Academic journal article Journal of Mental Health Counseling

Assessment of Malingered Psychosis in Mental Health Counseling

Academic journal article Journal of Mental Health Counseling

Assessment of Malingered Psychosis in Mental Health Counseling

Article excerpt

Malingering is the gross exaggeration or fabrication of physical and psychological symptoms for secondary gain. Though a client's potential secondary gain may be apparent to the counselor, determining the client's situational stressors and motivation for that gain complicates definitive detection of malingering. Adopting the adaptational model of malingering in assessment can reframe the deception and misrepresentation as possibly an adaptive way to meet basic needs. Because malingering is a diagnosis of exclusion, it must first entail differential diagnosis with somatoform and factitious disorders. Assessment requires a solid clinical background in understanding malingering response style, target symptoms, psychotic symptom manifestation, and the subsequent differentiation between genuine and malingered psychosis. This article provides practical strategies for detecting feigned psychotic symptoms and briefly surveys psychometric tools counselors can use to detect malingering.

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Malingering is intentional and voluntary deception for external incentive--secondary gain--through fabrication or gross exaggeration of medical or psychiatric symptoms (American Psychiatric Association [APA], 2013). The criminological model used to explain malingering in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013; Rogers, 1997; Rogers, Sewell, & Goldstein, 1994) links antisocial personality disorder (APD) and forensics to malingering, increasing the potential that mental health counselors will make a pejorative diagnosis (Chesterman, Terbeck, & Vaughn, 2008; Cunnien, 1997; Rogers, 1997; Rogers, Sewell, & Goldstein, 1994; Spiggle & Hughes, 1998). Threats to therapeutic rapport (Berlin, 2007; Garriga, 2007; LeBourgeois, 2007; Rogers, 1997; Rogers, Kropp, Bagby, & Dickens, 1992) and development of counselor countertransference (Berlin, 2007; Stone & Boone, 2007) can arise in reaction to client malingering. To reduce these challenges to therapeutic rapport, counselors should conduct assessments of malingering that consider contexts where, rather than being antisocial or criminological behavior, malingering is an adaptive act (Rogers, 1997; Rogers et. al., 1994) or abnormal illness behavior in a vulnerable client who has limited resources (Broughton & Chesterman, 2001).

The malingering response style is not uncommon (Rogers, 2008a) and should be evaluated when there is potential for external incentive (Rogers, 2008a; Young, 2010) or the client attaches importance to the counselor's assessment (Hollender & Hirsch, 1964; Rogers, 2008a; Young, 2010). Because of its prevalence Resnick (1997) recommended that all clients be assessed for malingering. A comprehensive assessment includes a detailed record review, a thorough client interview, a mental status examination, collateral information, and possibly psychological testing. These aspects of assessment must be used together to improve detection outcomes because the core problem in detecting feigned psychosis is the lack of a standard--other than admission of deceit (Cornell & Hawk, 1989; Edens, Poythress, & Watkins-Clay, 2007).

This article helps mental health counselors to identify person-centered strategies for detecting and engaging malingered psychosis. Discussion of malingering conceptualizations, explanatory models, response styles, and symptom presentation will fortify these strategies and engender a more ethical assessment of suspected malingering. Case conceptualization and treatment outcomes are better, and the underlying need of the malingering client can be addressed. Four assessment instruments are briefly considered: the Structured Interview of Reported Symptoms (2nd ed.; SIRS-2; Rogers, Sewell, & Gillard, 2010); the Personality Assessment Interview (PAI; Morey, 2007); the Structured Interview of Malingered Symptoms (SIMS; Widows & Smith, 2007); and the Miller Forensic Assessment of Symptoms Test (M-FAST; Miller, 2001). …

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