Psychological Reports, 1990, 67, 1315-1318

O Psychological Reports 1990

MALINGERING I N T H E CLINICAL SETTING: PRACTICAL SUGGESTIONS FOR INTERVENTION ' STANLEY RABINOWITZ AND MORDECHAI MARK

Israel Defence Forces Sackler School of Medicine Tel Auiv University ILAN MODAI

CHAIM MARGALIT

Geha Psychiatric Hospital Sackler School of Medicine Tel Aviv University

lsrael Defence Forces Bob Shape11 School of Social Work Department of Psychology

Summary.-The complex nature of malingering observed in the d t a r y is examined, and a practical approach to the handling of such behaviour in the clinical setting is outlined. The complementary tasks of the mental health professional, the primary care physician, and other community agents are discussed.

Malingering behaviour in the military has far-reaching emotional and other effects on the individual soldier, the commanding officer, the military physician and the wider military community. I t is a complex phenomenon which may act as an indicator of individual or group stress. Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external symptoms such as avoiding work, obtaining financial compensation, evading criminal presentation, obtaining drugs, or securing better living conditions (DSM-111-R). This goal can be recognizable given an understanding of individual circumstances rather than individual psychology. I t is important to note the difference between malingering, factitious disorders, and conversion/somatoform disorders (6). I n the military both positive (simulation) and negative (dissimulation) malingerers are found. I n the latter case, we refer to denial by history or examination of some mental or physical defect in pursuit of a goal that is recognizable, with an understanding of the individual's circumstances (6). These soldiers are likely to be found in highly prestigious military units. They are often narcissistic, highly overly motivated individuals who have great difficulty in admitting to being ill and not functioning perfectly. O n the other hand, the positive malingerer openly exhibits his symptoms. I t is such a person with whom we are concerned in this paper. --

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Address requests for re rints to Dr. Stanley Rabinowitz, Sackler School of Medicine, bepartmenr of Family ~ e J c i n e Building , 130, Tel Hashomer, Israel.

S. RABINOWTIZ, ET AL.

The Initial Detection Malingering is commonly found in the military system as a way of avoiding unpleasant military tasks (1). Malingering as a transient reaction may be an important way of coping with stress, often detected by "front line caretakers" (within the &tary, particularly by the primary care physician, and in civ5an settings by other primary community caretakers such as physicians or social workers). The professional must consider ways of correctly diagnosing the behaviour to be able later to treat the disorder effectively. Firstly, a comprehensive medical and psychiatric examination must be conducted to rule out obvious organic or psychiatric symptomatology. Secondly, a detailed psychosocial interview is proposed, aimed at searching for stressful life events (4) which may have precipitated the behaviour both within and outside of the military system. Next, a search for stressogenic past life stressors must be made to assess past coping styles. I n the military such information can be gained from the individual soldier, the commanding officer, and other soldiers who may know the person in everyday functioning. Sometimes family members have been interviewed to gain additional information. Thirdly, once the stressor or set of stressors has been detected, subtle positive or negative reinforcers from the system must be noted, e.g., soldiers receiving positive reinforcement from peers for having successfully manipulated the system. Notwithstanding the drive to cease manipulative behaviour, some soldiers have been unable to d o so because their officers show skepticism and regard them as untrustworthy and lying. This may lead to a vicious cycle which is often difficult for the soldier (and the professional) to control. I n short, it is important for the caretaker to consider subtle communication patterns within the military environment to avoid reinforcement of the deviant behaviour. It is essential that these "interfering reinforcers" be quickly detected and discussed openly and empathetically. Treatment of Transient Malingering When treating malingering behaviour, the professional needs to take into account that drafted soldiers enter the military during the second stage of adolescence, during which time many dynamic changes take place (2, 7). These include (a) identity conflicts, (b) authority conflicts, including dependency and independency struggles, and (c) superego issues which often clash with military demands. These conflicts may increase the soldier's stress and contribute to mdngering behaviour. I n our experience, the physician and other community agents, in appropriate collaboration with mental health specialists, may adequately treat transient malingering behaviour. By following the aforementioned steps, the caretaker will be able initially to gather appropriate information necessary to

MALINGERING: PRACTICAL CLINICAL SUGGESTIONS

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qualify (or disqu&fy) the diagnosis. Next the caretaker should ask: what lies behind the regressive behaviour? To what is the patient reacting negatively? Why does the soldier find it so unbearable to cope adequately with the stress? Short-term intervention involves empathic understanding and open discussion of the behaviour with the patient. I n all cases, the professional should establish a trustful relationship with the patient, in which exchange he expresses empathy and understanding of fears and stress. O n the other hand, the professional's own feelings should be considered to keep the appropriate distance. Often negative anger from the professional thwarts positive change. The caretaker should maintain the professional relationship and relate empathetically while remaining distant from soldiers' manipulations, a very common feature in malingering behaviour.

Habitual (Chronic) Malingering in the Military I n more complicated cases where maLngering behaviour is longstanding and involves continuous, habitual manipulative behaviour under stress, more specialized intervention is required. Here, mahngering may have become habitual, and appropriate intervention requires specific expertise. This includes at least two points: Group controls and group confronbtion.-Within the military setting multidisciplinary groups can be formed including the commanding officer, the physician, the mental health officer, and social welfare military agencies. Since malingerers are often seen to manipulate the various service agencies in the community (as well as in [he mhtary), such groups have a specific function, i.e., sharing information about the rnahngerer's behaviour, confronting the soldier's malingering behaviour and coordinating a joint plan o l action. This approach is a comprehensive, combined one, includtng group confrontation and often censure for continued manipulative behaviour. Similar multidisciplinary community groups may, of course, be coordinated within civilian community settings. Referral for psychotherapy.-An alternative way of referring the patient for psychotherapy has been proposed (3). Here, the primary care military physician does the confronting while the mental health professional may make a supportive offer of therapy. In cases of personality disorder, this splitting of functions can serve the regressive need to differentiate the world into good and bad objects. Later, during psychotherapy, the patient may be able to fuse these opposing views to achieve emotional maturation and integration.

I n some cases of malingering behaviour, the patient may reject all efforts made for help. Here we may be dealing with severe chronic malingerers, with clear personality disorders (antisocial, borderline, histrionic, narcissistic). Treating these soldiers with conventional psychotherapy has not proven successful, and disciplinary action may be the appropriate course of intervention (in civilian settings the only analogy is to stop treatment). I n such cases the soldier may be referred for psychotherapy only after disciplinary action has been completed.

Problematic Aspects of Malingering for the Therapist I n all cases of malingering one must consider the feelings of insecurity experienced by the professional. Such feeling is stimulated by the distortion

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S. RABINOWTIZ. ETAL

of the traditional doctor-patient relationship and delicate balance of fair play. There are often feelings of anger, disgust, and humiliation because the behaviour threatens the very cornerstone of trust within the helper-patient relationship. In this, several points need to be considered. Firstly, malingering is not an illness, so there is no professional obligation for intervention. Secondly, the professional, in dealing with malingerers, usually feels suspicious and on guard, which may distort effective communication and lead to competition of therapist and patient. Further, malingering affects the delicate balance of the professional person's functioning within the system. We refer to the professional's perceived moral judgement of the behaviour (5) and the multiple loyalty problems (1). Here the professional is caught up between a personal moral and value system and that of the profession, as well as the moral and value system of the employing organization. All these dilemmas make it even more important to implement a clearly organized treatment plan (including psychotherapeutic intervention) as well as appropriate consultation, supervision, and support for the psychotherapist. Conclusion Awareness of our inability to be infinitely understanding and to tolerate feelings of being manipulated over long periods may help us to realize the limits of our ability to provide perfect care. Bringing our own feelings into the open, while acknowledging the limits of our potential, may enable us to discuss freely the patient's feelings of helplessness and subsequent need for support and understanding. This may enable the patient to use a less extreme and more flexible coping mechanism. If this is possible, it may promote growth and better coping within the community. REFERENCES 1. BARR,N. I., & ZUNIN, L.

M. Clarification of the psychiatrist's dilemma while in d t a r y

service. American ]ourwl of Orthopsychiatry, 1971, 41, 672-674. 2. BLEICH,A , , C ~ NE., , & LEVY,A. Conflictual areas in the interaction between Israeli adolescents and compulsory &tary service-a possible source of crisis situations. Israel Journal of Psychiatry, 1968, 23, 29-37. 3 . HAMILTON, J., DECKER,N., & RUMBAUT, R. The manipulative patient. American Journal of Psychotherapy, 1986, 60, 189-201. 4. HOLMES,T. Life simations, emotions and disease. Journal of the Academy of Psychosomatic Medicine, 1978, 19, 747. 5. LMN, R. Combatant medics as selective conscientious objectors-morally or politically motivated behaviour? An Israeli example from the war in Lebanon. Psychological Reports, 1989, 64, 1275-1289. 6. MARK,M., RABINOWITZ, S., ZIMRAN, A . , FISCHER,U., &

~ A K J., Malingering in the military: understanding and treatment of the behaviour. Military Medicine, 1987, 152,

260-263. 7. RAB~NOWITZ, S. Inauguration for adulthood: the military system as an effective integrator for adult adaptation, an Israel Air Force perspective. Psychological Reports, 1982, 51, 1083-1086.

Accepted December 12, 1990.

Malingering in the clinical setting: practical suggestions for intervention.

The complex nature of malingering observed in the military is examined, and a practical approach to the handling of such behaviour in the clinical set...
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