Confronting Non-Disclosure Can Engage Patients in New Way


Physicians rely on patients to tell them what is wrong, but patients who distort or withhold critical facts can be challenging, especially for trainees, requiring advanced interviewing skills.

So said Alexander Lerman, M.D., director of residency training at the Westchester Medical Center (WMC), during the workshop “Interviewing the Non-Disclosing Patient: A Clinical Exercise for Psychiatric Residents” Tuesday at APA’s Annual Meeting. Lerman was joined on the clinical workshop panel by WMC program residents Jeffrey Gruhler, M.D., Sahil Munjal M.D., and Mohammad Tavakkoli M.D.

“Patients who distort or withhold important information are frustrating evaluation subjects, and often elicit dismissive responses from psychiatrists,” Lerman said. “If detected and engaged, however, a non-disclosure can itself tell a story, and yield both critical mental status findings and insight into a patient’s psychopathology.”

According to Lerman, who is also an assistant professor of psychiatry at New York Medical College and faculty member at the Columbia University Center for Psychoanalytic Training and Research, patient non-disclosure engenders boredom and psychological withdrawal on the part of evaluating clinicians. International medical graduates and minority physicians may face specific forms of devaluation by aggressive and non-disclosing patients, he said.

“A countertransference experience of this kind can serve as a signal that the patient’s material should be reviewed against available data for evidence of inconsistencies, omissions, and contradictory affective cues,” he said. “Many physicians in training avoid engaging behavior of this kind, sometimes feeling that to do so would represent a failure of professionalism or empathy. In fact, appreciation of non-disclosure—and, most critically, the motivation underlying non-disclosure—represents empathy in a unique form. Engaging a patient engaged in such behavior represents an advanced interviewing skill.”

Lerman explained that evidence of patient distortion and non-disclosure should be considered a critical mental status finding and calls for further investigation.

During the workshop, the resident panelists reviewed video recordings of interviews with non-disclosing simulated patients to illustrate challenges faced by physicians in training, including encounters with patients who are aggressive, uncommunicative, or dispute facts in the medical record. They then illustrated techniques of confrontation, persistent clarification, and focus on the diagnostic significance of “transactions” between the clinician and patient.

The validity of a psychiatric diagnosis is only as good as the information out of which it is composed, Lerman said. “Paradoxically, the phenomenon of non-disclosure represents a unique means to engage patients who are otherwise at risk of receiving inadequate assessments and inappropriate care.”

(Image: iStock/KatarzynaBialasiewicz)