Article summary with A model to approaching and providing feedback to patients regarding invalid test performance in clinical neuropsychological evaluations by Carone a.o. - 2010

What is the purpose of a feedback model?

Medical staff often fear conversations about a patient's effort due to the potential or interpersonal conflict with the patients. Even so, doctors have an obligation to provide an explanation about the assessment results. Therefore the potential harm to both patient and society when malingering, poor effort or exaggeration take place outweigh the experienced discomfort by the doctor in a feedback session. This feedback model described in this article is useful for patients in a clinical setting, when providing feedback regarding test performance, effort testing, response bias and exaggeration of symptoms.

How does exaggeration differ from malingering?

Exaggeration is not the same as malingering, although malingering always includes exaggeration. Exaggeration refers to one specific symptom that can occur independent of effort test failure and independent of malingering per se.

How does the symptom validity feedback model work?

The symptom validity feedback model can be divided into three phases.

Phase 1: Developing an effective working relationship and obtaining informed consent

In the first phase trust must be established so patients will more easily accept feedback about uncomfortable topics. When the patient provides questionable information, the model advises to challenge the information in a non-judgmental, respectful manner. However, patients should know the examiner will not blindly believe everything that the patient says and they should be made aware of the consequences of symptom exaggeration or poor effort on tests. Informed consent must be obtained from the patient. Patients should not be told which tests will be used to assess effort and honesty.

Phase 2: Completion of the evaluation

If test results show evidence of suboptimal effort, the examiner should decide whether it is useful to continue with the evaluation and how willing the patient is to acknowledge the poor effort. Patients are more likely to admit they are not fully invested than that they are faking or lying, and are more willing to admit that when disapproving terms are being avoided. If a patient does not want to acknowledge suboptimal effort, the topic can be discussed again later in another session. By holding the feedback session on another day the examiner has time to integrate the information and find the best approach.

Phase 3: The feedback session

The feedback session can be started by asking how the patient thinks he performed on the tests. This encourages patients’ values and decreases their anxiety for the results. When discussing the results, the examiner should start with the good test scores. When discussing the lower scores, the examiner should point out that the conclusions are based on objective data, not on a subjective impression. Elaborate the fact that in order to perform this poor on a test, while you know they have no neurological condition, there must be a non-neurological explanation for the results. Inform them the scores can be improved if the non-neurological factors are addressed (a form of good news), for example with psychotherapy. If a patient does not follow through with these recommendations, this is clinically informative. Keep basing your findings on data and facts, try to avoid an accusative tone and consist with the approach of building an effective working relationship. After the feedback has been provided, debrief the patients by asking how they feel about the information they received. Document the feedback session, including the patient’s responses and reactions

How does one use terms like malingering and exaggeration?

It is very important to carefully explain the meaning of the terms to prevent misinterpretation. For instance, it is useful to inform the patients that there are many factors that can cause an exaggerated presentation and that the term does not necessarily equate to willful deceit (although this may very well be the case). When using the term malingering, use the evidence which provides a high degree of diagnostic confidence. It is not useful to solely use the term malingering. Clinical services are encouraged to provide the patient’s motives for malingering and to suggest relevant treatment options.

How does one handle aggressive, defensive or resistant reactions and complaints?

Factors which affect how patients respond are their personality traits, expectations, and perception of the stakes of the evaluation. The sensitivity and empathy level of the examiner also influences the patient’s response. By anticipating and preparing for resistant reactions, for instance by planning ahead, not giving in to intimidation, and remaining open to explanations, neuropsychologists can improve the chances for a reasoned and tempered reaction.

Should patients be allowed access to their mental health file?

Opinions about providing a copy of the neuropsychological assessment report differ. Although the law typically grants patients access to their medical and mental health files, neuropsychologists have the right to withhold reports. This is permitted when providing a copy of the report would cause significant harm to the patient. This has to be determined for each case individually.

How to deal with the official complaint of a patient?

If a patient feels like filing a complaint after following all the steps of the feedback model, there isn’t much more to be done for a neuropsychologist. It is advisable to save a copy of the complaint in writing, because they might contain inaccurate information or inflammatory language that can be used in the neuropsychologist’s defense. Complaints are most likely to occur when the access to external gain is blocked for the patient by the neuropsychologist’s report. It can be useful to routinely collect patient satisfaction surveys, because it is likely these data will show that the vast majority of patients are satisfied with the provided service. There are two important issues that psychologists can use in their defense:

1. The patient provided informed consent for the evaluation and was aware of the possible consequences.
2. The conclusions in the report are primarily based on objective, empirically derived data.

In any case, the neuropsychologist should provide the members of the investigating body with a copy of the American Academy of Clinical Neuropsychology’s position paper handling ethical complaints during adversarial proceedings. This paper specifically focuses on the possible self-interested motives of those who file the complaints.