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Deception in clinical settings.Chapter 1. an introduction to response styles
- Complete and accurate self-disclosure remains a rarity even in the uniquely supportive
context of a psychotherapeutic relationship. Even the most involved clients may intentionally
conceal and distort important data about themselves.
- Deceptions routinely occur in personal relationships, including intimate relationships.
- Beyond therapy and relationships, deceptions commonly occur in the workplace, including
the concealment of mental disorders. Most of the 17 to 20% of employees affected by
mental disorders annually elect not to disclose their conditions due to public stigma or more
specific concerns about potential damage to their careers.
- What are two key implications of the study by Ellison et al.? First, decisions about response
styles (disclose or deceive) are often rational and multidetermined; this theme is explored
later in the context of the adaptational model. Second, these decisions are often
individualized responses to interpersonal variables (e.g. a good relationship with a coworker)
or situational demands (e.g. explanation of poor performance).
- Decisions to deceive or disclose are part and parcel of relationships across a spectrum of
social contexts. For instance, impression management plays a complex role in the workplace,
especially with reference to what has been termed concealable stigmas.
- Social desirability and impression management may prevail during the job application
process but later be abandoned once hiring is completed.
- Clients in an evaluative context may experience internal and external influences on their self-
reporting.
- Lexogenic effects = within a forensic context, for example, clients may respond to adversarial
effects of litigation, in which their credibility is implicitly questioned.
- In summary, all individuals fall short of full and accurate self-disclosure, irrespective of the
social context. To be fair, mental health professionals are often not fully forthcoming with
clients about their assessment and treatment methods.
- In the context of clinical assessments, mental health professionals may wish to consider what
level of deception should be documented in their reports. One reasoned approach would be
to record only consequential deceptions and distortions.
- Double failures; many simulators could be categorized as this. They failed to elude the ESCT-
R Atypical scales (i.e. screens for possible feigning) and also failed to produce anything more
than normal to mild impairment (i.e. they appeared competent) on the ECST-R Competency
scales).
- The general issue of inconsequential deceptions should be considered carefully. Simply as a
thought experiment, two extreme alternatives are presented: the taint hypothesis and the
beyond-reasonable-doubt standard.
1. Taint hypothesis = any evidence of nongenuine responding is likely to signal a broader
but presently undetected dissimulation. Therefore, practitioners have a professional
responsibility to document any observed, even if isolated, deceptions.
2. Beyond-reasonable-doubt standard = invoking the stringent standard of proof in criminal
trials, only conclusive evidence of a response style, such as feigning, should be reported.
- In forensic practice, determinations of malingering are generally perceived as playing a
decisive role in legal outcomes, because they fundamentally question the veracity and
credibility of mental health claims.
, - Mental health professionals must decide what evidence of response styles should be
routinely included in clinical and forensic reports. Guided by professional and ethical
considerations, their decisions are likely to be influenced by at least two dimensions: (1)
accuracy vs. completeness of their conclusion, and (2) use vs. misuse of clinical findings by
others.
- As an introduction to response styles, this chapter has the primary goal of familiarizing
practitioners and researchers with general concepts associated with malingering and
deception. It operationalizes response styles and outlines common misconceptions
associated with malingering and other forms of dissimulation. Conceptually, it distinguished
explanatory models from detection strategies. Because research designs affect the validity of
clinical findings, a basic overview is provided. Finally, this chapter outlines the content and
objectives of the subsequent chapters.
Fundamentals of response styles
Basic concepts and definitions
- Considerable progress continues to be made in the standardization of terms and
operationalization of response styles. This section is organized conceptually into four
categories; nonspecific terms, overstated pathology, simulated adjustment, and other
response styles.
Nonspecific terms
- Overspecification of response styles = when disabled clients express ambivalence toward
clinical or medical interventions, their less-than-wholehearted attitudes are sometimes
misconstrued as prime facie evidence of secondary gain.
- The working assumption for errors in the overspecification of response styles is that
practitioners approach this diagnostic classification by trying to determine which specific
response style best fits the clinical data. This approach asks practitioners to make an explicit
decision between nonspecific or general descriptions and specific response styles.
- Non-specific descriptions should be considered first to reduce the understandable tendency
of overreaching data when conclusions about specific response styles cannot be convincingly
demonstrated.
- BOX 1.1. two step (general-specific approach for minimizing overspecification:
1. Do the clinical data support a nonspecific (e.g. unreliable informant) description?
2. If yes, are there ample data to determine a specific response style?
- Nonspecific terms are presented in a bulleted format as an easily accessible reference. Terms
are defined and often accompanied with a brief commentary:
- Unreliability = a very general term that raises questions about the accuracy of reported
information. It makes no assumption about the individual’s intent or the reason for
inaccurate data.
- Nondisclosure = a withholding of information (ie. Omission). Similar to unreliability, it makes
no assumption about intentionality.
- Self-disclosure = how much individuals reveal about themselves.
- Deception = an all-encompassing term to describe any consequential attempts by individuals
to distort or misrepresent their self-reporting. As operationalized, deception includes acts of
deceit often accompanied by nondisclosure. Deception may be totally separate from the
patient’s described psychological functioning (see dissimulation).
- Dissimulation = a general term to describe a wide range of deliberate distortions or
misrepresentations of psychological symptoms.
,Overstated pathology
- Important distinctions must be realized between malingering and other terms used to
describe overstated pathology
- Recommended terms to categorize overstated pathology:
1. Malingering = consistently defined by DSM nosology as the intentional production of
false or grossly exaggerated physical or psychological symptoms, motivated by external
incentives. An important consideration is magnitude of the dissimulation; it must be the
fabrication or gross exaggeration of multiple symptoms.
2. Factitious presentations = are characterized by the intentional production or feigning of
symptoms that is motivated by the desire to assume a sick role. However, the description
of the motivation is no longer specified; the deceptive behavior is evident even in the
absence of obvious external rewards. Thus, the diagnosis of factitious disorders does not
preclude external incentives but rather requires some unspecified internal motivation
3. Feigning = the deliberate fabrication or gross exaggeration of psychological or physical
symptoms, without any assumptions about its goals. Determinations can often be made
for feigned presentations but not their underlying motivations. To underscore this point,
psychological tests can be used to establish feigning but not malingering.
- Several terms that are common to clinical and forensic practice lack well-defined and
validated descriptions. This absence stems from either the lack of clear inclusion criteria, or
the presence of multiple and conflicting definitions. Three terms to be avoided in clinical and
forensic practice are:
1. Suboptimal effort (also: incomplete or submaximal effort) is sometimes misused as a
proxy for malingering. This term lacks precision and may be applied to nearly any client
or professional.
2. Overreporting = simply refers to an unexpectedly high level of item endorsement,
especially on multiscale inventories. It has also been called self-unfavorable reporting.
Practitioners sometimes erroneously equate it with feigning. However, this descriptive
term lacks clarity with respect to its content.
3. Secondary gain = unlike the other unacceptable terms, does have clear definitions. Its
inherent problem for professional practice, stems from the presence of conflicting
meanings.
Simulated adjustment
- Three closely related terms are used to describe specific response styles that are associated
with stimulated adjustment. Defensiveness is operationalized as the masking of psychological
difficulties, whereas the other two terms apply more broadly the concealment of undesirable
characteristics
1. Defensiveness = the polar opposite of malingering. Refers to the deliberate denial or
gross minimization of physical and/or psychological symptoms.
Ego defenses = intrapsychic processes that distort perceptions
2. Social desirability = the pervasive tendency for certain individuals to present themselves
in the most favorable manner relative to social norms and mores.
3. Impression management = refers to deliberate effort to control others’ perceptions of an
individual; its purposes may range from maximizing social outcomes to the portrayal of a
desired identity. Is often construed as more situationally driven than social desirability.
Other response styles
- Several additional response styles are not as well understood as malingering, defensiveness,
and other approaches previously described. Four other response styles are outlined:
, 1. Irrelevant responding = refers to a response style in which the individual does not
become psychologically engaged in the assessment process. The given responses are not
necessarily related to the content of the clinical inquiry.
2. Random responding = this style is a subset of irrelevant responding based entirely on
chance factors.
3. Acquiescent responding = referred to as yea-saying, which is rarely experienced in its
pure form.
4. Disacquiescent responding = the opposite of acquiescence, nay-saing.
5. Role assumption = individuals may occasionally assume the role or character of another
person in responding to psychological measures
6. Hybrid responding = this style describes an individual’s use of more than one response
style in a particular situation.
Domains of dissimulation
- A convenient framework for understanding and assessing response styles is the concept of
domains = three broad domains encompass most attempts at dissimulation: (1) feigned
mental disorders, (2) feigned cognitive abilities, and (3) feigned medical
complaints/symptoms. These domains are essential to assessment of response styles,
because detection strategies are rarely effective across these three domains.
Common misconceptions about malingering
- Common fallacies about malingering held by both practitioners and the public:
1. Malingering is rare
2. Malingering is a static response style: “once a malingerer, always a malingerer”
3. Malingering is an antisocial act by an antisocial person. This serious error arises from
confusing common characteristics (e.g. criminality in criminal settings) with
discriminating characteristics (which consistently differentiate malingerers from
nonmalingerers.
4. Deception is evidence of malingering
5. Malingering is similar to the iceberg phenomenon. Like the taint hypothesis, this
misconception appears to be based on the theory that any evidence of malingering is
sufficient for its classification. The erroneous assumption appears to be that any
observable feigning, similar to the visible tip of an iceberg, represents a pervasive pattern
of malingering.
6. Malingering precludes genuine disorders; an implicit assumption is that malingering and
genuine disorders are mutually exclusive.
7. Syndrome-specific feigning scales measure syndrome-specific malingering. Clearly,
syndrome-specific feigning scales must be able differentiate designated syndrome-
specific feigning from generic feigning
8. Malingering has stable base rates. There are variations
- The additive effects of multiple misconceptions may fundamentally damage clinician’s
abilities to evaluate malingering and render sound judgments.
clinical and research models
motivational basis of response styles
- This section introduces a clinical framework for understanding response styles, such as
malingering. Because most response styles are conceptualized as deliberate efforts,
individual motivations become a central concern
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