Elissa Ely has a fascinating and troubling case history at the New York Times Mental Health page: the patient’s horrendous tales of lifelong abuse seem to have been made up, but so also was his subsequent report of improvement. The care team cannot decide whether to challenge him on either of these issues.

All through the first year [in therapy], he told terrible stories.

“My life’s a punishment for the things that went wrong,” he said.

The girlfriend who had died in his arms, the gang buddy he’d buried after an overdose [and much, much more]; each memory seemingly darker than the last. He came in thin, grim and intoxicated, and he could not promise to return the next month. Yet he did. There was something else to tell.

[Eventually,] [h]is depression began to clear. He moved into a sober house, began a day program, gave clean urine samples each week and considered looking for a maintenance job. . . . He was also spending every weekend with his old girlfriend and new daughter, the sudden family. Just recently, they had told him he was going to be a grandfather.

The patient goes on, week after week, with more and more grandiose stories of his new life, planned wedding to his girlfriend, and so forth.

His stories were so full of light that a student therapist on the team finally thought to call the halfway house for corroboration. The staff listened with surprise. The patient had never mentioned any girlfriend or daughter to them. He stayed in his room at night and did not mingle with the other guys. He never got phone calls. He was always home on weekends, and utterly solitary. They encouraged him to socialize. But he never went anywhere, ever.

Naturally, this causes some shock among the therapeutic team, and some concern about how to handle ongoing treatment. For some reason, they “agreed to disagree. The student, who earnestly wants to help, has decided to begin a firmer line of inquiry. I have decided to listen unquestioningly”. (This seems odd, since the two approaches seem likely to conflict, and because such team-based therapies usually proceed by way of clear agreement on a common strategy. That a student therapist would be permitted to pursue an independent therapeutic strategy in conflict with the team leader’s is very strange. But never mind.) I think there is a more pressing problem here, though.

I don’t know that it is possible to insist on “the” one correct therapy in a given case. Psychological therapies are so notoriously unreliable, and patient responses so varied, that it is impossible to say that a given therapeutic approach in a particular case is obviously right or obviously wrong. But even so, saying that it is hard to know which therapy will be best is very different from saying there is no best therapy, or that it doesn’t matter which one you choose. To the extent that they work at all, some are obviously better than others, and it matters very much to find that one, notwithstanding that that is hard to do. And to the extent that a therapeutic strategy hinges on responding to the content of the patient’s statements, it seems hard to ignore the apparent fact that a patient’s entire, immensely detailed, psychologically fraught self-description has been utter bullshit in all respects.

To some extent, the factual content of the patient’s statements may not matter all that much: he was clearly depressed and now clearly feels better, and those facts may be taken at face value even if the specific incidents to which the patient attributes them are made up. It may be that the patient’s fanciful history was simply an allegorical expression of his real situation, communicating his underlying psychological condition clearly even through a maze of falsehoods. But on the other hand, that may not be entirely true. If the patient is dissembling, the exact way in which he is doing so is probably psychologically significant - and therefore it is important to know that he is doing so. And if the patient’s condition is not the result of the personal history the patient relates, but some other, the choice and focus of treatment may be affected as well. Whatever Freud taught us, he surely taught us (unwittingly) that it matters whether you believe your patients are telling the truth or not.

I am no clinician, have less than no expertise in psychology, and don’t know the patient reported in this article. Nonetheless, I find it hard to credit that the patient’s therapist is that nonchalant about the patient’s history. Doesn’t the therapist commonly ask patients for their history? Why bother, if it doesn’t matter what the patient says, and you are indifferent whether it is true or not?

Aside from the question of therapeutic efficacy, though, this case leads me back to the issue of patient autonomy. (You saw that coming, right?) Autonomy is a particularly delicate issue in psychology, because so much of our psychological behavior is not directly accessible to self-examination, and because many psychological pathologies impair the will, the perceptions, or the cognitive apparatus in such a way as to hinder autonomous participation in one’s own therapy. This renders the matter of the patient’s truthfulness of both clinical and ethical significance.

It is a commonplace among strong autonomy advocates that one responsibility of caregivers is to enhance the patient’s impaired autonomy where possible (or at least long enough to allow the patient to direct the future course of care). Doing so may be necessary to the patient acting autonomously in the first place, and so is a pre-requisite to respecting autonomy in terms of the patient’s actual autonomous decisions. Among the common threats to autonomy are delusions or misinformation in respect of the facts of the patient’s condition - among which I suspect we must count beliefs by the patient about the patient’s own history and experiences.

If this patient actually believes he has experienced all the fanciful events he recounts to his therapists - much, at least, of which are known to be false - then he is clearly severely impaired in his grasp of reality, and one might think in his autonomy as well. It is very hard to imagine how he can make autonomous decisions about his treatment if he honestly believes he is being treated for the psychological sequelae of traumatic events he never actually experienced. In such a case, one might think that the therapist’s duty would be to force the patient to face the truth about himself (because that would allow him to see reality clearly, and that would help restore his impaired autonomy, which is an obligation of the therapist). But that course is risky. It may not work, and would thus expose the patient to confusion and distress for no benefit. Yet another possibility is that the patient is not truly deluded, but is simply creating a fantasy world, either as a way of communicating indirectly with the therapist (because the truth is too painful to face, or too hard to articulate), or because it pleases him to do so. In this case, the patient may be fully informed about his own case, and otherwise autonomous, but simply choosing to discuss it obliquely for whatever reason. Forcing “the truth” on this patient may actually block a self-chosen treatment strategy the patient values without contributing to his - unimpaired - autonomy. It is impossible to know which of these scenarios - sad delusion or sly escapism - actually describes the patient best, and it is thus impossible to know what approach is most in keeping with an autonomy-centered and effective approach to the patient, without much more information about the patient’s stories and why he tells them - precisely the information that is unavailable without confronting the patient.

In the end, it seems to me vital to know the truth about this patient’s history, not only to choose an effective treatment strategy but also to assess the patient’s own understanding of that truth, and his degree of autonomy in comprehending it and drawing on it to participate in his own therapy. The Catch-22, as I state above, is that this may not be possible to achieve without confronting the patient - a course we cannot know is right until after we have the information we seek in doing so. But either way, I do not think we can be indifferent to that question. Whether or not it factors into the effectiveness of therapy - and how could it not? - it is central to respecting and supporting the patient as a (potentially) autonomous individual.

Ely concludes by asserting:

In the end, our divisions don’t matter. The patient himself will decide what he wants to know and what he will imagine.

I completely disagree. The patient is not likely to decide that rightly, or in a way that supports and promotes his own therapy, unless he has the mental wherewithal to do so clearly and intelligently. (This may still be compatible with the creation of an elaborate fantasy about himself, but he cannot be the prisoner of that fantasy and still be an active component of his own therapy.) He may “choose” to “know” things that are quite unhealthy for himself, yet would do otherwise if brought into closer touch with reality. Neither an aggressive “truth at all costs” approach, nor an epistemological laissez faire attitude, is necessarily right for his therapists. To choose between them, we have to know just how crazy this imaginative patient is.