PAUL MCHUGH AND MEMORY

I’ve just finished reading the book “Try to Remember” by the noted psychiatrist Paul McHugh.*

He discusses, among other things, recovered-memory and the curious history of certain recent medical ‘disorders’ as they are described in the Diagnostic and Statistical Manual (DSM) that is – he regrets – the ‘bible’ of many mental health practitioners.

Since what he describes from his vantage point as a dedicated and highly-accomplished psychiatrist bears directly on the dynamics of the Sex Offense Mania Regime I am putting up a Post here (interrupting my Alinsky series which interrupts my Victimology series … I know).

A dedicated and competent professional, he recounts how in the 1980s he first came into contact with – was almost ‘ambushed by’ – the sinister growth of ‘deductive’ diagnosis. This means that the practitioner doesn’t follow the scientific method – which is ‘inductive’: you gather facts and then try to figure out an accurate explanation of what’s going on. Instead, deductively, you start from your own personal conviction (or ideology) of what’s wrong and then force whatever ‘facts’ you run into to conform to what you’ve already decided is – and HAS TO BE – the explanation.

It’s like choosing only to own a hammer and then deciding that it’s the only tool for every job and THEN hanging out your sign as a home-repair business and approaching any repair job as one that clearly MUST require the use of your hammer. Except that you are not some half-baked homeowner but rather a practicing professional in a field that everyobody expects to be ‘scientific’.

He noticed that he was encountering persons claiming to have ‘Multiple Personality Disorder’ (MPD) – believing that they were actually several or more distinct personalities in their one body. He did what he could to get them beyond that. But after a while, as he says, he stopped simply trying to save this steady flow of persons drowning in the river and started asking himself ‘Who’s throwing them all in?’.

This led him by a bit of detective work to a reputable clinician, a Dr. Loewenstein, who was asking patients if they ever felt there were parts of themselves that they couldn’t control (and who hasn’t had that feeling from time to time?) and then immediately assuring these troubled and confused souls that they had several personalities inside of them and thus were suffering from Multiple Personality Disorder.

There was absolutely no factual or scientific basis for presuming that such a feeling was a guaranteed indicator of any such thing as an ‘alter’ (another self besides the one you sorta know as ‘me’) let alone ‘multiple alters’. There were far less outré clinical explanations already well-established for dealing with a patient’s sense of loss-of-mastery or inability to control one’s interior or exterior life, feelings and/or behaviors.

But this clinician was convinced that such entities as ‘alters’ could and did exist. Worse, he had a ward all to himself at a Baltimore hospital where he gathered all these patients together, where they could set each other off like tuning-forks in a small room. And he restricted his selection of ward staff to only those who would grant “unequivocal support” for the patients’ beliefs that they had multiple-personalities (a belief that his own preconceptions had implanted in their mind).

McHugh asked for an appointment to talk to Loewenstein: it only lasted about 10 minutes, because when McHugh pointed out that the ‘diagnosis’ was based on an un-testable assumption; and that patient histories were ‘corroborated’ by un-testable anecdotal stories; and that there existed every possibility that such troubled souls might ‘manufacture’ material in order to please their prestigious doctor’s expectations and continue that doctor’s attentions … when McHugh pointed out these rather basic issues, he was quickly declared “too biased to be reasonable” and the meeting was terminated. McHugh, clearly, did not ‘believe’ and – I would expect – he ‘just didn’t get it’.

You can’t ask these types of questions, he was told, because you are asking for a sort of “x-ray” of the patient’s mind and that’s not possible. Precisely, McHugh responded: nobody can get a clear picture of what’s going on in anybody else’s mind and there are a number of possibilities that have to be run through, carefully and scientifically, before you can come to a diagnostic formulation.

No, he was told: the multiple-personality “made sense” of the patient’s story. Although this “sense” was only available to those who really did ‘get it’.

It gets worse. In 1973 a maverick psychiatrist, Cornelia Wilbur, had engaged the services of a reporter-ghostwriter to pen the book “Sybil”, allegedly about a woman who suffered from such multiple-personalities.

Worse than that, Wilbur went on instantly to assume that the only thing that could cause the development of the (mythical) ‘alter’ was – wait for it – childhood sexual abuse. And since most of the patients were female, then the perp was usually the father and – not to put too fine a point on it – a male.

McHugh began to get calls from men who, in that era, were suddenly being confronted by grown daughters showing up on the doorstep or in the living room claiming rather vividly that they had been abused as children. He started to be asked to offer expert opinions –ominously – in court cases, since more and more often these cases were being stove-piped (to use a phrase from the Bush-Cheney era of getting only the intelligence information they wanted to hear) right into the legal system.

The ‘evidence’, said these MPD aficionados, was simply “the revealing mental state of the patient”. In other words, the patient believes it so that’s all the evidence we need, not only to diagnose MPD but also to establish that some form of sexual abuse took place. (And of course, what was ‘revealed’ was exactly what a whole lotta ‘interests’ very much wanted to hear – see below.)

I didn’t pay much attention to “Sybil” when it came out as a book back then or – shortly thereafter – as a Hollywood movie.

But reading McHugh it becomes clear now just how marvelously (by intention or serendipity) Wilbur’s plot was positioned to harness the energies of, and ride the crests of, several very large cultural waves of that era: Youth was being ‘valorized’ just as ‘adulthood’ was being ‘deconstructed’; radical feminists were waging Alinsky-ite ‘war politics’ against Men and against Authority and against the Family and claiming that Men were sexually violent by their very nature and – in the view of some radical feminists – that all sex was rape whether it was intended to be or not; Victimology was just beginning to warm up to the ideas that Victims were being ignored, that their ‘pain’ (and their stories) must be ‘trusted’, and that skepticism constituted nothing less than re-victimization, and that instances of such outrages were 10, 50, 100 or more times as frequent as what was reported to the authorities or the media.

And on top of all that, the Beltway was robustly engaged in accepting every advocacy’s claim as true and simultaneously responding to their Alinsky-ite ‘pressure’ by making lots and lots of money available while also starting to monkey around with laws civil and criminal.

Wilbur had a male friend, also a psychiatrist, who happened to work at the National Institute for Mental Health, and – McHugh notes – by 1986 this sort of thing was established as a major focus of well-funded government ‘science’.

It is a sign of just how useful Wilbur’s book was that although the character of Sybil was said to have been sexually abused as a child by a mentally-ill mother, yet quickly the ‘classic’ scenario was morphed to being a daughter abused by a sane but rapacious father. And, as might be said at Santa Anita, they were off! And the band played on.

While McHugh notes that Freud (for whose intuitive and ‘gut’ approach with no scientific research to support it McHugh has scant regard) asserted that the core psychological drama is enacted within the individual, I would say that the combined effects of radical-feminism’s agenda and Victimology and a lot of government money transferred this to an ‘exterior’ battle with evil persons who victimize the individual and upset what was (presumably, if impossibly) a perfectly normal and utterly healthy life.

But Freud’s insight that the human family was in essence a seething swamp of human passions – sexual aggression, power-struggles for dominance and influence – was retained as the decade and the assorted advocacies went barrelling along.

And so too came the clinical ‘approach’ of “high suspicion, low skepticism” that grounded itself in no actual validated research data, but instead only in “assumptions, expectations, and fantasies” (on the part of the clinician even more than the patient).

The simplistic diagnostic equation ran something like this: Premise – all depression is caused by sexual abuse as a child; Observation: the patient is depressed; Conclusion: the patient was sexually abused as a child. He notes that this is nothing more than a travesty of the Scientific Method, and is based on nothing more than irrationality, illogic, and constitutes a gross betrayal of professional integrity and responsibility.

As McHugh pithily puts it: “don’t try to read between the lines until you’ve read the lines themselves”.

He notes that sizable numbers of persons began declaring themselves “survivors” although there was no evidence of just what it was they had survived.

I would add that it is a perennial human temptation to seek status to shore up one’s sense of self – and if you’re needy and desperate enough, by any means necessary or available. And this predisposition is not well-served by a culture that makes such status simultaneously ‘valuable’ and so easily achieved (you simply have to ‘declare’ it). This is NOT to breezily dismiss the possibility of sexual abuse but simply to observe how terribly fraught these matters are; and that they should not be played with any more than children or anybody else should be allowed to play with dynamite.

They declared themselves thus because, many said, their therapists had helped them ‘recover repressed memories’ – which, as I have always said, are things that constitute classic examples of ‘spectral evidence’ (visible only to the self-declared sufferer and not to any other person, clinical or judicial).

He was greatly discouraged when the American Psychiatric Association (APA; not to be confused with the American Psychological Association – also APA) did not quickly and effectively tamp down the growth of this entire clinical trend that included ‘recovered memory’.

What was happening here, I would say, is that these prestigious professional organizations were succumbing to the inherent organizational ambiguity of their objectives: on the one hand to maintain a certain integrity and competence among practitioners, but on the other hand to ensure as many lucrative employment opportunities and venues for ‘new’ and ‘cutting edge’ therapies as could possibly be construed as worthwhile. After all, every therapy that is officially denounced is some practitioners’ bread-and-butter. You see where this sort of thing can go. And there was lots and lots of government money if you were looking to solve the Correct problems.

And there’s the ‘professional’ and ‘scientific’ element ripe and ready for Stampede.

McHugh helped found the False Memory Syndrome Foundation, not simply out of concern for the integrity of his profession but also because by the early 1990s it was clear that large numbers of people were winding up in court and many families deeply disrupted if not wrecked.

But though the DSM was being revised at that time, its gatekeepers did not want to introduce the diagnosis of “false memory syndrome” since the proponents of buried-abuse and recovered-repressed memories were at the same time trying to bolster their increasingly-challenged theories and – indeed – were cagily trying to rename MPD as Dissociative Identity Disorder (DID) to distract the growing objections and give themselves a new lease on professional life (and profits). After all, the neat harnessing of multiple-personality, sexual abuse, and recovered-memories had proven to be quite a crowd-pleaser and certainly both government and media were robustly engaged with it.

Nor, I would add, are psychologists or scientists totally free from the usual foibles of the human mind and heart: thinking for oneself is a lonely business at the best of times. But in times of Correctness and Mania it can be positively dangerous (to your status, your employment, your career, your livelihood). And it always feels better to be part of the herd and even better - to be 'ahead' of the herd, leading the way. Yet being a 'wall-breaker' is not necessarily being a 'path-breaker', especially if the walls you are cherribly deconstructing are carrying and load-bearing structural walls and not just decorative or convenience room-partitions.

And for that matter, the busy and robust movement of a roller-coaster ride is neither 'travel' nor 'progress', though it offers some diverting fun if properly supervised.

McHugh notes that it is rarely if ever the case in matters psychological that A and only A can be the cause of B. There are usually many possible factors (C, D, E, F and so on) that might also be the cause of B, or a combination of those factors operating deep within the self in all manner of complex synergies.

The deductive approach – I believe that A and only A causes B and thus wherever I diagnose B then A must have been the cause – is illogical and cannot conform to the complex and subtle and variable realities of psychic causation. Patients must then be ‘helped’ (‘manipulated’ is more like it) to accept that the necessary ‘script’ happened to them even if they have no memory of such a script ever taking place in their lives.

Much better and much more accurate, says McHugh, to start with a focus on the patient’s actual problems in the Here And Now than to try to impose a script on an almost impossible-to-access ‘past’ set of ‘remembered’ experiences.

AND, he notes, his growing experience in court-rooms as a clinical expert was starting to demonstrate that once you let his deductive-presumptive approach into the court-room, you wind up with both 1) a presumption of guilt; and 2) the burden of proof being placed on the accused rather than on the accuser; and 3) the accused actually being assigned legally the logically-impossible task of proving a negative.**

Things didn’t get any better with the late-1970s explosion of a diagnosis called Post Traumatic Stress Disorder.***

You had a ‘diagnosis’ given to something that is not a disease-entity but rather is merely a set of emotional and behavioral responses to tremendous pressures generated by your experiences. Worse, ‘pain’ – while it can be real, in the sense that it is ‘felt’ by a sufferer – cannot by easily validated or corroborated by an outside observer and in that sense its dynamics function with a queasy similarity like the old ‘spectral evidence’.

But it was clear by the late 1970s that the Vietnam-era troops, some of them, were having a bad time of it in their post-military lives, and something should be done to ‘help’. ‘Valorizing’ PTSD must have seemed a quick, direct, and politically popular ‘solution’.

As early as World War 1 in this country some professional observers from the new psychological disciplines had noted what they called ‘war neurosis’ in some troops; although there were popular public awareness going back to the Civil War when those veterans thus-afflicted were said to have a case of ‘soldier’s heart’. The Brits actually had a hospital set up under a psychiatrist named Rivers that tried to help suffering soldiers (mostly officers) regain their balance.

As should come as a surprise to nobody, the assorted movements and advocacies took what was an already dubiously-cast ‘diagnosis’ stemming from war experiences and quickly applied it to ‘abuse’ experiences and assorted other ‘victimizations’. McHugh will note later in the book that there is now a movement afoot, agitated by this and that advocacy, to get the next edition of the DSM to declare that clinicians no longer have to – or should – try to determine if there really is any conceivably valid ground for a patient’s claimed or reported ‘pain’. Rather, the simple fact of the patient’s declaration should be ‘scientific evidence’ enough that the diagnosis of PTSD applies. I will allow myself here the observation that this is actually heading toward a mutation of the PTSD diagnosis to ‘NTSD’: Non-Traumatic Stress Disorder.

You don’t need a college-degree to realize that if you basically allow the patient to determine the diagnosis you are A) increasing exponentially the risk of inaccurate diagnosis (of what is already a conceptually dubious diagnosis in the first place) and B) increasing exponentially a ‘patient pool’ that could keep a whole lotta therapeutic practitioners in business for quite a while – the perfect clinical ‘self-licking ice cream cone’, as the Pentagon contractors like to say.

Members of the SO Community will be very familiar with the deployment of the ‘incalculable damage’ assertion that grounds so many of the ‘Findings’ which, legislators claimed, created the Emergency that required the Regime.

And again and again and again, I am not denying here that some very real cases of sexual-offense trauma can create valid issues that require professional attention. But I also note that the country has now become ‘medication-happy’, as any tally of TV commercials for prescription drugs (‘ask your doctor’, which works out usually to ‘demand from your doctor’) for this, that, and every other ‘pain’ and ‘issue’.

In this regard, McHugh notes sadly as a lifelong practicing professional, that Oliver Wendell Holmes, Sr. (the mid-19th century doctor, father of the Civil War hero and Supreme Court Justice into FDR’s first administration) noted acutely that his beloved discipline of Medicine was as susceptible to public fads “as a barometer”.

As McHugh found himself traveling all over the country in the 1990s he notes that prosecutors and law-enforcement personnel who would distrust a person’s claim of being assaulted would suddenly become utterly credulous if the person suddenly changed the claim to one of being sexually assaulted or raped. And he notes one judge who actually said that she expected the accused to prove that he did NOT do what he as accused of – which is a logical impossibility (and apparently basic logic courses are not part of the law-school curriculum any longer, or logic is no longer considered relevant to law and jurisprudence).

But there are occasional bright spots: in a Rhode Island case it was the prosecutors who moved to dismiss due to the “subjective character of the psychological data”. So something moved the prosecutors to recall the old ‘spectral evidence’ problem.

But the problem of “over-inclusive diagnoses” remains lethal in the DSM arena; the professional psychological community – true to Holmes’s ‘barometric’ observation – want to be ‘inclusive’ and don’t want to ‘re-victimize’ and so are tending toward accepting literally ‘whatever’ as evidence of validly diagnosable malady. And, I would venture, this will continue as long as the money holds out. And if not, not.

In a particularly acute observation, McHugh poses the hypothetical but quite probable question: But if it’s in the DSM, then it’s real, isn’t it? To which he responds firmly and clearly: No. A fact that courts – including the US Supreme Court – now realize in the matter of recovered/repressed memory cases.

It’s simply ungrounded speculation, and contrary to much of what is actually and validly known about human psychology, to claim as an Invariable Rule that Psychic Disintegration is caused by Repression which is caused by Childhood Sexual Abuse. The entire thrust of evolution, in order to protect and preserve the species, is that human brains are wired to ‘remember’ – at least in a general way; a species that couldn’t recall quickly whether saber-toothed tigers were good things or bad things wouldn’t get very far.

But specific memory remains a complex and hugely variable process: there is no evolutionary need for ‘photographic’ memory and the brain isn’t set up for it; many factors internal to you (your emotional state of arousal, your level of awareness and powers of observation) and external to you (the amount of distraction, the circumstances of tranquility or danger) affect what your memory records. Indeed, if anything, even if you have an I’ll-Never-Forget-It experience, there is serious question as to what a mind under great pressure is going to be capable of recording.

And which you then might be able to access at a later – perhaps much much later – date.

(I had an experience just last week: I had a flash-drive with important material on it in my briefcase on Monday. On Tuesday, rummaging in the briefcase, I couldn’t find it. Instantly, I was anxious. My mind – trying to be helpful – gave me two ‘answers’: first, on Monday I had stepped out of the car with the case and distinctly heard a ‘click’ as I walked away from the car but thought insignificant; second, my mind produced a clear and distinct image of that flash-drive lying among some papers at the coffee shop I had stopped into for a cuppa. I had two clear and distinct images (not to say ‘memories’). I went back to that town and the parking space and the coffee shop both yielded nothing. Getting back into the car, it quietly came to me that I had for convenience tossed my briefcase (the leather, open-topped kind that holds laptops) across the front-seat into the passenger seat. I looked down and there, in the crevice of the passenger seat, was the flash-drive. And yet my mind had – with the best of intentions, I am sure – given me two almost film-like images of ‘memory’ that turned out never to have happened that day.)

Nor is it necessarily established, McHugh goes on, that “one heals by remembering” – which is the mantra of the MPD proponents and recovered/repressed memory crowd and every group that finds their assertions somehow useful.

Clinically, you’re on much more solid and workable ground by focusing on the patient’s present complaint of behavior or feeling or thought and working through THAT – and THEN seeing if that hasn’t given the patient relief. Imposing a hugely dubious, not to say impossible, ‘script’ on the patient will run up bills, create probably more trouble and pain for the patient than s/he originally came to you with, and generally degrades not only the patient’s quality of self and life but your own professional integrity as a practitioner AND the overall integrity of the profession itself.

The “explosive phase” of the repressed-memory “craze”, he recalls, seems to have been at its height about 1994 (the Domestic Violence and Sex-Offense Regimes legislatively established, though court challenges hadn’t yet begun in earnest). He quotes an author who has researched that of the 250,000 licensed ‘therapists’ (a verrrrry broad term itself) that year, a quarter claimed themselves competent to offer “memory-focused therapies” (again, a verrrry broad term) and claimed to recover such memories in 34 percent of their roughly 50 female clients per year. Some math brings you to the rough figure of a million cases. And each case had several more persons attached to it, not infrequently as accused persons.

On the basis of questionnaires and surveys McHugh’s Foundation has done upon available official information, some characteristics of the group of accusers are: almost all Caucasian, 93 percent female, an average age of 32 years, 77 percent college-educated and working in professional, white-collar occupations.

Further, accusations were rare among this pool before 1985 but peaked in 1991-1992, declining down to 1999-2000 (which is around the time the courts began to back away from the validity of repressed/recovered memory … although the Sex Offense Mania Regime was by then performing the neat two-fer of almost completely overshadowing the equally misconceived Domestic Violence Regime and also picking up the slack left by the waning recovered/repressed memory craze).

McHugh raises the hugely intriguing and apt professional question: was all this the result of a ‘craze’ n actual illness OR a “craze in therapy”?

I would add the significance of the college-educated element: precisely the class that would have been exposed to the radical-feminist ideology as it infiltrated (is 'infested' too strong a word, d'ye think?) college campuses in the guise of this or that 'studies' course or department.

He then limns, ominously but informatively, recent jinks and jives among the MPD proponents. They have started now to spin themselves as “humanistic”, as if they were concerned for ‘people’ while clinicians trying to work according to established facts were merely ‘technicians’ concerned with ‘abstractions’ and ‘proof’ and ‘evidence’ and ‘research’ rather than with ‘persons and their pain’ (as if the two approaches were mutually exclusive AND as if the MPD proponents hadn’t caused huge human wrack and wreck).

Further they are trying to position themselves on the PTSD wave by talking about “betrayal trauma” as if it were a clinical disease-entity or constituted as awful an assault on the human being as direct combat experience or substantive disaster-level experience.

In that “betrayal” McHugh sees the continuation of the pervasive – indeed constitutive and indispensable – dynamic of “suspicion” introduced into psychology by Freud: you must always suspect that beneath any appearances of ‘civilization’ or ‘maturity’ in a person there is a deep, hidden, dark frothing mass of essentially sexual passion, repressed but active and indeed determinative in human behavior and motivation. Although this huge assertion of Freud’s is nowhere established by any credible scientific research.

(Curiously, I would note, Freud’s assumption that children are not immune from this because that’s how profoundly and quintessentially human the sexual-motivation is … this assumption of Freud’s was quickly ignored by assorted permutating advocacy positions in the scrum of politicking and political pressuring that has been an all-too-determinative dynamic in the on-going saga of all of this Sexual Violence and Male Sexual Violence stuff. The ‘Child’ is, for the purposes of those interests, an essentially pristine and pure and innocent (in the Victimology sense) entity – which is a vision that not even Freud would have accepted.)

And in this “persecutory psychiatry” as McHugh terms it I see as well the abiding political suspicion of Haves (out of Marx by Alinsky), as well as of Men (out of Alinsky by radical-feminism), and of Perps (out of Marx and Alinsky by Victimology).

The MPD proponents are now billing themselves as “traumatologists”, using a vague and elastic application of the PTSD diagnosis, while also seeking to have their former MPD diagnosis re-named Dissociative Identity Disorder (DID). Concerning their previously trumpeted assertions back in their salad days, these proponents are now claiming that their terminology was just “metaphor” and that they are victims of “misunderstanding”. And, no doubt, that in any case they ‘meant well’.

You can chart their course in shorthand as MPD to DID to PTSD as they continue to surf for a ‘place’ where they can set up shop (and continue billing).

McHugh concludes the book with a significant proposal for a new clinical classification system that I won’t go into here but is simple and well worth the read.

All patients resemble each other in their distress, he says, BUT NOT IN THE CAUSES OF THAT DISTRESS. Thus the DSM approach has been flawed from the get-go in trying to classify Symptoms rather than the possible Causes of that distress.

His new classification system would divide patients according to Causes: genuine brain deformity or disease; Dimensional Disorders (such as intellectual dysfunctions or overly strong emotions or extremes of introversion or extroversion); Behavioral Disorders (such as alcohol or drug dependence or abuse and hysterical illnesses****); and Life-Story Disorders (the cumulative consequences of maladaptive or ineffective emotional or behavioral responses to the challenges of one’s life and to distressing life experiences”.

In all patients, the goal is not only to ‘relieve pain’ but to do so by helping the patient develop and sustain a greater “mastery” over his/her life and thus over his/her self.

I support this approach strongly.

And I can’t help but notice how many elements in current American society are dismissive of the goal of ‘self-mastery’ – either because it is too ‘male’ a goal or because it doesn’t allow for the quick-burning political fuel so beloved of Alinsky-ite agitating and organizers of ‘pressure groups’.

So much remains to be done.

NOTES

*Published by Dana Press, New York, in 2010. McHugh is a Professor of Psychiatry at Johns Hopkins, and from 1975 to 2001 was Director of the Department of Psychiatry and Behavioral Science at the Johns Hopkins School of Medicine, as well as Psychiatrist-in-Chief at Johns Hopkins Hospital.

**You can prove a positive: if you can find one instance of your assertion, then you have proven it. So for example, if you assert that purple elephants exist then you need produce only one such elephant to prove your assertion. However if you claim that NO purple elephants exist, then – impossibly – you have to establish that no such creatures can ever be found to refute your assertion … and THAT task is impossible to achieve.

Thus it’s almost impossible to prove that you did NOT sexually abuse someone.

Which is a frakkulent gambit that has helped ‘keep up the numbers’ in the Sex Offense Mania Regime in all of its permutations and sub-variations.

***I’m going to have some critical observations to make about this PTSD diagnosis here. Given the state of public-discourse nowadays let me say here and now that I am NOT in any way making light of ‘the troops’ and the awful suffering that they face as a result of a decade of unremitting (and most unsuccessful) military operations. And it is the troops themselves who developed the lethally perceptive advice to ‘Embrace the Suck’.

****He uses ‘hysterical’ here in the formal, not the popular, sense. Formally, a hysterical illness is a deception practiced by a patient on him/herself, and NOT merely a conscious ploy perpetrated on others, and it is not a matter of conscious ‘pretending’. In response to a deeply-threatening perceived problem, a patient will pre-consciously develop a physical symptomatology that is actually a smoke-screen evolved by the patient to shield the actual problem from his/her own awareness.

The purposeful deception bit is formally termed ‘malingering’, which is a problem all its own.