I thought I’d write a more informal post today, based on some recent experiences I’ve had at work. Over the last couple of months, I’ve conducted several forensic evaluations in which the defendant has engaged in malingering. For those unfamiliar with the term, here is a brief definition from the DSM-IV:
The essential feature of malingering is the intentional production of pulse or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs. Under some circumstances, malingering may represent adaptive behavior - for example, feigning illness while a captive of the enemy during wartime.
Obviously there is much more to this diagnosis, but this definition should give you an idea of what I’m talking about. As I am conducting evaluations of individuals charged with Federal crimes, efforts to malinger or common. Here are a couple of observations I’ve made in doing this kind of work regarding individuals who are either outright faking a mental health illness, or are exaggerating the symptoms of an existing illness:
1) First, this can be much trickier to sort out than it sounds. Even if you have evidence that an individual is exaggerating, he still have the look at whether the mental health issue exists, and to what extent. This is where prior records are extremely important.
2) Non-forensic mental health professionals generally take clients at their word. Generally speaking, mental health professionals will take at face value reports of such problems as psychotic symptoms (i.e. hallucinations). Given that the diagnosis of malingering requires motivation by external incentive, clinicians outside the forensic arena generally see no reason to question the authenticity of a report like this. It seems to me this is because individuals who do not engage in secondary gain-type thinking, such as clinicians, don’t see the external incentive that is apparent to an individual who is motivated by the less apparent external incentive. What I mean is, the external incentive is pretty apparent when somebody is facing federal prosecution. That external incentive is not as apparent in non-forensic settings, and the clinicians are not looking for signs of malingering nearly as much.
3) This often results in two trends, one helpful and one not helpful. The “not so helpful” trend is that prior records will have documentation of mental health diagnoses at the individual does not actually have. That means more work in documenting a diagnosis of malingering. The good news is that an individual who is been successful in faking mental health problems on the street will assume the same strategy will work in a forensic setting. That leads to my next observation...
4) A poker face is extremely important what doing forensic evaluations of people who are malingering. You don’t want to give away that you are aware the individual his faking are exaggerating until you are ready to do so. People in general are not very good at pretending to have a mental health problems they’ve never actually had. In some cases, their efforts are so poor it takes real focus to avoid making any kind of facial expression that would tip off the individual. In a couple of cases, the effort was so bad it was difficult not to laugh. Unlike therapy however, were the therapist’s job is to confront denial, minimization, and other barriers to treatment, the evaluator’s focus is to evaluate, or gather information. Allowing an individual to provide more and more examples of their efforts to malinger allows for easier and more convincing report.
As I’ve written before, I feel a need to be careful when discussing malingering. I certainly do not want to provide any information on the Internet that would make it easier for somebody to fake or exaggerate mental health problems. On the other hand, I think it is important for anybody interested in this sort of work to be aware of this issue, be on the lookout for it, and formally screen for and assess whenever necessary. I’m often surprised when I see an evaluation conducted by somebody else where malingering was even considered, despite either the obvious external incentives, or the “remarkable” presentation by the client.