The Non-Disclosing Patient: A Clinician's Guide

By Alexander Lerman

This volume is to examine the phenomena of non-disclosure in its wide ranging forms, study its properties, and to deepen the capacity of a mental health professional --as well as all clinicians who provide mental health counseling -- to detect and engage it across a range of clinical settings.  Unengaged, sustained DNDD represents an impasse that is destructive to a clinician’s capacity to both understand and treat a patient.  Successfully engaged, on the other hand, DNDD offers a unique perspective on in individuals anxieties, presuppositions, and mental functioning.  A clinician who is both aware that a patient is withholding information, and comfortable with that awareness, may approach the patient material while listening for both indications of non-disclosed material and—critically—a growing awareness of psychopathology or other motivational forces driving non-disclosure.

Written by experts in this area from both adult and child psychiatric specialties, this book is the first to address the issue of DNDD and present clinical pearls for addressing it.  This text is a valuable resource for psychiatrists, psychologists, addiction medicine specialists, family physicians, and a wide array of clinicians treating patients who may struggle with disclosure and integrity.

• Language: English
• Publisher: Springer
• Release date: Dec 2, 2020
• ISBN: 9783030486143

Book preview

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

© Springer Nature Switzerland AG 2020

A. LermanThe Non-Disclosing Patienthttps://doi.org/10.1007/978-3-030-48614-3_1

1. A Personal Encounter with Deceit

Alexander Lerman¹  

(1)

Westchester Medical Center, New York Medical College, Valhalla, NY, USA

Alexander Lerman

Email: [e-mail]

Keywords

Biological depressionBlameDeceptionDepressionGuiltLethalityNondisclosureProtective factorPsychiatric assessmentRisk assessmentSuicide

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, 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.

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 treatment 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 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.

© Springer Nature Switzerland AG 2020

A. LermanThe Non-Disclosing Patienthttps://doi.org/10.1007/978-3-030-48614-3_2

2. Deception in the Psychiatric Interview

Alexander Lerman¹  

(1)

Westchester Medical Center, New York Medical College, Valhalla, NY, USA

Alexander Lerman

Email: [e-mail]

Keywords

Anxiety Clinical skills verificationCommunicationInterviewingInterviewing competencyNoncomplianceNonverbal communicationPsychological-mindednessResistanceStructured interviewTherapeutic allianceTherapeutic relationship

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.

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 emotional 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-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).

Table 2.1

Forms of nondisclosure

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 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 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).

Table 2.2

Impact of deception

Table 2.3

The non-disclosing patient: the big picture