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“My patient wouldn’t do that”, most therapists think

“My patient wouldn’t do that”, most therapists think

Photographer:Fotograaf: Loraine Bodewes

PhD-thesis on deception in the consultation room

Pretending that you suffer from an illness or disorder, for example in order to pocket compensation for damages. It happens more often than you would think. How do you separate the con artists from the patients? But also, how widespread is it? A Maastricht experiment showed that 94 per cent of the students would be inclined to do it.

Just how many ‘patients’ invent symptoms or strongly exaggerate them, is not known, but it is estimated that 30 per cent does so. It doesn’t only happen in the forensic setting (50 per cent), in order to receive a reduction of one’s sentence, but also in surgeries (10 per cent), in order to be declared unfit or to gain benefits or financial compensation. In the United States, it would concern almost twenty billion dollars, largely claimed by war veterans who are feigning a Post-Traumatic Stress Syndrome (PTST). In Germany, but also in the Netherlands, whiplash takes first place. “Just like nightmares, you can’t measure pain,” says psychologist Irena Boskovic, who recently completed a PhD on ‘malingering’ – jargon for pretending to be ill.

“Most tricksters feign symptoms that they are familiar with in their surroundings, for example because a friend or family member suffers from it. But there are also students who simulate ADHD in order to get their hands on Adderall, which enables them to concentrate better and prepare for exams. Even though a study has proven that the exam grade doesn’t go up.”

Forensic psychologists have designed scientific tests that can be used to expose swindlers. On the basis of these questionnaires, about 70 per cent of them come out as imposters. Boskovic has taken a good look at the latest version of the so-called Self-Report Symptom Inventory. This is a questionnaire with normal as well as atypical symptoms. Those who fake, often draw suspicion by ticking too many pseudo symptoms. In the previous version, there were so many rare complaints that some respondents became suspicious halfway through.


For the best results, Boskovic advises to combine this inventory with a technique that has been known for some time in lie detection: an analysis of the way in which patients describe their symptoms. If they do so with long-winded stories that are impossible to check, for example about their perception of pain, you need to be on your guard. Such descriptions turn out to be fake more often than those in which perceptions is mixed with facts that can be checked.

Her research - a total of eight studies - also shows what doesn’t work: the reaction time method. This was already controversial, but as far as Boskovic is concerned it can now be discarded. This is where patients have to name the colour of words that appear on the screen one after the other as quickly as possible. It is a mix of neutral terms (chair) and emotionally charged words that are connected to the disorder (nightmare, fear). The idea is that someone who is sincere and really wakes up screaming during the night, will take longer to react to these words. These words trigger the patient, as a result of which the brain needs more time to process them. Still, it was not possible to separate the con artists from the real patients using the reaction time pattern.

In practice, these tests still have far to go. They are actually used in forensic institutes, but rarely with regular patients. Therapists don’t care for them, because this is not the way they want to interact with their patients, they say. Boskovic: “They also feel that it is unethical not to help people, to send the fraudsters away. But it is of course just as unethical to treat people who don’t need treatment. This is at the expense of real patients.”

How desirable is it to introduce a lie detection test in the first contact between patient and therapist? “It may be awkward, but in the end it is a matter of presentation. By using the test, you are protecting the genuine patient, the therapy and the therapist. Once treatment starts, the fraudsters won’t co-operate, because that is not to their advantage. As time passes, therapists frustratingly question why the patient is not improving.”


In addition, most therapists think: ‘My patient wouldn’t do that.’ Boskovic assessed 93 professionals in 22 different countries and 64 per cent of them believe that ‘malingering’ hardly ever happens.

The fact that this doesn’t wash, is apparent from scientific estimations, but also from a thought experiment that Boskovic put before a group of 170 students. There were two scenarios, one in which something could be gained and one in which something could be prevented. One: they failed an exam and now run the risk of missing out on a letter of recommendation for a master’s study. They have a chance of still getting the letter if they say that they were not feeling well during the exam. In the second scenario, they also failed the exam and will be named on Eleum as the person with the lowest score. They can prevent this by convincing the tutor that they were sick.

What would they do? In both scenarios, 94 per cent of the students would be inclined to cheat. “They would make an emotional appeal to the lecturer, turn on the waterworks, and pretend to be nauseous, have diarrhoea or having periods. Many test subjects were female.”

Would students also simulate symptoms for the purpose of becoming a test subject for a study in their own faculty for extra credits? Boskovic wouldn’t be surprised. She warned her colleagues about this during a presentation. Also because this may distort the results. “This became clear in an Amsterdam study into the relationship between the hippocampus and memory. The first results showed no link, but after the fakers were removed, the link materialised.”



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