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Social work and malingering.

Malingering is the "intentional production of false or grossly exaggerated physical or psychological symptoms" in pursuit of "external incentives" (American Psychiatric Association [APA], 1994, p. 683), such as escaping criminal prosecution, receiving financial compensation, or gaining access to drugs or medication.

Clinicians most often encounter malingering in the treatment of individuals whose conditions are most easily faked, such as chronic pain, psychiatric illness, and cognitive deficits (Rogers, 1998). Although not considered a mental illness, malingering is often associated with certain psychiatric conditions, such as Antisocial Personality Disorder (Kaplan & Sadock, 1998). Malingering is to be distinguished from Factitious Disorder, in which individuals feign medical or psychiatric conditions, not for external reasons, but solely to assume the patient role and receive care (APA; Mercer & Perdue, 1993).

INCIDENCE AND SIGNIFICANCE

In their widely used psychiatric handbook, Kaplan and Sadock (1998) stated categorically that malingering has art"unknown" incidence (p. 860). However, if malingering is considered to be a common component of psychiatric conditions such as antisocial personality, its overall prevalence in the general population can at least be estimated at "about 3% in males and 1% in females" (APA, 1994, p. 648). Other studies suggest a somewhat higher incidence. For example, Rogers cited data from two large community surveys that indicate an incidence of "7.4% and 7.8%" but did not indicate the ratio of males to females.

Malingering is said to occur most often in male-dominated environments, such as the military, correctional facilities, veterans hospitals, and certain industrial and occupational settings (Kaplan & Sadock, 1998). Malingering has been noted but less often described in women's settings (Kunzel, 1993).

Although it is sometimes claimed to occur more often in public rather than private treatment settings, studies indicate that the actual prevalence of malingering is generally the same in both types of environments (Oldham & Skodol, 1991). It is also often stated that malingering is a common occurrence in medical and psychiatric settings (Kaplan & Sadock); Greiffenstein and colleagues (1994) found a high incidence of malingering in several neuropsychiatric clinics. There is a dearth of literature regarding a breakdown of the incidence of malingering among various racial and ethnic populations.

Social workers should be concerned about malingering because the appropriate identification and management of it is currently viewed as a critical element in the provision of health and mental health care, two areas in which social work services have a special prominence in the United States (Alonso, 2001). Clinical authors are nearly unanimous in stressing that the relatively small incidence of malingering belies its seriousness and significance as a social and health care disorder of the first magnitude (Rogers, 1998). Malingering is viewed as a serious challenge to legitimate health care delivery because it diverts treatment and resources from the truly ill, wastes staff time and energy, and increases burnout among clinical staff (Resnick, 1998). Others have stressed the dire economic and social consequences of malingering. Bienenfeld (2002), for example, has estimated that in the United States the total cost of fraudulent claims for health insurance when last studied (1995)"was more than $59 billion," and has presumably resulted in substantial increases in health care costs throughout the industry since that time.

Recently, social work authors have begun to address the topic of malingering directly (Alonso, 2001). Such studies have helped to improve the identification of individuals who deceive and manipulate, better defined the difficulties of social work practice with such individuals, and developed suggestions for improving the management of helping transactions.

IDENTIFICATION

At present, much work on malingering focuses on the detection of the malingerer (Kagle, 1998). Various approaches and schemes for evaluating malingering have been proposed, although none can be considered to be foolproof (Resnick, 1998; Rogers, 1998). Many authors have elaborated on ideas developed some years ago by Yudofsky (1985), who recommended that an "index of suspicion" be used by practitioners to help discriminate between clients who malinger and those who are genuinely in need of care. The following are some of the key items adapted from this index:

* The client's complaints seem exaggerated and "gamey."

* The client refuses to take steps to improve his or her situation.

* The client will not accept statements by the practitioner that minimize the seriousness of his or her condition.

* The client seeks permanent and ever-increasing financial reward for disability.

* The client's disability relieves him or her of important social, occupational, or legal obligations or responsibilities (Yudofsky).

Research has emphasized that under certain conditions (captivity in wartime, being held hostage, for example) malingering may be highly useful for the individual. In most ordinary situations, however, malingering is generally viewed as a highly stigmatizing pattern of behavior--a form of social disability that requires careful assessment, monitoring, and management for the client to be helped (Kaplan & Sadock, 1998).

DIFFICULTIES IN TREATING MALINGERERS

Ford (1996) has suggested that lying and deception are basic survival strategies often used by individuals who struggle to obtain access to valued resources.

Social work authors (Hepworth, Rooney, & Larsen, 2002) have also noted the adaptational nature of deception, especially on the part of individuals facing dramatic power disparities between themselves and their social environments. The classic literary expression of this tendency can be found in the novel Catch 22 by Joseph Heller (1961).

Nevertheless, although some degree of deception can be expected in most human relationships, malingering as encountered by social workers is generally characterized by a wide-ranging attempt by the client not simply to deceive, but also to commit fraud (Rogers, 1998). Therefore attempts to establish a helping relationship with an individual who may be seeking assistance on this basis are filled with difficulties from the start. Pervasive lying on the client's part tends to undermine the relationship, and the clinician's trust in the client can be quickly invalidated by repeated treatment failures (Kadushin, 1990). Oblivious to why the behavior is problematic, the malingering client often views the clinician merely as an obstacle to be manipulated and overcome in the smoothest and most troublefree way possible (Bienenfeld, 2002; Hare, 1999; Hepworth et al., 2002).

The current material now available on the subject of working with malingerers provides little information about successfully managing a helping relationship with such individuals (Kagle, 1998).

Some clinical authors have attempted to systematically describe helping processes with individuals who persistently engage in deceit and fabrication (Ford, 1996), but most of these guidelines focus on work with individuals whose lying and deceitful behavior stem primarily from psychopathology and not from malingering.

HELPING AND MANAGEMENT

Currently, suggestions about dealing with malingerers in a helpful and nonpunitive fashion consist largely of "practice wisdom" derived from the personal experience of the respective clinician. This literature is rich, though idiosyncratic, and it will be helpful to systematize what commentators have said on this topic. The following list of treatment suggestions includes material by both social workers and other clinicians who have addressed this issue:

Keep the discussion with the client focused on well-defined, immediate, and verifiable problems.

This rule is generally set forth both as an antidote to deception and as a restraining influence on weary clinicians, who can become frustrated and angry when they believe they are being duped by clients (Gabbard &Wilkinson, 2000). It is also important to remember that malingering clients can become highly litigious, and therefore practitioners must give the malingerers' demands and requests as much formal attention as possible. Identifying the important facts in the client's situation, prescribing specific means of treatment, and spelling out potential outcomes to the client in a calm manner can at least provide the practitioner with a sound basis on which to proceed with the helping relationship (Kadushin, 1990).

Stay in charge of the relationship. Treatment encounters with clients who are engaged in any kind of deception or manipulation must be firmly controlled by the clinician (Hepworth, 1993, Hepworth et al., 2002). In these circumstances, the clinician should not attempt to share power or otherwise enlarge the client's scope of action. Any attempt to "empower" the deceptive or manipulative client will only result in granting such clients permission to give free reign to their self-aggrandizing strategies. Various ways of asserting control have been mentioned in the literature. Some authors recommend a directive approach (Hepworth). Others emphasize an acceptance of the deceiver but not the deception, which is treated as a non-functional defense in the helping relationship (Kadushin, 1990). More recently, some researchers have advocated that clients who deceive should be offered behavioral remedies, sometimes reinforced by vigorous maxims and mottos. This particular approach is modeled on techniques used successfully by programs dealing with individuals afflicted by substance abuse and antisocial behavior disorders (Pidcock 8: Polansky, 2001).

Don't make commitments. Clients who use manipulative tactics are best dealt with by avoiding any type of promise or commitment to the client (for example, promises of future benefits, increased attention, advocacy for the client). Although this precept may be somewhat obvious in principle, in practice, it is sometimes difficult to follow because clients who malinger have the capacity to be extremely ingratiating, appealing, and well versed in persuasive arguments when it serves their purpose (Bienenfeld, 2002). Thus, getting "sucked in" by such individuals is always a distinct possibility.

Avoid an adversarial stance. Again, although this precept sounds obvious on the surface, countertransference elements can easily influence work with malingering clients and cause the clinician to jeopardize the helping relationship in fruitless attempts to "unmask" clients who engage in such behavior (Gabbard & Wilkinson, 2000). Although the practitioner's experience of being deceived can be highly unpleasant because it arouses feelings of victimization and raises both internal and external doubts about professional competence (Hanks, 1992), the best course of action appears to be acceptance by the clinician of the client's determination to deceive and manipulate, coupled with the recognition that aggressive confrontation by the clinician does not work.

Share puzzlement at inconsistencies in the client's story. Kadushin (1990) observed that the client's attempts at deception can sometimes be slowed or possibly reduced if the clinician shares his or her puzzlement or confusion about the inconsistencies in the client's story directly with the client. This approach not only lets malingerers know that they are not succeeding, but also grants the clinician useful breathing space in which to regain perspective and seek a more satisfactory approach to the client's requests. It should be emphasized, however, that although malingerers are often inconsistent, inconsistent clients are not all malingerers and may indeed be suffering from legitimate complaints. Therefore, caution is advised in using this approach (Rogers, 1998).

Engage in mild confrontation. Rogers (1998) recommended that malingerers be confronted in a firm but nonthreatening way about their attempts to deceive. The goal of this approach is to attempt to elicit the individual's reasons for lying and misrepresentation, and then to assist as much as possible with these factors as a way of countering, or at least slowing, malingering by the client.

Maintain clinical distance. Various authors (Gutheil & Simon, 1997; Kadushin, 1990) advocate a firm posture of clinical distance when confronted by clients using deception. Such an approach need not jeopardize empathy and understanding by the clinician, and can help direct attention to the client's actual needs and fears.

Consult and document. Risk management perspective researchers stress the need to thoroughly document and consult with colleagues about any contacts with clients whom the clinician believes to be engaged in deception and malingering. It is also important to document all attempts by the clinician to verify details of the client's story and the results of such explorations (Gutheil & Simon, 1997). These measures not only provide necessary backup in case of possible future litigation by the client, but also serve as an ongoing source of support to clinicians who can easily become the target of the client's inevitable feelings of anger, disappointment, and rejection when he or she does not receive the kind of care and attention demanded.

With social work's increasing involvement in criminal justice, forensic practice, police consultation, and correctional work, not to mention its already heavy involvement in mental health and health care, it is certain that many practitioners will face multiple encounters with certain clients who, for various reasons, will attempt to malinger to achieve their goals. I hope that the material presented here will be helpful by suggesting some basis for the establishment of sound helping relationships with such clients. In addition, it should be emphasized that for social workers to provide effective assistance crucial empirical work remains to be done on malingering, particularly regarding its actual incidence among different client groups, the effectiveness of recommended treatment guidelines, and the impact of this phenomenon on clinical practice in various settings.

REFERENCES

Alonso, K. E. (2001, September). The forensic clinician's role in evaluating cases of malingering. NASW California News, 28, 7.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.) Washington, DC: Author.

Bienenfeld, D. (2002). Malingering. Retrieved June 20, 2003, from http://www.emedicine.com/MED/topic3355.htm

Ford, C.V. (1996). Lies! lies!! lies!!! Washington, DC: American Psychiatric Press.

Gabbard, G. O., & Wilkinson, S. M. (2000). Management of countertransference with borderline patients. Northvale, NJ: Jason Aronson.

Gutheil, T. G., & Simon, R. I. (1997). Clinically based risk management principles for recovered memory cases. Psychiatric Services, 48, 1403-1407.

Greiffenstein, M. F., Baker, W. J., & Gola, T. (1994). Validation of malingered amnesia measures with a large clinical sample. Psychological Assessment, 6, 218-224.

Hanks, S. (1992). Translating theory into practice: A conceptual framework for clinical assessment, differential diagnosis, and multi-modal treatment of martially violent individuals, couples, and families. In E. C. Viano (Ed), Intimate violence: Interdisciplinary perspectives (pp. 157-176). Washington, DC: Hemisphere.

Hare, R. D. (1999). Without conscience. New York: Guilford Press.

Heller, J. (1961). Catch 22. New York: Simon & Schuster

Hepworth, D. H. (1993). Managing manipulative behavior in the helping relationship. Social Work, 38, 674-682.

Hepworth, D. H., Rooney, R. H., & Larsen, J. (2002). Direct social work practice: Theory and skills (6th ed.). Pacific Grove, CA: Brooks/Cole.

Kadushin, A. (1990). The social work interview (3rd ed.). New York: Columbia University Press.

Kagle, J. D. (1998). Are we lying to ourselves about deception? Social Service Review, 72, 234-250.

Kaplan, H. I., & Sadock, B. J. (1998). Kaplan and Sadock's Synopsis of psychiatry: Behavioral sciences/clinical psychiatry (8th ed). Philadelphia: Lippincott.

Kunzel, R. G. (1993). Fallen women, problem girls: Unmarried mothers and the professionalization of social work, 1890-1945. New Haven, CT: Yale University Press.

Mercer, S. O., & Perdue, J. D. (1993). Munchausen syndrome by proxy: Social work's role. Social Work, 38, 74-81.

Oldham, J. M., & Skodol, A. E. (1991). Personality disorders in the public sector. Hospital and Community Psychiatry, 4, 481-487.

Pidcock, B. W, & Polansky, J. (2001). Clinical practice issues in assessing for adult substance use disorders. In E. R. Welfel & R. E. Ingersoll (Eds.), The mental health desk reference. New York: John Wiley & Sons.

Resnick, P. (1998). Clinical assessment of malingering and deception. San Diego: Specialized Training Services.

Rogers, R. (1998). Assessment of malingering on psychological measures. In G. P. Koocher, J. C. Norcross, & S. S. Hill, III (Eds.), Psychologists' desk reference (pp. 53-57). New York: Oxford University Press.

Yudofsky, S. C. (1985). Malingering. In H. I. Kaplan & B. J. Saddock (Eds.), Comprehensive textbook of psychiatry (4th ed., pp. 1862-1865). Baltimore: Williams & Wilkins.

Allison D. Murdach, ACSW, LCSW, is a retired psychiatric social worker. The author can be reached at allisonandjo@hotmail.com.
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Author:Murdach, Allison D.
Publication:Health and Social Work
Geographic Code:1USA
Date:May 1, 2006
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