Deception in clinical settings
Clinical assessment of malingering and deception
1 | An Introduction to Response Styles
Complete and accurate self-disclosure remains a rarity even in the uniquely supportive
context of a psychotherapeutic relationship. Baumann and Hill (2016) found that outpatient clients
sometimes did not divulge personal matters related to sexual experiences, substance abuse, and
relationship experiences.
Despite imagining positive gains from such personal disclosures, many clients elected not to be fully
forthcoming about deeply personal issues.
Blanchard and Farber (2016) found that many minimized their distress (53.9%) and symptom severity
(38.8%).
Decisions about response styles (disclose or deceive) are often rational and multidetermined; this
theme is explored later in the context of the adaptational model. These deceptions are often
individualized responses to interpersonal variables or situational demands.
This model of complex, individualized decisions directly counters a popular misconception that
response styles are inflexible trait-like characteristics of certain individuals. Most individuals engage
in a variety of response styles that reflect their personal goals in a particular setting. E.g. certain
behaviours such as substance abuse, may be actively denied in one setting and openly expressed in
another.
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. The general issue of inconsequential deceptions should be
considered carefully.
1.1 | Fundamentals of Response Styles
Oftentimes 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. Often, this approach results in the specification of a response
style, even when the data are inconclusive, or even conflicting. A two-step approach is recommended.
, Two-Step (General - Specific) Approach for Minimizing Overspecification
1. Do the clinical data support a nonspecific (e.g. ‘unreliable informant’) description?
2. If yes, is there ample data to determine a specific response style?
This approach asks practitioners to make an explicit decision between nonspecific or general
descriptions and specific response styles. Clearly, conclusions about specific response styles are
generally more helpful, therefore nonspecific descriptions should be considered first to reduce the
understandable tendency of overreaching data when conclusions about specific response styles
cannot be convincingly demonstrated.
Nonspecific terms
→ 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 reasons
for inaccurate data. This is specifically useful when faced with conflicting clinical
data.
→ Nondisclosure
↪ This term simply describes withholding of information. Similar to unreliability, it
makes no assumptions about intentionality.
→ Self-disclosure
↪ This term refers to how much individuals reveal about themselves. Persons are
considered to have high self-disclosure when they evidence a high degree of
openness. It is often considered an important construct within the context of
reciprocal relationships. A lack of self-disclosure does not imply dishonesty.
→ Deception
↪ This term describes 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.
→ Dissimulation
↪ This is a general term to describe a wide range of deliberate distortions or
misrepresentations of psychological symptoms. Practitioners find this term useful,
because some clinical presentations are difficult to classify and clearly do not
represent malingering, defensiveness, or any specific response style.
1.2 | Overstated Pathology
, Important distinctions must be realized between malingering and other terms used to
describe overstated pathology. This subsection addresses three recommended terms: malingering,
factitious presentations and feigning. It also includes three quasi-constructs that should be avoided in
most clinical and forensic evaluations (secondary gain, overreporting, suboptimal effort).
Terms to categorize overstated pathology
→ Malingering
↪ Malingering has been consistently defined by DSM nosology (the branch of
medical science that deals with the classification of diseases) as “the intentional
production of false or grossly exaggerated physical or psychological symptoms,
motivated by external incentives”.
↪ It is important to consider the magnitude of the dissimulation; it must be the
fabrication or gross exaggeration of multiple symptoms. The presence of minor
exaggerations or isolated symptoms does not qualify as malingering.
→ Factitious presentations
↪ 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 motivation is no longer specific. Thus, the diagnosis of
factitious disorders does not preclude external incentives but rather requires some
unspecified internal motivation.
→ Feigning
↪ Feigning is the deliberate fabrication or gross exaggeration of psychological or
physical symptoms, without any assumptions about its goals.
↪ This term was introduced because standardized measures of response styles have
not been validated to assess an individual’s specific motivations. Thus,
psychological tests can often 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.
Mental health professionals bear an important responsibility to use professional language that is
clearly defined. Ambiguous terminology adds unnecessary confusion to clinical and forensic
assessments.
, Three terms to avoid in clinical and forensic practice
→ Suboptimal / incomplete / submaximal effort
↪ Suboptimal effort is sometimes misused as a proxy for malingering. However, this
term lacks precision and may be applied to nearly any client or professional.
→ Overreporting
↪ Overreporting simply refers to an unexpectedly high level of item endorsement,
especially on multiscale inventories. It has also been called self-unfavourable
reporting.
↪ This descriptive term lacks clarity with respect to its content, additionally it has
been used to describe both deliberate and unintentional acts.
→ Secondary gain
↪ Secondary gain, unlike the other unacceptable terms, does have clear definitions. Its
inherent problem for professional practice stems from the presence of conflicting
meanings.
↪ From a psychodynamic perspective, secondary gain is part of an unconscious
perspective to protect the individual that is motivated by intrapsychic needs and
defenses.
↪ From a behavioural medicine perspective, illness behaviours perpetuated by the
social context, not the individual.
↪ From a forensic perspective, individuals deliberately use their illness to gain special
attention and material gains.
1.3 | Simulated Adjustment
Three closely related terms are used to describe specific response styles that are associated
with simulated adjustment.
Descriptions for specific response styles associated with simulated adjustment
→ Defensiveness
↪ Defensiveness is defined as the polar opposite of malingering. Specifically, this term
refers to the deliberate denial or gross minimization of physical and/or
psychological symptoms.
↪ Defensiveness must be distinguished from ego defenses, which involve intrapsychic
processes that distort perceptions.
→ Social desirability
↪ Social desirability is the pervasive tendency for certain individuals to “present
