the study are instructed to simulate falsified responses [17]. In an effort to address the concerns regarding controlled settings, as the subject being instructed to lie, which almost all of the studies implied previously, Greene and Paxton [22] came up with an experimental testing of “will,” inhibition of temptation, and “grace,” absence of temptation, hypothesis using fMRI scanning. They found activity in cognitive control regions to be associated with dishonest behavior as anterior cingulate cortex (ACC), DLPFC, and VLPFC consistent with the prior research. In addition, their findings suggested that control network activity in the prefrontal cortex reflects decision to lie as well as to refrain from lying among dishonest subjects. Their findings supported grace hypothesis where no additional control-related activity is required when behaving honestly. Whether deception implies additional cognitive task or not? Potentially the answer depends on the nature of deception. Honest deception  – The beauty of deceptive behavior is that from the beginning of the intention to deceive, it does not rely solely on the falsified information but factual information known as true can also be manipulatively assembled and presented in a misleading way. This scenario also indicates the fact that retrieval of a relevant memory during assessment might generate stressful response in the subject not solely due to the fact that subject is lying and concealing but the coincid-

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ing irrelevant memory from elsewhere is potentially stressful. Interestingly in honest deception, where the deceiver uses the truthful information to deceive, Volz and colleagues found increased activity of anterior frontal gyrus, temporal gyrus, and right temporo-parietal junction (rTPJ). These regions are also implicated in settings where subjects found it difficult to be honest but chose to speak the truth for monetary gain, potentially reflecting the function of intention [22]. Inhibitory modulation and task selection – The anterior prefrontal cortex and its structures are implicated in almost all the deception detection studies with inconsistent results. Considering vital function of inhibitory modulation in deception, the right inferior frontal gyrus is reportedly associated with response inhibition [2]. Kireev and colleagues [28] utilized psychophysiological interaction analysis (PPI), which accounts for assessing changes in functional relationships between active brain areas while changing psychological context. They found an increase in connectivity between the left middle frontal gyrus and the right temporo-parietal junction (rTPJ). Consistent with the theory of mind, this finding provided evidence that the execution of deception relies to a greater extent on higher-order hierarchically organized brain mechanisms of executive control required to select between two competing deceptive or honest task sets. Desensitization  – The brain regions implicated for emotional regulation and feedback to one’s actions have the tendency to modulate responsive behaviors. An interesting work by Garrett et  al. [19] showed reduced activation of brain centers involved in emotional regulation, as the amygdala, after each repeated act of dishonesty, suggesting decreased sensitivity of emotion regulation centers to dishonesty escalation-­narrated by authors as a “slippery slope.” As we know today, deception involves complex connectivity across the brain and the regions most frequently implicated in various studies so far include cortical regions as superior frontal cortex (SFC), medial frontal cortex (MFC), orbitotofrontal cortex (OFC), and anterior cingulate cortex (ACC); the subcortical regions such as the striatum and the

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thalamus; posterior cortical regions such as motor and pre-­ motor cortex and preceuneus and inferior parietal lobule (IPL); and temporal lobe and temporo-parietal junction (TPJ) [32, 53]. These regions of interest implicated in various studies on deception are essential components of control networks of the brain. Despite significant differences in the activity of brain regions studied during deceiving and truthful responses, the generalizability of the results at individual level remains a challenging task. Another challenge posed by these findings is that the brain regions implicated in deception might not be solely involved in deception as it is not the only cognitive task the subjects under study might be performing. One promising approach could be studying the relative interactivity between these regions of interest and its correlation with the deceptive and truthful responses. In the following section, some of the pioneering work done in this regard will be reviewed in order to better understand and recognize the challenging neural processes involved in deception.

Connectivity Studies Deception is a complex psychosocial task utilizing executive control neural networks. Executive control, as conceptualized by Miyake and colleagues [37], comprises of at least three individual processes: working memory, task switching, and inhibitory control. The connectivity studies provide bases to study the strength of information sharing and degree of modulation between different brain regions of interest. There are ways devised to measure the interconnectivity between brain regions, as a brain-snap-shot, while being at task-free resting state. This baseline relative degree of brain connectivity, termed as resting state functional connectivity, has been recently utilized to predict associations with various psychiatric manifestations and behavioral presentations. Deception being a cognitive process utilizes executive function component processes. Working memory serves as simulating a deceptive response while being aware of the truthful

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response, inhibitory control favors suppressing a truthful response and attention control facilities smooth transition between truthful and deceptive responses [26, 48]. As discussed earlier, various regions of the frontal cortex and the mid-brain and even the distant regions as the cerebellum are implicated in deception. The frontal cortical regions and ACC are implicated in executive control and behavioral modulation, such as in inhibition of responses, during deceptive behavior [10]. The reward processing is crucial to deceptive behavior such as it provides feedback for modulation of actions. It is reported that subcortical regions play an important role in this process [3]. The situational analysis and evaluation of social context of deceptive behavior is another crucial component of overall contextual evaluation of deception considering its outcome. This process is reported to be supported by temporal and parietal brain regions [38]. The relative degree of connectivity between these regions during the deceptive and honest responses might serve as a better and a reliable predictor because it is hypothesized that deceptive responses require additional cognitive load [39]. Orientation of the brain – Resting state functional connectivity (RSFC) is a relative measure of connectivity between different brain regions in a task-independent state and has gained advantage over fMRI due to its ease in signal acquisition and proficiency in identifying the functional areas in different sets of population [6, 52]. It has been reported that the pattern of task-independent connectivity can be utilized as an effective predictive tool for individual difference in behaviors [42]. Tang and colleagues [23] utilized machine learning to predict the propensity for deceptive behavior using linear relevance vector regression. They were able to successfully categorize individual fMRI-based RSFC of brain regions involved in executive control (frontal cortical regions), rewards network (putamen and thalamus), and social and metalizing network (temporal and parietal lobes and inferior parietal lobule). In a study, Gao and colleagues [18] utilized EEG functional coupling based in brain scalp regions. They identified synchronous activity in three brain regions implicated in the deception by earlier studies as well. They found synchronous

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activation in prefrontal/frontal, central, and parietal regions with different strength of connectivity during lying, in particular high theta synchronization was observed. In another study, Liu and colleagues computed event-related coherence to investigate functional connectivity among brain regions of interest underlying neural oscillation synchronization reflecting system process of deception. They found out that frontoparietal and fronto-temporal networks demonstrated greater connectivity than fronto-occipital network during lying. Long-range connectivity and cognitive function  – It is hypothesized that the long-range connectivity plays a vital role in the functional connectivity network of the human brain and positively correlates with higher cognitive function [46, 55]. In a study, Jiang and colleagues [27] found 15 discriminating functional connections significantly different between lying and truthful responses. Interestingly these connections showed characteristics of long-range connectivity, spatially located and greater than 80 millimeters apart predominantly contributing to deception (almost 70%) as compared to shorter connections (almost 30%). They summarized 26 brain regions of interest in six networks and found that frontoparietal and cingulo-opercular networks and c­erebellum (cerebro-cerebellar connections) exhibited highest discriminative power for deception detection (accuracy of 82.81% (85.94% for lie telling, 79.69% for truth telling). They also found a strengthening connection between dorsal ACC (dACC) and occipital cortex as known to be involved in processing previously known stimuli. It is established that the cerebellum is involved in error processing [56]. Jiang and colleagues found that cerebro-cerebellar circuits may underlie the involvement of the cerebellum in deception as it may send error codes or receive codes from control networks of the brain as fronto-parietal and cingulo-opercular networks. They also found an increased connectivity between intraparietal sulcus (IPS) and inferior temporal region speculating this function as a reflection of emotional conflict during lie telling. It is believed that IPS plays a major role in top-down attention control through fronto-parietal network and contributes to the fine-tuning of control settings and decision-making [12].

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Despite the fact that there is a great success in differentiating various brain regions and connectivity patterns relative to honest and dishonest behaviors based on the level of activation and degree of interregional connectivity, respectively, the generalizability of these findings to come up with a reliable and replicable indicator of deception remains a challenge. Contrarily, these efforts have enabled us to better understand brain as a functional mind and its various projections as behaviors including deception. It will not be unfair to state that we deceive our dear ones and even our own selves on daily basis  – in social contexts  – in an effort to refrain ourselves from unrealistic wishes or wishing higher enough to encourage ourselves to stay engaged in achieving ones. It can be conceptualized like a wish leading to action initiation or inhibition – is there any neural marker to translate our wishes as distinct neural patterns?

Neurochemistry of Deception Deception, albeit seen as a unitary process, is a complex product of individual processes which includes preparation and contextual evaluation prior to the delivery of falsified information. The preparatory phase involves evaluating the outcome considering social and pragmatic aspects. From psychological and cognitive perspective, this phase extends in to retrieval of information and its manipulative processing. The entire preparatory phase involves attention control (also serves the delivery phase), memory retrieval, and maintaining altered working memory until delivery and inhibition of the corresponding factual response and alternative undesired manipulated responses. Theoretically the deceptive process can be broadly divided into three major cognitive domains as attention control, memory processing and maintenance, and inhibitory modulation. This section will subsequently explore the potential neurochemical correlates of these major cognitive domains serving deception. Neurochemical transmission is a vital mechanism in integration of deceptive behavior as of any other cognitive func-

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tion. Although there has been extensive work on studying morphological correlates of deception with equivocal outcomes, it is suggested as by Hoffer and Osmond that any understanding of cognitive processes will originate from studying chemistry of the involved neural processes but not the regional morphology. Hence in this section, deception will be approached from neurochemical perspective by discussing the potential role of executive and modulatory neurotransmitter systems integrating attention, memory, and inhibitory modulation as deceptive outcome. Glutamate and GABA are the principal excitatory and inhibitory neurotransmitters, respectively, and are distributed in neurons globally across the brain [44]. Contrarily modulatory neurotransmitters are localized in discrete nuclei and have widespread connections to diverse brain areas. Modulatory neurotransmitters include monoamines, acetylcholine, neuropeptides, and other chemicals, which function as neurotransmitters. The neurons containing these transmitters constitute several neurological pathways, which modulate various brain functions including but not limited to cognitive processing.

Attention Everyone knows what attention is. It is the taking possession of the mind, in clear and vivid form, of one out of what seem several simultaneously possible objects or trains of thought.

Attention is a cognitive process by which the brain monitors its own activity and hence provides objective experience. As it is hard to imagine meeting demands of daily living without the ability to pay attention, deception is no exception. Although crucial in identifying basic neural architecture of brain processes, earlier investigations tried to identify focal brain regions involved in various brain processes. It was later recognized that sophisticated and complex mental processes cannot be attributed to a single brain region rather these processes, such as cognitive abilities, are outcomes of integrated connections between several brain regions [43]. Therefore, the magnitude of activity in any single brain region might not predict the characterization of a brain process. The magnitude

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of such integrated wide range connectivity is the function of neurotransmitters connecting brain regions through neurochemical pathways and transmitting information. For a subject engaged in deceptive behavior, it is crucial to maintain attention span throughout the act to be able to meet up the demands of cognitively dynamic task. On theoretical basis, supervisory attentional system model proposed by Shallice describes attention control as a dynamic process in context of planning strategy and flexibility and inhibition. In this model, attention is function of difficult unlearned situations requiring error recognition and correction specifically when response competes the pre-­learned responses. The approach to study attention as a function of neurotransmission will be predominantly discussed here as studied as an impact of various drugs on it. The impact of drugs modulating inhibitory GABA system in primates suggests GABA agonist (muscimol) and antagonist (bicuculine) injections in to the pulvinar reduced and enhanced attentional shift, respectively. Considering attention as complex and widely engaged phenomenon across the brain [50], it will be further reviewed in context of the role of specific neurotransmitters such as acetylcholine, norepinephrine, dopamine, and serotonin. Acetylcholine has been widely studied and implicated in attentional processes. Considering deception as a cognitive domain, it begins predominantly by selective focus to the desired task. Cholinergic system not only plays a crucial role in selectivity of focus but impacts the intensity as well. Nicotine is reported to enhance the intensity of attention and reduce the processing time while scopolamine, a cholinergic antagonist, is found to impair the performance in attentional tasks. Noradrenergic system is reported to facilitate the attentional orientation, and reduction in its level impairs the ability of selection and updating of semantic structures. Conversely, it is believed that noradrenaline plays a role in arousal rather than attention as an entire process. The fact supports the notion that frontal noradrenaline system is reported to enhance the focused attention through attenuation of distracters.

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Historically, attention has been viewed as an engagement in a particular task while withdrawing effectively from the others. This property of flexibility is crucial to the deceptive process, which is reported to be potentially facilitated by cholinergic antagonism and impaired by agonist as nicotine. Relatively less studied, dopamine is also implicated in attentional shift rather than focused attention. Dopamine antagonism is reported to impair attentional p ­ erformance specifically set-shifting in tasks as Stroop testing while relatively spares the focused attentional tasks. Serotonin is reported to potentially impact the attention as a process through its modulatory impact on learning and memory consolidation. As studied by Schmitt and colleagues, serotonin depletion impairs the memory consolidation but in contrast enhances the focused attention. Attention is a crucial component of any task performance, and it varies depending on the task requirements. Attention can be considered sustained and focused while performing a single task at a time. Conversely, it is flexible and shifting during multi-tasking. Deceptive behavior can be viewed as multi-­ tasking where a deceiver overall maintains attention to the process while smoothly transitioning the focus between the honest and deceptive responses, keeping intact covert attention toward the surrounding environment queues. Just as the aforementioned neurotransmitters can impact any form of cognitive functioning through function of attention, deception can be perceived as a mediated outcome of these neurotransmitters (Table 7.3).

Memory Science and memory revolutionize our lives, but memory, tradition and myth frame our response. Arthur M Schlesinger

Memory is probably the foundation stone of any behavior, while it is argued that the ancestral memories are encoded genetically and transferred [29]. As it remains a debate that

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our ability to learn and evolve partially depends on the genetic framework we have inherited, the learning we acquire depends reliably on the experiences stored in our memory. Therefore, memories not only reflect the path of evolution and transformation within an individual but reflect the foundation stone of one’s personality itself. The beauty of the memories is that they can be consciously recalled and relived. Considering deception, its architecture is predominantly based on recollections of the past experiences while aspiring for the future outcomes; being able to relive a memory potentially serves the purpose. Conversely, in a situation of being assessed while deceiving, reliving the past with selectivity can become a challenging task. Also deception requires editing of past memories for desired outcome. In this section, we will briefly review the neurochemical underpinnings of memory while reviewing relevant neuronal processes and neurotransmitters involved in encoding our various life events. Memory can be broadly classified as explicit memory, related to specific events and facts, which can be consciously recalled and as implicit memory, which reflects the learned psychomotor skills potentially occurring without conscious awareness. The degree of overlap in these two domains still remains a question. Historically and even if argued today, this overlap potentially provides a window to study and assess the deceptive behavior through monitoring unconscious nonverbal physical cues accompanying the conscious deceptive act. Considering deception, the emphasis will remain on concepts regarding working memory and potential regulatory effect of responsible neurotransmitters. In a conclusive paper, Lomo [35] summarizes the proposed neurological models of memory and learning as a dynamic process due to continuous ongoing patterns of impulses in closed neural circuits and as activation of synapses results in increased efficacy due to enduring changes in their fine structures. The discovery of the electrophysiological phenomenon known as long-term potentiation (LTP) by Bliss and colleagues satisfied the proposed theoretical basis for learning

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Table 7.3 Neurotransmitters modulating cognitive substrates of deception Inhibitory Attention Memory modulation GABA Impact GABA GABA inhibitory memory by agonist neurons reduces while GABA-A impact receptor antagonist neuronal agonist effect enhances adaptation on spatial attentional and plasticity learning shift and LTP modulation Glutamate

Acetylcholine

Enhances memory facilitating LTP via NMDA and mGlu receptors function; facilitates memory retrieval through AMPA/kainite receptor function Impacts selectivity and intensity of attention, cholinergic antagonist impairs attention but facilitates attentional flexibility

Direct and indirect cholinergic modulation impairs working memory

Neurochemistry of Deception

Attention Nicotine

Enhances intensity and reduces processing time, impairs attentional flexibility

Noradrenaline

Enhances focused attention and facilitates selection and update of semantic structures

Serotonin

Serotonin agonist enhances focused attention

Dopamine

Dopamine antagonist impairs attentional set shift, no impact on focused attention

Memory

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Inhibitory modulation

Serotonin agonist impairs memory consolidation

LTP long-term potentiation, mGlu metabotropic glutamate

and memory. Lomo reported his findings as “an example of a plastic change in a neuronal chain, expressing itself as a longlasting increase of synaptic efficiency” [35]. Several studies have demonstrated LTP happening in various brain regions including hippocampal dentate gyrus. The most widely implicated receptors in LTP are subclass of excitatory neurotrans-

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mitter glutamate, N-methyl-D-aspartate (NMDA) receptor, and metabotropic glutamate (mGlu) receptor. In deception, while emphasis is laid on the working memory, retrieval of memory and its modulation are also crucial components. Although the exact mechanism behind retrieval of memory appears to remain challenging (Sara 2000), the integrity of hippocampal AMPA/kainite receptor function is reported to be essential for accurate memory retrieval. The inhibitory GABA-ergic transmission can influence the memory and learning itself as evidenced by GABA-A receptor agonist effect on spatial learning and LTP modulation. Conversely, working memory, which can be defined as ability to store and alter the information that is essential to complete a task, reportedly gets affected by direct and indirect cholinergic modulation; [60]. As reported by Schmitt and colleagues, serotonin depletion impairs the memory consolidation and potentially impacts working and long-term memory. Hence, memory is a vital substrate for deception that functions variably relative to neurotransmission modulation and is predominantly performed by cholinergic and excitatory glutamatergic system.

Inhibitory Modulation Our mental processes are predominantly regulated by effective modulation of inhibitory and excitatory control. From regulation of emotions to retrieval of memories, attenuation and filtering are achieved through various processes modulated by executive neurotransmitter system. The executive neurotransmitter system consists of excitatory and inhibitory amino acid neurotransmitters such as glutamate and GABA, respectively. GABA is the principal inhibitory neurotransmitter in the brain with direct depressive effect on neuronal transmission either by inducing hyperpolarization or reduction in the release of other neurotransmitters. Deception can be viewed as a predetermined learned behavior that we practice on daily basis in various contexts or it can be a spontaneously induced ongoing dynamic process. In both conditions, adaptation of neuronal networks to bring

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the desired outcome needs to take place. Such an adaptation in neuronal connectivity is defined as neural plasticity. Neural plasticity is the capacity of functional and structural modification of nervous system in response to experience [59]. GABA inhibitory neurons play a critical role in the neural plasticity by modulating changes in structure of synaptic junctions in response to functional changes. Deception is a complex social behavior potentially happening on the daily basis in our lives regardless of our conscious awareness. The understanding of neurochemical basis of cognitive domains of deceptive behavior will not only provide an opportunity to devise ways to detect it reliably but also can help establish targets of intervention for people with pathologic deception.

Deception and Role of Genetics Deception being a complex psychosocial engagement varies profoundly depending on the social context and the players involved. Individual propensity toward deception is an area under the study implying resting state functional connectivity as a control baseline trait of the subject. As discussed earlier, long-range connectivity between higher and remote regions of the brain is considered as a predictor of enhanced cognitive abilities. The relative degree of resting state functional connectivity of an individual can be considered as an indicator of one’s baseline propensity toward deceptive skills viewing deception as a cognitive function. Deception is a heterogeneous phenomenon being evident from individual variations and challenges of generalizability of findings as highlighted in various studies. The role of genetic polymorphism of enzymes involved in regulation of neurotransmitter systems integrating different neural ­processes and responsible for establishing regional connectivity patterns implied in deception is important to consider. The monoaminergic neurotransmitter system plays a vital role in various neural processes acquired during deception. The serotonin system is reported to potentially impact the decep-

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tion as a process through its modulatory impact on learning and memory consolidation. The frontal noradrenaline system is reported to enhance focused attention while minimizing the distractors. The dopamine system on the other hand is implicated to facilitate attentional shift between set of tasks. Polymorphisms in the gene encoding monoamine oxidase A (MAOA), which is responsible for deamination of dopamine, serotonin, and noradrenaline, can affect MAOA enzyme activity, impacting dopamine levels. The MAOA gene (Xp11.5) contains a length polymorphism in its promoter region that affects transcriptional efficiency [14]. The locus known as “MAOA linked polymorphic region” (MAOA-­LPR) includes a variable number of tandem repeats (VNTRs) located in the gene’s transcriptional control region and alleles at this VNTR differ in the number of copies of a 30-bp repeat motif; alleles including 3.5 or 4 repeats appear to be transcribed more efficiently and are associated with lower dopamine levels than those with 3 copies [14, 15, 54]. Likewise, genetic polymorphism of catechol-o-methyltransferase (COMT) enzyme responsible of monoamine metabolism predominantly in PFC, as compared to MAOA implicated predominantly in striatum, can impact the levels and hence the activity of the neurotransmitters. The COMT enzyme modulates the monoamine levels, and COMT gene allele encoding a valine-containing high-activity enzyme decreases monoamine levels and transmission in the prefrontal cortex [8]. Therefore, as functional connectivity between brain regions is a function of neurochemical transmission, the genetic polymorphism of regulatory and metabolic enzymes for respective neurotransmitters can potentially impact the individual propensity for deception.

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Conclusion Deception is a complex dynamic neural process and architecturally can be conceptualized as an intention- and motivation-­ driven process from the deep brain regions resulting in contextual evaluation and action modulation processed at the higher cortical level. Since it is a cognitive process, it will be a challenging task to entirely differentiate it from other cognitive processes on the basis of level of activity of implicated brain regions. Functional anatomy of the brain related to deception helps us better understand what we know deception as a behavior today and provides an opportunity to study its potential neurochemical correlates. The possibility to detect deceptive behavior reliably by studying brain morphology remains slim as would have been with any imaging method implied to detect and differentiate various conscious or unconscious thought processes. Recent advancements in imaging technologies and use of machine learning tools have provided a great opportunity to study and understand deception, which is conceptualized as an outcome of independent neural processes. Still the hope to reliably differentiate it from other cognitive functions remains low. Conversely, understanding of deception as a function of distinct neural processes enables us to better understand various pathologies related to deceptive behaviors, which are seldom encountered during clinical practice. Through this neurobiological understanding of deception, we might not only be able to clinically correlate its implications to various psychiatric manifestations but can also occupy a position to modulate it through psychopharmacological interventions. The complex phenomenon of deceptive behavior and its detection remains challenging. The hope is in building on what we know today by incorporating both scientific and psychological approaches to be better able to understand and detect deception. Acknowledgments  I am thankful for the opportunity, support, and guidance provided by Dr. Alexander Lerman for studying and exploring

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psychodynamic-rich phenomenon of deception. I am thankful to my teachers and my mentor, Dr. Kyle Lapidus, my wife, and my parents for ongoing support and guidance.

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ology. 2nd ed. Cambridge: Cambridge University Press; 2000. p. 772–93. 26. Johnson R Jr, Barnhardt J, Zhu J.  The contribution of executive processes to deceptive responding. Neuropsychologia. 2004;42(7):878–901. 27. Jiang W, et al. Decoding the processing of lying using functional connectivity MRI. Behav Brain Funct. 2015;11:1. 28. Kireev M, Korotkov A, Medvedeva N, Masharipov R, Medvedev S. Deceptive but not honest manipulative actions are associated with increased interaction between middle and inferior frontal gyri. Front Neurosci. 2017;11:482. 29. Seong K-H, Maekawa T, Ishii S.  Inheritance and memory of stress-induced epigenome change: roles played by the ATF-2 family of transcription factors. Genes Cells. 2012;17(4):249–63. 30. Kozel FA, Johnson KA, Mu Q, Grenesko EL, Laken SJ, George MS.  Detecting deception using functional magnetic resonance imaging. Biol Psychiatry. 2005;58(8):605–13. 31. Lee TM, Liu HL, Tan LH, Chan CCH, Mahankali S, Feng CM, Hou J, Fox PT, Gao JH.  Lie detection by functional magnetic resonance imaging. Hum Brain Mapp. 2002;15:157–64. 32. Lisofsky N, Kazzer P, Heekeren HR, Prehn K. Investigating sociocognitive processes in deception: a quantitative meta-­analysis of neuroimaging studies. Neuropsychologia. 2014;61:113–22. 33. Langleben DD, Schroeder L, Maldjian JA, Gur RC, McDonald S, Ragland JD, O’Brien CP, Childress AR. Brain activity during simulated deception: an event-related functional magnetic resonance study. NeuroImage. 2002;15:727–32. 34. Langleben DD, Hakun JG, Seelig D. Polygraphy and functional magnetic resonance imaging in lie detection: a controlled blind comparison using the concealed information test. J Clin Psychiatry. 2016;77(10):1372–80. 35. Lømo T. Discovering long-term potentiation (LTP)-recollections and reflections on what came after. Acta Physiol (Oxf). 2018;222(2):e12921. https://doi.org/10.1111/apha.12921. 36. Marcuse LV, Fields MC, Yoo J. Rowans Primer of EEG. 2nd ed. Edinburgh: Elsevier; 2016. 37. Miyake A, Friedman NP, Emerson MJ, Witzki AH, Howerter A.  The unity and diversity of executive functions and their

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51. Spence SA, Farrow TFD, Herford AE, Wilkinson ID, Zheng Y, Woodruff PWR.  Behavioural and functional anatomical correlates of deception in humans. Neuroreport. 2001;12(13):2849–53. 52. Smitha KA, Akhil Raja K, Arun KM, Rajesh PG, Thomas B, Kapilamoorthy TR, Kesavadas C. Resting state fMRI: a review on methods in resting state connectivity analysis and resting state networks. Neuroradiol J. 2017;30(4):305–17. 53. Spence SA, Hunter MD, Farrow TF, Green RD, Leung DH, Hughes CJ, Ganesan V. A cognitive neurobiological account of deception: evidence from functional neuroimaging. Philos Trans R Soc Lond B Biol Sci. 2004;359:1755. 54. Sabol SZ, Hu S, Hamer D.  A functional polymorphism in the monoamine oxidase A gene promoter. Hum Genet. 1998;103:273–9. 55. Knösche TR, Tittgemeyer M. The role of long-range connectivity for the characterization of the functional–anatomical organization of the cortex. Front Syst Neurosci. 2011;5:58. 56. Timmann D, Daum I.  Cerebellar contributions to cognitive functions: a progress report after two decades of research. Cerebellum. 2007;6:159–62. 57. United States v Scheffer, 523 US 303 (1998). 58. Vicianova M.  Historical techniques of lie detection. Eur J Psychol. 2015;11(3):522–34. 59. Von Bernhardi R, et al. What is neural plasticity? Adv Exp Med Biol. 2017;1015:1–15. 60. Zhang X, et  al. Central cholinergic system mediates working memory deficit induced by anesthesia/surgery in adult mice. Brain Behav. 2018;8(5):e00957.

Chapter 8 Shared Consciousness and the Emergence of Mind Sharing experience is a necessity for non-autistic human beings. This is obvious through casual social experience and has been formally demonstrated across many disciplines through an enormous range of research. For example, [6] summarizes research demonstrating how infants preferentially stare at items that are the objects of their mother’s attention and seek to direct their mothers’ attention to items they are interested in. The patient’s experience of empathy [8] and reinforcement of his or her capacity to empathize and understand the emotions of others, represents a major domain of the therapeutic effect of psychotherapy. The capacity to share experience is essential to social functioning, and listening to the concerns of involuntarily hospitalized psychiatric patients has proven a highly effective means of reducing the need for seclusion and restraint. Verbal attributions by others play a major role in the development and regulation of identity and self-esteem [1]. The ability to share perceptual and emotional experience is intrinsic to conflict resolution [10]. Advances in neuroscience offer the prospect of a nascent understanding of why communication is so important. For example, Rizzolatti and Sinigaglia [11] describe how a select population of “mirror neurons” in the human parietal cortex is activated when a given behavior is both observed and per-

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formed and is linked to frontal cortical circuits involved in interpersonal cognition. Jeon and Lee [7] summarize an expanding literature of associations between deficits in mirror neuron and a range of psychopathological states, most notably autism and schizophrenia. A widening body of evidence [3] demonstrates how linguistic signifiers (e.g., the word “hammer”) trigger neural activity in sensory and motor cortexes that is indistinguishable from that elicited by a direct sensory stimulus (e.g., a picture of a hammer). From these observations, a comprehensive understanding of the neural basis of language, cognition, and symbolic representation may follow. In other words, human beings need to be together. Like many higher-order mammals, human beings share a need to form different kinds of social groupings, often sharing food bodily warmth and mutual protection. Like other mammals, we broadcast information about our present level of arousal and motivational state through a variety of behaviors, or even pheromonal communication. The need to conceptualize and share experience, on the other hand, and to do so using artificial and manufactured symbols—among them, words—is uniquely human. At the same time, communication—like every other human need—is subject to the ancient dictum of “moderation in all things.” All human beings conceal or distort information they provide to others, and perhaps to themselves. As we will discuss below, this occurs for a range of different circumstances. The human need for communication goes far beyond the acquisition of information. In many instances, experiences don’t feel fully “real” until they are shared. In everyday life, in work with psychiatric patients, Yalom [13] describes how group discussion serves to “universalize” private experience, and clarify distorted or idiosyncratic perception, culminating in a deeper and more-secure sense of personal identity. Why is the need to communicate, to share not just our ideas, but our emotions, so important?

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An increasing body of experimental and observational evidence indicates that this human process of shared perception begins at birth, and is rooted in the mother (or caregiver)–infant relationship. Fonagy and Target [6] state “both internal and external reality are learned about within the mother-infant relationship…The external comes to be something inherently ‘other’ … but this is a developmental achievement, not accessible to all of us all of the time.” A capacity for differentiation of self from non-self, in other words, follows rather than precedes that for subjective perception. One means of demonstrating the primacy of the human need for shared perception comes from studies of gaze preference. Farroni et  al. [5] demonstrated the capacity of 2 to 5-day-old newborns to discriminate between direct and averted gazes, and preference for the former. Studies of 4-month-olds demonstrated increased EEG response to direct compared to averted gaze, suggestive of enhanced neural processing associated with a unique quality of direct gaze. Other researchers have demonstrated a wide range of “cultural learning” that occurs as an infant develops, built around shared perception, shared goals, and shared emotions. Liszkowski et al. [9] demonstrated that 12-month-olds point to objects when an adult both stares at the object and expresses pleasurable emotion about it, while gaze or emotion alone prompted minimal response. The results suggest that 12-month-olds understand that others have psychological states that can be directed and shared, and respond to shared affective salience. Brooks and Metzoff [2] note that infants younger than a year respond to motion, but acquire what they term “a special status for eyes” by the first year of life. The impulse to follow another’s gaze, they argue, represents a precursor to theory of mind, language acquisition, and understanding and sharing of emotion. They conducted a series of experiments in which toddlers of different ages were presented with different caregiver gaze conditions.

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In the first experiment, the caregiver made head movements consistent with tracking a moving target, with eyes either open or closed. Toddlers of 12, 14, and 18 months all demonstrated a three- to fourfold preference for the “eyes open” experience. Next, the caregiver wore either a blindfold or a headband composed of similar material that did not cover the caregiver’s eyes. In the second experiment, 12-month-old toddlers showed an identical response to the headband and blindfold condition, while older toddlers again demonstrated a three- to fourfold preferential response to the eyes-open headband state. This study demonstrated an emerging capacity to understand that another’s view may be obstructed, as well as an ability to transfer familiarity with the subjective experience of his or her eyes shut to inferences about the perceptual state of another individual. The authors note: At this point, gaze following can be used as a stepping stone for further development, for example, identifying the referent of an adult’s emotional reaction or linguistic. Seen in this way, gaze following is a crucial developmental bridge. It links observable bodily acts with referential meaning about objects in the external world.

Fonagy (2008) describes this work on the perceptual world of infants as the essential predicate of the development of a capacity for “mentalization” in the third and fourth year of life. Prior to this development, Fonagy states, the infant and toddler remain rooted in a “expectation of shared consciousness,” the belief that beliefs and experience are universally shared. It is only through a complex and at times frightening process that a child learns that the contrary is the case. Awareness of separateness, indeed, is one of the cardinal conditions of selfhood. Despite the imperatives of selfhood, evidence of a yearning to recover shared consciousness may be found at every stage of human life, from the ecstatic behavior of a crowd in response to an athletic or theatrical performance.

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Table 8.1  Domains of distortion, nondisclosure, and deceit (DND) Social Includes tact, “white lies,” conflict-avoidance strategies, conformity with social expectations, inhibition of displays of sexual interest, etc. Aggressive/ defensive

DND represents a precursor, intrinsic component and sequelae of many forms of physical, psychological, and social aggression, particularly when the behavior in question violates social norms.

Distortion of self-awareness

Modulation of self-awareness occurs across a range of settings, motivation, and volitional and avolitional form.

The Capacity to Conceal Alongside with the human imperative to share perception, however, stands its opposite counterpart: the impulse to conceal. This impulse may be grouped into three domains. First, in its more selective forms, the capacity to withhold or distort the information we provide others represents an essential prerequisite for all forms of social relationships. Wholescale deception, on the other hand, typically either represents a form of aggression or arises in response to the threat of aggression by others. Lastly, we have the capacity for selfdeception, which operates with different degrees of awareness and volition (Table 8.1).

 ypes of Deception: Concealment, T Falsification, and Dissociation Deception itself occurs in three forms: concealment, falsification, and dissociation. Concealment involves withholding information without actually saying anything untrue. Falsification rests on a predicate of information withheld, and then proceeds to the presentation false information in the place of the truth.

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Table 8.2  Types of deception Concealment Easily masked as non-recognition of significance, failure of memory, or as an exercise of social tact Falsification

Organized substitution of falsehoods for facts, reflecting underlying intent.

Dissociative

Represents disruption of consciousness, occurs in varying degree across a range of psychopathologic states.

Concealment is often perceived as less reprehensible than falsification. It is passive, not active, resembles social deception, and can be rationalized as a display of tact, or an appropriate assertion of privacy. Concealment lies are also easier to cover afterward if discovered, that is, attributed to ignorance of forgetfulness. Dissociation is perceived by the person engaging in it as partially or wholly involuntary, and reflective of disruption of normal mental functioning. Fluctuations in variables such as degree of awareness, volitional and secondary gain are frequently observed. Less-obvious forms of deception include “forgetting” or “forgetting to mention” critical events, or withholding selected aspects of information in a fashion that renders the creation of a shared understanding impossible. More-overt psychopathology is manifest in dissociative states, affective storms, and personality fragmentation. In settings of more-significant psychopathology, this manifests in marked dissociative states, affective liability, and personality fragmentation (Table 8.2).

Nondisclosure and the “Moral High Ground” Engaging Deceit How are we to understand deceit and nondisclosure, in all its forms? Like any form of human behavior, any act of deception can only be understood in context of the history and intent of the people involved.



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Clinical Example: Teenage Quarrel For example, consider a teenage girl who asked her parents “Do I look okay?” before going out with her friends. Should her parent respond “I think your acne is flaring up” or “You look wonderful”? It can be argued that a sensitive parent will recognize that the teen in this instance is in fact asking for reassurance, not information, and a “deceptive” response is in fact guided by a deeper recognition of what is actually being asked. Or, perhaps it suffices to say that “You look wonderful” is a simple instance of “social deception” (see below) that serves as a universal interpersonal lubricant, and is of no further psychological significance? But what if the teenager shouts “You’re just saying that because you’re my dad!” and runs upstairs weeping? Are we witnessing some kind of decompensation in the teen triggered by her anxiety as she anticipates going out? Or is it possible that she is responding in part to a tendency of her parents to “sugar-coat” difficult truths, of which her acne is just one? Is it ever the case that a social “white lie” can serve as a signal that other, nontrivial issues will likewise remain unacknowledged? As can be seen from even this simple example, the interpersonal and motivational determinants governing disclosure are complex, and may lead even a determined clinician or investigator to despair of ever sorting them out.

 roposition One: DND Manifests P as Hopelessness This leads us to what will be one of the central principles of the study, namely that DND, across its many forms, manifests in an experience of interpersonal boredom, psychological withdrawal, and hopelessness. The experience of being lied to by a patient is alienating. The encounter is often marked by

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feelings of confusion, anxiety, or self-doubt on the part of the more-sensitive clinician, or clueless self-confidence on that of the less-aware. Deceptive behavior on the part of subjects threatens the validity of clinical research, and poses profound methodological problems, which may explain the dearth of academic publications on the subject.

Proposition Two: DND Is a Window If one does not despair, if the apathy induced by nondisclosure can be reversed, we propose that the phenomena of DND itself can be studied and engaged and serve as a window into the psychological and motivational state of the person engaging it. In a clinical encounter the stakes can be high: treatment failure, on the one hand, and a deeper understanding of the patient, on the other.

Attributes of Deception DND in its many forms possesses a variety of different attributes which govern the timing, form, and profundity with which it becomes manifest. A partial listing includes the social setting in which deception occurs, the conscious and non-conscious intent of the person engaging in it. Other attributes include the degree of factual distortion, its impact on the recipient, the degree and type of psychopathology in the person engaging in DND, and its effectiveness as a means of self-­regulation. With even a simple classification system in place, one of the things we immediately are confronted by is the degree to which an active deception can reflect multiple determinants and serve multiple purposes at the same time. Let’s take a look (Table 8.3):

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Table 8.3  Attributes of deception Social setting Conformity with social expectations represents a powerful stimulus to DND in every form. Awareness of such expectations and presuppositions is of particular importance of cross-cultural delivery of mental health care. Intent

Conscious and non-conscious rationalizations of behavior

Impact

Expectations of outcome for self and others

Psychopathology

Associated mental illness affecting perception, reality testing, and emotional functioning

Function

Expected utility or gain

 axonomy of Deception: Nondisclosure T and Concealment One way of classifying deception may be based on the classification of the behavior. Ekman [4] notes that deception occurs in two primary forms of deception: concealment and falsification. We prefer the term “nondisclosure” to “concealment” in this text. Nondisclosure involves withholding information without actually saying anything untrue, while falsification involves not only withholding information, but presenting false information as if it were true. Ekman notes that nondisclosure is typically perceived as less reprehensible than falsification. It can be rationalized as social deception or a lapse of memory. Nondisclosure falsehoods are also easier to cover afterward if discovered. Falsification, on the other hand, denotes the active promulgation of information the subject knows to be false.

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Self-Deception Like many academic psychologists, Ekman’s formulation rests upon a black-and-white formulation of facts and non-­ facts, knowingly disseminated by subject based upon some calculation of self-interest. Behavior-focused models of this kind tend to deemphasize or ignore a third position, in which the subject’s capacity to perceive the truth is subject to a process of internal disruption. Ekman goes so far as to postulate that false statements made in a setting of self-deception do not deception, given that the subject is no longer aware of making, a factually false proposition. Experienced mental health clinicians, on the other hand, deal with such processes all the time. Regardless of the level of training or theoretical orientation, clinicians recognize that a patient or clients’ awareness of threatening is often one of degree rather than in all-or-nothing process. Disruption of self-awareness, up to and including non-volitional self-­ deception, is frequently intertwined with deception of others. In fact, as many actors will attest, the highest level of verisimilitude may be achieved through a process of self-­ indoctrination that a fiction is in fact real. We will refer to this process of disruption, in its myriad forms, as “distortion.”

DND and Psychopathology Another way to assess a falsehood is to place it in the context of the overall mental health (or lack thereof) of the mind that produced it. We assume, for the purposes of this argument, that there is such a thing as a “mind” which can be assessed and placed on a scale of one of “health” or another. For example, an unscrupulous attorney who fabricates a signature on a transfer of property may be judged to be in a composed state of mind, with a clear capacity to direct and understand the consequences of his actions. An individual who engages in

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identical behavior in the setting of a delusional belief that he is being controlled by the FBI is doing so in a grossly disrupted mental state.

Clinical Example Social Deception and “White Lies” If we envision deceit and nondisclosure occurring across a spectrum ranging from benign to malign intent, most of us would agree that there exist a range of “white lies” undertaken because it would be offensive, socially inappropriate or cruel to offer a more-candid opinion. Deceit undertaken in such circumstances could arguably be regarded as an act of kindness, tact, or courtesy. Clinical Example A family member ignores inflammatory political comments of other family members at the dinner table, masking her own distress (nondisclosure).

Pragmatic Lies Truthfulness, in its deeper form, can only take place in a social and psychological environment in which truthfulness feels possible, that is, when someone feels they will be heard, and when imbalances of power are governed by moral and procedural principles that are rational and fair. In short, many individuals distort or withhold information in response to an effort to exert control in a situation where one may feel otherwise powerless. Many acts of deception represent a pragmatic response to an environment in which telling the truth no longer seems feasible or wise.

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Clinical Examples • An employee reports that “everything’s great” to a supervisor despite great distress on the worksite, because she believes that to say otherwise will result in a negative evaluation. • A husband minimizes his wife’s accellerating alcoholism, because he knows from experience that to do otherwise will exacerbate bitter and unresolvable marital distress. A police officer conceals evidence that could be used to exonerate a suspect he believes to be guilty. This condition is of particular relevance to the psychiatric interview, because a special form of powerlessness pertains to the setting of a mental health evaluation, where the patient may reasonably or unreasonably perceive him or herself to be at risk of being misunderstood, receiving a morbid diagnosis, or being subject to involuntary detention based on the outcome of the interview. This anxiety is multiplied in the setting of doubts about the clinician’s competence, preconceptions, or willingness to listen.

Deception in the Setting of Psychopathology Nearly all emotional and psychiatric problems disrupt perception of self, others, and or factors governing the environment, and such disruptions in their manifold forms lead many patients to distort or withhold information.

Affect Containment Telling the story of what happened to another person offers the path both to shared understanding and to reexperience of prior events. Most of us have a catalog of stories we enjoy telling again and again. For people who have experienced acute states of distress and mental disorganization, the invitation to “tell the story,” however innocently framed, represents a threatening and in some instances impossible task.

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Nondisclosure by the patient, in such circumstances, may be regarded as a form of affect management, via the activation of immature defense mechanisms, that is, deception of others as well as oneself in the service of minimizing distress. Clinical Examples • A poised, friendly patient (see the “Jazz” case discussed below) insists on characterizing a recent overdose of more than 200 tablets of various medications as a non-­volitional “accident” and the concerns of the physicians treating her as a “misunderstanding.” When confronted, she grows increasingly defensive and distraught, accusing the evaluating psychiatrist of prejudice against her. During a subsequent hospitalization, she is able to discuss her emotional dependence on an abusive boyfriend and the behavior on his part that triggered her suicide attempt. An elderly patient in treatment for depression refuses to discuss the death of her child in a household accident, even though this occurred decades previously.

Shame and Guilt Shame denotes a state of humiliation or mortification based on the judgment of others, whereas guilt implies a process of self-judgment and rebuke. Most individuals are ashamed of some aspect of their mental lives, or perceive themselves to be defective or inadequate in a few or many respects. Such people frequently experience the psychiatric interview as a threat of humiliation or exposure, often anticipating a reaction of disgust or rejection on the part of the clinician. Guilt is less ubiquitous in contemporary American society, possibly reflecting the decline of rigid educational and religious doctrine. But this renders guilt no less clinically important in the lives of individuals living with a “guilty secret” they feel either unwilling or unable to reveal. Guilt and shame frequently co-occur. Patients who irrationally mistrust clinicians withhold or distort information for what they perceive to be pragmatic

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reasons. Like other manifestation of paranoia, such ND frequently has an odd or indiscriminate character reflecting the underlying thought disorder.

Paranoia and Psychopathy Thus, we can establish a gradient of psychopathy contributory to nondisclosure and deception: • At the healthier end of the spectrum, we have patients who engage in something very similar to social deception, in response to concerns about being misunderstood, Shame, or anxiety about finding themselves in a second interview. Such individuals, when reassured are able to express themselves candidly, will experience a feeling of relief. • At an intermediate level, we find individuals who are employing, and externalizing, immature defense mechanisms to manage their own level of distress and excitation during the interview, and possibly reflecting gaps in their own self-awareness. For these individuals, candid self-disclosure may feel threatening or psychologically destabilizing. • At a more severe level of psychopathy, we have a patient who actively resists and seeks to distort information provided to the interviewer, motivated by delusional anxiety, a sense of the evaluation as a form of combat, or the need to conceal frank criminal behavior—or some combination of these elements. For these individuals, self-disclosure represents a defeat to be avoided at all costs. Clinical Example: The Man Who Won’t Give His Address • A patient confirms that he lives in particular town but grows circumspect and ultimately refuses to answer questions about the geographic relation of the town to the hospital, in response to what later is established to be a terrifying paranoid delusion.

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Paranoia is frequently observed in the setting of comorbid psychopathy and represents a unique and daunting clinical challenge (see below).

Dissociation and Disorganization Many patients provide information that is not false, but is incomplete, or missing connecting links between different pieces of information. A patient may mistakenly believe they have related information they did not disclose. The result is a distorted or in some cases incoherent history. Patients engaging in this form of DND are frequently unaware of doing so, and describe themselves to be as confused as the clinician. Such behavior may be variously considered an avolitional form of DND, a sign of a neurocognitive deficit, or a reflection of the activation of an “immature defense mechanism” (i.e., mental processes that reduce tension or distress accompanying a stimulus by altering how it is consciously perceived).

Type IX: Predatory Deception At the other end of the spectrum is deceit consciously undertaken to gain interpersonal mastery, frequently for exploitative or predatory purposes. In such instances, deceit represents a pragmatic aggressive instrument, frequently in the setting of paranoid and borderline personality dynamics. • An abusive spouse lies about an act of domestic violence after his wife calls the police (see the “Karl” case discussed in Chap. 11). • A confidence artist plays on the anxiety and infirmity of an elderly person to get them to sign a financial document. • A teenage girl continues to secretly self-mutilate while in an intensive outpatient DBT program. She relates with glee that she conceals her razor blades in the pages of her DBT workbook.

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“Multiple Function” A brief consideration of this taxonomy leads to an obvious problem; instances of DND are frequently complex rather than simple and their attributes may easily fall into more than one category of this taxonomy. Perhaps the antique psychoanalytic “principle of multiple function” [12] should be pulled out of retirement as we consider the following example. Clinical Example: The “Cosmopolitan Christian” A depressed, socially prominent businesswoman offers little information when questioned about her religious beliefs on intake, joking that she is a “cosmopolitan Christian,” a reference to her heavy drinking at Church-related social functions. Only after extended treatment does a more complete picture of the patient’s bitterness and sense of abandonment emerge; she witnessed an extended sexual affair between an ordained priest and a member of her own family in childhood, and in her present leadership capacity in her church has authorized secretive multimillion-dollar settlements for sexual misconduct. The patient characterizes her feelings about her religion as “repulsion,” but adds I do this same thing Sunday I do every other day of the week, I go in there and just smile, smile, smile.” She acknowledges that she sometimes wishes she wasn’t alive, but denies suicidal impulses or intent. In this example, the patient’s characterization of herself as a “cosmopolitan Christian” may be alternatively understood to simultaneously represent: • A social “white lie” designed to avert purposeless conflict • A “pragmatic” undertaken in a social setting governed by an oppressive social and religious hierarchy poised to punish candor • An effort to contain her own affective distress • An act of self-parody born out of shame and guilt • A self-negating, sarcastic response may mask a patient’s depressive psychopathology and poorly-defined suicidal impulses.

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Which interpretation of the patient’s statement is correct? There is no single “right” answer, and each way of understanding the comment is in part an accurate reflection of her motivation. The balance between them, additionally, may shift on a moment-to-moment basis during the psychiatric interview and in a longer time frame over the course of treatment (Table 8.4).

Qualities of DND A range of other attributes can be used as a means to classify DND as it arises in the clinical encounter.

Active Falsification The process of any component of DND (i.e., deception, nondisclosure, and distortion) undertaken with the specific intent of leaving the interlocutor in a state of ignorance of critical information possessed by the subject.

Dissociation and Self-Deception To what extent does DND occur in the context of some internal process which simultaneously restricts the subject’s awareness of nondisclosed material. This phenomenon is defined as “repression” in psychoanalytic literature but is widely observed in domains beyond psychoanalytic practice and theory.

“Soft” Versus “Hard” DND All of us engage in various forms of nondisclosure for a variety of reasons and by a variety of methods. For most individuals, the impulse to withhold information is conditional, that is, subject to revision if the circumstances of the interview

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Table 8.4  A taxonomy of deceit Social continence—undertaken to regulate interpersonal relationships and to conform with social expectations.  Avoidance of offense (tact)  Regulation of intimacy  Suppression of aggression and sexuality  Affective continence  Recognition of hierarchal relationship  Conformity with social or professional expectations Instrumental deception—undertaken to achieve pragmatic result:  Response to power gradient.    Need to propitiate power   Increased arbitrariness of exercise of authority → increased deception  Social hypocrisy  Salesmanship  Avoidance of blame  Malingering  Involuntary referrals  Response to negative experiences with prior caregivers Regulation of shame and guilt—defensive and self-regulatory deception  Shame  Anticipation of rejection/humiliation  Impaired capacity for trust Self-deception  Internal correlate of anxiety and social conflict regulation  Reconcile conflicting impulses/beliefs

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Table 8.4 (continued)  Avoidance or perpetuation of guilt  Personality fragmentation   Psychosis    Trauma/dissociation   Factitious illness Paranoid states  Mistrust  Alienation & fear  Delusional perception of threat Psychopathic deception (undertaken to conceal or promote aggression, exploitation, and other asocial behavior)  Deceiving the evaluator to neutralize threat of exposure  Predatory deception  Manipulation/control  False accusations

changes. Sometimes this is as simple a matter as becoming more familiar with the interviewer and establishing a congenial rapport. Examples of other conditions favoring disclosure include gaining confidence of about interviewers’ affirmative and non-judging posture, diminution in shame, increasing confidence in an interviewer’s general trustworthiness and motivation for seeking information. Creating such considerations is of paramount importance in psychiatric interviewing. The common denominator in “soft” DND is that the motivation to withhold or distort information is subject to revision and change over time.

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Clinical Example: An Alcoholic at “Rock Bottom” An alcoholic patient is initially uncommunicative and internally preoccupied. After a clinician displays familiarity with the subjective powerlessness and shame that accompanies addiction, an alcoholic patient describes the collapse of his marriage, estrangement from his children, and episodic suicidal ideation. “Hard” DND, on the other hand, is stubbornly defended, characterized by fixed, often immutable barriers to disclosure, in a setting of minimal or absent treatment alliance. Its significance must be assessed in context. Resistance of this kind is frequently observed in patients referred on an involuntary basis, in a rigid hierarchical system, and in the absence of confidentiality—for example, in forensic, military, and mandated-treatment settings. In such circumstances, a posture of nondisclosure may represent a rational response to an interviewer environment characterized by unknown intention and potential threat. DND behavior may thus be of relatively low psychological significance. Clinical Example: The Veteran Who Avoids Psychiatrists A law enforcement officer and military veteran who suffers from PTSD and depression states “I’d never see a psychiatrist. If some shrink knew half of what goes on in my mind, my career would be over.” Within a therapeutic environment, on the other hand, a “hard” posture may reflect a range of major psychopathology, including psychopathy, paranoia, and identity disturbance, is associated with more-severe personality disorders. As we will see below (note) the interview of a “Hard” subject is often a frustrating and/or confusing affair. Close attention to process is required to identify contradictions, and demonstrations of open or covert resistance to cooperation. Clinical Example: The Gun Owner An involuntary interview subject insists that a recently purchased firearm in his possession is non-functional. He

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describes the firearm in technical terms which are difficult for a non-expert to understand. When confronted with a receipt for hundreds of rounds of ammunition for the same weapon, the patient denies ever saying the weapon was non-functional and insists that the interviewer misunderstood his explanation of removing packing grease from the weapon before making it ready for use. He discusses the corrosive nature of cartridge residue in detail. As a result of training and instinct, most non-forensic mental health clinicians engage DND by attempting to establish an atmosphere of trust. This is impossible to achieve with a “hard” DND subject who is actively withholding or fabricating historical information. Such patients often elicit powerful negative affects and aversive impulses in mental health professionals. When DND is detected, differentiation of “hard” from “soft” DND represents an essential mental status assessment task. As discussed above, there were many motivational and emotional factors that lead patients to withhold information. “Soft” DND, if properly engaged, leads to a deeper understanding of the patient, improves rapport and insight into the patient’s motivational state. “Hard” DND, on the other hand, reflects a critical breakdown in the evaluation or treatment relationship, with profound diagnostic and clinical implications. Early career clinicians often fail either to detect “hard” DND or to identify it as such. It is not unusual for a clinician in such a circumstance to withdraw psychologically, or blame themselves from an increasingly frustrating or threatening encounter. Once again, this difficult circumstance represents a unique clinical opportunity to better understand the interview subject. Clinical Example: The Executive Accused of Domestic Violence A corporate executive is brought to the emergency room by police, after he allegedly assaulted his wife and daughter in a family quarrel. He vehemently denies this is the case and states that his wife is making this allegation because she has

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been “brainwashed” by her therapist. During the interview, he maintains a mask of politeness as he intimidates and denigrates the female evaluating clinician, who for her part becomes increasingly angry and unsure of herself as the interview proceeds. On reflection, the clinician is able to reformulate her experience of the subject’s deceptive and provocative behavior as evidence of an underlying narcissistic personality traits including intense rage towards women (this simulated case is discussed in detail in Chap. 11).

Dissociation, Disorganization, and Nondisclosure The Patient as Storyteller The phenomenon of “self-awareness” represents the integration of a range of mental and emotional processes. One such process is the construction and maintenance of a personal narrative: a story in which “I” is the principal character, through the telling of which an individual’s behavior, motivation, and awareness can be examined and explained. A story is more than the sum of its component facts. A “good storyteller” lays out facts in a particular sequence, governed by considerations of form and coherence, in the setting of some kind of relationship with the listener. A more-­ talented storyteller is usually aware that the form of a story may be just as important as its content and accordingly adjusts the sequence and character of the narrative. Such storytellers are often described as “captivating” or leaving their audience “spellbound.” These are terms that attest to the narrator’s power. In the case of a mental health assessment interview, we typically begin with a request to the subject: “Tell us your story…What happened? …How did you feel? …Why did you do what you did?” Less-experienced clinicians typically over-rely on the narrative that the patient then provides, and give privilege to

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“facts” over form. It’s not uncommon to see beginners transcribe the patient’s words into the medical record wholesale. Alternatively, if the subject does not cooperate, or if contradictory information is obtained from another source, the patient is then characterized as an “unreliable” or “bad” historian, as if the patient has in some way betrayed our expectation, and in consequence their account is of no further interest to us. The problem is many patients are “bad” storytellers and typically grow “worse” as they approach material with high effective valence. Most clinicians will listen for gross aberrations, and appropriately record them in the mental status exam rather than the history. There is however another more-­ subtle process of psychic disorganization, which is frequently less detectable on a cursory exam. A patient fails to give us a complete account because their capacity to relate a personal narrative has been disrupted, rather than as the result of a volitional decision not to cooperate. Critical facts are often omitted, or else presented without context or link to other critical information. If detected and understood, such a process of disrupted mentation can be studied, and can serve as an index of the disruption of the patient’s capacity to conceptualize, as well as communicate, their own experience.

References 1. Blatt S.  The destructiveness of perfectionism. Am Psychol. 1995;50(12):1003–20. 2. Brooks R, Metzoff A. The importance of eyes: how infants interpret adult looking behavior. Dev Psychol. 2002;38:958–66. 3. Damasio A.  Self comes to mind. New  York: Random House; 2010. 4. Ekman P. Telling lies. New York: WW Norton & Co; 2009. 5. Farroni T, Csibra G, Simion F, Johnson M. Eye contact detection in humans from birth. Proc Nat Acad Sci. 2002;99(14):9602–5. 6. Fonagy P, Target M.  Playing with reality: a theory of external reality rooted in intersubjectivity. Int J Psychoanal. 2008;88(4): 917–37.

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7. Jeon H, Lee SH.  Neurons to social beings  – short review of the mirror neuron system research and its socio-psychological and psychiatric implications. Clin Psychopharmacol Neurosci. 2018;16(1):18–31. 8. Kohut H, Wolf ES. Disorders of the self and their treatment: an outline. Int J Psychoanal. 1978;59:413–25. 9. Liszkowski U, Carpenter M, Henning A, Striano T, Tomasello M. Twelve-month-olds point to share attention and interest. Dev Sci. 2004;7(3):297–307. 10. Overall NMJ.  What type of communication during conflict is beneficial for intimate relationships? Curr Opin Psychol. 2017;13:1–5. https://doi.org/10.1016/j.copsyc.2016.03.002. 11. Rizzolatti G, Sinigaglia C.  The functional role of the parieto-­ frontal mirror circuit: interpretations and misinterpretations. Nat Rev Neurosci. 2010;11:265–74. 12. Walder R. The Principle of Multiple Functinop: Observations on Over-Determination. Psychoanalytic Quarterly, 1936;5(1):45–62. 13. Yalom I. The theory and practice of group psychotherapy. 4th ed. New York: Basic Books; 1995.

Chapter 9 Personality Disorders, Psychopathy, and Deceit

Do patients with personality disorders lie? If so, do lying and other forms of nondisclosure play a greater or different role in the treatments of patients with personality disorders than of other patients? We believe that the answer to both questions is an unqualified “yes,” but if so answered, we confront a thicket of other questions, starting with “what is a personality disorder?” which immediately leads to the question: “what is a personality?” To this question, all too often there is no answer, perhaps due to the complex psychological and cultural issues associated with it. The problem of treatment of a “personality disorder” is compounded when it occurs in a setting of deception and nondisclosure. In some cases, as most experienced clinicians can attest, failure to address and engage DND promotes bad and, in some instances, dangerous outcomes. Few, if any, authors outside the psychodynamic literature address this subject. Jones [8] describes how the nineteenth century concept of “moral insanity” reflected an effort to destigmatize the mentally ill and those who attempted to care for them. Croqc [2] reports that Kraepelin attributed the “psychopathic personality” to constitutional defects and the impact of mental illness. At the same time, he noted that the limit between pathological and normal is gradual and arbitrary. Kurt Schneider defined “psychopathic” personalities as those individuals who suffer, or cause society to suffer, because of © Springer Nature Switzerland AG 2020 A. Lerman, The Non-Disclosing Patient, https://doi.org/10.1007/978-3-030-48614-3_9

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their personality traits, which, like Kraepelin, he attributed largely to constitutional factors. Whitehorn (1944) described “character” as determined by the “stability and integrity of one’s sentiments,” a stability which he identified as a critical aspect of what he termed “personality functioning” and mental health. The DSM-II (1968) defined personality disorders as “deeply ingrained maladaptive patterns of behavior that are perceptibly different in quality from psychotic and neurotic symptoms. Generally, these are life-long patterns, often recognizable by the time of adolescence or earlier.” The DSM-5 (2013) definition has been modified to “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” The remarkable similarity in these two definitions seems to be less a measure of the value of the original definition than a testament of the difficulty of agreeing on a better one. A number of dimensional and trait-based systems such as RDoC [7] and the DSM-5 Alternative Model (2013) have been proposed, but they face resistance to universal adoption. Andreasen [1] has characterized the reliance on DSM-driven categorical diagnoses as “the death of psychopathology” and warned of the dangers of overreliance on simplified diagnostic categories. Various behavioral therapies [13] are supported by the impressive literature documenting the beneficial therapeutic effects of psychotherapy combined with skills and other supportive modalities (Table 9.1). One of the shortcomings of the DSM in particular, and the psychiatric literature on personality disorders in general, arises from the effort to achieve scientific validity through the use of observable, measurable criteria to describe phenomena that • Reside within the patient’s subjective experience • Occur at a non-conscious level • Are not disclosed by the patient

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Table 9.1  A hierarchy of selected defense mechanisms Degree of conscious Category Defense awareness Psychotic Denial (of external reality) Low

Immature

Distortion (of external reality)

Intermediate

Splitting

Intermediate

Acting out Dissociation Passive aggression Substitution of fantasy for reality Neurotic

Intellectualization

High

Repression Isolation of affect Somatization Displacement Undoing Mature

Suppression Altruism Humor Sublimation

This brings us to psychodynamic or psychoanalytic concepts of DND.

A Psychoanalytic Perspective on Personality As [6] observes, the validity and relevance of psychodynamic theory (PDT) to issues of personality functioning represent a matter of controversy, dismissed by some contemporary psychiatrists as nonscientific, despite evidence-­based literature

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supporting the use of modern and specialized psychotherapeutic techniques (e.g., [20]) and the integration of translational neuroscience with core psychoanalytic principles [18]. The difficulty in part reflects the complex and internally referential nature of the psychoanalytic terminology, as well as its links to controversial and, in some instances, discredited aspects of psychoanalytic theory. We believe the value of the PDT, with reference to efforts to conceptualize and engage DND, rests on the following points: • A “structural” or “ego” model of different mental agencies governing consciousness, perception, and impulse control. • A “defense” model addressing apparently non-volitional exclusion of information from consciousness, mediated by a structural entity described above. • A “motivational” model including primal self-gratifying and aggressive impulses, frequently maintained below conscious perception due to the operation of defenses as described above. • A “disintegration” model predicting the potential for psychic fragmentation under stress or in the setting of severe mental illness. • A clinical model based on intense focus on the moment-­ to-­transactions between clinician and patient, with specific reference to fluctuations in treatment alliance and affect in both patient and clinician, through which the operation of the first four principles can be inferred. In their broad outline, and stripped of their Freudian legacy, most of these propositions are noncontroversial. Behavioral and affective regulation clearly takes place in the human mind and brain, mediated largely through frontal cortical and related structures. The exclusion of non-­preferred information from consciousness appears to have been demonstrated on functional imaging (Westen 2006), as has the role of the basal ganglia in regulating perceptual salience [9]

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and the existence of primitive motivational schemas in the brain stem [14]. This and other literature do not validate the PDT, but persistence of these core principles across differing domains of theory and inquiry. First, let us briefly review some aspects of later Freudian and post-Freudian theory.

Structural Model The legacy of psychodynamic personality disorder theory begins with the concept of the structural “ego,” denoting a mental agency involved in consciousness the perception of reality, and the evolution of a cohesive sense of self, an agency capable of differentiating internal from external stimuli, regulating and redirecting more primitive impulses and desires. Freud also coined the term “superego” to describe second agency, often intertwined with the “ego” and at times indistinguishable from it, involved in the regulation of guilt and self-­ esteem. This concept represented a major revision of Freud’s original model of instinct and repression and symptom formation [4]. Freud’s famous aphorism, “the ego is a precipitate of abandoned object-cathexes,” refers to his theory that higher functions of consciousness (such as identity, language, and self-regulation) develop as a result of child’s capacity to develop and sustain internal representations of caregivers and other important figures in a child’s early life [5]. Such representations or “objects” retain a high emotional valance and are subsequently experienced as aspects of the self. In aggregate, this process of identification results in the format of composite agencies Freud termed the “ego” and “superego” (1923, 1964). To give but one example, a toddler is taught by her mother that being “dirty” is “bad” and being “clean” is “good.”

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Initially, a child may rebel against such instruction, but quickly learns that obedience will avert bad consequences that will otherwise follow. Eventually, the mental record of the child’s interaction with mother is internalized and being “clean” is experienced as the child’s own preference, just as mother’s approval is transformed into an experience of self-­ esteem and freedom from anxiety. Freud viewed this process of conflict-free internalization of parental values as intrinsic to personality development.

Defense Model One inevitable outcome of this regulatory process, however, is that the “ego” must inevitably reconcile conflicting internal impulses, as well as dichotomous representations of caregivers who may be experienced as loving in one instance and threatening in the next. The self-regulating agency of the “ego”, Freud argued, works to mitigate anxiety associated with such conflict through a series of regulatory mental maneuvers he termed “defense mechanisms.” Freud’s model was later neatly summarized by Vaillant (1968), who stated, “Defense mechanisms represent an innate, involuntary regulatory process that allows individuals to reduce cognitive dissonance and to minimize sudden changes in internal and external environments by altering how these events are perceived.” Anna Freud (1937) later codified a hierarchy of “defense mechanisms” more or less associated with mental health that was further refined by Vaillant (2011) based upon the degree to which the defensive operation distorts or disrupts the perception of reality. Examples of “mature” defenses include humor and redirecting frustrated impulses and desires into other goal-directed activities (sublimation). At the other end of the spectrum, we have “immature” defense mechanisms associated with gross distortion of perception, such as dissociation, projection, and even psychotic denial. (A complete listing can be found in Table 8.4). Both Sigmund and Anna Freud

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correlated psychological health with the integration of experiences of loving and reproving parental figures, and the consequent evolution of the capacity for morally based selfregulation through the formation of the “superego.”

Motivational and Early Fragmentation Model Melanie Klein [11], by contrast, focused on the vulnerability of internal “object representations” to fragmentation into dichotomous “all good” and “all bad” elements. She proposed that such “splitting” represented a primitive defense mechanism implicated in psychotic states and other forms of psychopathology associated with rage and paranoia. Her proposition that such conflicts characterize early infant life has been widely criticized, but the concept of splitting and personality fragmentation has been extensively applied to the understanding of borderline and psychotic states in adults. Stern [19] was one of the first psychoanalysts to identify “a large group of patients (which) fit frankly neither into the psychotic group nor into the psychoneurotic group,” and who proved difficult to treat due to a range of problems, which included “narcissism...masochism…use of projection mechanisms…(and) difficulties in reality testing, particularly in personal relationships.” Stern noted a high prevalence of psychopathology in the mothers of these patients and noted histories of “actual cruelty, neglect, and brutality… of many years duration… operating more or less constantly over many years from earliest childhood.”

 ragmentation Model “Borderline Personality F Organization” Kernberg (1975) integrated Freudian and selected Kleinian concepts to describe what is “Borderline Personality Organization,” an underlying condition of impaired capacity to sustain a stable subjective sense of identity or self-­

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regulation. Kernberg believed that this state of vulnerability reflected impairment in mental functioning, which, following Freud, he termed “ego weakness,” reflecting unreconciled and contradictory object relations, and a heavy reliance on “splitting” and paranoid “projection” (i.e., attribution to others) of disavowed self-experience. Such patients characteristically present with a range of different, state-dependent symptoms, including anxiety, conversion disorders, unregulated aggression and masochism, weakened sense of identity, and vulnerability to transient distortions of reality.

 ifferentiation of “Borderline Personality D Organization” from DSM Important distinctions exist between Kernberg’s concept of “Borderline Personality Organization” (BPO) and “Borderline Personality Disorder” (BPD) as defined by the DSM. These are important to our effort to place the phenomenon of DND in the co-occurring phenomena of a personality disorder. • The DSM represents a syndromal classification based on observable phenomena, rather than an effort to understand human mental functioning. The construct of BPO, by contrast, rests upon a conceptual foundation of inferred mental structures and describes observed symptomatology as the result of impairment in the functioning of the structures. • The concept of “defense mechanisms” is intrinsic to BPO, with particular regard to the disruptive impact of ­“primitive” defense mechanisms such as “splitting” and “projection” on insight and self-awareness. The BPD criteria note a description of generally similar symptoms, (e.g., “identity disturbance”); but eschew any effort to characterize an underlying defect which gives rise to them. • In the BPO model, “ego weakness” represents a general condition of structural personality instability, within which a range of characterological traits may manifest, e.g. “narcissism” or “psychopathy” (see Fig. 10.2), whereas the cat-

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egorical approach of the DSM stipulates a range of putatively different disorders. • As one result, aberrations of moral functioning are not considered in any iteration of the DSM concept of Borderline Personality Disorder, whereas disruptions of “superego” functions are intrinsic to the concept of borderline organization. We will consider this further below. • The BPO concept preserves the principle of vulnerability to transient psychosis, while the same is minimized or even Table 9.2  Contrasting elements of “Borderline Personality Disorder” and “Borderline Personality Organization” DSM-5 Borderline Borderline Personality Personality Disorder Organization Frantic efforts to avoid real or “Nonspecific ego weakness,” that imagined abandonment is, reliance on “primitive defense mechanisms” (see below) Impulsivity Identity disturbance

Identity diffusion

A pattern of unstable and intense relationships characterized by … extremes of idealization and devaluation

“Dichotomous” object relations

Moral functions only engaged through concept of comorbid “Antisocial Personality Disorder” or traits

Primitive of disrupted “superego” functioning

Recurring suicidal (or self-­ injurious) … behavior

Primitive masochism, envy, and shame

Affective instability

Habitual us of “primitive defenses” with restriction of self-­ awareness, identity formation, and capacity for impulse control  Splitting  Repression  Paranoia

Chronic feelings of emptiness Inappropriate, intense, or poorly controlled anger Transient, stress-related paranoid ideation or severe dissociative symptoms

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ignored by various iterations of the DSM.  The DSM-III (1980) criteria for “Borderline Personality Disorder” by contrast does not include psychotic symptomatology, whereas the DSM-5 specifies “Transient, stress-related paranoid ideation or severe dissociative symptoms.” Hypochondriasis and other “neurotic” symptoms are likewise excluded from the DSM (Table 9.2).

“ Defensive” and “Malignant Narcissism” Models of DND The BPO model translates readily into at least two hypotheses regarding deception and nondisclosure. • The first may be termed a “defense model.” Ford (1996) characterizes reliance on “immature defense mechanisms” as a form of self-deception that occurs in a state of disrupted self-awareness. Impaired self-concept and self-­ esteem intensify effects of shame and anxiety, rendering self-disclosure more threatening. • The second may be termed a “Malignant Narcissism” model. Drawing on the work of [10, 11] set forth a concept of a psychological syndrome combining narcissistic, borderline, and antisocial personality traits with deep feelings of anger and envy. Rosenfeld [15] described it as a condition within which “destructive omnipotent parts of the self” ward off intimacy-­associated anxiety by negating and destroying relationships with others. In a clinical setting, these dynamics are frequently evident as selfdestructive acting out and treatment failure. Both models of DND are consistent with a shifting and at-times unclear distinction between volitional acts of deception, on the one hand; and the impact of “immature” or “primative” defense mechanisms of awareness and capacity coherent volition, on the other. All too often, we find both mechanisms in play simultaneously.

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 orality, Self-Esteem, and Descent into M Primitive Masochism A final matter of consideration is the fate of the capacity for moral judgment and regulation of self-esteem in “borderline” states. Reliance on defensive “splitting” leads to pervasive object fragmentation and consequent defects in “superego” functioning. Due to the immature nature of the defenses so employed, individuals displaying BPO characteristically possess only limited awareness of their motivation or psychological functioning. “Impulsivity” and “acting out” may thus represent behavioral manifestations of BPO and refer to action taken in the partial or complete absence of awareness of motivation. • In more-moderate cases of BPO, moral judgment is marked by unduly dichotomous self-judgment, frequently complicated by externalization through projection and blame. • In more-severe settings, moral governance of behavior and self-esteem is entirely disrupted and replaced by distorted perception, rage at others, paranoid experiences of persecution, or masochism. Consider the following case history: Clinical Example: Linda and the Listerine Linda was a 45-year-old unemployed financial officer referred for transference-based psychotherapy following psychiatric hospitalization precipitated by a series of suicidal gestures. Part of a glamorous celebrity scene as a young woman, Linda now felt empty, ugly, and hopeless about herself. She had been hospitalized a total of eight times, in a setting of deepening depression and alcohol abuse, loss of her job, and deepening social isolation. At time of initiation of therapy, she had been abstinent from alcohol for 8 months and was regularly attending a day treatment program and AA meetings. She

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reported a high level of optimism about beginning treatment, particularly since her new therapist was male and in her opinion “intelligent, funny, and kind.” Linda’s early psychotherapeutic work focused on her feelings of shame and inadequacy. She recalled how as a teenager she pretended to others that her father was a minister at an affluent church, where he was actually employed as a janitor. At her previous job, she had gained promotions through affairs with married executives at her company, whom she felt had exploited her. She felt her therapist was disgusted by her transgressive behavior, stating “you probably want to throw me out, but you’re too professional to say so.” Linda nonetheless complained that her therapist was unsympathetic and cold. She said she “felt like a child going to the principal” when coming to the office. When the therapist commented that his neutral style was intended in part to leave room for the patient’s rage, Linda responded “I don’t think there’s room for it anywhere.” She reported instances of sexual victimization, which the therapist did not pursue. She described leaving sessions both “suffused with rage…that doesn’t feel like part of me” and “feeling like an asshole” for wanting so much from her therapist. Linda behaved provocatively with her therapist. She claimed to have independently “deduced” that the therapist had recently had a baby and voiced her envy, reporting that she herself had miscarried twins after being raped. She claimed to have defended the therapist in conversation with other patients who had ridiculed him. She recalled a relationship years previously with a medical resident and “putting on a white coat” to sneak into the hospital after hours to have sex in the on-call room and help him do chart work. On several occasions, she moved around the room to study the therapist’s diplomas, wondering aloud if they were forgeries. There was little demonstrable change or improvement over the 18  months of the psychotherapy. Increasingly, the therapy material revolved around themes of the patient’s guilt and shame regarding her unmet emotional and sexual needs, and her masochistic belief that “pain is the currency of caring” that she could only win the therapist’s love through

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suffering. At the same time, she complained that the therapist was distant, twisting her words. “I feel like I have a hole in my stomach, and part of me wants to jump off a bridge,” she said. “What you need is chicken soup and a hug, but what you get is a remote psychiatrist.” On several occasions in the course of the treatment, the therapist noticed that the patient frequently smelled of mouthwash, but never discuss this or considered it further until the patient physically collapsed on her way into session, falling to the floor and vomiting copiously. Emergency service personnel determined that the patient is grossly intoxicated. In the course of her subsequent psychiatric hospitalization, the patient confessed to drinking 1–2 pints of mouthwash daily, arriving to each session intoxicated in what she viewed as an act of self-medication to regulate her anxiety and distress in response to the material discussed. Despite the patient’s plea to “please don’t abandon me,” psychotherapeutic treatment was regarded to have failed and was thereby terminated. The patient was referred to a detox facility and subsequently lost to follow up.

Discussion of the Linda Case Why did Linda lie? At what point in the psychotherapy did she resume consuming alcohol? Could different practice by the therapist (e.g., a warmer clinical style, engagement of the patient’s sexual abuse history, more focus on here and now objectives) have led to a different outcome? What other information did she withhold? As is the case in most instances of more severe DND, we are left with a frustrating paucity of information. But this doesn’t mean we can’t learn anything from her case. Linda’s behavior and what we know of her experience over the treatment offers a rich history of deception and human suffering. • From the outset, Linda’s treatment was flooded by her dependent needs and her terror of rejection. • Much of what otherwise would have been the goals of the therapy was overwhelmed by the intensity of this process.

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• Linda’s belief that her therapist despised her represented a “projection” of her own self-judgment on to the figure of the therapist. She perceived this as a fact, not a feeling. • Linda displayed gross disruption of her capacity for self-­ esteem, expressing a history of shame and self-loathing extending back to childhood. • Linda displayed numerous clear instances of “splitting”. For example, she characterized her new therapist as “intelligent, funny, and kind,” only to accuse him a short time later of being “disgusted” with her and wanting to throw her out of his practice only he was “too professional to say so.” • After an initially hopeful induction, she began to experience the therapy relationship as a humiliating and degrading repetition of her childhood experience. She equated attending therapy sessions with “going to the principal’s office” and made a masochistic declaration that “pain is the currency of caring.” • Linda never made an overt sexual overture toward her therapist, but she referred repeatedly to boundary-­crossing relationships with married men and a sexual relationship she carried on with a medical intern while he was on duty in the hospital. She responded to her discovery that the therapist had just celebrated the birth of a child with her own account of miscarrying after a violent sexual assault. • Linda referred repeatedly to fantasies that her therapist had obtained his diplomas fraudulently. • Linda described herself as “suffused with rage” but never expressed this emotion directly toward the therapist. • At some point in treatment, Linda resumed consuming alcohol and coming to therapy sessions while intoxicated.

“ Structural” Problems or “Nonspecific Ego Weakness” To return to the core proposition of PDT, Linda appears to have exhibited a “structural” failure in her capacity to regulate her own impulses and differentiate internal from exter-

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nal stimuli. Her sense of need and fear of abandonment overwhelmed the treatment. Instead of taking rational action to improve her level of functioning, she subsided into inactivity and at some point resumed drinking. In this setting, it is not surprising that Linda exhibited similarly severe problems in her moral self-appraisal, seeing herself as “disgusting” and defective and then attributing this to her therapist. Rather than seeking help from the therapist, she perceived him as a cruel and judgmental parent for whom “pain is the currency of caring.”

“Defensive” Problems Linda’s case exhibits, of course, a range of “primitive defense mechanisms.” We find that a characteristic instance of “splitting” in her alternating experience of her therapist is “sensitive and kind,” in one moment, and a cruel, abandoning parent, in another. As noted, she exemplifies “projection” in her attribution of negative self-appraisal to her therapist. The clinical and detached nature of the clinician’s termination interview with the patient may even be seen as an instance of “projective identification,” that is, a circumstance within which a clinician exhibits characteristic mentation and behavior in response to a patient’s material. But what was wrong with Linda transcends a summary with a label or theory. Something larger was in play: • The normal behavioral process of the treatment relationship was distorted and deformed into an “actual” relationship in which the patient’s drama of overwhelming need and subsequent abandonment was reenacted, rather than understood or otherwise healed. • Linda’s perception of her therapist appeared to grossly distorted. It appears likely that, early in treatment, she believed that she might initiate a romantic or other intimate relationship, as she appears to have done in the past. As it became clear that this was possible, she appears to have been “overwhelmed by shame” and alternately “suffused with rage”.

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• In addition to failures and self-disclosure due to non-­ conscious “defense mechanisms,” it is clear that Linda was intentionally and volitionally withholding critical information (e.g., her drinking), with the result that the treatment was destroyed. In hindsight, Linda’s material offers many hints that this was going on, for example, her account of impersonating a doctor in order to have sex in a hospital and helping her boyfriend with his clinical notes, or lying to her friends about her father’s occupation. She deceived her therapist about her drinking for a period of months, if not years. Lying like this is not simply a “defense mechanism.” It reflects a posture of deceptiveness and likely a profound capacity for dissociative compartmentalization, including self-deception as well as deception of others. She may have rationalized that she did so in order to protect herself from feelings of overwhelming shame and distress and appears to have been in a state of denial about the destructive impact of her behavior, particularly on herself. The patient additionally appears to have regarded her behavior as in part an act of self-punishment, which allowed her to perceive her behavior as, in a limited sense, morally just. Rosenthal [16] makes similar observations in a case study of gamblers, noting “anyone who has spent time in the presence of the pathological gamblers cannot fail to be impressed by the capacity for self-deception,” characterized by pervasive grandiose and omnipotent fantasies and extending to every domain of the individual’s life. Rosenthal notes “one of the most common personifications of the omnipotent self is a con artist – it is noteworthy that these are often the qualities the gambler most admires these others.” Rosenthal notes that overvaluation of money frequently obscures deep underlying deficits in self-esteem. Gambling victories and defeats represent a cycle of winning and losing associated with dramatic “splitting” and manifest as swings in self-concept and self-esteem, feeding a compulsion to continue gambling in the face of escalating losses. Rosenthal notes the more money one has, the more substance to oneself,

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the more one is. The pathological gambler tries to win back what has been lost as if his or her money were some lost and necessary part of the self. Rosenthal notes the high correlation of uncontrolled gambling and suicidal ideation, including an idealization of self-­ destructiveness, and perception of suicide as a means of both moral atonement and as a reassertion of grandiose self-control. Seen in the light of Rosenthal’s formulation, Linda’s self-­ destructive deception and acting out may be understood as reflecting a profound and inadequately diagnosed personality disorder that was not engaged in the psychotherapy. Linda appears to have exhibited profound personality fragmentation and may be inferred to have simultaneously enjoyed a profound sense of guilt, a fragmented sense of triumphant “malignant narcissism”, and simultaneous guilt accompanied by a gesture of atonement.

Case Studies in Psychopathy “Nondisclosure” is not limited to people with personality disorders. As patients, most of us either consciously or unconsciously hold back information from our care providers. At times that information may be crucial to our medical care. However, we may also have very good reasons not to disclose, that is, fearing judgment from our providers, not wanting to admit to ourselves the truth about a problem, and not wanting to acknowledge to others that there is a problem. When we are not ready to acknowledge the most vulnerable parts of ourselves, deception becomes a way of keeping our self-­ image intact. All this means that we can empathize with this instinct as humans, as patients, and as clinicians. This chapter’s purpose is not to critique the average person’s reasons for holding back. Trust in a provider takes time. People need to feel like their treatment provider is a team member and that their relationships are collaborations. Like any other relationship, this one can be dysfunctional as well,

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with poor communication between patient and provider, a difference in priorities, and the overall illusion that it has occurred. This chapter’s purpose is to examine case presentations of those patients who are ultimately not looking to connect with their providers in an authentic manner. Nondisclosure (including blatant lying, giving selective or distorted information, and withholding key facts about oneself) will be the consistent norm. Their motive for seeking psychiatric care, including hospitalization, is specifically for secondary gain, whether that is the attention that comes from assuming the sick role (factitious disorder) or the material gain involved (malingering). Not every person with a personality disorder purposefully (or unconsciously) will present to a psychiatric inpatient ­setting for secondary gain. Many will present with primary affective disorders or psychotic disorders, with or without cooccurring substance use, and often with stressful financial/ social circumstances that are preventing them from getting adequate care. However, not engaging their personality in a formal, consistent way, that is, through development of a cogent treatment plan, will hinder care. And in the case of those patients who are nondisclosing for secondary gain, this will guarantee treatment failure. Any vulnerability in our treatment system will be magnified, not least the treatment team’s vulnerabilities as human beings at the receiving end of deception. Clinicians will treat “the wrong thing” and get predictably poor results.

Case 1: Johnny Johnny is a 34-year-old man with diagnoses of schizoaffective disorder, cannabis use disorder, and antisocial personality disorder (ASPD). He has also endorsed a diagnosis of epilepsy, later clarified to be seizures due to alcohol withdrawal. He has had 39 psychiatric admissions in his lifetime, including 19 psychiatric admissions. He has often presented to inpatient

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care while endorsing suicidal ideation and psychotic symptoms. He has endorsed multiple suicide attempts and presented with scant superficial forearm cuts of varying ages. His symptoms have been exacerbated by chronic treatment noncompliance and marijuana use. Johnny’s first admission was at age 8, after which he became a ward of the state. Both of his parents struggled with substance use disorders. He had multiple psychiatric admissions during childhood and adolescence. He remained in foster care until aging out. He completed high school. Employment history is limited, and he is on diability. He has been homeless multiple times. Legal history is relevant for incarceration due to drug-related charges and assault. Johnny will usually bring himself to the hospital but provides limited to no consent for collateral contacts. He initially displays psychotic and depressed symptoms on admission and expresses that he requires a staff member to watch him in order to prevent harm toward self or others. He threatens suicide and violence if his demands are not met, that is, wanting to be admitted to a particular inpatient unit. During multiple admissions, he has demanded that the hospital should find him housing prior to discharge. In one instance, he presented after his girlfriend attempted to end their relationship. During multiple presentations, he has expressed that a friend has been killed recently leading to his destabilization. During inpatient stay, he refuses to participate in any therapeutic activities. He is resistant toward medication changes, and expresses that medications do not work for him, but requests supplemental Seroquel and Ativan on the unit. He attempts to extend his stay by endorsing many somatic complaints with demands for more medical workup. During multiple presentations, he has reported having a seizure just prior to coming to the emergency department. He often gives projective dates of when he would be ready to go. Interactions with patients and staff demonstrate his poor frustration tolerance, intrusiveness, and irritability. He engages in staff splitting. He is provocative toward female

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staff and aggressive toward male staff. He demands specific staff members to accompany him during constant observation and acts out when those demands are not met. He is also intimidating and aggressive toward vulnerable peers in an instrumental manner and appears to enjoy their reactions. When confronted about his behavior, he completely denies its severity and externalizes blame on staff. His behavior is largely volitional and deliberate despite endorsing severe psychotic symptoms that would likely preclude this level of thought organization. During an admission in 2015, an attending psychiatrist noted that this patient was well versed with the mental health system due to his multiple hospitalizations and residential admissions. He is able to emulate the necessary psychotic symptoms and voice threats to gain inpatient admission and choice of staff and hospital unit. The attending also noted that Johnny has expressed openly that he likes to accumulate his social security money by staying in the inpatient unit for prolonged periods and tries to get “uncooperative staff” fired. Ten days after being discharged from this admission, Johnny presented again to psychiatric emergency department and was readmitted after he cut his forearm superficially with a razor. He has been admitted multiple times since then despite the attending’s assessment. During his last inpatient admission, he assaulted a psychiatry resident in an effort to be moved to a different unit. Although this demand was honored, he was discharged within a week and arrested for the assault. He has not been admitted to our hospital since then.

Case 2: David David is a 37-year-old man diagnosed with schizoaffective disorder, bipolar subtype, polysubstance use disorder, and antisocial personality disorder. He has been hospitalized over 25 times over 10 years, with estimated 70 total psychiatric admissions. Diagnosis of malingering was noted in the as early as 2006.

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David generally presents to our hospital in the midst of drug intoxication or in the setting of withdrawal, that is, due to phencyclidine (PCP) or cocaine. Alternatively, he will come in when feeling anxious in setting of an upcoming court date and endorse suicidal ideation. He reports history of one suicide attempt by hanging after his first admission. He has made suicidal threats after, but no further attempts were recorded in the electronic medical record.  He has been on multiple antipsychotics, antidepressants, anxiolytics, and mood stabilizers. He gives limited consent for collateral contact. David started to use alcohol and marijuana by age 14, PCP by age 20, and cocaine by age 24. Per patient report, he had his first psychotic break at age 20, and around the same time he started using marijuana and PCP frequently. He began hearing voices and developed ideas of references about people on the radio and TV talking to him. He became very anxious, paranoid, and depressed, as well as increasingly isolative. More recently, he was also using K2 and heroin. He reports liking PCP specifically because it made him feel less paranoid. Although he has attended rehab multiple times, he often signed out or was discharged irregularly due to his behavior. He has been banned from multiple substance use programs in the area due to acts of violence toward staff and patients, as well as selling of illicit substances on the premises. Family history includes substance use disorder in both parents. He also reported that a maternal aunt had tried to commit suicide. David was raised primarily by his extended family. He is demonstrably intelligent, having completed college credits in Business. He was last employed in 2005 and since then has supported himself with disability payments.  Legal history is relevant for multiple assault charges, including forcible touching, holding a woman against her will, and breaking a male staff member’s arm during a psychiatric hospitalization; other charges included petty larceny and possession and sale of illicit substances. Record of trauma history is limited.

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During his inpatient stays, he initially presents with impulsive aggression while under the influence or withdrawing. Afterwards, his aggression becomes instrumental and targeted toward people he deems as vulnerable. He is belittling, demanding, and intimidating toward both staff and patients, using his size and threats of violence. He is sexually provocative and degrading toward female staff and patients. He is physically aggressive toward male staff and patients. He frequently makes denigrating statements about people’s perceived sexuality. He has made false claims against staff, once alleging that a male staff member had made inappropriate advances toward him and called the police. When this claim was evaluated, he was dismissive of the incident. He is grandiose at baseline, taking pride in his number of psychiatric admissions, incarcerations, and his diagnosis of schizoaffective disorder due to its perceived rarity and complexity. Additionally, he expresses beliefs about the FBI and police being after him. However, he often voiced these beliefs with a tone of pride, rather than fear, or as a justification for secondary gain, that is, needing to use the phone during off-­ hours on the inpatient unit or needing symptomatic anxiety relief via medication. This antisocial behavior continues in outpatient treatment. As a result, he has been discharged from multiple clinics. Even when maintaining sobriety over the course of months, he has been verbally aggressive, sexually provocative, and manipulative toward his outpatient provider. David ultimately passed away at age 37 from overdose. Both Johnny and David exhibit behavior consistent with antisocial personality disorder (ASPD). ASPD is manifested by impairments in self-functioning including egocentrism, goal setting based on personal gratification with lack of prosocial internal standards, trouble with interpersonal functioning, that is, lack of empathy and remorse, and incapacity for mutually intimate relationships. The alternative model divides these into malicious personality traits, such as manipulativeness, deceitfulness, callousness, and hostility, and disinhibition

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characteristics, such as irresponsibility, impulsivity, and risk taking (DSM-5). Both Johnny and David also exhibit symptoms concerning for malignant narcissism. Kernberg defines this as a significantly dysfunctional form of narcissistic involving narcissistic personality disorder with antisocial features, ego-syntonic aggression, absence of conscience, and a need for power/ control [12]. In such a treatment dynamic, the patient “wins” by losing. Thus, in situations in which this feature is present and is not the central treatment focus will essentially guarantee that treatment will fail, even more certainly when substance use is involved.

Case 3: Lisa Lisa is a 22-year-old woman diagnosed variably with major depressive disorder, bipolar disorder, and schizoaffective disorder, as well as borderline personality disorder and mild intellectual disability. She has had multiple suicide attempts at her group home, as well as interrupted attempts. She has been engaging in chronical habitual self-injurious behavior since age 15 as a way of coping with distress. She has had over 25 psychiatric admissions starting at age 12, including 13 admissions in 12 months. Between May of 2015 and May of 2016, she spent about 150 days in our hospital. From June of 2016 to June of 2017, she spent about 170  days in the hospital. Lisa will typically present complaining of suicidal ideation with plan to strangle or cut herself. She will also endorse command auditory hallucinations of a woman telling her to harm herself. She will voice homicidal ideation against the residential supervisor at her group home due to the latter’s strictness. If she feels she is not getting enough attention, she will engage in escalating self-­injurious behavior. She will appear sexually preoccupied and engage in inappropriate behavior with male residents at her group home.

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Lisa has been in residential placement since age 9. She has few friends at her group home and is unemployed. She has completed high school. She reportedly witnessed her father physically abusing her mother and sisters and has accused him and other family members of physically and sexually abusing her. Family history is relevant for bipolar disorder and alcohol use disorder in mother and depression in father. On the unit, she presents as needy and childlike. She is flirtatious and provocative with male staff and patients. She will make verifiably untrue accusations against other patients. She lacks coping skills to tolerate distress and resists to learning new ones in the inpatient setting. She will hide objects with sharp edges on her person or use her clothing and her hands to self-injure. Like at the group home, she will engage in swallowing foreign objects and escalating self-injurious behavior, including attempting to asphyxiate herself with clothing, trying to jump off a balcony, and so on. Sometimes she will blame her self-injury on “voices,” despite the rest of her clinical presentation being inconsistent with psychosis. A clinician accurately pointed out that she does not know how to relate to others outside of her role as the girl who self-injures. She will act out particularly when she is close to discharge through superficial self-injury. Despite readmission reduction plans created with her group home, it is unclear to what degree they are implemented. In one instance, she tried to jump out of the ambulance on the way back to her facility after being discharge. She has repeatedly been hospitalized within a few days of discharge (occasionally within the same day). Eventually, Lisa aged out of her group home and was moved to another group home in a different part of New York. She has not presented to our hospital since. In this cognitively limited person, egocentricity is increased, while there is less non-self-directed violence or sexuality. Her concept of sexuality is childish. She engages in egocentric gratification, including public masturbation, pica, aggression toward property, and threats of tantrums, all as repeated ploys for immediate attention (whether good or bad).

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Case 4: Leon Leon is a 38-year-old man with schizoaffective disorder, substance use disorder (marijuana, cocaine), antisocial personality disorder, and Type 1 Diabetes. He has at least 18 lifetime psychiatric admissions.  He reports attempting suicide five times, including trying to throw himself in front of a bus in one instance. He will present to the emergency department in setting of depressive symptoms with suicidal ideation, auditory and visual hallucinations, and neglected physical health as well as ongoing cocaine and cannabis use. Social history is limited. Leon completed high school and trade school. He has not been employed for over 12 years and supports himself with disability payments.  He cycles among staying in psych wards, medical hospitals, jail, homeless shelters, and being on the street. His parents are deceased and he is not in contact with the rest of his family. Legal history includes 42 misdemeanors in less than 15  years, violent crimes, and gang involvement. During his hospital stays, he is intimidating, volatile, and demanding. He is focused primarily on receiving opioids for reported chronic pain and benzodiazepines, including upon discharge. He will refuse medical care if these demands are not met. He will refuse diabetic diet and intermittently refuse insulin, essentially holding himself hostage against staff. He admits to throwing away his medications upon discharge. He is minimally receptive to teaching regarding his DM.  He will be verbally aggressive and intimidating with staff and peers. He will attempt to split staff and become defensive when confronted about this behavior. He has had to be escorted out of the hospital upon discharge by police multiple times. Deceptive behavior is very clear in this case. Staff overheard him discussing how much money he can get for a bottle of Oxycontin. In one instance, a bottle of opioids did go missing from the medication room. After it was retrieved, he demanded to be discharged, saying he had his own way of getting Oxycontin. In another instance, he presented com-

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plaining of auditory hallucinations. Once he was admitted, he found out that his Medicaid was still active. He reported that he had presented because he thought it had been inactivated, denied auditory hallucinations, and requested discharge. During a medical admission, psychiatry was consulted as he was asking to be admitted to the psychiatric hospital. He said he was suicidal, had scratched his left arm superficially, and also reported lying down in front of a parked car. Upon evaluation by the psychiatry attending, he could not voice how a psychiatric admission might help him, expressing largely that he wanted medications for his pain. He lacked insight into his addiction as well as his manipulative behavior. The consulting psychiatrist assessed that he was not psychotic and was clearly manipulative in setting of his antisocial ­personality disorder and substance use. Psychiatric admission would hold no therapeutic value. He was discharged from the medical unit and has not been seen in our medical or psychiatric hospital since then.

Case 5: Carla Carla is a 61-year-old transgender female with major depression with psychotic symptoms, panic attacks, benzodiazepine use disorder, borderline personality disorder, and significant cardiac history. She has been psychiatrically hospitalized twice and reports one other psychiatric hospitalization at age 18 in setting of suicidality. However, she would not give consent for a medical records search to confirm this information and was resistant to providing collateral contact. Much of her history is unclear as she has not been forthcoming throughout her admissions. Carla initially presented to the emergency department during her first admission endorsing active suicidal ideation with plan to jump into traffic in setting of recent death of her wife. She reported that her wife had intellectual disability and Carla was her primary caretaker. She initially denied any

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psychotic symptoms but endorsed intent and plan to kill herself. Carla was adopted as an infant into a family that was involved in organized crime. She witnessed domestic violence growing up. She dropped out of high school in 11th grade and has a limited work history. She is not in touch with her family. She denied addiction to substances but endorsed physical dependence on benzodiazepines. Medical history was relevant for significant cardiac issues; however, Carla has not been adherent to her treatment, including medications and recommended follow-up testing and other interventions. Throughout her admissions, Carla was noted to be help rejecting. She was isolative and would not participate in therapeutic activities and had limited engagement during psychiatric interview. Hygiene was notably very poor. She was also making sexual comments to other women about their appearance. She was hypervigilant and suspicious with the treatment team; she expressed not remembering basic aspects of her life. At one point during the first admission, treatment team found out that her wife was still alive. Furthermore, Carla had been a perpetrator of domestic physical violence, requiring an order of protection. When she was confronted about this, she became very defensive, reporting suicidal ideation in a more threatening manner, saying the hospital would be sued if she were to be discharged and then “do something” to herself or someone else. Within a month of being discharged during her first hospitalization, she presented to the emergency department again, endorsing suicidal ideation, this time with command auditory hallucinations to harm herself. This led to a protracted psychiatric admission lasting 3 months, during which time she intermittently endorsed suicidal ideation with command auditory hallucinations directing her to engage in self-harm. She would also agree to cardiac workup and then refuse at the last minute. Many of her complaints sounded rehearsed and did not fit with her mental status exam or staff observation of her day-to-day functioning. Although she was endorsing psy-

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chotic symptoms, her behavior was organized; although she endorsed poor appetite, she was notably eating double portions. She made multiple attempts to sabotage her discharge during both of her inpatient hospitalizations.  She was ultimately discharged, but subsequently presented to the emergency department endorsing suicidal ideation twice more, and was deemed not for admission both times. She has presented to the emergency department a few times since for chest pain, but was not always compliant with medical care, including blood draws; she has not been admitted for medical hospitalization during any of these visits.

Discussion Of the three cases of patients diagnosed with ASPD, notably, only Johnny’s last treatment plan (out of 24 initial and follow­up treatment plans in the electronic medical record) contains the words “antisocial personality disorder.” Treatment focus is specifically on reducing aggression in that instance. Previous treatment plans utilize diagnosis of “intermittent explosive disorder.” Neither David’s nor Leon’s treatment plans mention ASPD, although Leon’s last treatment plan discusses antisocial behavior, manipulation, aggression, and identity issues as being barriers to care. None of Carla’s treatment plans contain the words “borderline personality disorder” or “unspecified personality disorder,” despite the latter diagnosis appearing in the psychiatry resident’s notes within a week of her first admission. Only Lisa’s treatment plans contain “borderline personality disorder” as a diagnosis with specific treatment focus and interventions. This may be understandable for multiple reasons. Personality disorders are not billable inpatient diagnoses. Furthermore, if their purpose is to track progress toward discharge from inpatient hospitalization, the thought may be that personality disorders are unlikely to change over a period of weeks.

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There are a few counterpoints to these lines of reasoning. First, although personality disorders are non-billable, based on the five cases discussed here, certainly their existence in these five patients contributed to their presentation to the hospital, and the degree to which they received care. In David’s case, his ASPD was a major contributing factor in his death. His compulsive antisocial behavior precluded him from completing rehab successfully or staying with one outpatient clinic where he could have consistent treatment. It kept him from having protective factors in his life such as stable housing or stable relationships and this ultimately led to his overdose. Finally, awareness of these personality factors by the entire treatment team would affect our interactions with these patients. The so-called intervention may be on our part, rather than the patient’s. Improved awareness of the challenge these patients represent may help clinicians remain in theraputic role. Recognizing the function deception may play for a vulnerable patient in maintaining asense of control and identity may help a clinician both avoid being duped, and mitigate the reflex to withdraw. Clinicians who learn to recognize their own frustration as an indicator of deception may be better able to build a more-complete assessment, leading in turn to better allocation of resources and improved patient care.

References 1. Andreasen N. DSM and the death of phenomenology in America: an example of unintended consequences. Schizophrenia Bulletin. 2007;33(1):108–12. 2. Croqc MA. Milestones in the history of personality disorders. Dialogues in Clinical Neuroscience. 2013;15:147–53. 3. Freud A. The ego and the mechanisms of defense. London: Hogarth Press; 1948. 4. Freud S. Studies in Hysteria. New York: W W Norton & Co.; 1895, 1964. 5. Freud S. Mourning and Melancholia. New York: W W Norton & Co.; 1917, 1964. 6. Gunderson. Borderline Personality Disorder: Ontogeny of a Diagnosis. Am J Psychiatry. 2009;166(5): 530–39.

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7. Insel T, Cuthbert B. Research Domain Criteria (RDoC): Toward a New Classification Framework for Research on Mental Disorders. Am J Psychiatry. 2010;167:7. 8. Jones D. Moral insanity and psychological disorder: the hybrid roots of psychiatry. History of Psychiatry. 2017;28(3):263–79. 9. Kapur S. Psychosis as a state of aberrant salience: A framework linking biology, henomenology,and Pharmacology in Schizophrenia. Am J Psychiatry 2003;160:13–23. 10. Kernberg. Borderline personality organization. Journal of the American psychoanalytic association. 1967;15:641. 11. Klein M. Notes on some schizoid defense mechanisms. International Journal of Psychoanalysis. 1948;27:8–21. 12. Lenzenweger M.F, Clarkin J.F, Caligor E, Cain N.M, & Kernberg O.F. Malignant narcissism in relation to clinical change in borderline personality disorder: An exploratory study. Psychopathology. 2018;51:318–25. 13. McMain S et. al. A Randomized Trial of Dialectical Behavior Therapy Versus General Psychiatric Management for Borderline Personality Disorder. Am J Psychiatry. 2009;166:1365–74. 14. Pankskepp. Affective neuroscience of the emotional BrainMind: Evolutionary perspectives and implications for understanding depression. Dialogues in Clinical Neuroscience. 2010;12(4). 15. Rosenfeld H. A clinical approach to the psychoanalytic theory of the life and death instincts: An investigation into the aggressive aspects of narcissism. International Journal of Psychoanalysis. 1971;52:169. 16. Rosenthal R. The pathological gambler’s system for self-deception. Journal of Gambling Behavior. 1986;2(2):108–21. 17. Shenhav A, Botvinick M, Cohen J. The expected value of control: An integrative theory of anterior cingulate cortex function. Neuron. 2013;79(2):217–40. 18. Solms M. The Conscious Id. Neuropsychoanalysis. 2013; 15(1):5–19. 19. Stern A. Psychoan alytic investigation and therapy in the border line group of neuroses. Psychoanalytic Quarterly. 1938;7(4): 467–89. 20. Yeomans F, Clarkin J, Kernberg O. A Primer of Transferencefocused Psychotherapy for the Borderline Patient. New York: Jason Aronson; 2002.

Part III

Assessing DND in a “Gated” Simulated Patient

Chapter 10 “Biggie” Assessing a Deceptive Patient in a “Gated” Simulated Patient Interview Introduction How does one teach a psychiatric interview? Is it an “art” that lies beyond the range of pedagogy, or can it be broken into component parts, and taught as a set of skills? Is it possible to reliably assess a clinician’s capacity to conduct an interview? How relevant are relational and emotional “human factors” to the interview process? How relevant are any of these considerations to the conduct of psychiatric assessment in contemporary practice? In the following discussion, we will argue that simulated clinical exercises offer a hands-on didactic method which affords an opportunity to consolidate knowledge, and afford opportunity to assess teaching effectiveness and achievement of educational goals. One of the challenges in designing a simulated scenario, however, is determining what to measure, and how to measure it. This is particularly true in the case of psychiatric practice.

A Simplified Process Clinicians-in-training are typically taught a simplified process: a symptom history is elicited from the patient and collaterals, a cursory mental status examination records whether © Springer Nature Switzerland AG 2020 A. Lerman, The Non-Disclosing Patient, https://doi.org/10.1007/978-3-030-48614-3_10

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the patient is hallucinating or not, and the patient is asked if he is considering suicide. Often the patient or clinician is required to complete additional rating scales focused on symptom severity and behavioral risk. The resulting information is matched with more or less precision to the syndromal categories in the current Diagnostic Statistical Manual (DSM) or International Classification of Diseases (ICD) compilations, and a range of treatment protocols.

Good Patients/Bad Patients Some patients are notably accommodating in their willingness to provide information, and organize their account in a form that lies very close to the clinician’s format—for example, onset and quality of symptoms, precipitating and alleviating factors, and previous history—and so could be said to interview themselves. Clinicians tend to refer to such patients as “good historians.” Other patients present formidable barriers in the form of insight, self-awareness, and other variables which impinge on both a patient’s capacity and willingness to participate in an interview and tend to be identified as “poor” or “unreliable” historians. Another class of patients are those who demand attention from, and display intense emotional feelings toward, the clinicians treating them. Irrespective of the quality of the history they provide, members of this third class are typically referred to as “borderline,” and most clinicians are trained to maintain such patients at an appropriate professional distance.

Different Challenges All these types of interview subjects present challenges. The difficulties encountered with an overtly “difficult” patient are obvious and are frequently met with a decision to terminate treatment, or obtain information by other means. But even the “easy” patient, on further examination, may not be so easy. The patient may be attempting to please the interviewer

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with an overly simplified account, or may have learned from experience that a clinical interview consists of a battery of standardized questions which a reasonably intelligent patient quickly learns to anticipate, and to avoid answering questions in a fashion that prompts undue, similarly predictable follow­up questions, for example, regarding alcohol consumption or episodes of suicidal ideation.

Higher Goals for Interview Clearly, there can and should be more to a psychiatric interview than this. A skilled clinician endeavors to gain a subject’s confidence and elicit a history from the subject’s point of view. This received history is then subjected to a process of assessment as the interview unfolds. It is the object of a series of interventions by the interviewer to deepen both the detail and affective tone of the narrative, clarify what is unclear, and explore omissions and limitations in the subjects account. This process itself stimulates a range of patient experience and behavior, which represent powerful mental status findings. Elsewhere in this volume, we have schematized this process as the rubric of a “Stratified Listening” consisting of the patients subjective narrative, omissions, and distortions within that narrative, and assessment of the psychological and psychopathological factors that lead to such distortions (Table 10.1). Table 10.1  Stratified listening Level I: The patient’s subjective narrative Level II:

Emotional valence

Level III:

Omissions and distortions in the patient narrative

Level IV:

The patient narrative as assembled in the clinician’s observing mind, guided by knowledge of psychopathology, and scrutiny of the discrepancy between levels I and II

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Table 10.2  Four principles of engaging DND I: The clinician can only listen effectively when guided by a developing clinical formulation (i.e., level III of the stratified interview). II:

A clinician’s emotional or “countertransference” response is the most sensitive indicator of unassessed DND in the clinical formulation.

III:

The “why” driving DND is almost always more important than the “what” that is being concealed.

VI:

Emotion is a better guide than logic during the interview.

We have developed a similarly simplified rubric for engaging patient Deceit and Non-Disclosure (DND): Some clinicians, including talented early-career trainees, grasp this intuitively and demonstrate an ability to use even brief encounters with patients to build trust and hope, to gain a sense of a patient’s current situation in relation to longitudinal history, and to both listen to a patient’s account and assess it as psychopathological data. Other clinicians appear to have far more difficulty with the interview process (Table 10.2). It seems that interview ability reflects in part a matter of aptitude distributed across a normal curve, like singing or the ability to catch a ball, which some are fortunate enough and others less so. But while one may be sanguine about the prospect of a mental health clinician who can’t catch a ball, we should not be so with regard to the capacity to conduct an interview. Is there a way to identify less naturally talented interviewers, identify and remediate weaknesses, and improve their interview skills?

Role of Simulated Scenario—Positive Reports One potential response to this problem is the use of simulated patients and standardized clinical scenarios. A small but evolving literature on simulated patient interviews reflects a growing interest in the use of standardized patients in medi-

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cal education and assessment. Subodh (2012), Pheister (2015), and Attoe (2016), each reported the usefulness of simulated patient exercises in enhancing basic health care skills, such as communication, collaborative work, and development of a therapeutic alliance. A study by Rimondini (2010) demonstrated the positive impact of a brief training protocol on specific parameters, such as use of reflective and clarifying questions, and inquiry about the patient’s emotional state. Each of these studies appears to involve relatively brief, narrowly focused simulation exercises.

 autionary Views of Simulated Patient (SP) C Exercises McNaughton (2008) reviewed controversy about the validity of simulated patient encounters, including concerns regarding performance variability in the portrayal of affect, response to open-ended questions, the capacity of actors to portray emotional problems they have not personally experienced, and inadequate realism in the actor–learner encounter. Brenner (2009) warns that while simulated patient exercises can be effective “in the assessment of discrete, operationalized skills and behaviors, such as whether or not an examinee asked about a specific symptom… Encounters with (actual) psychiatric patients…require subtle empathic skills and the capacity to discern nuanced levels of veracity and self-deception in the patient’s presentation. The ‘suspension of disbelief’ that is necessary for successful performance with an SP is not clearly analogous to the skills required of a psychiatrist.”

WMC SP Scenario Goals The scenarios developed in recent years in the Department of Psychiatry at Westchester Medical Center (WMC), by contrast, are designed to replicate the challenges of psychiatric practice by placing trainees into ambiguous clinical scenarios

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which replicate challenges found in clinical practice. This almost always involves placing the interviewer in an encounter with a subject who, for one reason or another, is either unwilling or incapable of giving a complete account of their situation. The interviewer is then challenged to develop a clinical formulation and engage the patient accordingly.

The “Biggie” Scenario  evelopment of the WMC Simulated Patient D Program In the design of the simulation at our program institution (Lerman A) undertook to engage such concerns through the construction of realistic scenarios with a subject who displays a range of verbal or non-verbal behavior, including evasion at different points during the interview, each of which represents a specific checkpoint or “gate” at which the progress of the interviewer can be observed. Issues of verisimilitude are addressed by use of professional actors trained in patient simulation, and the use of scripts that include complex background stories and discussion of the SP’s motivational state, along with specific instructions on how to behave at key moments, for example, when confronted by the interviewer, or when the interviewer fails to confront the subject. Certain challenges within the interview can be standardized (Table 10.3). Table 10.3  Deception/nondisclosure behavior in the “Biggie” interview scenario Malingered psychotic symptoms Denial of despair and fear related to current life circumstances Denial of previous psychiatric history Suppression of affect regarding catastrophic childhood life event

Method

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The “Biggie” scenario was designed to serve as a teaching tool focused on the interpersonal dimensions of the interview encounter, particularly the capacity to • • • •

Cultivate a therapeutic relationship. Establish that the patient is withholding information. Understand why the patient might be doing so. Intervene clinically and offer hope.

Interviewers were assessed not only with regard to basic interviewing skills, but on the parameters of “subtle empathic skills” and “the capacity to discern nuanced levels of veracity and self-deception” Brenner cited with concern.

Method Scenario Design Each of 17 residents participated in the following simulated case scenario involving a malingering patient suffering from a concurrent major depressive disorder in a setting of multiple developmental trauma. “Biggie” is a 19-year-old, a gregarious, street-smart, homeless man who presents to the Emergency Department with a report of new-­ onset command auditory hallucinations and suicidal ideation, a facial bruise of recent origin, and no other mental status findings consistent with a psychotic mental state. An ED “triage note” was made available prior to the interview indicating that the patient was in possession of a kitchen knife, several “dime bags” of marijuana and packs of cigarettes. A hospital discharge note dated eight years previously, indicates that the patient was hospitalized for suicidal behavior and hallucinations at age 11, shortly after the death of his grandmother and his placement in institutional care. (See Appendix III for the comprehensive scenario script)

Interviewers were instructed to conduct a brief ED assessment. As detailed in Appendix III, a range of detailed historical material provided for the actor in the interview script, much of it unlikely to be elicited directly during the interview,

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including the patient’s abandonment by his mother in early childhood; loss of his home after the death of his ­grandmother; history of physical and sexual abuse while in residential care; and subsequent episodic prostitution. The actor portraying the patient enjoyed wide latitude regarding his dialogue on a moment-to-moment basis, but was instructed to (a) deny any prior history of psychiatric assessment or treatment; (b) respond to inquiries about his facial bruise by bragging about fighting off local gang members who attempted to rob him and subsequently threatened to bring a handgun to their next encounter; (c) minimize emotional distress of any kind until or unless the death of his grandmother was mentioned, at which point he was to become withdrawn and visibly distressed and then ask to change the subject; and (d) minimize and deny chronic feelings of hopelessness and desperation. Each of these points was designed to serve as demarcated checkpoint or “gate” at which the interviewer’s performance could be observed. Interviewers were instructed that they had 15 min to assess the patient and make a determination about whether the patient should be admitted. No further instruction or goals for the interview were provided.

Actors and Interview Setting “Biggie” was portrayed by two different professional actors with extensive experience in case simulation, who were provided with detailed scripting information indicating how to behave during the interview, as well as background information about the character. Interviews were conducted and videotaped in the NYMC Simulation Center. Both actors appeared to adhere closely to the script, although this was not formally assessed. Verisimilitude was not formally assessed, but numerous members of the interview cohort commented on the extraordinary realism of the actor’s performance.

Method

161

Interview Cohort All 17 interviewers were residents in the Westchester Medical Center/New York Medical College psychiatry residency program. Six interviewers were US born. All were fluent in English. Five interviewers were in the second year of residency (PGY-2s), eight were PGY-3s, and four were PGY-4s.

Measures Interviews were rated in a non-blinded fashion by two different raters using a 26-item scale of 5-point Likert ratings, which assessed conduct of the interview and engagement of gated interview targets. Likert ratings gauged the frequency of interviewers use of specified techniques, where 1 = never, 2 = rarely, 3 = sometimes, 4 = most of the time, and 5 = all of the time. A score of 3.5 or above was considered indicative of competency in the scored domain. Wording was occasionally shifted to match the tense and vocabulary of the given ­questions. Interview targets found to be highly correlated (e.g., inquiring about the patient’s facial bruise and establishing that the patient is homeless) were aggregated into composite values to simplify data analysis (Table 10.4). Table 10.4  Composite values in caps, see Appendix I for definitions Basic interviewing  Establishes basic facts of patient’s stated problem  Asks about facial bruise  Balanced use of open/closed questions  Redirects when necessary  Obtains past psychiatric history  Asks about substance abuse  Natural conversational style

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Table 10.4 (continued) Confrontation and identification of discrepant facts  Identifies contradiction  Clarification  Follows up “hints”  Confronts distortion/nondisclosure Empathy and rapport  Rapport  Exudes “warmth”  Offers hope  Responds to affect and non-verbal cues  Responds to breakthrough affect when discussing death of grandmother Other assessment values Resident performance on the overall psychiatry domain in the Psychiatry Resident-in-Training Examination (PRITE). Year in training. Review of clinical skills verification (CSV) when available.

Results Most interviewers performed well in the tasks of eliciting and aggregating factual information which comprise the “Basic Interviewing” domain; and significantly less-well in engaging discrepancies and in setting or responding to the emotional tone of the encounter. As can be seen in Table 10.5, the interview cohort achieved a mean score of 3.9 (SD = 0.5) out of a maximum of 5.0 (clinical competence associated with a score of 3.5 or higher). Mean scores in other domains were lower (1.9 − 2.8), with a

Results

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Table 10.5 Average interview competency scores (maximum score = 5.0; ≥3.5 indicative of competency) Mean score SD Basic interviewing 3.9 0.5 Confrontation/ID

2.8

1.2

Empathy/relatedness

2.5

1.7

Engage affect

1.9

1.3

wider variation in level of individual performance (SD = 1.2 – 1.7). The wide standard deviation of this second set of values reflects the wide variation in “higher level” interview performance.

Covariance of Interviewing Competencies The authors hypothesized that cohort performance in the “higher level” domains would aggregate into cohorts that were either “softer” (i.e., more receptive to the patient’s emotional state) or “harder” (i.e., more likely to engage in critical analysis and potentially adversarial confrontation of the patient’s deceptive behavior). Unexpectedly, the authors found that interviewers who were rated as more effective in identifying and confronting discrepancies were also more likely to elicit affect and develop a trusting relationship with the patient during the encounter. As noted in Table  10.6, a bivariate correlational analysis found a strong, highly significant positive correlation between Empathy/Relatedness scores and Confronting Nondisclosure scores (r(16) = 0.640, p   0.05) (Table 10.6). The mean PRITE Psychiatry Global Score for this cohort was 458. There was no statistically significant correlation between PRITE scores and any other scoring category, that is, Basic Interviewing (r(16)  =  0.022, p  >  0.05), Empathy/ Relatedness (r(16)  =  −0.129, p  >  0.05), Confronting Nondisclosure (r(16)  =  −0.009), or Breakthrough Affect (r(16)  =  0.092) (Table  10.6). This also confirms the authors’ hypothesis that PRITE performance exam would not predict performance on the simulated interview sessions. Notably, there was no significant association between interview performance and training year (see Appendix II for an exhaustive assessment), or International Medical Graduate (IMG) status. Clinical skills verification (CSV) assessment was complicated by the non-standardized nature of the patients, the number of different raters, and the fact that many junior residents had yet to complete a CSV. Informally, many residents with significant weaknesses on higher-level interview performance received excellent CSV scores. Chronbach’s alpha found high inter-item reliability of 5-point Likert scores across all 26 survey questions included in this analysis (α = 0.861).

Discussion The findings of this study are notable for the clarity and power with which they suggest that many trainees overemphasized data collection, and tend to underemphasize or ignore interpersonal, emotional, and non-verbal aspects of

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the interview process. A small cadre of more-capable residents exhibited superior performance in higher-order interviewing domains (i.e., confrontation, empathy, and warmth), but the majority did not. Potential factors favoring this tendency may include the high pressure and documentation-­ focused environment in which most training experiences occur, training in psychopathology that focusses on syndromal templates, and trainee anxiety in a simulated encounter that, although repeatedly described as a training exercise, is invariably perceived as a “test.” A number of traditional assessment measures were notable for their lack of predictive power with regard to “gated” interview performance, including (a) in-service testing, (b) clinical skills verification (CSV), (c) IMG status, and (d) year in training. With regard to the CSV examination (subject to the limitations noted above) this finding is unsurprising, given that the CSV interview is roughly equivalent to the “Basic Interviewing” component in the gated assessment. Similarly, the PRITE represents a fact-based examination with little reference to interpersonal perceptual or communication skills. Cross-cultural or other potential issues related to IMG status might be hypothesized to predict barriers to higher level interview performance, but are likely obscured by the rigorous nature of the selection process. The lack of association between gated interview performance and training year was unexpected and troubling. This finding raises a question of whether the residency program suffered from a previously undetected deficit in interviewing instruction at the time this study was performed. Even the most-capable residents tended not to pursue emotional material, most notably when an otherwise-superior interviewer immediately desisted from asking the simulated patient about a charged subject, after the patient requested he do so. One striking exception occurred in the case of a resident from a violent and underprivileged background, who immediately perceive the simulated patient’s distress and established a caring and engaged relationship.

Conclusion

167

Conclusion This pilot program represents an effort to render what is often considered the “art” of psychiatric interviewing into discrete competencies which can be defined, measured, and taught. Our finding that a variety of disparate skills covary in small population, independent of training level, suggests that advanced interviewing ability reflects an underlying capacity for interpersonal perception and engagement, perhaps more succinctly defined as “talent,” which some interviewers possess and others do not. If valid, our finding that “non-­ talented” residents tend neither to be identified nor correctively engaged is a subject for concern and further study. It may be argued that advances in modern psychiatry render interviewing skills unnecessary and irrelevant. Our findings in this modest study indicate that the opposite is the case; that is, that key traits and skills (e.g., sensitivity and use of confrontation) predict capacity to establish a therapeutic patient–provider relationship, which in turn predicted candor and emotional engagement on the part of the simulated patient. One could hypothesize that this would, in turn, result in better treatment outcomes; however, treatment outcomes were not assessed in this study. We hope to correlate gated interview performance with this and other measures of clinical effectiveness in the future. The “gated” design of the otherwise non-structured interview affords an opportunity to assess higher-order skills in a quantitative fashion, and to track the effectiveness of training. Above all we see this assessment technique as a training tool which helps identify and support the strengths of some residents, and supplement deficient skills or traits in other residents. A notable aspect of the simulated interview exercise was the anxiety that many residents experienced while participating in it. The possibility that this negatively affected the capacity of residents to engage with the simulated patients requires further assessment. We consider the use an interview

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of this kind as a proficiency exam as ill-advised, and likely to exclude opportunities for learning and growth. Other significant limitations attending the present study include its limited size, brevity of the interview, and the evolving nature and rudimentary validation of the assessment parameters. On the other hand, the data presented here are consistent with informal qualitative assessment. We expect a wider body of data, across multiple SP encounters, to afford a better opportunity to assess both the reliability of our results and their relevance to other training performance observations.

Appendix I Definitions of Selected Terms Therapeutic Relationship A relationship between clinician and patient characterized by a commitment to understand and help on the clinician’s part; confidence on the in the clinician’s capacity to do this on the patient’s part, and governed by an deepening sense of shared purpose as the relationship evolves.

Response to Breakthrough Affect Positive rating: Behavior on the part of the interviewer in response to the subject’s emotional display, including direct commentary on patient’s emotional state and changes in the direction of questioning, which prioritizes observation and response to the subject’s emotional state over factual content of the material. Represents modification of the interview in response to “empathy” • For example, “you seem sad when you say that.” • “You’re crying – where are your tears coming from?” • “You’re saying your dad died – but you’re smiling a little when you say that.”

Appendix I Definitions of Selected Terms

169

Negative rating: Behavior on the part of the interviewer that reflects lack of interest or obliviousness to patient’s emotional display. • For example, patient becomes despondent and states “that’s my life” in a forlorn tone of voice → interviewer responds with a question about domicile status.

Rapport An ability to develop a deepening relationship with the patient, as manifest by increased elaboration of data, shared understanding, humor or other evidence of shared and mutual experience, over the course of the interview. Positive case: • Interviewer reuses the terms by which the patient describes their experience, and conveys a grasp of the patient’s material that makes it clear that the interviewer is listening. • Interviewer displays evidence of collaboration in eliciting patient’s narrative. • Patient appears to enjoy or gain satisfaction from the interaction, and shows a desire to share further information.

Empathy Direct or indirect acknowledgment of patient’s emotional state, including the interviewer’s statements, modification of the interview, or “affective mirroring,” including changes of vocal tone and pitch by interviewer. Positive case: Interviewer aware of and sensitive to patient’s emotional state, as evidenced by • “Affect matching”—for example, changes in interviewer’s tone of voice, posture, facial expression, in response to patients’ inferred emotional state (e.g., sadness, humor, and anxiety).

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• Modification in interview style—for example, slowing down or decreasing specificity of questioning, asking patient if it is ok to continue. • Questions or comments that show interest and concern about the patient’s emotional state. –– “That must have been hard for you.” –– “I can see this isn’t easy for you to talk about – but it would really help me understand if you can answer a few more questions.”

Negative Case Examples • Interviewer seems bored and pursues an interview template. • Subject is obviously upset, interviewer pursues specific details of the incident without modification or apparent awareness of the patient’s distress. • Subject discusses sensitive material showing no emotion, interviewer records factual data but doesn’t attempt to elicit information about the patient’s emotional state.

Confrontation Positive case: Presentation to the subject by the interviewer of comments, observations, or information (known/unknown to subject prior to that point) which significantly modifies or contradicts a patient’s account (does not necessarily imply an emotionally heated or aggressive tone). • “You said that you took about 8 pills in the overdose, but the record says you took 68.” • “You say you and your daughter have a close relationship, but you sound pretty angry at her.” • “You say things are great, but I understand everyone in your family is pretty worried about you.”

Appendix I Definitions of Selected Terms

171

Negative case: Interviewer fails to pursue contradictions during the interview. • Patient states he never saw a psychiatrist. Interviewer has record of prior admission but doesn’t comment. • Patient with history of repeated aggressive behavior states he was “just minding his own business” when someone else assaulted him → interviewer does not respond. • Clarification/follows up hints: Pursuit of details and resolution of miscommunications or points of misunderstanding between the interviewer and subject. • “How old were you when that happened?” • “I thought you were discharged yesterday, but now it sounds like you’re talking about something that happened two months ago.” • “Can you tell me more about that?” Negative case: Interviewer passively takes down subject’s account with no attempt to sharpen understanding. • Persistent clarification: Pursuit of relevant details in the face of sustained (>2) acts of evasion or non-clarity on the part of the patient. • Warmth: Positive case: Conveys kindness, concern, and a sense of genuine personal interest in the patient’s well-being. • Often a non-verbal quality, conveyed through empathetic vocal tone, timing of questions. • Verbal or non-verbal disclosure of actual personal feelings (or at times information). • Frequently reflected in feedback that validates subjects’ emotions or experience. Negative case: Interviewer is overly formal, nervous, self-­ satisfied, appears to judge patient or not be interested. Sympathetic framing: Re-statement of patients’ distressed or self-denigrating comments in a fashion that suggests compassion or respect on the part of the interviewer, and dignity on the part of the patient.

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Natural Conversational Style Patterns of speech that by tone, pitch, pacing, avoidance of technical terms and responsiveness to the other participant, invite an experience of unselfconscious engagement with the interviewer. Avoidance of “template” questioning or distancing commentary (e.g., “I’m sorry, but I have to ask you whether…”).

Hope “Affirmative comments which directly or indirectly convey a sense that the patient is capable of growth or positive change.”

Appendix II: Correlation by Training Year Mean Performance Scores by Training Year Empathy & relatedness mean Training 2 18.40 year

Basic interviewing mean 33.0

Confronting non-disclosure Breakthrough PRITE mean affect mean score mean 3.00 2.20 495

3 18.00

31.4

2.81

1.81

455

4 14.88

32.8

2.63

1.50

419

Equal variances not assumed

0.511

0.646

0.810 10.119 0.437

Equal variances 3.229 0.100 0.680 11 assumed

Equal variances not assumed

0.799

0.260 8.508 0.801

Breakthrough Equal variances 1.469 0.251 0.472 11 affect assumed

Basic interviewing

Equal variances not assumed

0.879 0.261 11

0.38750

1.5625

1.5625

0.18750

0.18750

0.40000

0.82019

1.9292

2.2979

0.72171

0.71842

3.22728

t-test for equality of means Sig. Mean Std. error (2-tailed) difference difference 0.905 0.40000 3.28031

0.124 9.089 0.904

F Sig. t df Equal variances 0.002 0.963 0.122 11 assumed

Confronting Equal variances 024 non-disclosure assumed

Empathy & relatedness

Second Training Year Versus Third Training Year Levene’s test for equality of variances Upper 7.61992 7.68978 1.76872 1.83462 6.6201 5.8542 2.19273

Lower −6.81992 −6.88978 −1.39372 −1.45962 −3.4951 −2.7292 −1.41773

95% confidence interval of the difference

Appendix II: Correlation by Training Year 173

df

Equal variances not assumed

0.634 6.768 0.547

0.509

0.446 7.153 0.669

t

Equal variances 0.929 0.356 0.682 11 assumed

Sig.

Confronting Equal variances non-disclosure assumed

Equal variances not assumed

0.023 0.884 0.442 7

0.672

0.995 6.791 0.354

62.297

57.879

0.86817

0.37500

3.52500

0.84805

3.54386

t-test for equality of means Mean Std. error difference difference 3.52500 3.58019

39.475

39.475

0.38750

166.866 187.813

−87.916 −108.863

Upper 11.99081 11.95759 2.38033

Lower −4.94081 −4.90759 −1.63033

96% confidence interval of the difference

2.43156

−1.65656

t-test for equality 95% confidence interval of means of the difference Sig. Mean Std. error (2-tailed) difference difference Lower Upper

Second Training Year Versus Fourth Training Year Levene’s test for equality of variances Sig. F Sig. t df (2-tailed) Empathy & Equal variances 0.109 0.751 0.985 7 0.358 relatedness assumed

PRITE score

Equal variances not assumed

F

Levene’s test for equality of variances

174 Chapter 10.  “Biggie” Assessing a Deceptive Patient…

Equal variances not assumed

Equal variances assumed

Equal variances not assumed

PRITE score Equal variances assumed

Equal variances not assumed

Breakthrough Equal variances affect assumed

Basic interviewing

Equal variances not assumed 0.875

0.482

0.312

1.153 6.703 0.289

2.130 0.188 1.090 7

0.788 6.658 0.458

6.256 0.041 0.743 7

0.158 5.639 0.880

0.119 0.740 0.163 7

0.443 6.628 0.672

75.350

75.350

0.70000

0.70000

0.2500

0.2500

0.37500

65.377

69.154

0.88882

0.94188

1.5851

1.5370

0.84595

2.39835 3.8845 4.1895 2.92720 2.82379 238.872 231.341

−1.64835 −3.3845 −3.6895 −1.52720 −1.42379 −88.172 −80.641

Appendix II: Correlation by Training Year 175

Basic interviewing

Equal variances not assumed

−1.3125

−0.613 9.784 0.554

0.18750

0.18750

−1.3125

6.105 0.815

0.812

3.12500

2.1411

2.6158

0.76583

0.76623

3.28699

t-test for equality of means Mean Std. error difference difference 3.12500 3.46512

0.627

0.245

Equal variances 1.856 0.203 −0.502 10 assumed

Equal variances not assumed

10

7.011 0.373

0.951

Equal variances not assumed

Sig. (2-tailed) 0.388

df 10

F Sig. t Equal variances 0.059 0.812 0.902 assumed

Confronting Equal variances 0.000 1.000 0.245 non-disclosure assumed

Empathy & relatedness

Levene’s test for equality of variances

Third Training Year Versus Fourth Training Year

−6.0975

−7.1409

3.4725

4.5159

−1.67863 2.05363

−1.51977 1.89477

−4.64499 10.89499

Lower Upper −4.59576 10.84576

95% confidence interval of the difference

176 Chapter 10.  “Biggie” Assessing a Deceptive Patient…

Equal variances not assumed

PRITE score Equal variances 660 assumed

Equal variances not assumed

0.735

0.435 0.689

0.459

Breakthrough Equal variances 0.421 0.531 0.417 affect assumed

0.685

0.506

7.245 0.485

10

7.860 0.659

10

35.875

35.875

0.31250

0.31250

48.787

52.061

0.68098

0.74922

151.874 150.454

−80.124 −78.704

−1.26271 1.88771

−1.35686 1.98186

Appendix II: Correlation by Training Year 177

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Appendix: III—Biggie Scenario Documents Background Information for Standardized Patient Introduction A small-time hustler, Raquan Smith or “Biggie” has manufactured a false history of auditory hallucinations in order to get himself admitted to the hospital, after he fended off a group of juvenile gang bangers who tried to rob him, and now want to kill him, due to the humiliation they suffered at his hands when he fought them off. Unknown to himself, Biggie suffers from a pervasive compensated depression, post-traumatic hypervigilance, and psychosocial problems which have left him uneducated and homeless. He was raised by his grandmother, and suffered a catastrophic loss when she died when he was 9, which precipitated a suicide attempt and psychiatric hospitalization (see records below). In spite of these problems, and his intense underlying rage, there’s something irrepressible about Biggie—and he’s right when he says most people like him. He’s funny, extroverted, and despite his lack of education and potty mouth, highly observant and intelligent. But Biggie has also reaching a breaking point—he was sexually abused in residential, has been repeatedly robbed since he’s been living on the streets. He lives with a fair amount of self-directed hatred, but this is boiling and anger, leading to the circumstances that precipitated his fight with the kids who tried to rob him. A successful interview will at the very least raise questions about the genuineness of biggie psychotic symptoms, as well as expose his intense effort to survive against an interior backdrop of emotional pain and desperation.

Appendix: III—Biggie Scenario Documents

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Appearance + Behavior Biggie is a large, friendly, somewhat obese, tough-looking kid who is either a minority or “Wigger” (white kid who behaves like a street black kid). His cheerful, laid-back demeanor masks his vigilance. He’s very good at figuring out what other people want to hear. He’s grown up in a string of institutions, and generally gets along well with staff he trusts. He’s aware that a complaint of hallucinations and suicidal ideation will virtually guarantee that he will be hospitalized— he has seen this device used before. Biggie has a very large and recent bruise over his left eye and check, and crusted blood in his nose.

History of Present Illness “Hey what’s up? My name is—well everybody just calls me Biggie. People call you all kinds of shit—that doesn’t mean it’s real, am I right? I am what I believe I am, not what you believe I am—if you want to say that’s same for you, I don’t have a problem with that. I don’t go looking for problems with people. I don’t have problems with nobody. The thing is Doc, I’m hearing these voices, these shit-ass scary voices. They’re telling me I got to kill myself. Sometimes I get so loud, I feel like I’m good have to do it. How long has this been going on? It started about 2 or 3 weeks ago. Yeah, maybe I heard them before that, sometimes—but never this bad. What kind of voices? I don’t know exactly. I guess one of them is the scary old man. He just says “you gonna die” and “you better kill yourself” over and over again. And then there’s this other one, she’s like an old woman, and she just says “I hate you.” Most the time, I don’t pay no mind, when they get really loud and shit, sometimes I feel like I just got to do what they say and kill myself. (If asked about suicidal ideation) Did I ever actually think about killing myself? Yeah—just this morning, I was walking on McClean Avenue, you know

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the bridge where it goes over the throughway. And both of them started screaming at me, and I almost jumped over. That’s what as I know you guys can help me. I think I got a take medication or something. (If asked about other signs and symptoms of psychosis and schizophrenia, such as the notions of “thought broadcasting,” mind control, and somatic delusions) Biggie will essentially endorse as many symptoms as he can, as long as he thinks this will be credible and lead to his hospitalization. When asked to elaborate further, he will be vague, and say “it’s hard to explain… I just don’t feel right.” (If asked about drug use) No, weed just makes me bug out—I see weird shit. (Continues only if asked) I see my grandmother’s dead body, and shit. It just makes me bug out. I don’t do any other kinds of drugs. I don’t use no K2— they put turpentine in that shit, did you know that? I drink a beer now and then, but I’m not into any of that crap. (if asked about the bruise on his face) Huh? Oh that—that ain’t nothing. Some motherfuckers tried to rob me. (If asked for further details) Well, there was three of them—they think they fucking own my corner, and one of those niggers sucker-punched me, and they tried to get my cigarettes—that’s it. That’s all. (Biggie is avoiding revealing that he pulled a knife.) (If asked for further details) What do you want me to say, doc? You need me to explain it to you? They were fucking street niggers, that’s it—three of them. They’re gonna rob you if you let them. That’s it. I don’t let nobody do shit to me—I don’t care what they say they gonna do to me—cause the minute you let somebody do that to you—they own you. That’s it. No fucking way—that’s not me. (If interviewer expresses interest or respected how biggie was able to defend himself against three assailants, Biggie will relax, and enjoy telling a “war story”)

Appendix: III—Biggie Scenario Documents

181

Yeah, that shit-ass punk thought if he come up and tap me the fight would be over—but that fight was just starting, you feel me. He was like this (imitates blow) and I come back and get them right in the chest—I mean hard, so he went down. And then the other nigger is try to get my backpack, and I get them in the head right behind the ear (imitates blow), and they are still thinking there’s three of them against me—and I said “this is just getting started. You going to fuck with me, it gets real.” They say they’re going to come back with some fucking iron (i.e., gun) and do me—then bring it. Fuck that. Bring it. I just can’t take this shit any more. Gate: does interviewer follow up reference to “I just can’t take this shit any more”?

(If asked what he means by “I just can’t take this shit any more”) You know, people robbing you. Everybody try to get over on you, all the time, everybody is talking with you. Sometimes, sometimes you just say fuck it—you know what I mean? Gate: does interviewer follow-up veiled reference to suicide?

(If asked at this point about suicidal ideation) Yeah, sometimes I think about it. Yeah—there’s a lot of times I wish I was dead—but then I’m just like—yeah, fuck that—bring it. Bring it. You know what I mean? (Biggie is unaware at this point that he’s contradicting his stated complaint of command hallucinations inducing suicidal ideation. If confronted about this, he will immediately recover, and resume his original complaint that he is hallucinating and at risk of committing suicide.) (If asked, Biggie will now go on to describe pulling a knife—if specifically asked if this is what happened, in a sympathetic non-judgmental fashion)

Past Psychiatric History No, I’ve never seen a psychiatrist. I just live with those voices, on and off. They didn’t get real bad, until now.

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(If confronted with records of his psychiatric hospitalization at age 9) oh yeah… I forgot about that. That was right after—all kinds of shit happened. (If asked) you know, like my grandmother dying and all. I bugged out—that’s why didn’t remember. But then I went to residential, and a whole bunch of those components. I didn’t have no problems after that (eyes fill with tears). Forget it, I don’t want to talk about that shit. Gate  A more capable interviewer will note the flooding emotion on mention of grandmothers death and “follow the affect.” A highly skilled interviewer will back off if rebuffed, and return to the subject tactfully later. (If interviewer persists) There ain’t much to say. My grandma was the one who took care of me, and then she died, and I went into residential. That’s what happened—that’s it. (continues to fight back tears) I don’t want to talk about it. (If interviewer persists tactlessly) I said I didn’t want to talk about it, doc. Are you fucking deaf? Sexual History: I’ve never had what you call a full-time girlfriend. A little of this, a little that. You know what I mean. That’s about all I can handle right now. (Big is actually gay, but he would never reveal this)

Social History I’m 19 years old, and I live in South Yonkers—I don’t have an exact address, I tend to move around a lot. Sometimes they let me sleep in the basement of AME Church, sometimes I crash at other places—a little of this and a little of that. It doesn’t bother me. I’ve got friends everywhere—understand. I make a little money—I do some odd jobs here and there, and yeah I sell loosies (loose cigarettes)—you got a problem with that? Then don’t buy them from me, man. Weed? I don’t so no weed (he is lying) and I definitely don’t sell no other kinds of drugs—that just get you into trouble with all kinds of fuck-ass assholes, and gangs, and people try to rob you.

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I grew up in Yonkers (skips grandmothers death), and then I was in residential, and then all these crappy foster homes. That’s it. There’s nothing much to say. I got a GED last year, because the social worker said it would help me get a job—but it didn’t—in any way I don’t want no job. (Proudly) I’m a businessman. I sell loosies, lighters, you know—whatever people need.

Family History You want to know about my family? I think my father’s dead. I don’t exactly know. My mother? She’s doing a bid, you know what I mean? She’s in prison, way the fuck upstate. I don’t exactly know what for, and I don’t care what for. I got taken away from her when I was about 9 years old—and I don’t think she gave a shit, except for the check. She called me once, and she was like “where’s my money?” And I was like— shit, don’t you even want to try to pretend you’re my mother? I mean, fuck that—you know? I had an older brother, but I never did nothing with him. He was into gangs and shit, and he got shot, down on Locust Hill Avenue. There is a lot of fucked up shit that goes on down there—but there’s shit everywhere, you know what I mean? But none of that shit bothers me. It’s like what this guy at the residential told me—Mr. J—do you know him? He was all right—anyway, he said you don’t get to choose where you come from, but you do get to choose where you’re going. And I’m going to be a record producer. They let me DJ sometimes at club X, you know, down on McClean Avenue? That’s my future, all right? That’s where I’m going

Critical Information Items Biggie will not reveal under any circumstances: • The fact that he is lying about having auditory hallucinations (and pressing about this will only alienate him).

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• The fact that he is gay (this is a source of overwhelming shame and self-hatred). Items Biggie will not reveal spontaneously but will reveal if directly questioned in a sympathetic fashion: • The fact that he pulled a knife on his assailants. • The devastating impact on him of his grandmother’s death, and the subsequent desperate circumstances of his life history. • Episodes of profound depression and loneliness, which he is usually able to fight off. • The fact that he has at times considered suicide (although he will never reveal the underlying precipitant, that is, self-­ disgust regarding his own sexuality).

Chapter 11 Aggression in the Simulated Case Scenario: Karl Moehller A core thesis of this volume, laid out in Chap. 8, in the proposition is as follows: • An innate human need to share experience is frequently opposed by the need for autonomy and privacy. • Deception in its myriad forms serves to mediate a balance between these contrary principles. • When deception is detected and explored, nondisclosure and deception can serve as a powerful means to understand an individual’s motivation and other concerns. These principles assume that the patient or subject is motivated, to one degree by or another, notwithstanding often-­ powerful ambivalence, by a desire to be understood by the clinician, and to share a human experience (e.g., [2]). But what happens in the clinical encounter when the patient or subject does not wish to be understood? What happens when the subject’s goal is to control, manipulate, or even cause the clinician harm? As in the case of deception generally, we have found little or no literature on the subject. There are likely many reasons for this, ranging from the reluctance of clinicians to publish failure, the unique and heterogeneous nature of each case, and problems associated with attempting to publish treatment data of behaviorally unstable or potentially litigious patients (as has been a consideration in the preparation of this volume). Such literature as there is tends to be subsumed © Springer Nature Switzerland AG 2020 A. Lerman, The Non-Disclosing Patient, https://doi.org/10.1007/978-3-030-48614-3_11

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in the scanty discussion of “Malignant Narcissism” [1], and the vast and generally apsychological literature regarding “Antisocial Personality Disorder.” It is our observation, across a series of simulated patient interview encounters, that many early-career clinicians overrely on the patient narrative to orient themselves with regard to the task of organizing from the patient’s material into a narrative history. In a setting with a cooperative patient possessed of reasonable self-awareness and insight, this isn’t a problem. Overreliance on deceptive or psychologically incapacitated patients, on the other hand, quickly leads to confusion, often experienced by the interviewer as anxiety, boredom, or both. This in turn is often behaviorally manifest (as discussed in Chap. 5) in a range of anxiety-related behaviors such as “bobble heading,” queuing, and psychological withdrawal on the part of the interviewer. Many interviewers in such circumstances cease to attempt to engage the patient, and turn instead to collateral sources of information, and consideration of involuntary or somatic treatment in which the patient’s cooperation is not required. A patient who is determined to subvert and distort the evaluation process presents both technical and complex psychological challenges for any interviewer. This is particularly the case with regard to subversive evaluation subjects who attempt to conceal their subversive intent. All the regular conditions of the psychiatric interview are suspended. Instead of trust, there is mistrust. Instead of discourse, there is deceit. Instead of some process of mutual recognition moving to some degree of collaboration and trust, we have a battle of wills in which one party (the interviewer) may be unaware that a battle has begun. In the hands of an interviewer who is psychologically prepared for such an encounter, an obviously deceptive or aggressively controlling patient may be unpleasant to deal with; but the course of the interview may nonetheless serve as a rich mine of data regarding the patient’s psychological and motivational state. For a less experienced clinician, on the other hand, such an encounter may be disturbing and disrup-

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tive of professional identity and sense of confidence. This is particularly the case for individuals already struggling with social or professional anxiety—and how many beginners are? With these considerations in mind, members of the Westchester Medical Center (WMC) simulation team set out to design a scenario in which a trainee-interviewer would confront a superficially cooperative yet intimidating patient bent on subverting the interview. The “Karl Moehller” scenario presents a patient who is systematically lying to distort and conceal the facts of the charge of domestic violence that led to his evaluation in a psychiatric emergency room (ER). A successful executive, he deploys his professional rank and corporate fluency to intimidate the interviewer and control the course of the interview. At the same time, however, Karl is struggling to control expression of his rage and maintain a veneer of polite cooperativeness. A range of discrepancies provides clues to the nature of Karl’s deceit. The interviewer is instructed to assess the patient, establish a diagnosis, and reach a determination whether the patient should be involuntarily admitted.

Problems with the “Karl Moehller” Scenario Although employing the same cast of professional actors as our other scenarios, the “Karl” simulation project encountered unique difficulties that compromised our ability to collect aggregate data regarding trainee performance. Many actors appeared to be reluctant to engage in the full-on level of psychological abuse called for in the script (see Appendix IV below). A preponderance of interviewers failed to confront discrepancies in “Karl’s” history, with the result that many of the planned “check-points” were not encountered, for example, “Karl’s” explanation for removing his daughter’s door, or the bruises on his daughter’s arms (see Appendix IV below). One of the actors who most effectively portrayed “Karl” as specified in the scenario protocol, on the other hand, reported significant distress at depicting such a repellent character, as

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well as guilt about the emotional distress he was inflicting on the interviewer. After the exercise, a trainee sought out the program director, stating that he found the exercise extremely upsetting, and was distressed by what he regarded as his failure to respond effectively to “Karl’s” racist and xenophobic gibes.

Interview with Dr. Choudhury—Transcript Let’s examine a transcript of “Karl’s” interview with Dr. Nasir Choudhury (name changed), a capable PGY-3 psychiatric resident, and observe how the interviewer fares in the gap between fact collection and the shifting seas of a transactional interview with a psychopathic patient. In the following transcript “Comment” will refer to this writer’s commentary to the text, and “Interviewer’s comment” will refer to Dr. Choudhury’s after-the-fact commentary.

Transcript Dr. Choudhury enters the interview room to find Karl talking on his cell phone. Karl:

(to Dr. Choudhury while speaking on the phone) I’ll be right with you—have a seat. (Speaking into to the phone) Sure, okay…right… (to Dr. Choudhury, as concludes his call) Someone at work – Hi! Comment: Within the opening moments of the interview, Karl makes a number of powerful nonverbal interventions. He keeps the doctor waiting while he speaks on the phone, indicating his concerns are more important than her own, and that she must do his bidding. Interviewer’s comment: This was my first experience with a patient who made me wait and kept on talking on the phone. Felt a bit high-handed. Dr. Choudhury: My name is Dr. Choudhury.

Interview with Dr. Choudhury—Transcript

Karl:

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(Quizzically, testing his pronunciation of the unfamiliar name) Dr. Choudhury?

Interviewer’s comment: I felt alienated and anxious—how does one explain one’s name. His expressions were a bit harsh. Dr. Choudhury: Yes. Could you please have a seat? Karl: No, please, ladies first. How’s your day going? Comment: Karl’s display of gender-based pseudo-­ courtesy repudiates the interviewer’s status as a clinician and establishes a precedent that she should obey his instructions. Dr. Choudhury: Good. How about you? How’s your day? Comment: Then Dr. Choudhury attempts to redirect the patient back to a normal interview relationship. Karl: Not very good. Dr. Choudhury: How so? Karl: I don’t know, doc, you tell me why I am here. Comment: Karl parries the clinician’s request. His comment suggests an attempt to reverse the dynamic of the assessment interview, that is, the patient, not the doctor, will be asking the questions. Interviewer’s comment: This reversal of dynamics made me realize that he is going to be a difficult case. He also gave me a sense of aggression. I could feel him trying to overpower or control the situation or probably me. Felt more anxious as I felt threatened. Dr. Choudhury: You don’t know why you are here? Comment: The clinician, by her tone of voice and open-ended question, attempts to redirect the patient to explain his situation. Karl: Um, I don’t know. Apparently, it’s against the law for a father to tell his daughter to do her homework, and that’s all I know.

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Comment:

The patient again parries the clinician’s request, using an absurd, ironic response that also represents the patient’s effort to establish himself as a victim. His statement “that’s all I know,” functions to close down further inquiry. How will the clinician respond?

 oing a “Dorothy” (i.e., Ignoring Subject’s D Aggression) Dr. Choudhury: Oh, that’s what happened? Well, let me explain it to you. Basically you are here for a psychiatric evaluation because of all the reasons, and all the circumstances you have in your home. Comment: The clinician has responded to the patient’s rejection of her request by providing an explanation, as if the patient was behaving reasonably, and simply needed more information. How does Karl respond? Karl:

Could you speak a little bit more slowly please? Dr. Choudhury: Sure (nodding). Interviewer’s comment: I started becoming angry and insecure. Insecurity of an IMG and English not being my first language. Didn’t want to speak to him. Karl: I am having a hard time with your accent. Dr. Choudhury: Sure (nodding) okay sure.

Bobbleheading Comment:

Karl’s request that the clinician speak more slowly represents a veiled reference

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to the clinician’s nonnative origin. In an exchange that lasts only a few seconds, the clinician nods and repeatedly says “sure,” in what appears to represent an unconscious attitude of submission. In rating interviewers, we view repeated nodding by the interviewer as a submissive response to anxiety, and call it “bobbleheading.” Although only 60 seconds have elapsed, an interactive pattern has been established that will persist throughout the interview. We will see the clinician repeatedly attempt to engage Karl in a discussion about the events that led to his arrest, only to be thrown off balance by Karl’s increasingly overtly insulting and domineering behavior. Karl: Where’s your accent from by the way? Dr. Choudhury: Does it matter? Comment: Note the indirect fashion in which the clinician responds to Karl’s insulting and inappropriate question. Karl’s question has already made clear the fact that it matters to him. “Why does it matter?” would place Karl’s motivation under scrutiny. Another, more direct option would have been to say “let’s focus on understanding what happened to you this morning.” Instead of, for example, encouraging Karl to discuss the reason he was arrested, she asks, “does it matter?,” eliciting a predictably deceptive response from Karl. Interviewer’s comment: I could feel anger in me building up and he was getting to me. This stemmed from the fact that as I felt that he was rubbing my nonnative status in my face. Karl:

Oh, I’m just curious.

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Comment:

The interview up to this point makes clear that Karl’s statement that he is “just curious” is a lie. In the space of a few moments, he has begun to establish a relationship with the interviewer characterized by superficial politeness, and an underlying dynamic of denigration and control. How will the clinician respond? Dr. Choudhury: It is from India, actually. Karl: India! (nods repeatedly) Comment: Karl’s nodding in this instance is behaviorally identical to the clinician’s “bobbleheading,” but there is nothing submissive about his meaning. He is using the nod to add emphasis to the personal information he has manipulated the clinician to reveal: she is from India. In response, the clinician rallies and again resumes her effort to get Karl to give a history. Dr. Choudhury: Yes. So, how can I help and what do you think is going on. I mean, I read the charts. It … seems like a lot has been going on. Interviewer’s comment: I didn’t feel comfortable disclosing information to him; made me feel vulnerable. Somehow felt trapped in this situation of disclosing information in order to establish rapport. So give a bit of myself or probably he took it by force. Tried to re-deem myself as I started to feel little. Karl:

Comment:

Well, yeah. I think I have got some, a little bit of brainwashing happening between my wife and my daughter and this therapist that she is seeing, whatever, this psychoanalyst or whatever that is called. Note Karl’s disparaging lack of awareness in the therapist’s professional qualifications, which may be regarded as an indirect disparagement of the clinician herself.

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Dr. Choudhury: Uh-huh and how long she has been seeing this therapist? Karl: I am not really sure. It is a few months or a year. She keeps that pretty secret from me, so something we are going to probably have to discuss a little bit later on between me and her. Comment: Karl’s statement that his wife’s privacy about her psychotherapy will “probably have to be discussed” has an ominous quality, to which the clinician does not respond. This might reflect a practical decision by the clinician not to intervene at this time—but in fact we will see that the clinician never returns to the nature of this potential “discussion” for the rest of the interview. While it’s always easy to “Monday morning quarterback” the conduct of an interview, it may be argued that there is a more-­specific process at work, that is, that the clinician’s state of frustration and humiliation have led her to a state of diminished confidence and acuity. We may even consider that the clinician is receiving a form of nonverbal communication from Karl, that is, that he is acting out his relationship with his wife in the session, rather than talking about it. Dr. Choudhury: Uh-huh. Karl: I realize she might have to talk to someone, but the very least she should be able to do is to talk to her husband, I think. Dr. Choudhury: Uh-huh. Dr. Choudhury: Sure. So what happened at home that brought you here? Comment: Once again, the clinician attempts to shift the interview back to a collaborative discussion by asking the patient to provide

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information as appropriate to a clinical interview—which is perfectly reasonable, except that her behavior constitutes an act of denial of the patient’s menacing behavior only moments before. The clinician, in other words, is “Doing a Dorothy.” How will the patient respond? Karl: Well, apparently something happened. Someone is accusing me of physically confronting my wife and I did not lay hands on her at all. We were all in a little bit of an elevated state I suppose. Comment: While remaining superficially cooperative, the patient responds by offering a deeply deceptive statement, deepening the state of alienation between himself and the patient. Dr. Choudhury: Uh-huh. Interviewer’s comment: Starting to lose interest in the patient. Zoning out. Don’t want to listen to his blabber. Karl:

Comment:

And I just walked past her and she had to move out of the way. She said I threw her up against the wall. So, it’s too bad we don’t have videotapes. Speaking of videotapes, I do notice that thing up there (points to camera) I do notice that thing up there. Isn’t there something I’m supposed to sign? Karl has again pivoted from a discussion of his own situation to a question about the videotaping of the interview. This is a superficially reasonable expression of concern on the part of the patient, which functions to mask the patient’s underlying paranoid experience of the interview as a threatening assault.

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Dr. Choudhury: I don’t know if it is working right now, but generally this is for the patient’s safety but… we are under HIPAA… So, whatever you say is going to be confidential. Karl: Yes, like you know this is a very different kind of a situation here because police brought me in. I am being accused of something I did not do. So, if you put yourself in my shoes, which is what I think an empathetic psychiatrist or psychologist or whatever you are should be able to do. What are you? What’s your background in this? Dr. Choudhury: Mine? Karl: Yeah. Dr. Choudhury: I am a psychiatrist. I am a psychiatry resident. I just introduced myself. Karl: Oh. Dr. Choudhury: Okay. Karl: Where did you get your training? Interviewer’s comment: Am I not good enough for you? Dr. Choudhury: Um, I did it from India. I am still in training here. But let’s backtrack to you, okay. Karl: That’s right. Dr. Choudhury: And I can give you more information about myself later. I can give you my card. Okay? Karl: Sure, sure, sounds great. Dr. Choudhury: So, you said that you did not push your wife and you were in kind of an elevated position at home that you kind of lost it, what was happening around there? Karl: You have to slow down. I swear to god, I cannot understand your accent, so can you repeat the question again? Comment: As the interview proceeds, the clinician repeatedly attempts to establish a better sense of the relationships in the home,

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only to be put off by Karl’s evasions, role reversals, and comments about the clinician’s non-native origin. Dr. Choudhury: Okay. Interviewer’s comment: Really frustrated with the patient’s behavior and feeling trapped this situation. Karl:

Maybe if I were an Indian, I probably would be able to understand it, but sorry, a little bit more slowly please. Comment: What other options does the clinician have? One option might be to challenge the patient’s claim not to understand, and in fact confront the patient with an observation that the patient seems to be doing his best to change the subject and give evasive answers. Another, less-provocative option might be to simply note the difficulty that the clinician and patient are having communicating, along with an observation that other people don’t have much difficulty understanding the clinician’s accent. Dr. Choudhury (with obvious frustration): So, what was happening at home, you know, this kind of tense atmosphere that you had at home. Can you please describe that to me? Interviewer’s comment: felt he was mocking me and was ingenuine. Karl:

Well, the tension is that she is not doing her homework. Dr. Choudhury: Okay. Karl: It is just simple as that. Her grades are falling. Dr. Choudhury: Uh-huh. Karl: What am I supposed to do as the father, just ignore it?

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Dr. Choudhury: What class is she in. What grade is she in? Karl: She is in 9th grade. Dr. Choudhury: She is in the 9th grade. Okay. Okay. How is your relationship with her? Comment: The clinician’s request for information about Karl’s relationship with his daughter is entirely reasonable, except that for the continued implicit expectation that Karl will answer cooperatively, which flies in the face of the implicit and explicit process of the interview so far. The clinician’s question appears to provoke him further. Karl: Well, it’s been fairly good I would imagine, but lately she has been acting out or something, maybe you know, the thing, you know, she is turning into a young woman, though she is getting her periods and you know, no disrespect, but all gals once a month they drive us all crazy, on the male side here. Dr. Choudhury: Really? Interviewer’s comment: WTF moment. What is this creature and how do I tame him?

Pheromones Karl:

Yeah. I think it is probably. I think my wife told me, it is something about it. I think I have read somewhere about women, when they are all in the same room, they all kind of smell each other, something like pheromones. They all start cycling at the same moment, so I should say it is like a perfect storm with my wife and my daughter, so, uh. Hopefully it just could be attributed to that and we can talk that out. I just feel

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that maybe, maybe I’ll spend the night at a hotel that night, or something. Comment: Karl’s bizarre statement represents an extraordinary revealing comment on the part of a man accused of domestic abuse. In the heat of the moment, however, the interviewer appears temporarily overwhelmed by its insulting character, and at least temporarily unable to appreciate it as an indicator of Karl’s psychopathology; in fact, she changes the subject. Dr. Choudhury: Okay. So, is this the first time that this has happened at home? Karl: Yes. Dr. Choudhury: Okay and before your daughter hit her teens, how was your relationship with her?

Perfection Karl: Comment:

Dr. Choudhury: Karl: Yeah. Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury:

It was perfect. Karl’s claim of a “perfect” relationship with his daughter raises questions about his level of insight, and his conflation of his daughter’s obedience with attunement and happiness. It was perfect? I got a great family. I’m sure. We go to church every Sunday. Hmm. Do you go to church by the way? Hmm. I don’t feel comfortable disclosing that…

Interviewer’s comment: Didn’t want to disclose another piece of information about me to him and also felt scared of how he might react to me being a Muslim.

Interview with Dr. Choudhury—Transcript

Comment:

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It is perfectly reasonable for the interviewer to decline to answer Karl’s question. Her refusal, however, perpetuates the dynamic of submission vs. dominance that suffuses the patient’s request. The clinician is again placed on the defensive, apparently temporarily incapacitated by the force of Karl’s bullying and intrusive questions. An alternative pattern of response, guided by a spirit of continued interest and curiosity, might be to ask, “Mr. Jensen, why are you asking me about my religion? You’ve been brought here by the police, and I’m trying to understand what’s going on. How am I to understand your behavior as I try to talk to you?” Karl: Yeah. We are a very Christian family. I have a very ordered life because I value traditional values and it’s something that seems to be going out of the window more and more. May God finally have a president finally who will wake this country up a little bit. Um, did you vote by the way? Dr. Choudhury: I don’t have the right to vote here. Karl: I see… Comment: Many international trainees experience anxiety regarding anticipated or, all too often, actual hostility from patients based on religious, racial, or cultural differences. As offensive and at-times threatening as such attitudes are, they also frequently mask a patient’s own sense of insecurity. A sympathetic question about the patient’s level of anxiety might offer a basis to move forward. Dr. Choudhury: Tell me more about your traditional values.

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Karl: Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury:

Comment:

Karl: Dr. Choudhury: Karl:

Well, father makes the rules in the house for the good of everyone. Sure. The wife listens to the father, the husband, because I have their best interest. To say this is my family. I love them. Uh-huh. And I don’t know now it is still I, like, I am getting a little bit grilled about what traditional values are. Look, I am just asking these questions so that I have to understand, because like you are saying, I am not from this country, so that I have an understanding people of different cultures are different, right? The clinician is again placed on the defensive, justifying the basis for asking reasonable and relevant questions. In doing so, she emphasizes her nonnative origin, rather than her professional status; and in doing so insensibly accepting the patient’s frame of reference. Right. So, I have an understanding like what’s the baseline at your home, what your values are, how you feel about it. So, what are you asking me specifically, that’s what I want to know and I guess what I would really like to know is why I am here? Tell me why I am here?

Domestic Violence Comment:

The patient repeats his demand, and the clinician will now comply, but for the first time confronting the patient with specific allegations from the police report.

Interview with Dr. Choudhury—Transcript

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Dr. Choudhury: Sure, sure. I will let you know about that. So, you were brought in here for a psychiatric evaluation because your wife has given a statement that you hit her and you restrained your 16-year-old daughter and there was a domestic dispute. Karl: I did what to my daughter? Dr. Choudhury: You restrained her violently against her wish. (Due to her accent, the interviewer pronounces “violently” as “wiolently” in a perfectly intelligible fashion.) Karl: Why would what? Dr. Choudhury: Violently which means. Interviewer’s comment: Again made me feel inferior or somehow alien. By doing so, the patient was able to take away my speech/form of communication as I became more anxious of my accent. Karl: Violently, oh I am sorry, V and W, it’s okay. I just, I am trying to understand the situation by listening.

The Door Dr. Choudhury: I understand it is a difficult situation and honestly your daughter also alleges that you removed the door from her room. Karl: I did. It was breaking off. I had to fix the door. Dr. Choudhury: Uh-huh. Karl: She has this tendency now over the last couple of months every time she wants to act out like a teenager; she slams the door, so the door is coming off its hinges. So, instead of the whole thing crumbling and breaking the door frame I took the door off the hinges, I brought it downstairs. I got to sand it down, put epoxy down on it,

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plane it down. So, I had to take the door off. Comment: Note the patient’s fluent delivery of his explanation. His detailed account of repairing the door serves to establish his masculine expertise about a subject that the interviewer is unlikely to understand, and directs the focus of the interview away from the circumstances under which the door was broken. Dr. Choudhury: Okay. Interviewer’s comment: Actually believed him and presumed that door probably came off hinges from slamming. Karl:

So you know, I left it underneath the porch. Dr. Choudhury: The removal of the daughter’s door is an important physical fact, suggestive of aberrant behavior on the part of the patient, and a source of insight into his mental state (e.g., a violation of the patient’s adolescent daughter’s need for privacy). His claim that the door is ­“coming off its hinges” is easily verified or disproven. On the other hand, an important mental status observation could be derived from the patient growing more evasive in response to a request for detailed information about the damage to the door that supposedly made it necessary for the patient to remove it. Karl: Yeah, eventually. Dr. Choudhury: Okay. Because she Karl: I have full time job…

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Longitudinal History Comment:

Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury: Karl:

Comment: Dr. Choudhury: Karl: Dr. Choudhury: Karl:

The clinician pivots to collect longitudinal history. There is nothing wrong with gathering this information. Note however that the inquiry regarding the removal of the door is never resumed. That’s nice of you. Uh, what kind of job do you do, sir? I am the VP of research at Regeneron. Oh, that’s interesting. How long have you have had this job for? Just about my entire life. Well, adult life I should say? Uh-huh. I worked only for Regeneron and they have been good to me. How was growing up for you. How was your relationship with your parents? Uh, fine. Okay. I had a good father. Uh-huh. Mother. I wasn’t really close to her, but my dad showed me a lot about how do you make your way through life. So, I would say I had almost a perfect childhood. Once again the patient introduces the concept of “perfection” to foreclose further inquiry into family relationships. That’s good to know, any siblings, brothers and sisters? I have a brother and sister. Okay, and are you close to them. How’s your relationship with them? I see them once in a while. Once in a while we have a Christmas together. I go back to Ohio. When I am here I don’t see them

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Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury: Comment:

Karl: Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury:

very often, but you know, phone calls once in a while. Are your parents alive and well? My father has passed away. I’m sorry to hear about that. Thanks. When did that happen? Um, right after college. It must have been a lot tough. Interviewer’s condolences about a loss occurred in the distant past has a propitiatory, conflict avoiding quality. As we will see, Karl responds to weakness with a new effort to invert the clinician–patient relationship, using seemingly polite but inappropriate personal questions to undermine the interviewer’s role, followed by a resumption of racist and anti-immigrant insinuations. Note how discussion of accusations that the patient has engaged in domestic violence has fallen by the wayside. Emboldened by this reversal of roles, the patient returns to intrusive personal questions put to the interviewer. Yes. It was. Is your dad still around? Yeah, he is. Are you close to him? Yeah, I am. Um, so. Where does he live? Does he live here or in India? He is back in India. Yeah. Do you ever want to bring him over here? Uh, well, I was trying to bring him here. Why did you, so, let me just ask, why did, what, you are still getting training here, right. Hmm.

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Karl:

Is getting better training the reason why you are here, because you couldn’t get the same kind of level in India? Dr. Choudhury: Yes. So, like I said before, I am in discussion and I am talking to you. No more about me and credentials. Interviewer’s comment: Felt further threatened but this time had to act as he wanted information about my parents. Comment:

Clearly flustered, the clinician asserts herself. Karl: Well I think this is all going on record. I just want to know who is interviewing me and why I was here. Dr. Choudhury: Sure, sure. Karl: Your name is clinician, right. Dr. Choudhury: I understand all that and I will be happy to talk about my CV and resume right after this interview because you have a time crunch and I want to focus more on you rather than me because Interviewer’s comment: Felt frustrated and angry and didn’t want to lose my cool. Comment: Note that interviewer is simultaneously offering to share her CV in response to Karl’s insults, and becoming less coherent. Both behaviors appear to reflect the Interviewer’s mounting confusion. Karl: Okay, so what else do you need to know? Dr. Choudhury: Well, um, why is Gina, that’s your daughter’s name right? Gina? That’s your daughter’s name. Karl: Nancy. Dr. Choudhury: Nancy. Sorry. Uh, why does she act out? Karl: Why does she act out? Dr. Choudhury: Yeah. Karl: I mean she is a teenager. She is a teenager. She is getting her period. I don’t know what else to tell you about that, but comes

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a time where the father has to get involved. Her grades are slipping. She is not getting. Her older sister is at RPI (Rensselaer Polytechnic Institute). She is not going to get anywhere near that if this continues. So, I am just being a father, who told his daughter to do her homework and now I have handcuffs on. What the hell is happening in this country? Dr. Choudhury: Okay. Karl: Have you ever had handcuffs on? Comment: Note how the patient returns to politically tinged themes of victimization. While some measure of his posture may be volitionally undertaken by the patient in his effort to distort and undermine a potentially threatening interview, it also seems to be the case that he believes himself to be the victim of unfair and unreasonable treatment. This is a theme the patient appears to be eager to discuss, and if given liberty to do so may reveal more about his life and mental state. Dr. Choudhury: No. What about the Order of Protection? I believe there is an Order of Protection against you. Karl: I don’t know. I think it is just some stupid conspiracy theory with this woman that she is seeing, this Nesbit, this Nurse Ratchet person. Dr. Choudhury: Tell me more about it. What you think about this conspiracy theory, why would your wife do this to you? I mean it seems like you have the perfect life, a perfect family, everything was going around well, and suddenly these things are happening. Comment The interviewer has begun to confront the patient’s saccharine characterizations of his family relationships: were all the

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patient’s relationship actually “perfect”? What family can actually make such a claim? The patient appears blindsided by his present difficulties; is it possible that he has failed to perceive that his family relationships are in fact less “perfect” than he believes it to be? Karl: I think I am a pretty decent guy. Dr. Choudhury: Yes. Karl: I try my best. Dr. Choudhury: I believe you. Interviewer’s comment: I was sarcastic. Karl:

Wow. Great. I appreciate that. That’s actually the first time anyone has actually said that to me. It’s whatever. Um, well, if you believe me. Dr. Choudhury: Uh-huh. Karl: I am barely. If you try to come to my point of view, tell me what you think I am saying because I don’t, I cannot see what is happening here. What have I done wrong? I don’t understand what I did wrong. Comment: Possibly encouraged by the seeming genuineness of Karl’s question, we see the clinician mobilize and renew her attempt to engage the patient in a meaningful discussion. She concludes the next intervention with a gentle confrontation of Karl’s inconsistent account Dr. Choudhury: So, let me tell you. I am here for evaluating you. There is no judgment here. You tell me what’s going on and what you feel about it. There is no judgment here. You tell me what’s going on because you look I believe actually more-qualified than me who is doing very well in life, so what’s going on. Something is not fitting in the picture.

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Comment: Karl:

How does Karl respond? I don’t know. All I know is that, it is about time that we finally have a president who is going to start changing the laws because the next time I come back here, but I will not come back in here again. No, I will not sign something that will not be on. There is just too much. We have, I am so glad I was not – Comment: As we see, his reply is almost incoherent, swinging to praise the then-recent election of Donald Trump, whose anti-immigrant views are well known. The common element appears to be his belief in “traditional” structures of authority, in his home, and in the nation at large. The conflation of the two topics in this form is bizarre, and suggestive of either significant mental status abnormalities or a psychopathic grandiosity. We have, well, look this is not a personal thing about you, but your gender is a little, little whacked out in the last 50 years, about you want equal rights, you want to be able to behave in certain places in certain ways, and I am telling you right now that it is not going to fly anymore. I will vote the way I want, I will send money the way I want it sent, and I will be on those people, the people that are spending our tax dollars in a way that will (slaps his thigh) make sure that we have the kind of country that a church going board member like myself who is paying taxes, (slaps his thigh) that are paying for half of the facilities that you use here. Speaking of which, you know Tom Bellasono? Interviewer’s comment: Really angry by now and wanting out from this situation. Regretted my decision to leave my

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country and to study in the USA. I had a happier life back at India—at least no one looked down upon me. Dr. Choudhury: No. Karl: Well, he is on your board, so I would think that if you would. I don’t know. Look I am sorry. Comment: Karl has careened from his frustration with his home situation, to a political rant, concluding with a clumsy boast about his relationship with a member of the Medical Center Board of Directors. Karl appears to be in a state of tenuous self-­control. His degree of agitation is evident through his behavior of slapping his legs and fist. These are a finding that is of critical relevance to the questions evaluating the interviewer is to answer, that is, does the patient represent a threat to the well-­ being of his wife and daughter? How will the interviewer respond? Dr. Choudhury: Okay. Interviewer’s comment: Paralyzed my anger and frustration now. Didn’t want to look at him anymore. Just want to get the check list done. Somehow I stopped being sympathetic to him. Thought of provoking him and calling a code grey and giving him IM sedatives but instantly felt guilty of the unethical thought. Karl: Dr. Choudhury:

Comment:

(repeatedly punches his palm) Okay. Sorry. I am going to interrupt you. Let me ask you a few more questions. How’s your sleep going on? How’s your sleep? Let’s talk about you now, okay. For your safety. How’s your sleep? In the face of Karl’s vulgar behavior and poorly regulated rage, the interviewer appears to be unable to establish a clinical assessment of what is happening.

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Karl: My sleep? Dr. Choudhury: Do you sleep well? Comment: There’s nothing objectionable to the individual questions, except that they are irrelevant to an understanding of the patient, and represent an active effort to ignore the actual interaction that is unfolding during the interview. This pattern of behavior, which our raters refer to as “templating,” is surprisingly common. Interviewers engage in it when they are at a loss for words, usually in a setting of at least temporary incapacity to conceptualize the case, or understand what is happening in the interview. Karl: Do I sleep well? (acts incredulous that he is being asked this question.) Yeah. Dr. Choudhury: Which means you are doing fine. Karl: What does that have to do with this? Comment: The patient is correct; the line of questioning is irrelevant. Having shaken up the interviewer, the patient now questions her handling of the interviewer. Dr. Choudhury: Generally, you know, when you go to a doctor, like you go to a medical doctor, they will ask you questions like how you have breathing, how you are being, do you have any shortness of breath, you know, just check the review of the systems.

Templating In this case, the clinician temporarily overwhelmed by the extent to which she has become ensnared in an abusive relationship with the interview subject.

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For the interviewer, irrelevant “templating” represents a relief from immediate anxiety of the interview, while for the patient it is baffling. Karl:

Comment:

Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury:

Comment: Karl:

What it is to do with my daughter? I mean, I don’t understand this line of inquiry. Is this the stuff you learn in India? Because it doesn’t make any sense to me. I swear. I am just sorry. It doesn’t make any sense to me. You are asking about my health. I would go see my doctor for that, you are asking me about. What do you think brought me here? The patient’s pseudo-sincerity elicits a propitiatory response from the clinician, along with yet another appeal for information. Note, however, that the patient is still asking the clinician to explain to him why he is being interviewed. Well, it is part of a psychiatric evaluation, so. Okay. So, I have to talk about. I am going to talk to Tom about this later. Okay, sure. I don’t know, maybe if it is mandated this is the way you have got to do things here. It just does not make any sense. Okay. All right, I’m sorry. Go ahead. Some questions might offend you, but generally this is like a protocol. Are you hearing any voices in your head when there is nobody around or being shouted and stuff and there is actually nobody in the room? Continued “templating,” in this case regarding irrelevant psychiatric questions. Booo! (Mocking the clinician)

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Dr. Choudhury: That scared me. Karl: (Laughter.) I guess not, the voices you hear, that is the ghost of Hillary Clinton coming out right now. Dr. Choudhury: Uh-huh. Interviewer’s comment: Thinking to myself that he is so full of shit. Karl: Dr. Choudhury:

Karl: Dr. Choudhury: Karl: Dr. Choudhury:

Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury: Karl: Comment:

All right, never mind. It’s, no, I’m fine. I am not seeing anything. Okay. Any thoughts of hurting yourself or hitting anybody else? Any thoughts of harming yourself or anybody else for that matter? Harming myself. Well, have you fantasized of killing ants like a kid and you fantasize about killing them. Uh-huh. We all do it, but the acting out. No, I’m a law-abiding citizen. I don’t do that kind of stuff, absolutely not. Uh, does that mean more about like you know there is an Order of Protection now, so how are we going to go back home? Where are you going to go? So, where would you go from this place if we discharge you from this place? Go work. I need to get to work. And I believe there is an Order of Protection at home, so where would you stay? Well, Motel 6. Okay. (sarcastically) I love cinder blocks. Note how these considerations obscure the clinician’s valuable line of confrontation of the patient’s claims of “perfection.” In contrast to a collaborative patient, Karl

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works to obscure and undermine the clinician’s effort to develop a meaningful formulation. Interviewer’s comment: Didn’t understand his comment but felt why bother to clarify. Would give him a chance to devalue me again. Dr. Choudhury: You talked about conspiracy in your past; you still having these thoughts? Karl: They are not conspiracies. Dr. Choudhury: Okay. I am trying to understand. Karl: You know, I just have, you know there is a newsletter called the Judicial Review. You can subscribe to it. Dr. Choudhury: Okay. Karl: And you will see exactly what is going on in this country. Dr. Choudhury: Hmm. Comment: The clinician appears to be incapacitated at this point. Note how these considerations obscure the clinician’s valuable line of confrontation of the patient’s claims of “perfection.” In contrast to a collaborative patient, Karl works to obscure and undermine the clinician’s effort to develop a meaningful formulation. Unopposed, the patient launches into a politically charged rant that contains a thinly veiled assault on the interviewer.

Founding Fathers Karl:

And it’s just, you know the founding fathers had an idea of how this country should look. It was pretty much set up in the constitution, about, we all had rights. We have a government. We got to all get along and get it. But we all have the rights

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and the government and the people coming in and telling other people what to do because someone feels like it. This is, it can't be. This is not the way. More, the constitution, now those rights are based upon the Bible and I don’t know what you believe in, it doesn’t matter, but if you are in this country to some extent you have to believe in Judeo-Christian law and that is what I am saying is being lost in this country. We don’t have enough. As long as I am alive, I swear to God, I will not let my family fall crazy to this idea of this country getting mumbo jumbo, everyone’s got to come around to our view, around each other and love each other, because this is not the way the world works. I am trying to impart that to my family and I am trying to protect them. Comment: The interviewer now attempts to restore the focus on the patient’s behavior and the accusation against him. Interviewer’s comment: Now fully enraged and wanting to rub it in his face. Found it hard to be polite with him anymore. Dr. Choudhury: Okay and how do you intend to do it in the future, protect your family and imbibe these values in them. Do you have a plan? Karl: My plan? Dr. Choudhury: Because it seems like your daughter and your wife are not on the same page like you. I think that is the problem. Karl: Yeah, they are not on the same page. So, do you want to give me a suggestion about what we should do for the same page? Dr. Choudhury: No, I just want to know like how do you feel about it, like, because they are not on the same page.

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Comment:

Karl:

Comment:

Dr. Choudhury:

Karl: Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury: Karl: Dr. Choudhury: Comment:

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The patient responds to the clinician’s efforts by stating that the interview “isn’t working,” and demanding to speak with the interviewer’s supervisor. I don’t know. I don’t know. So, I’m asking. I just sat here and they said someone is going to be here and help you and as much as you are trying, it’s not working. So, I maybe, maybe can I see your supervisor. It’s nothing personal, but maybe someone with a little bit of work experience, someone who has had a little bit of more training in this country, so perhaps we can probably make some progress here because we are just going around in a loop and a loop and it is, time is money. I got a, I got a. The clinician responds with a direct confrontation of the patient with his actual circumstances and known facts about the case. Uh-huh. So, I will cut with you. I will just end it. The concern here is the safety of your wife and daughter. They are still frightened of you right now. So, the question is, how are we going to change that. How are we going to change it? Uh-huh. Let me hear your proposal. You tell me what you think about it, first. What do I think about it? I should go home. Uh-huh. Have a frank discussion with them. Uh-huh. As the discussion unfolds with clearer focus on the part of the interviewer, Karl grows increasingly unstable.

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Karl:

Iron out what has happened and move on. (Karl grows increasingly angry). The way that what has happened anyway, if things that this Nesbit woman, this harpy, had not gotten in our way, putting ideas in my wife’s head that somehow I am out to do something to her and do something to my daughter. I just don’t understand. (abruptly enraged) I want to see the supervisor! Dr. Choudhury: Okay. Karl: (Shouting.) No, just don’t, okay. I want you to get on the phone right now. Dr. Choudhury: Sure, sure, just calm down. So, for the sake of safety, how about having you know getting admitted to the hospital right now, for the safety of your wife, for your safety, for some time, so that. Comment: Abruptly, this experienced trainee announces her intent to involuntarily hospitalize the patient. Her rationale for doing so is unclear, and follows a series of provocative tirades from the patient. Interviewer’s comment: I couldn’t get a good history on him as he was guarded and defensive. I felt threatened by his behavior. That and the police report made me arrive at the decision of involuntary hospitalization. If he was threatening me in a hospital, what were the odds at home? I wanted to guarantee his wife’s and daughter’s safety. Karl:

Comment:

What do I need to go to the hospital for? I can't sleep. Is that what you are saying? I’m seeing things. Oh, there goes Hillary Clinton again. She’s in the closet and she is you know, she is actually a lesbian. The clinician now seems to be struggling to justify her decision to seek involuntary admission for the patient.

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Dr. Choudhury: Because your behavior right now. It is kind of like you are shouting. You are raising your voice. You are threatening me. Karl: Raising my what? Dr. Choudhury: Voice. You are raising your voice (pronounced “woice”). Karl: I’m sorry. You have got that V and W. You would be very good in Germany because that’s how they pronounce the V and W. Dr. Choudhury: Uh-huh. I’m sure. Karl: All right, so listen, I am sorry. Dr. Choudhury: Uh-huh. Comment: Intimidated by the clinician’s threat of involuntary commitment, the patient seeks to mollify the clinician, again casting himself as a victim. Karl: Okay. I am sorry for raising my voice, but it is (pause) handcuffs hurt. Handcuffs hurt. Dr. Choudhury: I am sorry for that. I am sorry for that. Do you have anymore? Karl: It’s embarrassing, and no one seems to take that into account. Dr. Choudhury: I’m sorry. Karl: I am walked out in front of my neighbors with handcuffs on. Getting ready to go to work. Dr. Choudhury: I’m sorry. Karl: I am on the board of the Boys & Girls Club of Westchester. I am the softball coach for my daughter’s team and it is going to go out all over. Dr. Choudhury: So, it makes all the more reason to be here, take a break, gather yourself. It seems like a good idea at this point of time. I will give you some time to think about it and I will come back and talk to you later about it, okay. Karl: Bring your supervisor here.

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Dr. Choudhury: Sure. Karl: And get that camera off please. Dr. Choudhury: Sure. Lovely seeing you. Interviewer’s comment: I was feeling completely opposite of this – hurt, frazzled, anxious, insecure but didn’t want to give him that satisfaction. Hence commented “lovely seeing you.” I didn’t want to give in. Comment:

As the interview reaches its end, the clinician appears to introduce the possibility of reconsidering her hasty decision to seek involuntary care. The patient responds by demanding to speak with a supervisor, and the clinician responds in turn with a statement that it’s been “lovely” to speak with the patient. Karl: Yeah. Close the door please as you go out. Dr. Choudhury: Sure. Karl: Thank you.

Conclusion This challenging simulated interview illustrates challenges clinicians in training struggle with in encounters with resistant and hostile patients, including the following: • Overreliance on the patient or subject to provide narrative structure to the interview • A tendency to retreat from engaging discrepant data, or evidence of active nondisclosure (see Chap. 5) • Intense anxiety and confusion about how to respond on encountering active aggression in the interview

Good Intentions, Frustrated As noted earlier, most of those who seek careers in mental health are motivated at least in part by concern for others and a desire to achieve deeper levels of communication and

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understanding. Demonstration of such concern appears in some settings to enhance clinician effectiveness, for example, the findings reported in Chap. 10 that demonstrate that empathetic engagement and warmth in the conduct of the psychiatric interview are strongly correlated with more-­ advanced interviewing and formulation skills. Virtually all clinicians seek to achieve a dialogue, and trusting therapeutic relationship. The question, discussed in Chap. 5, is what becomes of the interview when these commodities are not forthcoming? We are reminded of Jasper’s dictum remains the case: “We can grasp and investigate only what has become an object to us.” A clinician who identifies a patient’s hostility as a critical mental status finding is better equipped to understand and possibly help a hostile patient.

 ppendix IV: The “Karl Moehller” Simulation A Scenario—Design and Supportive Documents Goals of the Interview The interviewer should: • Develop awareness that Karl is in a state of tenuous emotional control, engaged in deception and nondisclosure • Identify and respond effectively to “countertransference” anxiety stimulated by patient’s behavior • Confront patient’s behavior and adversarial posture • “Follow the affect,” that is, prioritize issues relevant to patient’s emotional state over collecting a (distorted) factual history

Presenting Problem Karl is a 48-year-old man who presents in the ER after his wife (Sandy) made a 911 call stating that he assaulted her. He believes this to be false, and this evaluation to be a charade staged by his wife’s therapist (Ilene Nesbit, PhD).

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Recent problems in the home are related to Karl’s conflict with Jenna, a 15-year-old who is the younger of his two daughters. Unlike Karla, her high-achieving older sister, Jenna is a B student, and her grades have recently been falling. Her father has punished her by confiscating her phone and computer, grounding her and restricting her contact with peers. Sandy (Jenna’s mother) recently discovered that Jenna has been restricting her food intake and lacerating her thighs for many months. Sandy has long struggled with her husband’s domineering style. She has been struggling with depression for years, and recently began seeing a therapist a friend recommended. The therapist has expressed alarm about Jenna’s condition. Sandy’s concern about her daughter has overcome her long-­ standing submissiveness, even as Jenna’s defiance has escalated. Jenna talks back to her father, provoking his icy rage and escalating punishments—causing Sandy to inject herself into the arguments and herself becoming a target for Karl’s anger. A day ago, Jenna slammed her door on her father’s hand during an argument, and Karl removed the door from its hinges as a “consequence.” He then threw the door into the woods behind the family home. He has walked past her room, apparently accidentally, while Jenna has been changing, prompting a hysterical reaction from his daughter. This is what happened this morning, as Jenna, half-dressed, rushed at her father in a disorganized attempt to attack him. Sandy became involved, uncharacteristically agitated, pushing herself physically between Karl and Jenna, and in the ensuing argument Karl shoved her against the wall. Following the previously given advice of her therapist, Sandy called the police and reported that her husband attacked her. Sandy’s therapist spoke with police, telling them that Karl is, in her opinion, a threat to Sandy’s physical safety and sexually aggressive to Jenna. A physical exam found bruises on her upper arms, presumably where her father

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grabbed her. Karl has been arrested and brought to the emergency department (ED) for psychiatric evaluation.

Karl’s Background Karl is a systems engineer who works as a senior project manager in software engineering at a subsidiary of General Dynamics, where he is on the short list for a possible promotion to senior corporate leadership. He makes $300K per year, plus a developing portfolio of stock options and bonuses. He is an acutely intelligent, physically fit, disciplined, and organized man who is respected, if not actually liked, by everyone around him. His life is built around work, focused ongoing study associated with his work, physical fitness, and his family—which in his view requires his constant ongoing scrutiny and exercise of authority. He is calm at all times, yet when he is among those he considers his intellectual and moral inferiors (almost everyone except his deceased father and superiors at work) his posture and gaze are subtly intimidating, his mouth set in a slight, contemptuous smile—although his language is respectful and appropriate. If Karl were to openly discuss his core beliefs (something he would consider a sign of weakness and has never done with another person), he would say that life is fundamentally based on aggression, and that most human beings are unwilling to acknowledge this truth, and therefore flee into submissive, weak-minded myths—including all religious practice, belief in love, psychology, and psychotherapy, and almost all political beliefs. He believes that it is natural and appropriate for the strong to dominate the weak. Another topic Karl would never willingly discuss is his pejorative views of all women, homosexuals, men he considers effeminate, and people he considers racially inferior. He has no interest in history, politics, or art. Karl considers ­himself a realist, not a racist. He sees social equality as yet another myth.

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Karl understands that one should never discuss or reveal such views. In other words, part of being “strong” involves conforming to social pretenses that render the rest of humanity submissive, amenable, and more amenable to control. He also understands that such pretenses are important to his ascension on the corporate ladder. Karl attends a Lutheran church regularly, sits on the board of a local Boys and Girls Club, and until recently coached and played a major administrative role on his daughters’ softball league. Unknown to anyone other than his wife and two daughters, and to selected subordinates he periodically targets to destroy, Karl is also a psychopathic bully. He himself is unaware of this. He does not examine himself (this is another thing weak people do). He is unaware that, like every other human being he craves and needs empathetic contact with other human beings. Karl is unaware that, compared with most people, he is profoundly limited in the type and range of contact he is capable of: hurting people and feeling their pain, humiliating others and feeling their shame, controlling others, and feeling their anxiety and dependence on his approval. These same dynamics carry over into his sexual life. Karl considers himself a “normal” man in every respect other than his potency, which he considers superior. He has had a number of affairs with women he meets through work, choosing partners with care to avoid anything that might taint his reputation in his company. These partners find him sexy, exciting, but ultimately cold and shallow. Karl is perfectly happy to see these relationships wither, and behind his interpersonal mask sees these women as disposable. Karl’s relationship with his wife, on the other hand, is more complicated. He sees her as weak, submissive, and stupid. In private, he patronizes and insults her constantly, usually in a friendly tone with words that are overtly reasonable. He considers it her duty to submit to him sexually. He finds her ­passive submission to him boring, and lacks the self-aware-

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ness to perceive how important his dominance of her is to him. In short, Karl is a capable but detestable man who, behind his mask of probity, damages the people around him, and feels morally superior as he does so. Yet on a deeper level, of which Karl himself is unaware, he is growing depressed. His athletic strength remains impressive, but is less than it was 10 years ago. He loves his younger daughter more than his eldest (in a slightly creepy way) and is wounded by her rejection of him. He has received negative ratings from his subordinates, and is going to be passed over for the promotion to senior leadership he yearns for.

Sandy Karl’s wife, Sandy, is a kind, gentle artist of modest ability (she draws pictures of horses), who works extensively in charities in their church community, and counsels her female friends. She is quite religious in a nondenominational way, and struggles to convince herself that her husband loves her in his own way, no matter how he ignores and hurts her. Emerging from a troubled family, she did not do well in school and considers herself stupid. Karl controls all family spending and gives Sandy an “allowance” of $20 per week for her incidental expenses, entering all other spending in a computerized program. Sandy has become increasingly depressed and, at the urging of her friends, recently began seeing an inexpensive therapist. She is paying her therapist with a small savings she has accumulated from the sale of her pictures. Sandy’s therapist, Ilene Nesbit, is appalled by the situation and has urged Sandy to get a divorce. Karl has two daughters, 14 and 19. Karla, the oldest, is currently an outstanding engineering student at RPI (Rensselaer Polytechnic Institute). She resembles her father, and is deeply identified with him, including her mocking, patronizing atti-

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tude toward her mother. She and her father enjoy a cold but respectful relationship with one another

Other Background Information If asked about his background, Karl will answer questions in a supercilious, superficially cooperative fashion, making clear that he thinks such questioning silly, yet painting his background as a nostalgic portrait of hard work, discipline, and family unity. Karl is from Ohio. His father was a perfectionistic expert tool and die worker who later established his own metal fabrication business. He was a tyrannical master of both his workers and his family. Karl was an outstanding student. He respects and emulates his father, seeing his mother and siblings as “weak.” He refers to his father as “a hard man, but a fair man” who could be “tough” when needed. If asked specifically about violence, Karl will acknowledge receiving and witnessing beatings, including with an electrical cord, but minimize the significance of this and state the harshness of such punishment taught a lesson that made such punishment seldom necessary. Karl studied engineering at Ohio State University and received a master’s degree in electrical engineering at Cal Tech. He has worked at a single major corporation for his entire career. He met Sandy when he was a senior in college and she a freshman in fine arts. They married almost immediately, and she dropped out of college. Karl has many acquaintances and is respected and feared at his company, but has no friends. If asked, he will boast that he has dozens of close friends at work, through church activities, and as a board member of the Boys & Girls Club. (He will then name-drop by way of asking the interviewer if the interviewer knows Tom Curtis, a member of the Westchester Medical Center Board of Directors; Rob Astorino, the Westchester County Executive, noting that both are “good friends.”)

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Weapons: Karl has a “Marlin XT 22” target rifle in his home that he has owned since boyhood, and a “Savage Model S1200 pump action shotgun” he keeps in his vacation home, from “back when I used to do a little duck hunting.” He views his weapon possession as normal, and while cooperative, clearly thinks the interviewer is wasting time discussing it.

Interview Scenario Karl is contained, controlled, and aware from a lifetime of corporate experience of the need to control himself, manage perceptions, and direct the flow of the evaluation toward a finding that he is perfectly normal. Karl rightly believes that the shove he gave Sandy was trivial. He believes that his wife is a fool who has been brainwashed by a man-hating therapist. He is also inwardly seething with rage. He is aware of the need to control and conceal his emotions, both in order to control the interview, and also because he perceives emotionality as a weakness. Thus, Karl presents as calm, rational, and cooperative. He cannot restrain himself, however, from giving out a series of involuntary “tells” that reveal his underlying emotional state.

Interview Process The interviewer will have documentation that contains a police report quoting both Jenna and Sandy describing Karl shoving, grabbing them, removing the door from the hinges, controlling their behavior, looking in Jenna’s room while she is changing. Karl will deny all of this in uncompromising clarity detail. He has “an answer for everything” and will put real persuasive pressure on the interviewer to accept his account. • Level One: Karl will initially be falsely courteous, believing that he can shape and control the interview as he has in many other situations. He will skillfully contest the facts implicating him, even when he has to flatly lie. He will

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enjoy frustrating and confusing the interviewer. Unless directly confronted, Karl will remain in this posture for the duration of the interview. To move Karl out of this position, the interviewer is going to have to confront him, for example, “Mister Moeller the facts as I have them simply don’t add up. Are you saying that all these different people are lying or mistaken? • Level Two: Upon confrontation, Karl maneuvers to reassert control, aggressively questioning the interviewer’s experience, competence, and qualifications, and ask to speak with the interviewer’s superior (a disruptive demand that should be particularly surprising during an simulated patient (SP) interview). This will remain Karl’s position, unless or until the interviewer flatly states that, while a supervisor may be brought in at a later point, the interviewer expects Karl to cooperate, or otherwise will have to record this behavior in this report. • Level Three: Forced to continue and losing control of the interview, Karl loses control of himself, becoming openly angry, sarcastic, and disparaging. He is never physically threatening, but he is nonetheless frightening and revealed. LEVEL ONE Behavior During the Interview Karl is polite and formal, shaking the interviewer’s hand and inviting the interviewer to sit down as though he, not the interviewer, were in charge of the interview. Beneath his formality, Karl is probing for weakness, and establishing dominance, and setting the agenda for what will or won’t be discussed. Any peculiarity in appearance, attire, and nervousness will be noted with a slight smile. • Karl will open the interview by correcting the interviewer’s pronunciation of his name (however the interviewer pronounces it) and asking the interviewer’s training level. He will adopt a posture of friendly patronizing cooperation. • Karl will point to the camera, and ask if the interview is being videotaped. Isn’t he supposed to give consent under

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Health Insurance Privacy and Accountability Act (HIPAA) He will then graciously say that it’s fine to go ahead with the taping. • At various points, he may adopt a posture of an educator and senior supervisor, guiding the interviewer through what questions he should ask. Karl will display an apparently appropriate level of frustration over his arrest on trivial pretenses, explaining that his wife has not been well, that she became very agitated as he was trying to redirect their daughter to do her homework (there is a discrepancy: the incident happened in the morning when Jenna was getting ready for school). “Apparently, it’s against the law to ask your daughter to do her homework now.” His initial presentation is friendly, relaxed, and sophisticated. In the guise of friendly inquiry, Karl will search for any “weakness” he can find. For example: • If the interviewer is from a non-Caucasian background, he will as “What kind of a name is that?. Have you been in the country long?” • If the interviewer appears to be a Muslim, he might interject “Allah be praised.” • If the interviewer has an accent, he may repeatedly ask the interviewer to repeat words and phrases as if he can’t understand • If the interviewer has a non-English name, he will ask how it is spelled. • If the interviewer is female and fashionably dressed, an up-and-down look, such as “wow, this is what you consider appropriate for work?” • With females in general, he adopts a patronizing “mansplain” attitude, while with men he will insinuate a good-­ old-­boy camaraderie about women being flighty, critical, or “that time of the month.” • Karl will make at least one pejorative reference to his wife’s or daughter’s distress as a consequence of “being on her period.”

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• When discussing his employment, he will add an intimidating technical description “I’m developing avionics subsystems with RDX 1047 program for the F35 and AIM-9 passive targeting system.” The interviewer will either have to accept this gobeldygook as is, or as a follow-up question, whereupon Karl will respond, “I’m sorry, it’s heavily classified – you don’t have a security clearance, do you?” • Karl refers to all psychological consideration as “psychoanalysis,” with veiled contempt. If confronted by the interviewer, he may inquire “Is this some kind of psychoanalysis? I think I already explained this to you.” • As the interviewer asks about Karl’s background, educational, family history, etc., Karl will politely ask why this is relevant, and then comply with a display of cooperativeness and veiled contempt. • Etc. These digs should be relatively subtle (especially at first), injected between a display of apparently rational cooperation—BUT they should be offensive, irritating, and ideally intimidating to the interviewer, probing for weakness without giving adequate grounds to the interviewer to actively resist or confront. If confronted, Karl will immediately apologize for any difficulty the interviewer is having, while indicating with a supercilious smile that he considers the interviewer’s difficulties pathetic.

Examples of Karl’s Dialogue “What brought me here? You tell me, doctor. Apparently, it’s illegal for a father to tell his daughter to do her homework.”

I f Confronted with the Fact that the Incident Occurred as Jenna Was Getting Ready for School “No, no, you’re mistaken—I’m talking about what happened last night. That’s when the problem happened. I think your

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information was wrong—I think that came from Sandy. She’s been very confused recently.” I think my wife is very upset, and actually unstable. I’ve been pleading with her to get help, for months. (This is a lie.) His company has referral information for very highly qualified mental health specialists—psychiatrists who are actually trained in how to do this kind of work—but Sandy took a name from one of her girlfriends, and she’s gotten herself into the hands of this Miss Nesbit (by using “Miss” Karl implies that she’s a man-hater or a lesbian). She calls herself a psychoanalyst. I don’t know what that is. I don’t know what her agenda is. I’ve begged Sandy to let me come to her sessions with her (this is a lie) but apparently Miss Nesbit won’t allow it.” “So here are the facts. I asked my daughter to do her homework last night. Jenna responded very disrespectfully – frankly I’m very worried about her too. And Sandy seemed fine with it. In fact, since she’s started receiving counselling from Miss Nesbit, she’s become very aggressive. I am doing my best to help both of them, and working a full-time job. I have to tell you, Doctor, Doctor – what was your name again? It’s very difficult at times. (If addressing a female) I’m sure you don’t engage your husband like that  – but of course you’re a successful professional.” “So what happened this morning—I was trying to encourage our daughter to go to school. I brushed past Sandy in the hallway—and the next thing I knew, she was calling 911.”

If Questioned About Removing the Door “Well this is another example, Doctor (mispronounces interviewer’s name) of how things get distorted. Jenna has been very unstable, and one of the things she does is slam her door when she gets angry—and in the process of this one of the linchpins got bent and took the door out of alignment—and I told Sandy it was only a matter of time before the door came off its hinges (this is a lie) and so I took the door off its hinges, and I moved it down under the deck so I could realign

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the hinge—I have to build up the base with epoxy, and then plane it off and re-drill the screw holes for the hinges—do you follow? Well, the thing you need to understand is that it was a big job, and I knew it would have to wait until the weekend. I left the door under the deck—it’s possible that some of the neighborhood kids might have moved it, as a prank. That’s been going on recently”.

Asked About the Bruises on Jenna’s Arms “Well, all I can tell you Doctor, is I didn’t see any bruises on her arms this morning. It’s possible that I didn’t notice them. I wasn’t going to mention this, but I’ve been concerned recently that Jenna has been sneaking out of the house. Her grades are falling, and her mother has been telling her it’s all right, and encouraging her to blame me  – I’m afraid this is affecting her self-esteem and may be leading her into some kind of promiscuous activity. That’s possible. If there are bruises on her arms, that’s where it’s coming from.” After gathering other background information, the interviewer is left with an account from Karl that is at variance with the police report and other documents accompanying the case. Karl will insist that all the collateral information is wrong. If the interviewer fails to confront him, the interview will stall at this point. The SP should not help or provide further information unless the interviewer specifically asks for help. A major part of this teaching exercise is to give experience with what happens if you fail to confront a dishonest or unreliable historian. Successful confrontation could take many forms, and should be delivered calmly, professionally, with tack and empathy, for example, “Wait a minute Mr. Moehller – there’s something here I don’t understand. You’re saying that nearly every piece of information in this report is wrong (i.e., police statement that door was found in woods, bruises on daughter’s arm, wife’s account of Karl shoving her). How do you

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explain that? It isn’t just your word against your wife’s (as Karl maintains). Your daughter says you did these things. The police say you were agitated. They found the door of your daughter’s room in the woods. How can you say this just didn’t happen? I have to tell you, you make a lot of sense, but your story doesn’t line up with the available facts.”

LEVEL TWO Behavior During the Interview Karl now feels threatened and responds to the interviewer’s confrontation by ignoring the interviewer’s question, and abruptly asking once of his own in a pseudo-curious fashion, for example, “Doctor, can you tell me a little bit about yourself? You completed medical school—where was that? (expresses contempt in a deniable fashion by raising eyebrows, asking that the unfamiliar name be repeated, etc.) And I understand that you’re currently in training here? Do you have any training in marital psychiatry?” • If the interviewer graduated from Osteopathic School (i.e., DO), Karl will repeatedly touch on this, for example, asking if the DO degree confers the title of “Doctor” or something else, referring to interviewer as an MD and then correcting himself, asking questions about osteopathy being related to chiropractic medicine, joking about needing a realignment of his back, etc. This should be reasonably subtle, but disparaging and annoying. As interviewer attempts to conciliate Karl, encouraging him to talk, stating a supervisor will be available later, Karl responds “Doctor, I have been arrested based on a false accusation. I have answered all your questions. I have repeatedly attempted to give you the actual facts of the situation. Not the “facts” as Miss Nesbit sees them. Not the “facts” that Sandy has brainwashed our daughter to parrot back. And now you’re telling me that you don’t understand. Please tell me exactly what it is you don’t understand?”

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Karl refers to the interviewer as a “psychiatrist” when currying favor, or invoking the interviewer favorably in contrast to his wife or his wife’s therapist. As he becomes more actively denigrating, he refers to the interviewer as a “psychologist” or “psychoanalyst.” Karl will take the role of a teacher, schooling the interviewer on how he or she should conceptualize the interview, what questions he/she should be asking. At various points in his “teaching role,” Karl will ask intrusive and irrelevant personal questions, as if to understand his “student” better. • “Are you married? If so, for how long?” • “Were you born in the United States?” • “Are you (Jewish? Hindu? Islamic? Christian?) based on the apparent background of the interviewer.” • “May I ask what church you attended?” The interviewer should redirect away from these questions, but likely will be intimidated into answering at least some of them. Karl will respond with patronizing “helpful” guidance about the nature of marital commitment, American values and constitutional rights (his have been violated), the sanctity of marriage in the Christian religion (unlike other religions), the importance of religious observance in his own life. Karl will continue to restate these questions, indicating that he already answered, until or unless the interviewer becomes openly confrontational. At such a point, Karl will become openly angry, and will demand that he speak with the interviewer’s supervisor. This demand creates a crisis that can only be bridged by the interviewer insisting on completing the interview, and brings us to Level 3

LEVEL THREE Behavior During the Interview Karl is now engaged and emotionally out of control—though he still speaks in measured tones. He confronts the interviewer with icy, threatening contempt. His narcissism reaches

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an almost delusional level as he seeks to disparage the interviewer. Karl’s rage and bigotry will further escalate, again playing off any perceived weakness—race, gender, immigration status, peculiarities in attire, again with a near-delusional notion that the interviewer, not he, is under examination and facing legal threat. For example: • To a foreign-seeming resident “Doctor, I wasn’t going to ask this, but now I think it may be relevant: I want to know about your immigration status. Are you here on a visa? (asks about dates of entry and other personal information)” • To a minority resident: “Can I ask where you went to medical school? Let me ask you this – I assume you had the benefit of an affirmative action program is that correct? What you don’t want to discuss that? I can’t say I’m surprised. But we’re not in some academic fantasy world any more. You are a professional, however you got here, and you’re going to have to act like a professional, or face the consequences.” • To a female resident: “Now I assume you chose to become a psychologist for lifestyle reasons. Do you have children? Well I assume you’re going to have children. You need to understand that this is serious business. This isn’t a game.” More generally • “I have to tell you that I’m growing concerned by the number of factually false representations you’ve made here, Doctor.” (Invites question, then lists his alleged shoving of his wife, the removal of his daughter’s door, the bruises on her arm, etc.). “I don’t know if you have some kind of agenda, or if you’re simply misinformed.” • “Let me ask you this  – I should have asked this before. What contact have you had with Miss Nesbit? Do you have a financial relationship with her?.... Oh really? “ (nods contemptuously)

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• “Are you aware of the potential consequences of filing false information in a medical report?” • “Do you really think that I am going to be judged by you, Doctor, Doctor (mispronounces name or other insult)? I’ve asked to speak to your supervisor. (Interrupts interviewer, raising his voice). How dare you  – how dare you question me!” It’s unlikely that any of the interviewers will be able to respond to this effectively. An appropriate strategy would be, for example, to say “Mr. Moehller, I am doing my best to listen to you and get your side of this story. I have no agenda other than to understand what happened – and you can help me by answering my questions.”

LEVEL 4 If the interviewer keeps his or her cool and politely but persistently confronts Karl despite his insults, eventually Karl will simply refuse to cooperate (although the SP should feel free to improvise in response to a more novel response). The interviewer may go back to clarify events or get other information. In this case Karl will be sullen but cooperative. In short, the “Karl” encounter is designed to plunge the trainee into a contentious environment in which facts are of minimal immediate significance, and Karl’s abusive domineering personality is demonstrated rather than described.

References 1. Goldner-Vukov M, Moore L.  Malignant narcissism: from fairy tales to harsh reality. Psychiatr Danub. 2010;22(3):392–405. 2. Hill C, et al. Aspiring to become a therapist: personal strengths and challenges, influences, motivations, and expectations of future psychotherapists. Couns Psychol Q. 2013;26 https://doi.org/10.108 0/09515070.2013.825763.

Conclusion

Beware of lying! Verily, lying leads to wickedness and wickedness leads to the Fire.” (Sahih Al-Bukhari: Book 73, Hadith 116)

The core thesis of this volume is that human communication transcends the mere exchange of information. Every communicative statement represents a balance between an innate human need to share ideas perceptions; and the need for privacy and autonomy. In contemporary psychiatric practice, interpersonal aspects of the clinical encounter are frequently ignored, or at best compressed by a range of institutional concerns. We have attempted to demonstrate both the potential value of attention to this domain and the negative consequences of neglecting it. Nowhere is the interpersonal process of greater importance than in the instance of deceit and nondisclosure in the psychiatric interview. As we have discussed throughout the volume, unacknowledged DND exercises a powerful negative influence on the formation of a therapeutic relationship between clinician and patient, often manifest as boredom or anxiety on the part of the clinician. When engaged, on the other hand, DND is not only far more likely to be successfully detected but also can serve as a means of attaining profound understanding of the concerns and motivational state of the patient. Interpersonally, such concerns include shame and the fear of prejudicial conclusions on the part of the clinician. To the extent that in evaluating clinician serves as a representative of the patient’s own © Springer Nature Switzerland AG 2020 A. Lerman, The Non-Disclosing Patient, https://doi.org/10.1007/978-3-030-48614-3

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observing consciousness, DND may also represent the result of an effort of self-deception. As a result, identification and engagement of DND afford a unique means of assessing personality functioning. Nowhere are these dynamics more evident than in the case of substance use disorders. It is virtually a cliché to observe that individuals struggling with deepening substance use engage in “denial”; and in deeper stages of dependency are frequently highly deceptive regarding their behavior while simultaneously experiencing deep affective shame. A process of fragmentation of self-awareness and capacity to regulate behavior appears to lie at the heart of the addictive process. Repair of this fragmentation is, similarly, a major component of recovery. We may hope that functional neuroimaging may bring a new age of biologic empiricism to the daunting complexity of the human capacity for deception, but as yet this remains a hope only. Efforts to develop a biological “lie detector” remain limited to a rudimentary capacity to detect states of arousal. The aspects of neural functioning that govern deception are likely to represent higher-order phenomena engaging a range of substrates throughout the brain. Well this question represents an ongoing area of interest, there is little evidence of major progress in determining veracity through study of the biological mind. Simulated patient interviews represent a unique means to both teach and study the processes of deception. A developing body of experimental data offers an evidence base to support the importance and validity of long-established principles of therapeutic engagement, including empathy and warmth; the capacity to sustain inquiry in the face of evasive or deceptive behavior on the part of the patient; and response to nonverbal and affective cues during the interview. Lastly, we have the special case of psychopathic behavior. That is to say clinical contact with individuals whose goals for the engagement include only deception, manipulation, or, in some cases, the desire to hurt or denigrate the clinician. Most models of training with this population tend to focus

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e­ xclusively on physical safety concerns. While this is certainly important, attention to the full range of the interpersonal encounter affords awareness of other dangers, such as degradation, loss of confidence, or in some cases professional injury. Within the safety of a simulated encounter, this specific and particularly hazardous form of DND can be examined, identified, and clinicians in training given the opportunity to develop a means of engaging it. In sum, the practice and extent of DND are as varied as the human race itself.

Index

A Acetylcholine, 83 Action statement, 58 Active falsification, 113 Aggression in the simulated case scenario, See Karl Moehller scenario American Association of Directors of Psychiatric Residency Training (AADPRT) Clinical Skills Verification worksheet, 9 Antisocial personality disorder, 145, 148, 186 Anti-therapeutic relationship, 30, 31 Anxiety, 62, 63, 166 Attributes of deception, 104, 105 Autism, 98 B Basic interviewing, 162 Behavioral psychotherapies, 30 Behavioral therapy, 30, 31 Bias, 73 Bilateral ventrolateral prefrontal cortices (VLPFCs), 74 Blood-oxygen-level-dependent (BOLD), 74 Bobble heading, 186, 190, 192

Borderline personality disorder, 129, 130, 143, 148 Borderline Personality Organization, 127–130 C Case studies in psychopathy, 137–148 Character, 122 Cholinergic antagonism, 84 Chronbach’s alpha, 165 Chronic passive suicidal ideation, 21 Clinical Skills Verification (CSV), 166 Clinicians-in-training, 153 Cognition, 67 Cognitively rich and complex mental process, 73 Concealment, 101 Confronting non-disclosure scores, 165 Connectivity studies, 78–81 Countertransference, 36–38 Cultural learning, 99 D Death of psychopathology, 122 Deceit and its meaning clinical example, 51–53

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Index

Deceit and its meaning (cont.) psychodynamic principles absence of treatment frame, 56, 57 anxiety, 62, 63 failure of neutrality, 57–61 imbalance of power, 61, 62 transactional encounters, 53 extramural significance, 54 intimacy without context, 55 template question, 54 transactional interview, application of, 49, 50 Deception detection techniques, 69, 70 attention, 82–84 connectivity studies, 78–81 deceptive skills and role of genetics, 89 definition of, 68 electroencephalogram (EEG), 72, 73 functional magnetic resonance imaging, 74–78 inhibitory modulation, 88, 89 memory, 85, 88 neurochemistry of deception, 81, 82 neuroimaging and deception, 73, 74 polygraph test, 71, 72 thermal imaging, 72 types of, 101, 102 Deceptive behavior, 145 Deceptive skills and role of genetics, 89 Defense mechanisms, 45, 126, 128, 136 Defense model, 126, 130 Defensive problems, 135–137 Dissociation and disorganization, 111

Dissociation and self-deception, 113 DND and psychopathology, 106 affect containment, 108, 109 dissociation and disorganization, 111 manifests as hopelessness, 103 paranoia and psychopathy, 110, 111 pragmatic lies, 107, 108 predatory deception, 111 qualities of, 113 shame & guilt, 109, 110 social deception and white lies, 107 window, 104 Domestic violence, 200 Dopamine antagonism, 84 Dorsal ACC (dACC), 80 Dorsolateral prefrontal cortex (DLPFC), 74 DSM-5 Alternative Model, 122 E Ego weakness, 128 Electroencephalogram (EEG), 72, 73 Engaging deceit, 102–103 clinical example, 39–48 principles of, 35, 36 clinician’s emotional or countertransference, 36–38 follow the affect, 39 transactional assessment, 36 why driving DND, 38, 39 Engaging DND, principles of, 156 Event-related potentials (ERPs), 72 Executive functions, 67–69 Expectation of shared consciousness, 100 Explicit memory, 85

Index F Fact-based interview, 17, 18, 38 Failure of neutrality, 57–61 Falsification, 101 Formulation-guided interview, 38 Fragmentation model “Borderline Personality Organization”, 127, 128 Freudian and post-Freudian theory, 125 Functional magnetic resonance imaging (fMRI), 74–78 desensitization, 77 honest deception, 76 idiographic approach, 75 inhibitory modulation and task selection, 77 intention determines outcome, 75 real life settings versus laboratory settings, 74 reliability and generalizability, 76 G Gated simulated patient interview biggie scenario, 166 actors and interview setting, 160 covariance of interviewing competencies, 163, 165 deception/non-disclosure behavior in, 158 interview cohort, 161 measures, 161 performance results by correlation, 164 results, 162, 163 scenario design, 159, 160 selected rating categories, 161–162

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WMC simulated patient program, development of, 158, 159 cautionary views of SP exercises, 157 different challenges, 154 good patients /bad patients, 154 higher goals for, 155, 156 simplified process, 153 simulated scenario, positive reports, 156, 157 WMC SP Scenario goals, 157 Glutamate and GABA, 82 Guilty knowledge testing (GKT), 74 H Hands-on didactic method, 153 Hard and soft DND, 25, 52, 113, 116, 117 I Idiographic approach, 75 IMG status, 166 Immature defense mechanisms, 126 Implicit memory, 85 Inhibitory modulation, 88, 89 Inservice testing, 166 Insight-directed psychotherapies, 27, 30 Interviewing, types of, 17 fact-based interview, 17, 18 meaning-focused interview, 19, 20 transactional interview, 20, 21 Intraparietal sulcus (IPS), 80 K Karl Moehller scenario, 187 design and supportive documents, 224

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Index

Karl Moehller scenario (cont.) behavior during interview, 226–228, 230–234 goals of the interview, 219 interview process, 225 interview scenario, 225 Karl’s Background, 221–223 presenting problem, 219, 220 Sandy, Karl’s wife, 223, 224 good intentions, frustrated, 218, 219 interview with Dr. Choudhury, 188 bobbleheading, 190, 192 domestic violence, 200 founding fathers, 213, 214 ignoring subject’s aggression, 190 longitudinal history, 203 pheromones, 197 templating, 210 the door, 201, 202 problems with, 187, 188 L Lifetime vigilance, 4 Long range connectivity and cognitive function, 80 Long term potentiation (LTP), 87 M “Malignant Narcissism” model, 130, 186 Masochism, 127 Mature defense mechanisms, 126 Meaning-focused interview, 19, 20 Medial prefrontal cortex (mPFC), 74 Memory- and encoding-related multifaceted

electroencephalographic response (MERMER), 73 Mental health assessment interview, 118 Mentalization, 100 Mirror neurons, 97 Modulatory neurotransmitters, 82 Moral insanity, 121 Motivational and early fragmentation model, 127 Multiple function, 112 active falsification, 113 alcoholic at rock bottom, 116 cosmopolitan Christian, 112, 113 dissociation and selfdeception, 113 executive accused of domestic violence, 117, 118 gun owner, 116, 117 qualities of DND, 113 soft vs. hard DND, 113 taxonomy of deceit, 114–115 veteran who avoids psychiatrists, 116 N Narcissism, 127 Narcissistic personality disorder, 143 Neural oscillation synchronization reflecting system, 80 Neural plasticity, 89 Neurobiology of deception deception detection techniques, 69, 70 attention, 82–84 connectivity studies, 78–81 deceptive skills and role of genetics, 89

Index electroencephalogram (EEG), 72, 73 functional magnetic resonance imaging, 74–78 inhibitory modulation, 88, 89 memory, 85, 88 neurochemistry of deception, 81, 82 neuroimaging and deception, 73, 74 polygraph test, 71, 72 thermal imaging, 72 executive functions, 67–69 Neurochemical transmission, 82 Neurochemistry of deception, 82 Neuroimaging and deception, 73, 74 Neurotransmission, 82 Neurotransmission modulation, 88 Neutrality, failure of, 57, 58 clinical example, 58–60 Francine clinical example, 58, 59 Karl clinical example, 60, 61 N-methyl-D-aspartate (NMDA) receptor and metabotropic glutamate (mGlu) receptor, 88 Non-disclosure (ND), 5, 15, 33, 101–103 classes of, 44 and Concealment, 105 Nonlinear process and transference, 60 Nonspecific ego weakness, 134, 135 Noradrenergic system, 83 O Objectify experience critically, 35

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P Paranoia and psychopathy, 110, 111 Patient Care, 9 PDT, 124 Personal encounter with deceit, 3–7 Personality disorders, 121, 148 clinical example, 131–134 defense model, 126 defensive and malignant narcissism models of DND, 130 defensive problems, 135–137 definition of, 122 differentiation of “Borderline Personality Organization from DSM, 128 fragmentation model “Borderline Personality Organization, 127, 128 hierarchy of selected defense mechanisms, 123 morality, self esteem and descent into primitive masochism, 131 motivational and early fragmentation model, 127 psychoanalytic perspective on personality, 123–125 structural model, 125, 126 structural problems or nonspecific ego weakness, 134, 135 Pheromonal communication, 98 Pheromones, 197 Polygraph test, 71, 72 Pragmatic Lies, 107, 108 Predatory deception, 111 Primitive defense mechanisms, 135

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Index

PRITE Psychiatry Global Score, 165 Psychiatric evaluation, 9 Psychiatric hospitalization, 21 Psychiatric interview, 17, 35, 153 fact collection and templating, 10, 11 assessment goes awry, 11, 12 forms of non-disclosure, 12 psychotherapeutic literature, 12, 13 therapeutic repulsion, 13 higher goals for, 155 impact of deception, 14 non-disclosing patient, 15 purpose of, 9 simplified process, 154 Psychoanalytic perspective on personality, 123–125 Psychodynamic, 52 Psychodynamic principles absence of treatment frame, 56, 57 anxiety, 62, 63 failure of neutrality, 57, 58 clinical example, 58–60 Francine clinical example, 58, 59 Karl clinical example, 60, 61 imbalance of power, 61, 62 Psychodynamic theory (PDT), 123 Psychological withdrawal, 15 “Psychopathic” personalities, 121 Psychopathy, case studies in, 137–148 Psychotherapeutic literature, 12, 13 Psychotherapy, 97, 133 Q Qualities of DND, 113

R RDoC, 122 Reliability of polygraph testing, 71 Resting state functional connectivity (RSFC), 79 S Schizoaffective disorder, 142, 145 Schizophrenia, 98 Self-deception, 106, 136 Serotonin, 84 Sexuality, 144 Share perceptual and emotional experience, 97 Shared consciousness and emergence of mind attributes of deception, 104, 105 capacity to conceal, 101 concealment, 101 cultural learning, 99 dissociation, disorganization and non-disclosure, 102 patient as storyteller, 118, 119 DND and psychopathology, 106 affect containment, 108, 109 dissociation and disorganization, 111 manifests as hopelessness, 103 paranoia and psychopathy, 110, 111 pragmatic lies, 107, 108 predatory deception, 111 shame & guilt, 109, 110 social deception and white lies, 107 window, 104

Index domains of distortion, non-disclosure and deceit, 101 engaging deceit, 102–103 falsification, 101 mentalization, 100 mirror neurons, 97 multiple function, 112 active falsification, 113 alcoholic at rock bottom, 116 cosmopolitan Christian, 112, 113 dissociation and selfdeception, 113 executive accused of domestic violence, 117, 118 gun owner, 116, 117 qualities of DND, 113 soft vs. hard DND, 113 taxonomy of deceit, 114–115 veteran who avoids psychiatrists, 116 self-deception, 106 taxonomy of deception, 105 teenage quarrel, 103 Sharing experience, 97 Social Deception and “White lies” , 107 Soft vs. hard DND, 113, 117 Stratified listening, 22, 23 assembling narrative, 22 emotional narrative, 23, 24 formulation-guided listening, 25 listening for emotions, 22 listening for facts, 21 listening for inconsistencies/ omissions and why they occur, 22

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omissions and distortions, 24 subjective narrative, 23 Structural model, 125, 126 structural problems, 134, 135 Suicidal ideation, 143, 145 Superego, 125, 131 T Taxonomy of deceit, 114–115 Taxonomy of deception, 105 Templating, 37 Therapeutic and anti-therapeutic relationships, 27–29, 33 clinical example, 28 patient experience and behavior, 31 Therapeutic relationship, 29, 30 behavioral therapy, 30, 31 Therapeutic repulsion, 13 Thermal imaging, 72 Transactional encounters, 53 extramural significance, 54 intimacy without context, 55 template question, 54 Transactional interview, 20, 21 application of, 49, 50 Transference-based psychotherapy, 131 Treatment frame, 56, 60 U Unspecified personality disorder, 148 W White lies, 107, 112 Working memory, 88