Thursday, May 22, 2008

Everybody Lies


Back in the Dark Ages when I applied to medical school, all applicants were required to take the Minnesota Multiphasic Personality Inventory or MMPI. This is a personality test designed to identify psychopathology by examining the answers to literally hundreds of questions, many of them innocuous-sounding or not clearly related to any pathological answers. For example, one question that stood out in my mind was "I like to paint flowers." Now, I happen to like flowers and paintings of flowers but never in my life have I ever even tried to paint flowers. You're supposed to answer "true" or "false" to this question. Keep in mind that the answer to this question was going to have some bearing on whether or not I got accepted to medical school. OK, you make your best guess on the "right" (non-pathological) answer, whatever that's supposed to be, and then you run into this question:

"I always tell the truth."

Oy. Talk about your wife-beating question. (In other words, "Sir, when did you stop beating your wife?"). If you answer "yes" then you're obviously lying because everyone fibs now and then. If you answer "false" then you look like a dishonest person who couldn't be trusted to hold a friend's purse much less a scalpel.

So anyway, that brings up the issue of truth-telling in psychiatric treatment.

No patient ever tells the truth. Not the whole truth, not at first, and not in the way they want you to hear it. It's not a matter of intentional dishonesty or deception and it's not a character flaw, it's just being human. I've had friends (not my co-bloggers) who have told me, "Oh, only your patients lie." Well, as Dinah puts it, in my little bubble world it would be nice to believe that the only misleading people were the ones inside the prison walls.

There are many reasons not to tell the whole truth, or to tell it in a way that puts the best light on things. Self-deception (or therapist/psychiatrist) deception is a way to look your best to help the therapeutic relationship form. It's a defense mechanism for people who are feeling self-conscious about their problems or embarrassed about their background or humiliated by their real or self-perceived failures. In extreme cases, it's a way of protecting oneself from negative consequences (eg. "If I tell my doctor I'm suicidal, I'll get 'put away'.") For my patients inside the walls, it's the way they've found to cope with life and get their needs met because they learned early on that simple requests for help often didn't work.

The gradual unfolding of truth, the step-by-step admission of distortions, is part of the treatment process. It's a positive sign that trust is growing between patient and doctor. In psychiatric treatment, at least in my clinic, you don't get punished for admitting you lied.

So now in all honesty, I'll admit that I'd love to paint flowers.

(Wow, this is a first in the history of the blog---I've posted over myself!)

12 comments:

Anonymous said...

Great post!
I guess I've never thought of it as "lying"...I'm not sure why. Expecting someone to fully and totally trust a stranger, whether a doc, or an MMPI being used for career purposes, does not seem like a reasonable thing to ask of anyone.
Why should you be absolutely obligated to fully reveal things you feel uncomfortable with simply because someone asks?
Often, on the first evaluation (hours) I can tell I'm pressing on things that someone doesn't want to talk about. If it's obvious, I just acknowledge their discomfort, ask if they want to talk about something else, and often this is enough to get someone to talk, otherwise they tell me they don't want to talk, and I back off.

I wondered if painting flowers meant painting depictions of flowers on paper/walls or putting paint onto the flowers themselves. I think I'm getting very concrete in my old age.
dinah

Therapy Patient said...

I wanted my psychiatrist to have totally accurate input from me so I have painstakingly tried to tell the whole truth with a balanced perspective (how other people see a situation) right from day 1. What I find though, is that there are things I just CAN'T talk about. It has at times taken me MONTHS of twice a week sessions before I can bring up something that's extremely uncomfortable for me. My psychiatrist kids me that I use Chinese water torture on him: that I bring up one tidbit at a time and let him fully digest that as though if I brought up too much at once I that somehow "he" might not be able to handle it. Right now at this writing I have been through 2 full (50 minutes each) sessions with a major issue to discuss, without telling him. It's not AT ALL lying by my perspective. Usually what I "can't" talk about is generally much deeper, darker, scarier, horrible than what I end up discussing. Sometimes I write down what I want to discuss with him on a small pad, bring it with me, and STILL can't discuss it. A couple of times I have called his answering machine before a session ... the night before or early morning and told him on the tape the TOPIC that I want to discuss at the next session with apologies for having been putting it off. I guess he understands what's going on because in the next session he'll ask in those circumstances if I am "able" to have the discussion I have called him about. Usually all this causes me great distress: extreme fear, shaking, crying, difficulty speaking, difficulty breathing. The things I "can't" discuss have a TON of emotional impact. NOT discussing it really isn't an "omission" of fact the way a lie is, but digging deeper into my personal demons than is comfortable to go.

Closer to a "lie" is my normal demeanor though once again I am not trying to deceive my psychiatrist. I really am WANTING to reveal myself to him. I look calm, pleasant, happy almost all the time, even when I have been feeling close to suicide and can barely make it through a day. (A survival skill I learned living with 2 abusive parents and an abusive sister). I am EXTREMELY hard to read emotionally, even though I have been trying to be more expressive. My psychiatrist has learned to read me so well that he can tell my mood transitions from slight changes in pinkness of my facial skin.

Alison Cummins said...

The question I remember from the MMPI was "I sometimes have a sore spot right on the top of my scalp." Which annoyed me. Yes, it's true: it's called sunburn. On the other hand it's a tiny symptom that it had never occurred to me to complain about or even think about much. And I was absolutely not there to discuss minor weirdnesses: I was there because I was going to die soon without a lifeline.

I said No, not because it wasn't true but essentially because I thought it was irrelevant and didn't want to go into it. I've always wondered whether I got a Liar! flag because of that. Perhaps a Stoic flag?

I have lied in therapy a couple of times over things like that. I worry that saying "Yes but I don't want to talk about it" could send the wrong message: that I am protecting a tender wound that will be a fertile source for therapy once the therapist gets let in to see it. "Really, no, it's not an issue" = "Methinks my lady doth protest too much." And as I am paying by the hour I don't want to spend my time and money arguing with a professional about whether or not X is a big deal. So I just say X doesn't exist and we move on.

Though i think these days I might just say something like "Look, I'm paying you by the hour because I have things I want to talk about. I am perfectly satisfied with X and I am not paying you to talk about it with me."

There are topics that are harder to deflect either way. One's mother is a classic. If "I don't have a mother" is true, then there's an interesting story to get at, so the probing will only intensify. And even if "I am perfectly satisfied with my relationship with my mother" is true, few therapists will find this credible or even relevant if you are a woman under thirty-five in therapy.

I have tried the approach of explaining kindly to a therapist that while I know I am satisfied with my relationship with my mother she (the therapist) has no way of knowing that. Therefore I will pay for three sessions where she gets to ask all the irrelevant questions she desires and I will answer them fully and she can see where that gets her. This backfires because the therapist has then set the agenda for therapy and it's difficult to switch to what I actually want to talk about.

I have tried going for CBT at a CBT clinic to get around this, but my therapist there was sneaky. She told me she could see me at her home office more cheaply than she could see me at the clinic, so I should see her there. Which i did. Once I was seeing her at her home she took me out of the CBT program "because now we can talk about things like your relationship with your mother, and most thirty-year-old women want to talk about their mothers." Aaaargh!

My mother is fine! She is smart, non-judgemental, I call her every week because i like to, she has never tried to interfere in my life, only ever expressed interest. She is not perfect - she is curious, not demonstrative; she was depressed when I was a child and she was poor and trapped in the house. But she's pretty darn close. Yes, I feel as though I have not achieved as much with my life as she has with hers, but she genuinely doesn't care and it doesn't affect our relationship. (I care about what I have achieved but because i would have liked to achieve things for my own sake, not hers. And there are lots of people on the planet besides her that I can compare myself to that I have either achieved more than or less than.)

My issues are about me not being perfect, really. I feel completely positive about my mother and my relationship with her, and any growing-up issues I am introspective enough to have already dealt with on my own.

I find that now that I am in my forties with a regular job and a partner and property that a therapist is much more likely to believe me when I say that there are things I want to talk about that are much more interesting than my mother. But it would have been so much simpler if, back in my twenties, I could have just said "Oh, i don't have a mother. Let's talk about school. Or suicide. Or abusive girlfriends. Or identity. Because all of these are really present right now."

Psychiatry101 said...

As long as they are not lying out of habit... right?
At one point I had to take MMPI and Rorschach inkblot test.I did ok but I never thought of lying.

drx said...

Hi,

I couldn't find your email address on the site. If you're curious about that MMPI item, I'd be happy to explain what's actually going on with it. It isn't quite what you think. It's proprietary information, so I can't share it in comments.
drxblog at gmail.com

ClinkShrink said...

I agree that I don't necessarily think of it as lying if a patient is reluctant to reveal information, depending on what the information is. I think it's interesting to think about the range of vocabulary we've invented to describe nuances of truth-telling based upon motivation and the level of awareness involved in doing it. Someone who is totally aware of the fact that they are giving false information, and does it intentionally to avoid criminal consequences would be considered a liar. Someone who witholds information and actively suppresses the information from consciousness would be using the defense mechanism of repression or denial (like the infanticide cases where the girl conceals pregnancy from everyone).

T: Good point; putting a good face on things to get through life is another variation on truth-telling that would not be considered a lie. Rather, it's adaptive.

Alison: I like the idea of a Stoicism scale on the MMPI. Then again, since it was originally based on 500 Minnesotans that might make the rest of the world look pretty neurotic!

Psych: Lying out of habit, or pseudologia fantastica, is an interesting phenomena that might warrant its own blog post.

DrX: Thanks for the offer; I did eventually get the explanation for that item (I think I remembered it all the way into my residency, and asked during my psych testing lectures) and am happy to report I gave the 'right' answer.

Oh, and our email is:
shrinkrapblog AT gmail.com OR (for the My Three Shrinks podcast):
mythreeshrinks AT gmail.com

Last but not least, we now have our RSS feed chicklet back up on the blog for those of you who want to subscribe, as well as an RSS hyperlink for the podcast. I don't know when or how it disappeared, but I put it back yesterday.

Anonymous said...

My first experience with a psychiatrist was a complete disaster. I lied at every opportunity. I was only 17 years old and in therapy for an eating disorder that I didn't want treated. I was scared my psych would tell my parents everything. So I told her lies.

This time around I went to my psychiatrist with the aim of NEVER telling a lie. A big ask, but so far (18 months in) I've stuck by this. I have, at times, withheld information purely to protect myself from "breaking down", but I don't consider this lying. If he asks me a question about something I don't want to talk about I just simply tell him that it's not something I'm ready to talk about yet. It makes me feel better in myself knowing that I'm not being deceitful, and I've made a lot more progress this time because of it.

Anonymous said...

Catch-22 ahead: Sometime soon I will be discussing medical treatment for ADHD with a psychologist, and I am sure to be asked about non-medical drug use.

I'm uneasy about this because I imagine that the therapist will take what I say on the topic and assume it has been minimized for his consumption, and inflate what I say to obtain "a more accurate account".

If I say I tried cannabis and psilocybin 20 years ago, and didn't find them especially interesting, would the therapist assume any mention at all indicated much more significant use? If I virtuously claim no drug use, would he assume this is unlikely, and assume much more drug use, perhaps of substances I have never heard of?

All I know is, I sure don't want to be offered only antidepressants when stimulants are the first choice in ADHD treatment. It's a puzzle.

Therapy Patient said...

Anonymous-
You seem to be making it much more complicated than it is. Just tell the truth! It does not make sense to lie because you anticipate not being believed. The closer you can come to giving an absolutely accurate description of yourself, the more the therapist can help.

Dr. Pink Freud said...

Despite its length, I'm a big fan of the MMPI-2. The test has gone through an extensive validation process on numerous populations. And, it's both highly reliable and valid.

All this being said, what of lying? The MMPI-2 is sensitive to deliberate attempts to exaggerate (to appear good, or more psychologically ill than one is), and these can be both diagnostically and clinically useful indicators. Ultimately, how you interpret the information obtained depends on the setting in which you're working. Certainly, in an outpatient setting, attempts to minimize perceived flaws might be considered a "normal" (whatever that is) inclination. Depending on the stage of Tx., it might be less expected and suggest trust issues would be appropriate to address. Forensic settings are a whole other ballgame. Pretrial detainees may obviously have strong motivations to present in a certain manner. Once incarcerated, the motivations for lying may change (e.g., to gain a transfer, or access to sedating medication), but are certainly still present.

For me, it's not so much whether or not somebody lies (we all do for any number of reasons), but rather "why." I can't imagine a clinician who would look solely at indicators of "lying", because this would miss the big picture. "Lying" is only a small facet of a much bigger gem. The proper clinician, with access to the appropriate psychological tests, a therapeutic Hx. with the patient, and reliable collateral information helps bring the whole gem into focus.

Anonymous said...

I have way to much time on my hands at the present... Victor

The Lie
by Sir Walter Raleigh

Go, soul, the body's guest,
Upon a thankless errand;
Fear not to touch the best;
The truth shall be thy warrant:
Go, since I needs must die,
And give the world the lie.

Say to the court it glows
And shines like rotten wood,
Say to the church it shows
What's good, and doth no good:
If church and court reply,
Then give them both the lie.

Tell potentates, they live
Acting, by others' action;
Not lov'd unless they give;
Not strong, but by affection.
If potentates reply,
Give potentates the lie.

Tell men of high condition,
That manage the estate,
Their purpose is ambition;
Their practice only hate.
And if they once reply,
Then give them all the lie.

Tell them that brave it most,
They beg for more by spending,
Who in their greatest cost
Like nothing but commending.
And if they make reply,
Then give them all the lie.

Tell zeal it wants devotion;
Tell love it is but lust;
Tell time it meets but motion;
Tell flesh it is but dust:
And wish them not reply,
For thou must give the lie.

Tell age it daily wasteth;
Tell honour how it alters;
Tell beauty how she blasteth;
Tell favour how it falters:
And as they shall reply,
Give every one the lie.

Tell wit how much it wrangles
In fickle points of niceness;
Tell wisdom she entangles
Herself in over-wiseness:
And when they do reply,
Straight give them both the lie.

Tell physic of her boldness;
Tell skill it is prevention;
Tell charity of coldness;
Tell law it is contention:
And as they do reply,
So give them still the lie.

Tell fortune of her blindness;
Tell nature of decay;
Tell friendship of unkindness;
Tell justice of delay:
And if they will reply,
Then give them all the lie.

Tell arts they have no soundness,
But vary by esteeming;
Tell schools they want profoundness,
And stand too much on seeming.
If arts and schools reply,
Give arts and schools the lie.

Tell faith it's fled the city;
Tell how the country erreth;
Tell manhood, shakes off pity;
Tell virtue, least preferred.
And if they do reply,
Spare not to give the lie.

So when thou hast, as I
Commanded thee, done blabbing;
Because to give the lie
Deserves no less than stabbing:
Stab at thee, he that will,
No stab thy soul can kill!
ca.1592

NeoNurseChic said...

Interestingly, the headache center I go to requires that all new patients complete the first 270 questions of this test on the day of their 1st appointment. That day, you are also required to be interviewed by a psychiatrist/psychologist in addition to seeing a nurse and the headache specialist. I remember sitting there with my mom filling out the test and laughing at some of the questions! Many people in the waiting room over the years have complained about taking the test and having to have the psych eval. I understand, because we even wondered what the reason was for the psych eval at first. People with headache problems severe enough to go to a headache specialist have generally seen a whole gamut of professionals, and have probably heard that it's all in their head, they are lying, they are drug seeking, they are exaggerating, they are having headaches for attention, or some other response by a clinician taking out his/her frustrations that they cannot fix the problem by turning the blame on the patient, stating that they somehow deliberately created the problem for some other gain. As a side note, it is really amazing how many health care professionals just don't believe it is possible to have headaches for the severity or duration that they exist for some people. No, 2 aspirin and rest does not work for everyone!

All that aside - people worry that the psych eval on the 1st appointment is to weed out those who have made up their problem, or to blame the headaches on stress, or some other factor such as this. It's normal, given the past histories from health care providers that many headache sufferers have experienced. The psych eval is really designed just to ascertain whether there are any psychiatric factors that may be impacting the headache condition - such as depression and migraine being often comorbid.

It's not as scary once you understand the reason why they have the eval. They do not explain the reason for the psych eval or the MMPI before the day of the appointment. You are told that you will be having the psych eval (and that you are expected to pay for it out of pocket!), but not the reason why. You aren't told that you will have to do the MMPI until you get there and they hand it to you. And at the time they hand it to you, they don't explain why it's needed.

So I think those things are definitely a good part of the 1st appointment at a headache center, but I do think they could be explained better prior to springing them on new patients who have already had very stressful experiences on top of the neurologic condition they are suffering with!

Sorry to ramble on!

Take care,
Carrie :)