Forensic Psychiatrist/Psychologist determining if someone is lying

[whopper]

I'm writing this here cause someone PM'd me on the forum and it's a good information for anyone to know.

Can psychiatrists tell if someone is lying better than others?

NO.

Repeat NO.

AGAIN NO.

This has been studied. In the study various professions were tested to see they could tell someone was lying. I've read the study but it was years ago (I was able to find it online, link is below). The only profession that was able to tell if someone was lying better than others was the Secret Service.

https://pdfs.semanticscholar.org/4387/dcd6339f9f070ea9915f5b62a05c77ebd5a8.pdf

So some may ask then why should psychiatrists then tell if someone is malingering?

Cause that's a different phenomenon than lying about things in general. E.g. if someone's not showing signs consistent with real mental illness we do have better ability to be able to tell in that regard. Further there are validated psychological tests available to both forensic psychiatrists and psychologists in determining if someone is malingering.

There is an emerging science in being able to tell if someone's lying but the overwhelming majority of psychiatrists and psychologists do not have training in this field.

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[PsyDr]

With all due respect, you are partially wrong.

The literature base absolutely indicates that determination of lying based upon interview is basically meaningless.

However, when combined with psychological tests you are absolutely wrong.

Someone offers a statement “I was not at the scene of that murder.”. You create a 500 forced choice questionnaire. “Was the victim wearing a red shirt or a black shirt?”. The person scores 0/500. The probability of failing every single question due to pure chance is 7.888609052210118e-31.

Or they actively knew the right answer and actively selected the wrong answer to disguise this.

 

[Bartelby]

I tend to think of it like this: imagine someone, who is reasonably bright and motivated, is pretending to be a plumber. They have read a book, watched a series of videos, and done some basic online reading. If both a plumber and I conduct an interview to determine whether this person is indeed a plumber, the plumber is likely to do a better job. That does not mean the plumber is better at detecting lies generally, just that he has a depth of knowledge about the subject matter that allows him to more easily spot inconsistencies and inaccurate portrayals.

In the same way, we are not better at detecting lies generally. When it comes to, for instance, detecting malingered psychiatric illness we should be.

 

[WisNeuro]

With all due respect, you are partially wrong.

The literature base absolutely indicates that determination of lying based upon interview is basically meaningless.

However, when combined with psychological tests you are absolutely wrong.

Someone offers a statement “I was not at the scene of that murder.”. You create a 500 forced choice questionnaire. “Was the victim wearing a red shirt or a black shirt?”. The person scores 0/500. The probability of failing every single question due to pure chance is 7.888609052210118e-31.

Or they actively knew the right answer and actively selected the wrong answer to disguise this.

Didn't Marty Rohling actually do this in a court case? Not 500 questions, but a decent amount.

 

[PsyDr]

Didn't Marty Rohling actually do this in a court case? Not 500 questions, but a decent amount.

Several forensic psychologists and neuropsychologists have employed this technique in court. I don’t know about any case where Dr. Rohling has used this technique but it would not surprise me to learn he does on a regular basis. It’s been mentioned in book chapters by Larrabee, Denny, and Rubenzer. I know of many others who use this regularly in court that do not publish.

 

[Merely]

So we all agree that it’s impossible to determine a lie through an in person interview. However, what about if I video tape the person then study their micro expressions afterward. Is that a scientifically based way to determine a lie or is that pretty controversial?

 

[PsyDr]

So we all agree that it’s impossible to determine a lie through an in person interview. However, what about if I video tape the person then study their micro expressions afterward. Is that a scientifically based way to determine a lie or is that pretty controversial?

Drs. Eckman and Friesand have published the facial coding system, which has decent inter rater reliability. It requires a significant amount of training, is grossly based upon video tape review, and takes significant time to perform. Once coded, one looks for discordant emotions between affect/micro expressions and speech content. There are some expressions which are reliable for deception but not necessarily lying. However there is also some research indicating some reliability for facial behavior as indicators for lying (e.g., Vrij). Likewise, there is some evidence that some sunsets of people are very good at detecting lies via micro expressions which is the study whopper was likely referring to. However, the methodology has been highly debated and has a commercial interest variable at play.

So, to some degree the answer is yes.


Edit: forgot to mention that Gottman, the famed marital guy, used ekmans fac to predict divorce with a fairly significant accuracy. Even sold ekmans stuff on his website.

 

[whopper]

However, when combined with psychological tests you are absolutely wrong.

I never stated with psychologists tests. Further the overwhelming majority of psychiatrists have no idea about this type of testing get no training in it and even among forensic psychiatrists many programs still don't teach about psychological testing available in regards to malingering or lying. (Original question was can psychiatrists tell if people are lying). When I interviewed at forensic psych fellowships less than half were going to give training in various psychological tests such as an M-FAST.

As I stated there's an emerging field and that includes psychological testing.

So I don't exactly get what you mean by I'm partially then absolutely wrong. Also "absolutely"? The science of determining lies has a lot of grey zones. Psychological testing for malingering could be very accurate and can stand up to very tough mathematical standards, but the original question was lying and not malingering which is a much more specific type of lying, and I made that distinction in the original post.

If one is a psychiatrist expect them not to know about this type of emerging science in the determination of lying. If one, however, did some side work that gave them expertise in it that's different, but literally grab 100 psychiatrists I'd bet less than 5 of them would even know about this stuff. Heck I'd be surprised if even up to 3 did.

 

[psyguru]

I believe I heard that there are some FBI agents who are experts on lie detection and probably have more training in it than the average forensic psychiatrist.

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[dl2dp2]

Drs. Eckman and Friesand have published the facial coding system, which has decent inter rater reliability. It requires a significant amount of training, is grossly based upon video tape review, and takes significant time to perform. Once coded, one looks for discordant emotions between affect/micro expressions and speech content. There are some expressions which are reliable for deception but not necessarily lying. However there is also some research indicating some reliability for facial behavior as indicators for lying (e.g., Vrij). Likewise, there is some evidence that some sunsets of people are very good at detecting lies via micro expressions which is the study whopper was likely referring to. However, the methodology has been highly debated and has a commercial interest variable at play.

So, to some degree the answer is yes.


Edit: forgot to mention that Gottman, the famed marital guy, used ekmans fac to predict divorce with a fairly significant accuracy. Even sold ekmans stuff on his website.

Their studies, in particular Gottman's study, suffer major methodological limitations including a major one called testing a predictive validity on a training data set. Secondly and more importantly, replication studies of these results have resoundingly failed.

I work in this field (i.e. mental health and tech dev). The general consensus as of right now is that 1) Lies cannot be reliably predicted on an individual level with a degree of accuracy that can be used in clinical/forensic scenario (i.e. with ROC > 90%). 2) Divorce cannot be reliably predicted on an individual level. In fact, no major psychiatric condition as of right now has any quantitative metric of risk/prognosis and this represents a major area of research at NIH level.

There are "risk factors" that alter the probability of someone telling a lie or someone having a divorce, but the performance of the prediction models is not good enough to be used in any kind of definitive way. Several potential reasons for this: these risk factors are often limited to a very specific sample and therefore don't generalize well; the sample studies in psychological experiments are often small; the methods used are idiosyncratic and difficult to standardize (i.e. Eckman); the inferential consistency of things like micro-expression and body posture have now largely been discredited due to non-replication. This is in contrast to say some classic machine learning task (i.e. speech recognition/handwriting recognition, etc) which are now fairly standard commercial products (i.e. Amazon Echo, ATM machines).

 

[dl2dp2]

I tend to think of it like this: imagine someone, who is reasonably bright and motivated, is pretending to be a plumber. They have read a book, watched a series of videos, and done some basic online reading. If both a plumber and I conduct an interview to determine whether this person is indeed a plumber, the plumber is likely to do a better job. That does not mean the plumber is better at detecting lies generally, just that he has a depth of knowledge about the subject matter that allows him to more easily spot inconsistencies and inaccurate portrayals.

In the same way, we are not better at detecting lies generally. When it comes to, for instance, detecting malingered psychiatric illness we should be.

Sure, this is the intuition. But what if we do a study that actually compared whether you can tell that particular lie than others and it says that you can't? I say data win every time, especially if the finding is consistent.

This issue of malingering in my mind frankly is stupid and abused by "anti-psychiatry" as ammunition. Much of differences between 1) malingering 2) primary gain 3) "real" psychopathology are arbitrary and reside in a continuum. What really matters is whether a particular set of symptoms respond to treatment, and what is the the prognostic future of someone who has a condition that would function in a particular way. Someone who has the label "psychotic" depression have a vastly different kind of prognosis if they are 1) high IQ from well off family and a great pre-morbid functional history 2) low IQ never employed didn't graduate high school and from poor family. These issues are not captured by DSM diagnosis, even though there's no reason to believe that the medications strategy would be different between the two. To obsess over whether one is "real" depression and the other is "fake" is completely arbitrarily manufactured. Similarly, is it really ethnically sound to discharge someone back to the street if they "fake" psychosis vs. admit them so they have a bed to sleep in for a night? Does it really matter? Let's say someone constantly comes in and fake their psychosis and get hospitalized 10x for various reasons, is this personally really better off than someone who has "real" psychosis and gets hospitalized for a similar number of times? Why is it that a clinical decision that has trivial long term consequences became an obsession for people who don't know much about how psychiatry is actually practiced in the field as a way to undermine the legitimacy of the whole field?

I suppose the idea that psychiatrists can't tell lies undermines the legitimacy of forensic assessment of not guilty for reasons of insanity. Whopper, do you have an answer to that? My sense is that the level of legitimacy for that assessment can't be any lower than overall legitimacy of a criminal proceeding in the first place. So again, this becomes a moot issue. Adjudication in any court will have some element of chance/injustice intrinsic to its idiosyncratic practices, and the fact that it doesn't work perfectly doesn't mean that there's a better replacement.

 

[clausewitz2]

I believe I heard that there are some FBI agents who are experts on lie detection and probably have more training in it than the average forensic psychiatrist.

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Data on what law enforcement does it harder to come by because they are a little leery of research that gets too specific but none of the lie detection methods the FBI tends to shill have ever really held up to empirical scrutiny.

 

[Crayola227]

Now that I know about that forced multiple choice questionnaire... totally gonna beat that test next time.

I know many of you have been wondering if I'm writing from prison or house arrest. SDN is one of those sites that you can access from any hole in the ground.

 

[nitemagi]

Now imagine that a clinical interview is itself a forced choice test. If you as a skilled clinician can guide, question, and astutely challenge in a clinical interview, that is itself revealing, though less controlled than any standardized exam. My point being that if you're doing more than a purely observational interview, you can detect lying/deception/falsifying to some degree.

Check out Rogers' textbook -- Clinical Assessment of Malingering and Deception, as an ongoing reference (updated regularly).

 

[clausewitz2]

Now imagine that a clinical interview is itself a forced choice test. If you as a skilled clinician can guide, question, and astutely challenge in a clinical interview, that is itself revealing, though less controlled than any standardized exam. My point being that if you're doing more than a purely observational interview, you can detect lying/deception/falsifying to some degree.

Check out Rogers' textbook -- Clinical Assessment of Malingering and Deception, as an ongoing reference (updated regularly).

I also love Rogers but I not sure I agree that lying can be detected via the method you describe (although it describes my standard approach). I think that you can detect significant variance from known patterns and prototypes. Sometimes the answers you get may not make any gd sense because the interviewee is feigning. Sometimes it is because the situation is just very unusual.

 

[SeniorWrangler]

Collateral information is a better lie detector than any psychiatrist I've ever met. Pick up the phone and play detective.

 

[whopper]

Not the same topic but somewhat related...
Psychiatry is the medical field involved with treating mental illness through a medical model.

It is NOT the study of the human mind, the study of personalities, or pretty much anything else with the human mind outside of mental pathology.

So why is it that so many people expect us to be psychologists?

Why is it that so many psychiatrists seem to be a bit insecure with simply admitting, "this is outside my expertise" and refer out to a psychologist in matters of the human mind outside of medical treatment just like you'd expect to refer to a cardiologist when you see a patient with a heart problem not being treated?

I've worked with plenty of very skilled psychologists whose expertise in things we psychiatrists never get training in are impeccable and have been very useful for me.

 

[nitemagi]

Not the same topic but somewhat related...
Psychiatry is the medical field involved with treating mental illness through a medical model.

It is NOT the study of the human mind, the study of personalities, or pretty much anything else with the human mind outside of mental pathology.

So why is it that so many people expect us to be psychologists?

Why is it that so many psychiatrists seem to be a bit insecure with simply admitting, "this is outside my expertise" and refer out to a psychologist in matters of the human mind outside of medical treatment just like you'd expect to refer to a cardiologist when you see a patient with a heart problem not being treated?

I've worked with plenty of very skilled psychologists whose expertise in things we psychiatrists never get training in are impeccable and have been very useful for me.

Well psychologist is a much more recent development. Historically all the innovation and expertise in the mind were psychiatrists.

 

[clausewitz2]

Well psychologist is a much more recent development. Historically all the innovation and expertise in the mind were psychiatrists.

This is a somewhat ahistorical assertion. If we go back to the beginning of modern psychology Fechner and Peirce were not physicians by any stretch of the imagination and while Helmholtz and Wundt were technically physicians the fact that they were also physicists was waaaaay more relevant to their contributions to the field.

That was in an era in which Half of Everyone Doing Science had a medical degree, not to be confused with the somewhat earlier era when Half of Everyone Doing Science was an Anglican clergyman.

EDIT: fixed autocorrect's bizarre idea that I was trying to write in Spanish.

 

[dl2dp2]

Why is it that so many psychiatrists seem to be a bit insecure with simply admitting, "this is outside my expertise" and refer out to a psychologist in matters of the human mind outside of medical treatment just like you'd expect to refer to a cardiologist when you see a patient with a heart problem not being treated?

I don't think this is the issue. The issue is that for certain practical questions in general western (and developed, in general) societies has determined that the medical ["scientific"] model is the final arbiter. This is not to say that evidence based practice is not applicable in psychotherapy or forensic psychology or education psychology etc. It's just saying that when outside person wants the answer of a question like "is this person 'insane'?" and "did this particular stressor cause/contribute to this mental illness?" and "does this person need to get medication against his will?" and "is this person's mental illness severe enough for us to prepare to spend hundreds of thousands of dollars on welfare programs?"... The questions that have the highest stakes in mental health in practice end up go up to be evaluated by someone with an MD...

 

[deleted343839]

Well psychologist is a much more recent development. Historically all the innovation and expertise in the mind were psychiatrists.

Some history: http://home.uchicago.edu/rjr6/articles/Wolff.pdf

 

[WisNeuro]

I don't think this is the issue. The issue is that for certain practical questions in general western (and developed, in general) societies has determined that the medical ["scientific"] model is the final arbiter. This is not to say that evidence based practice is not applicable in psychotherapy or forensic psychology or education psychology etc. It's just saying that when outside person wants the answer of a question like "is this person 'insane'?" and "did this particular stressor cause/contribute to this mental illness?" and "does this person need to get medication against his will?" and "is this person's mental illness severe enough for us to prepare to spend hundreds of thousands of dollars on welfare programs?"... The questions that have the highest stakes in mental health in practice end up go up to be evaluated by someone with an MD...

These tend to be what they call me in for to evaluate in my hospital. I am about 80% outpatient and 20% inpatient with these types of questions, competency/guardianship and the sort.

 

[clausewitz2]

These tend to be what they call me in for to evaluate in my hospital. I am about 80% outpatient and 20% inpatient with these types of questions, competency/guardianship and the sort.

Right. But I think the point he was trying to make was that this mode of operating is firmly within the medical model. I can tell you that this function is performed by consult/liaison psychiatrists in many other places. If you are doing work that psychiatrists also do on a regular basis, I think it is fair to say you are probably operating in the same paradigm.

 

[WisNeuro]

Right. But I think the point he was trying to make was that this mode of operating is firmly within the medical model. I can tell you that this function is performed by consult/liaison psychiatrists in many other places. If you are doing work that psychiatrists also do on a regular basis, I think it is fair to say you are probably operating in the same paradigm.

The VA's handle this largely within neuropsych consults too. I'd agree that it fits largely within the medical model, but I see this largely split, and in some systems wholly the realm of psychology/neuropsychology on the team. We have more than enough to go around here, I pretty much only see the cases that are in a tough gray area.

 

[clausewitz2]

Makes sense that the VA tends to use psychologists as they seem to employ them much more liberally. In our academic medical system I think we employ a grand total of two neuropsychologists (I don't like this state of affairs, but that is the sad reality at the moment). It takes approximately 4 months to get an appointment for referrals from within the system.

I am utterly disheartened by the lack of psychological training/sophistication offered to psychiatry residents. If I had not done a cognitive neuroscience focused doctorate my understanding of many of the issues I face on a daily basis in practice would be quite arid and superficial. More psychologists, please.

 

[WisNeuro]

I am utterly disheartened by the lack of psychological training/sophistication offered to psychiatry residents. If I had not done a cognitive neuroscience focused doctorate my understanding of many of the issues I face on a daily basis in practice would be quite arid and superficial. More psychologists, please.

Seems to be the way that large systems are going, bringing in more midlevels. I'd love to see more integration with psychology/psychiatry at the training levels. It'd lead to much better patient care in both disciplines. I used to guest lecture for my wife's residency where we used to live, and have tried to foster more relationships between the residencies here, but it's been an uphill battle.

 

[PsyDr]

I don't think this is the issue. The issue is that for certain practical questions in general western (and developed, in general) societies has determined that the medical ["scientific"] model is the final arbiter. This is not to say that evidence based practice is not applicable in psychotherapy or forensic psychology or education psychology etc. It's just saying that when outside person wants the answer of a question like "is this person 'insane'?" and "did this particular stressor cause/contribute to this mental illness?" and "does this person need to get medication against his will?" and "is this person's mental illness severe enough for us to prepare to spend hundreds of thousands of dollars on welfare programs?"... The questions that have the highest stakes in mental health in practice end up go up to be evaluated by someone with an MD...

That's simply not true.

 

[whopper]

I don't think this is the issue

If that hasn't been your experience then you've had better than mine. I've had several experiences literally on the order of daily where psychiatrists significantly overstepped their expertise thinking they know much more than they did and thinking that psychiatry applied in very inappropriate ways.

E.g. psychiatrist determines the prescription based on "art" literally-the color of the packaging labels, thinking they can take a stab at determine if a patient is lying, posing themselves as authorities on the human mind in areas that had nothing to do with mental pathology, etc.

E.g. Hospitals are trying to get psychiatrists to predict if a patient will take their transplant-rejection meds, despite that hardly any of those psychiatrists have actually studied the science behind this phenomenon nor is it in actual psych training. (Yes I know this is an emerging field, but the bottom line is predicting this is separate from mental pathology though there is overlap).

Of course if a psychiatrist takes it upon him/herself to get the suitable expertise that's one thing but I'm only taking about cases where they did not, yet narcissistically made allegations they could do things where they didn't have the expertise.

 

[clausewitz2]

E.g. Hospitals are trying to get psychiatrists to predict if a patient will take their transplant-rejection meds, despite that hardly any of those psychiatrists have actually studied the science behind this phenomenon nor is it in actual psych training. (Yes I know this is an emerging field, but the bottom line is predicting this is separate from mental pathology though there is overlap).

That kind of depends on your psych training. I have done a number of transplant evals as part of my required consult/liaison months. Probably going to be very center-dependent. Saying it is totally outside of the scope of psychiatry is a bit like saying psychiatrists shouldn't treat eating disorders because some of them don't get training on it in residency.

EDIT: Also if (generic) you as a psychiatrist don't know anything or get any training about things that determine whether or not someone will take their meds, that may be a problem.

 

[Salpingo]

That kind of depends on your psych training. I have done a number of transplant evals as part of my required consult/liaison months. Probably going to be very center-dependent. Saying it is totally outside of the scope of psychiatry is a bit like saying psychiatrists shouldn't treat eating disorders because some of them don't get training on it in residency.

EDIT: Also if (generic) you as a psychiatrist don't know anything or get any training about things that determine whether or not someone will take their meds, that may be a problem.

Agree that this reflects more on quality of training programs than the state of psychiatry as a whole. I’d add that most transplant programs will ultimately defer to whether or not the surgeon wants to do the case and if the resources are there. I’ve seen and heard of a few cases where psych and SW strongly protest the procedure, it happens over their objection and the patient turns out... totally fine.

Maybe to Whoppers point, I see our role as searching out potential psychosocial obstacles and intervening - our crystal balls aren’t particularly good. Maybe the patient will or won’t relapse into active substance use. We won’t be able to say as psychiatrists (or psychologists), but we can at least advise of the various ways to prevent relapse, types of rehab, pharmacotherapy, etc.

I don’t agree that we should “know our limits” when it comes to the science of behavior and mind. I’m sure the average community cardiologist doesn’t know as much of the details of cardiac physiology as an NIH PhD physiogist specializing in the heart, but that doesn’t mean every cardiologist should stay in their lane and defer commenting on how the heart works. Maybe the brain and behavior is more complicated than an electric pump sitting in our chest, but realistically we should have some expertise on normal development, cognitive functioning, conditioning, etc.

 

[whopper]

Saying it is totally outside of the scope of psychiatry is a bit like saying psychiatrists shouldn't treat eating disorders because some of them don't get training on it in residency.

It's not that it's "totally" out of the scope vs did the psychiatrist actually have training and expertise to make the statement.

Further several push psychiatry to handle transplant cases on an erroneous thought process. "Well it's transplant and psychiatrists predict the future so let's let them do it." Then the psychiatrist, if they fit my description above, foolishly does the consult instead of refusing.

While there is an emerging field of transplant psychiatry, for a psychiatrist to accept a transplant consult having no training in it is getting into what I'm bringing up, not if that psychiatrist has the training and knowledge (and the overwhelming majority do not).

WHICH IS WHAT I STATED IN MY POST...

Of course if a psychiatrist takes it upon him/herself to get the suitable expertise that's one thing but I'm only taking about cases where they did not, yet narcissistically made allegations they could do things where they didn't have the expertise.

 

[whopper]

but that doesn’t mean every cardiologist should stay in their lane and defer commenting on how the heart works.

That's different. Cardiologists do have expertise and training in how the heart works, hence they do have a foundation to explain how it works.
Psychiatrists do have a foundation of knowledge in many things neurological, and even psychological,. but we have some but no where near as much as a psychologist. So, just like all physicians have some radiological training I'm not going to start telling the radiologists I'll take over their expertise or even pretend to do so.

E.g. psychiatrists don't have classes on child development, personality development, sensation and perception, etc. except for at most perhaps a once a year 1 hr PP presentation where the resident was falling asleep anyways cause he was post-call, where as the psychologist spent about 30+ hours, one one of those topics, and had it on their board exam. Let the hospital psychologist do some of the work for you that they should be doing anyways.

So to hear some guy who has his antipsychotics memorized then talk about how he's an expert in seeing if someone is lying....despite that the data shows psychiatrists can't tell better than a layman, he has no training in determining if someone is lying, etc. that's what I'm talking about.

Psychiatrists could talk about some things psychological such as mood, where we actually have some decent knowledge above a laymen, but we have a heavily pathology-treatment based foundation and for that reason possible bias, but on things such as lying, sensation and perception, etc. No.

 

[LadyHalcyon]

That's different. Cardiologists do have expertise and training in how the heart works, hence they do have a foundation to explain how it works.
Psychiatrists do have a foundation of knowledge in many things neurological, and even psychological,. but we have some but no where near as much as a psychologist. So, just like all physicians have some radiological training I'm not going to start telling the radiologists I'll take over their expertise or even pretend to do so.

E.g. psychiatrists don't have classes on child development, personality development, sensation and perception, etc. except for at most perhaps a once a year 1 hr PP presentation where the resident was falling asleep anyways cause he was post-call, where as the psychologist spent about 30+ hours, one one of those topics, and had it on their board exam. Let the hospital psychologist do some of the work for you that they should be doing anyways.

So to hear some guy who has his antipsychotics memorized then talk about how he's an expert in seeing if someone is lying....despite that the data shows psychiatrists can't tell better than a layman, he has no training in determining if someone is lying, etc. that's what I'm talking about.

Psychiatrists could talk about some things psychological such as mood, where we actually have some shred of knowledge above a laymen, but we have a heavily pathology-treatment based foundation and for that reason possible bias.

Well yeah. Who is going to push all the psych meds that make so much money?? I'm kidding!

Sent from my SM-G950U using SDN mobile

 

[Salpingo]

That's different. Cardiologists do have expertise and training in how the heart works, hence they do have a foundation to explain how it works.
Psychiatrists do have a foundation of knowledge in many things neurological, and even psychological,. but we have some but no where near as much as a psychologist. So, just like all physicians have some radiological training I'm not going to start telling the radiologists I'll take over their expertise or even pretend to do so.

E.g. psychiatrists don't have classes on child development, personality development, sensation and perception, etc. except for at most perhaps a once a year 1 hr PP presentation where the resident was falling asleep anyways cause he was post-call, where as the psychologist spent about 30+ hours, one one of those topics, and had it on their board exam. Let the hospital psychologist do some of the work for you that they should be doing anyways.

So to hear some guy who has his antipsychotics memorized then talk about how he's an expert in seeing if someone is lying....despite that the data shows psychiatrists can't tell better than a layman, he has no training in determining if someone is lying, etc. that's what I'm talking about.

Psychiatrists could talk about some things psychological such as mood, where we actually have some decent knowledge above a laymen, but we have a heavily pathology-treatment based foundation and for that reason possible bias, but on things such as lying, sensation and perception, etc. No.

If a program doesn’t provide a good education (both didactic and clinical) on child or personality development, I see that as a huge gap in training. Personally, I feel those are essential parts of our professional identity, akin to a cardiologist not knowing the phases of cardiac action potential. Sensation and perception are questionable, although there are people pushing for greater neuroscience education in residency, and I spent enough hours in med school memorizing those neuro pathways to say I had more than an hour lecture. If I wanted to be considered an expert in schizophrenia or psychotic disorders, I would definitely dust off those lecture notes. Again, not going to be at the same level as a PhD, but not far off.

I agree with the original point that lying or magical prognostication is not our domain, unless we’re being called to assess if a person is fabricating a mental illness (in the same way some ophthalmologists and neurologists are called to assess if a patient has a “non-organic” visual or neurologic disorders). We’re also not experts in cold reading, poker tells, predicting stock market behavior or other pseudo-psychological magic tricks. But we have to be careful what we’re abdicating or else we’ll just be the “guy who memorized antipsychotics”. Again, this is more personal, but I would fight to be the expert on ways that psychosocial factors can effect health outcomes, and if your argument is that we’re not trained to do that, I would fight for better training.

 

[erg923]

Only charlatans make the claim that "those people/the person in question are/is lying" in all but the most extreme and obvious cases.

Of course, using a combination of psychometric and statistical/actuarial methods and clinical knowledge about disease course and presentation is the best we can do regarding attesting that someone is feigning a psychological/psychiatric problem. Wasn't there a book about this in like....THE 50s?!

Can psychiatrists do this? Yes. Can psychologists do this? Yes. Are most psychologists and psychiatrists trained to do, at all. No. Are police detectives just as good as we are about assessing truthfulness from very short interactions (which isn't very good on average)? The literature says yes.

 

[watto]

Required reading for shrinks is Ottessa Moshfegi's "My Year of Rest and Relaxation," where the narrator lies lies lies to her hapless psychiatrist, Dr. Tuttle, to obtain downers. It paints a hilariously uncharitable portrait of psychiatrists who believe everything their patient says.

My favorite quote from Dr. Tuttle:

"Fill the lithium and Haldol prescriptions first. It's good to get your case going with a bang. That way later on, if we need to try out some wackier stuff, your insurance company won't be surprised."

 

[whopper]

We’re also not experts in cold reading, poker tells, predicting stock market behavior or other pseudo-psychological magic tricks.

Several of the top minds in psychiatry such as Paul Applebaum argued several times we psychiatrists should not go outside our box when the law asked us to predict if a sex-offender was going to re-offend. The APA (in part based on his recommendations, after all he's one of their head-guys), also backed this up. Along with the statement were some very specific comments that it was inappropriate for people to expect us to somehow predict the future based on a completely faulty premise that because we treat mental illness we somehow know the human mind better than others in predicting the future.

So when transplant psychiatry started emerging and transplant doctors asked us to predict if a patient will take their meds, IMHO it's the same issue all over again with a different mask on. The psychiatrists that were foolish enough to say they could do it IMHO were as foolish as those arguing they could tell if patients were telling the truth, validating re-emerged memories, and selling the idea that truth serums were 100% accurate.

It's different now because there actually is an emerging science where personality factors are being attributed to compliance with transplant meds but this is now, not then, and that field is still emerging, and not part of the usual training. I know not 1 psychiatrist, literally, not 1 trained in it yet I see a few saying they can do a psychiatry transplant consult for things like predicting if the patient will take meds. Further when I see hospitals ask psychiatrists to do it, the ones doing it aren't standing up and stating this it outside their expertise and oddly do it despite that they have no training or expertise in it. If one, however, does have training and expertise in it, there's nothing wrong with it.

It's not inappropriate to tell a hospital "this is outside my specialty," or "simply because I am a psychiatrist doesn't mean I can tell if this person is lying." and I've written that into charts where the consults were asking for such things. One time a nurse manager insisted I do the consult requesting I determine if the patient was telling the truth and I told her, "I find it very odd that you, who are not a psychiatrist, seem to know more about me about my ability to do this." I did my training in Atlantic City and she kept it up without dropping it.

I told her "If I could actually tell if he was lying don't you think I'd walk across the street to Caesar's Palace and use my psychiatric skill at the poker table?"

I walked out of there, (mind you I spent over 20 minutes being nice but she was trying to bully me into doing the consult), she called the department chair, and the dept chair backed up everything I said.

 

[splik]

So when transplant psychiatry started emerging and transplant doctors asked us to predict if a patient will take their meds, IMHO it's the same issue all over again with a different mask on. The psychiatrists that were foolish enough to say they could do it IMHO were as foolish as those arguing they could tell if patients were telling the truth, validating re-emerged memories, and selling the idea that truth serums were 100% accurate.

I'm not sure you understand what transplant psychiatrists do. No one has ever asked me to comment on whether patients will take their meds, and I have never commented on that. The purpose of a pre-operative psychiatric transplant eval is to do a psychosocial risk assessment, and identify barriers and ways of optimizing the patient's psychosocial candidacy for transplantation. This may include the use of validated tools such as the SIPAT which has been validated as correlating with outcomes post-transplantation. Of course, we do look at current adherence to medical treatment and recommendations (e.g. exercise, dietary restrictions in ESRD patients, attending pulmonary rehab in pre-lung patients) which informs how ready a patient is for transplantation and has been shown to do so.

Also as a forensic psychiatrist you know full well that psychiatrists are asked about whether someone will be dangerous in the future, and we reformulate this as a question of risk assessment rather than prediction, and there are several structured risk assessment instruments (e.g. VRAG, HCR-20, LS/CMI, Static-99R, SORAG, STABLE-2007 etc) that be used to informed our assessment of recidivism risk. As you know, we are usually not testifying to the ultimate issue which is left to the trier of fact, and in the adversarial system both sides have the opportunity to present their experts and cross-examining the opposing experts. Of course, we have to be careful to not get into the "black and white" way of thinking that lawyers have, and be honest that even "high risk" individuals are not guaranteed to re-offend. The limitations of the our current SRAIs (if they are even used) should come out in these cases, but often times they will not.

 

[whopper]

I am aware of what you mentioned. Like I said, if you are doing evidenced-based work there's nothing wrong with it.

Yet there are psychiatrists who are asked in the name of "transplant psychiatry" to do things outside of what you mentioned. E.g., as I mentioned, a psychiatrist trained like almost any other, they know their antipsychotics, antidepressants, etc, but they never once used a structured tool in their assessment nor were ever trained on ever using one. Their training did not include 1 lecture on transplant psychiatry. Then they are asked "will the patient be compliant" and the doctor foolishly answers so on a consult.

Also the 2nd paragraph you mentioned, the APA asked that we not "predict the future" but what happened was the SCOTUS basically in a landmark decision nicely told the APA something to the effect of screw you, we don't care. We're going to make you do it whether you like it or not even if the science doesn't back you up. So psychiatry took it up despite that it argued it wasn't within our skill-set.

So since then some psychiatrists and psychologists took up the challenge and started adding tools as you mentioned with a full declaration that what the SCOTUS did was highly questionable at best, but in that regard (and that one only) we've been forced into the bad position and we have to push the science further. The science still leaves a lot of of grey area but it is better than clinical judgment alone.

But even along what you mentioned, actually several forensic psychiatrists aren't schooled into those assessment tools. Several, even forensic psych fellowships, aren't teaching their students about the use of assessment tools or aren't expecting them to use them. Several PDs I've seen don't know how to use an assessment tool, even expressed anger you even brought it up. Further some psychiatrists, especially in areas that do not use the Daubert expert-testimony standard courts are still using psychiatrists that make claims based on no science but based on "I'm a psychiatrist so I'm right" despite that there's no real hard evidence to back their claims.

 

[Salpingo]

I am aware of what you mentioned. Like I said, if you are doing evidenced-based work there's nothing wrong with it.

Yet there are psychiatrists who are asked in the name of "transplant psychiatry" to do things outside of what you mentioned. E.g., as I mentioned, a psychiatrist trained like almost any other, they know their antipsychotics, antidepressants, etc, but they never once used a structured tool in their assessment nor were ever trained on ever using one. Their training did not include 1 lecture on transplant psychiatry. Then they are asked "will the patient be compliant" and the doctor foolishly answers so on a consult.

Also the 2nd paragraph you mentioned, the APA asked that we not "predict the future" but what happened was the SCOTUS basically in a landmark decision nicely told the APA something to the effect of screw you, we don't care. We're going to make you do it whether you like it or not even if the science doesn't back you up. So psychiatry took it up despite that it argued it wasn't within our skill-set.

So since then some psychiatrists and psychologists took up the challenge and started adding tools as you mentioned with a full declaration that what the SCOTUS did was highly questionable at best, but in that regard (and that one only) we've been forced into the bad position and we have to push the science further. The science still leaves a lot of of grey area but it is better than clinical judgment alone.

But even along what you mentioned, actually several forensic psychiatrists aren't schooled into those assessment tools. Several, even forensic psych fellowships, aren't teaching their students about the use of assessment tools or aren't expecting them to use them. Several PDs I've seen don't know how to use an assessment tool, even expressed anger you even brought it up. Further some psychiatrists, especially in areas that do not use the Daubert expert-testimony standard courts are still using psychiatrists that make claims based on no science but based on "I'm a psychiatrist so I'm right" despite that there's no real hard evidence to back their claims.

To piggy-back on splik's post, if thats what's being asked of the psychiatrist, then there's a systemic problem with the program. In my experience, the decision has already been made by the clinical team, but they're struggling to articulate their reasoning -- i.e. they know intuitively this is a high risk candidate based on having done thousands of procedures, but may need help putting it into words and determining if the problems are reversible. The training, tools and instruments help organize that - to what extent is it untreated depression, personality disorder, cognitive impairment, poor social support, past episodes of being burnt by the patient, etc. but its not like they're ready to put a patient on the transplant list then hit the brakes when they find out they scored high on the TERS or SIPAT (which have fairly subjective components, anyway). If you can do a thorough psychosocial assessment, treat basic depression/anxiety, counsel problematic relationships, uncover MCI, etc., all things learned in general training, you can add something without calling yourself a "transplant psychiatrist."

If you're really into it, you can add value as an MD by providing another source of medical information, either to reinforce what the patient may have missed at previous appointments, or answer questions they were unable to ask, which is not something psychologists would feel comfortable with.

Of course, that doesn't mean there aren't inappropriate consults but, again, not a reflection on the field of psychiatry. There are plenty of consulting services who want a rubber stamp or just to be told what they want to hear, and many don't have the interest or capability to seek out the appropriate specialists. Then there are psychiatrists who give up on trying to explain for the millionth time whats a reasonable consult question, or just want to collect a paycheck, or just want to be a team player/get the respect of the jocks, and go along with it. And I imagine its ten times worse in the forensic world with lawyers willing to pay exorbitant amounts to get the "expert" testimony that they need for their case, and doctors happy to sellout (I'd add thats not just a problem with psychiatry but all of forensic medicine/dentistry/science -- see exhibit A).

If your point is people have unrealistic expectations of psychiatry, sure. Its the flip-side of "I'm afraid to go into psychiatry because I'll stop being a real doctor" post. In both cases, I think the answer is to have enough self-confidence in what we do well, not ceding more turf but being aware of our limitations.

 

[SeniorWrangler]

Not the same topic but somewhat related...
Psychiatry is the medical field involved with treating mental illness through a medical model.

It is NOT the study of the human mind, the study of personalities, or pretty much anything else with the human mind outside of mental pathology.

So why is it that so many people expect us to be psychologists?

Why is it that so many psychiatrists seem to be a bit insecure with simply admitting, "this is outside my expertise" and refer out to a psychologist in matters of the human mind outside of medical treatment just like you'd expect to refer to a cardiologist when you see a patient with a heart problem not being treated?

I've worked with plenty of very skilled psychologists whose expertise in things we psychiatrists never get training in are impeccable and have been very useful for me.

I like this idea of being able to refer patients to psychologists to do all the things with the "human mind" that I don't feel comfortable with... I have never had this as an option any place I practice. But it must be nice!

Most of the time when I am working together with non-psychiatrists, I'm the most psychologically savvy person in the room (unless it's a primary care doctor who has a social worker part time in their clinic), and if I don't offer an opinion, the psychological assessment will be performed by Dr. Phil and a 6-month old copy of "Psychology Today" sitting in the waiting room.

 

[erg923]

I like this idea of being able to refer patients to psychologists to do all the things with the "human mind" that I don't feel comfortable with... I have never had this as an option any place I practice. But it must be nice!

Most of the time when I am working together with non-psychiatrists, I'm the most psychologically savvy person in the room (unless it's a primary care doctor who has a social worker part time in their clinic), and if I don't offer an opinion, the psychological assessment will be performed by Dr. Phil and a 6-month old copy of "Psychology Today" sitting in the waiting room.

Sadly there is just as much, if not more, variability in thoroughness and competence with psychologists as there are with psychiatrists, but are you saying of all the places you've worked, you have never been able to work with a psychologist regarding diagnosis and/or other psychological process and issues that may be affecting your patients?

The clinical psychology field has become quite saturated in the past decade, sans very rural areas.