Is Your Patient Telling the Truth?

Patients mislead physicians for all sorts of reasons, such as addiction, the need to conceal that an abusive relationship caused an injury, or malingering.  I asked Retired FBI Agent, Robert Bettes, currently with Behavioral Assessment Resource Group, LLC, to share some tips on when you can tell a patient is lying.

Martin Merritt: You are frequently retained by companies to employ your FBI training to detect dishonesty in the workplace, whether in a job application or after a loss, can you share some tips and techniques you use to detect dishonesty? 

Robert Bettes:  When individuals are being deceptive, they exhibit both verbal and non-verbal deceptive behaviors.  There are approximately 27 deceptive behaviors that we regard as reliable indicators of deception.  Some of the more common include:

1. Failure to answer the question: When posed a direct question, the interviewee fails to answer because a truthful answer may bring him consequences.

2. Attack Behavior: The deceptive person will attempt to discredit the interviewer to get them to abandon their line of questioning (i.e. You look to young to be a doctor. What medical school did you go to?)

3. Qualifiers: The deceptive person will qualify their answer with terms such as "basically," "fundamentally," "probably," to carve out the bad information that may be detrimental to them.

4. Hiding the mouth/eyes: We tend to cover a lie. It is a way to shield the truth from the one being lied to.

5. Throat clearing before an answer: There is a natural tendency to improve the way a lie sounds. Anxiety triggers difficulty in speaking.  Clearing the throat attempts to counter this effect. 

6. Movement of major body parts in response to a question: Anxiety will cause a person to exhibit uncontrollable body movements.

7. Grooming gestures: A dishonest person may begin to fidget and begin to tidy up surroundings. In a physician's office, the only thing to tidy up is one's self. Adjusting a tie, shirt cuffs, straightening a skirt can be a way of dissipating anxiety.

8. Verbal disconnect with behavior: When the narrative answer adds up to a "no," but head movement indicates the opposing, you may have a problem.

9. Repeating the question: Repeating the question can be an attempt to buy time to make the answer more believable.

10. Providing too much information or overly specific responses:  One way to hide a lie, is to bury it an avalanche of true details.  If a person appears completely open and honest, we believe them. A dishonest person will overdo it and is able to recount very specific details in which the lie is but one detail.

MM:  In an examining room, anxiety can be normal? 

RB: Indicators are a starting point. Sometimes a cigar is just a cigar, but that is why we look for deceptive behaviors to occur in "clusters." A cluster is two or more deceptive behaviors that occur in response to a question.  If the patient displays a cluster of behaviors, then follow-up questions must be asked.  Active listening is required to identify a patient's true motive.  Suppose there is a pain medication, the patient wants to keep taking, you suspect at any cost.  Ask the patient, "What is the most significant side effect you have experienced when taking this prescription?"  

This is a very good question. Suppose the patient answers, "This prescription really relieves my pain and basically has improved my quality of life. It is the only thing that works." Notice the effect of the answer. The question was about side effects.  Talking about side effects takes the patient away from his goal. So the patient provides an answer which pivots the discussion back towards the target.  Further questions are warranted. If the medication always causes some side effects, dry mouth, drowsiness, or constipation, denying all side effects may be further indications of dishonestly.