Thursday, May 22, 2008
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!)