I've touched upon the subset of the mentally ill population whom I believe is most impaired. On the opposite end of the spectrum there are those who pretend to be mentally ill. They are referred to as malingerers. They pretend to be sick for secondary gain, that is, hospitalization or a crisis unit stay. Although the most common reason for this is to secure "three hots and a cot" because of homelessness, there are other reasons. For instance, they might have just encountered a drug-deal-gone-wrong and now are in danger of getting killed, thus need to hide out. Or, they might want to build a case to try getting financial benefits from the government.
I want to give attention to this population not because I believe they deserve to occupy my brain space. It should be shouted from the rooftops that they are part of the problem. They occupy precious and limited bed space. They waste health care resources. They waste our tax dollars.
How prevalent is this problem? I haven't found any state specific or nationwide statistics when I searched for this. However, I tracked one hundred cases in a row randomly dispatched to me in order to see what percentage of these were malingering. The results were alarming.
In graduate school at Columbia University, the possibility that patients could lie about their mental states never crossed my mind. When searching for continuing education courses to take in order to maintain my license, I've never come across this topic. When clinicians are educated about how to identify malingering, they are better prepared to show them the exit door rather than enable them.
8 comments:
Interesting. I never would have considered this a major problem. How can you tell when they are malingering?
Here are the signs: 1)Suddenly voicing suicidal ideation upon notice of discharge from a formal overnight level of care 2)Using many back-to-back formal overnight levels of care 3)Having lost the ability to reside where they were residing immediately before seeing me 4)Chronic pattern of non-compliance with outpatient referrals and medications provided by inpatient units 5)Vague descriptions of depression, anxiety, or psychosis 6)Listing symptoms in a rehearsed fashion, as if common diagnoses were just searched online 7)Reporting information inconsistently. An example of this last one was when a patient told me he was depressed about his sister having died within the last couple months. I suppose he didn't think that I'd check the record of me having evaluated him years previously, where I found this same sister died.
This is big in VA circles. A diagnosis of PTSD gets Veterans benefits (I think $2K/month). Many Vets have serious PTSD, many have mild. The VA changed the criteria to get PTSD. It used to require having experienced trauma, like being in battle. Now one can qualify if they fear they may go into battle. Sally Satel has written a lot on this (Wall St. Journal, etc.) and her book one nation under therapy discusses it.
Wow...I never considered this before. Could the schools or community centers help?
I am not an expert on the childhood educational system. However, I believe that basic courses in psychology should not begin with the premise that all patients are truthful. Students aspiring to begin careers in psychology or fields related to this would benefit in knowing that malingerers interact with certain types of mental health professionals regularly.
Regarding community centers, it's important for the public to be aware that a large percentage of homeless people are not seriously mentally ill. Many of these people are substance abusing malingerers. I would caution these centers to be aware of this problem. Money given to this type of homeless population, believed to be helping them, could instead be enabling their addictions.
If it's freezing cold outside and someone is homeless, what are they supposed to do if not go to the hospital and try to get shelter and safety for a few days? If someone is "malingering" in the ways you describe, they must be in a terrible situation to prefer being in a psych unit to be in their own residence (assuming they have one) and deserve help just as much as an actual schizophrenic. Mental "health" workers should not pass judgment on anyone who comes to the ER or a crisis unit, and if someone is so desperate for the "secondary gain" of being admitted, then something is seriously wrong in their lives, and they are just as deserving of help as anyone else.
Of course not everyone tells the truth. More than just SMI don't know truth from "memory." There are very few alcoholics, esp on the streets who do not have something they drink to obliterate from their reality. Same for the drugs. as the young man at bus stop said several weeks ago. "I never chased the high of heroin. I took it to get relief from issues." He was talking about the wall of untouchability. the world inside and outside on one side, the injured soul on the other, untouchable, in a proximity of peace, the best some can approximate it.
No one sinks because they have faith in themselves. No one sinks because life has dealt them a winning hand. No one chooses to fight for very moment out of the rat race because they like doing that. Would you condemn a battered woman for staying with a batterer? I hould hope you understand enough not to. Would you condemn a child to prison who has 4 or 5 significant ACEs in his/her background? would you insist on saying a 12 year old prostitute be jail for reacting in a predictable way to her past?
I do agree that throwing money at these problems like a liberal loves to do is foolish and feel good. I also agree with the conservatives who understand how costly not dealing with personal issues has a huge social cost we all pay.
If "malingerers" cycle through agencies, blame the ineffective programs those agencies cling to. Blame the heads for not knowing what they are doing other than playing poverty pimp, mental health pimp!
Ann Pollack: If someone is homeless, there are appropriate resources that can be used to alleviate or resolve this besides hospitalization. Hospitals are financially expensive institutions designed to provide medical and psychiatric care. They are not hotels. Nor are they motels. Hospitals are not expected to provide respite.
Just because someone is desperate to flee from a terrible situation for a few days doesn't mean this person has a mental illness. Not granting them inpatient when they don't clinically qualify is helpful.
The person in crisis with schizophrenia is a much higher priority in psychiatric emergency services than a malingering drug addict who is not mentally ill.
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