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Summary Deception In Clinical Settings
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A model to approaching and providing feedback topatients regarding invalid test performance in clinical
neuropsychological evaluations
- The use of symptom validity assessment has become commonplace in clinical
neuropsychological evaluations. However, clinicians often struggle with how to provide
patients with feedback regarding invalid responding or effort, because of the sensitive nature
of the information that must be conveyed. A conceptual framework for providing such
feedback is outlined in clinical neuropsychological evaluations, and recommendations for
how to handle complaints are offered. Our feedback model is not meant to apply to
individuals referred by attorneys or other non-clinical third parties (e.g. independent medical
examination companies).
Introduction
- The primary focus of the present article is on providing feedback to patients in clinical
settings about their performance on tests of effort and response bias; however, the article is
also relevant for feedback about apparent exaggeration of cognitive, emotional, behavioral,
and physical symptoms or problems based on other data sources, such as self-report
measures and behavioral observations.
- Although one may exaggerate without malingering, malingering by definition includes
symptom exaggeration.
- The extent to which such exaggeration is intentional, with the goal of attaining some sort of
secondary gain, can be difficult to determine.
- Some patients exaggerate their symptoms to influence the dynamics of the doctor-patient
relationship. From the patient perspective, the exaggeration might bring them more
attention and make them a more interesting patient in the opinion of their physician or
psychologist.
- Despite the anticipatory fear of potential conflict with the patient, it is our experience that in
most cases honest feedback about poor effort and exaggeration can be provided without
causing significant conflict and without grossly distorting the meaning and clinical
implications of the evaluation findings.
- The model presented in this article relates to clinical, rather than forensic, evaluations.
- Social-psychological factors can influence how a person perceives and reports his or her
symptoms:
1. Nocebo effect = negative expectations are causally linked to the sickness or symptoms;
that is one’s mind set or belief system can affect the outcome of his or her health,
independent of other risk factors
2. Misattribution = normal everyday symptoms, or symptoms that are due to another
cause, are incorrectly attributed to a specific injury, illness, or condition
3. Good-old-days bias = response bias in which patients’ retrospectively recall themselves
as being healthier in the past and experiencing fewer pre-injury or pre-illness symptoms
than the base rates of those symptoms in the healthy population. Thus, they over-
estimate the degree of change.
Phase one: building rapport and obtaining informed consent
- For a feedback session to be successful following a clinical neuropsychological evaluation, it
is important for the clinician to lay the foundation by making specific attempts to build
rapport from the initial point of contact, which is typically the intake interview.
, - This early rapport building is a crucial aspect of our clinical feedback model, which is
premised on the notion that patients are more willing to accept feedback about topics that
are uncomfortable if a trusting relationship has been established.
- Our approach involves making patients aware that there is no guarantee that the results of
the evaluation will be in agreement with their (or their family’s) views of what is wrong with
them and why. Furthermore, we suggest making patients aware that they are to try their
best during the evaluation and to avoid exaggerating their problems
- We recommend informing patients that identification of symptom exaggeration or poor
effort on tests can lead to inconclusive findings and can have a negative impact with regard
to compensation-related claims and pursuit of others forms of secondary gain (e.g. academic
accommodations) that is coincident with a clinical referral.
- Assent = willingness to participate (for patients who lack the cognitive capacity to provide
consent, their assent is obtained and documented)
- The informed consent process also affords the neuropsychologist the opportunity to ask
about prior exposure to psychological or neuropsychological tests, including information
provided by others or obtained from the Internet.
Phase two: completing the evaluation and preliminary discussions with the
patient
- When the results of initial symptom validity measures reveal unequivocal evidence of
suboptimal effort, the examiner must decide whether to administer the remained of the
planned evaluation
- When the evaluation has been completed, we suggest that the neuropsychologist initially
explore how willing the patient is to acknowledge poor effort
- Cognitive restructuring technique = the patient is led to think differently about a particular
topic so as to alter the resultant emotional reaction (e.g. the word “faking” is replaced with
the word “disengaged”). In doing so, our model proposes that patients will be more willing to
discuss sensitive and controversial issues.
- We advocate holding the full feedback session, whenever possible, on a date separate from
that of the test administration, so that the neuropsychologist has time to integrate all of the
available information and consider how to best broach with the patient the particular issues
unique to the case. However, there may be instances in which such delay may not be
possible. In such instances, the techniques described in phase Three can be applied
immediately after testing has been completed.
Phase three: the feedback session
- Because many patients are understandably anxious when arriving for a feedback session, it
can be helpful to begin the session with a general conversational comment such as “So how
do you think you did on the tests?”
- The next phase of feedback is informing the patient how the neuropsychologist generally
reached the aforementioned conclusion, without identifying specific tests or methods. It is
emphasized to the patient that the conclusions being made are based on objective data and
that the neuropsychologist is obligated to rely on such data. Such information helps the
patient understand that the neuropsychologist has objective evidence to support the
conclusions and that the conclusions are not based on subjective impressions
- Patients are next asked if they would agree that they should perform better than a severely
impaired clinical group, such as patients with Alzheimer’s disease or children with mental
retardation.
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