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Most practitioners maintain some definition of what they consider the ideal client, and for Dr. Haggarty, Marilyn Safer sums it up perfectly. In addition to listening attentively to the veterinarian, Ms. Safer also asks intelligent questions that reflect an understanding of the subject in question. She also makes it clear that she has the utmost faith in Dr Haggarty’s ability: “Don’t even think about ever referring us,” she tells the veterinarian with certainty, “If anyone can solve this problem, you can.” The clinician basks in these compliments as well as the belief that her client religiously follows all veterinary recommendations to the letter. What more could any practitioner ask for?
When Dr. Haggarty first conceived her ideal-client definition as a veterinary student, and even after she modified it somewhat when she entered the real world of practice, the net result of the interaction between such a client and the veterinarian was always the same: the resolution of the animal’s problem. However, in the case of Ms. Safer’s animal, that never happens. The animal’s condition may improve and it may even disappear for a while, but it always comes back. Because of her genuine desire to help the animal and relieve the burden this places on her very nice client, Dr. Haggarty spends long hours trying to determine the cause of the problem and how to treat it. When she can’t sleep at night, she thinks about the case: What is she missing? What additional tests might pin down the cause? What treatment might work better? Because Ms. Safer has some medical training herself, she is always receptive to the veterinarian’s ideas, as well as being very grateful for Dr. Haggarty’s concern. Nonetheless, the animal’s problem never resolves. Soon the veterinarian feels so sorry for this wonderful client and her poor animal that she gives Ms. Safer her private cell phone number, “in case something comes up on my day off or while I’m on vacation.”
The above vignette touches on the primary characteristics of a rare, but highly troubling, client-clinician interaction called Munchausen by Proxy (MBP). Named after the notorious liar, 18th century German soldier Baron von Munchausen, this condition was first described in 1977 in the human pediatric and psychiatric literature. Parents or guardians who fake or create illnesses in their children to gain and retain attention of physicians and medical staff are defined as being MBP. Most fall into 1 of 3 categories. The doctor addicts believe the child is sick, but report false symptoms to increase clinician attention and response, even if this might harm the child. Paradoxically, these individuals may be very health-conscious themselves and go to extremes to avoid becoming sick. Help seekers may generate or falsify real symptoms and are very grateful and relieved when these are alleviated. For example, they might give a child a purgative, then seek medical attention because of the resultant diarrhea. The active inducers both cause possibly life-threatening symptoms and undermine the clinician’s attempts to resolve these. Using the same example, in addition to creating the diarrhea, these people would not give oral fluids or would covertly disrupt the IV fluid administration prescribed to prevent dehydration. False symptoms reported in the pediatric literature include seizures, vomiting, diarrhea, hematuria, apnea, and bleeding from various orifices.
As a group, veterinary clients with MBP are primarily women with some medical background who often become the favorites of the medical staff because of their apparent dedication and willingness to help. Often they investigate the animal’s condition and any drugs to the point that they can talk easily and intelligently to the practitioner about these. For medical personnel who may struggle to speak to clients in the clients’ own language, the seduction of a client willing and able to speak medical language also can be difficult to resist.
Another quality, the “belle indifference,” displayed by those with MBP may alert human medical practitioners but not their veterinary counterparts. Physicians refer to this quality as a form of excessive coping or denial. However, the different relationship between human and animal may lead many veterinarians to view this as realism rather than indifference. Dr. Haggarty wants her clients to be attached to their animals, but not so much that they’re incapable of summoning the wherewithal necessary to treat them.
Aside from the effect MBP has on the child or animal, its effect on the medical staff can be devastating. This occurs because those displaying the condition, albeit possibly subconsciously, use their awareness of medical hubris regarding knowledge, technology, and skill to manipulate clinicians trained to believe they are in control of the situation. The moment Dr. Haggarty realizes that her ideal client has not been truthful regarding the animal’s history, clinical signs, and treatment, she feels totally betrayed, like “a trained monkey in a circus,” as she put it. In that instant she realizes that all of her knowledge and skill, all of her state-of-the-art technology, all of her lofty goals of relieving animal suffering for highly appreciative clients rest on a foundation of trust. If she cannot trust the client to tell her the truth about the animal’s condition, if she cannot trust that person to have treated the animal as directed when that person claims to have done so, all her training and technology become irrelevant. And if she cannot trust this seemingly perfect client to tell her the truth, how can she possibly trust any others?
In human medicine, MBP is classified as a form of abuse and diagnosed in 2 ways: by hospitalizing the child and using hidden cameras to observe parental interaction, or observing the recovery of the child when taken away from the parent. However, little is know about the psychodynamics of the condition, because those affected often vehemently deny any accusation, even when presented with proof. Additionally, most also resist or refuse any therapy.
For as much as any practitioner will cringe at the idea of being sucked into such a malignant client-clinician vortex, it is also readily apparent that there are problems with both the definition of this condition and its diagnosis. Obviously, even if veterinarians suspected a client of such deception, few have the wherewithal to orchestrate hidden camera monitoring. Even if they did, the legal implications of this could be quite complex. Furthermore, one insinuation, let alone accusation, that a client might be deliberately undermining his/her animal’s well-being could destroy a practitioner’s reputation. Even in the case where the clinician feels reasonably certain that the client is actually abusing an animal in this way, barring the existence of concrete evidence, it makes sense to seek legal advice before making any accusations. Also, MBP should not be used as a diagnostic dumping ground for all patients that never get better. Currently, there is no shortage of chronic, immune-mediated problems in animals, the signs of which will wax and wane in spite of the most conscientious treatment by the most truthful and truly dedicated client.
Given the small amount of information regarding this form of abuse in children and the even lesser amount regarding it in veterinary practice, as well as the confusion generated by all those legitimate chronic and recurring problems, prevention once again should be the focus. In spite of its rareness, MBP serves as a valid reminder of the need to maintain balance in all client interactions and relationships. Surely nobody questions that a supportive veterinarian and veterinary staff are crucial to owner compliance and animal recovery. However, that support should reflect a professional standard to which all clients and animals are entitled.
Does this mean that strict objectivity must be maintained when interacting with clients? Not at all. Nobody wants his/her animal treated by a “robodoc.” Although Dr. Haggarty might turn off any potential Ms. Safers with such a cool, detached demeanor, she runs the risk of alienating a much larger population of quality clients.
On the other hand, most people do want their animal treated by someone they perceive as a professional, so that elusive quality known as professionalism, and the equally elusive presence that goes with it, is the best protection practitioners can have from a whole host of problematic client-animal interactions. Unfortunately, some practitioners mistakenly believe that professionalism simply reflects a certain scientific and medical competency and ignore the powerful role that presence plays in the process. This is understandable because, although most people recognize when another person has presence, they can’t define exactly what it is. It is also sometimes especially difficult for new practitioners to summon it, because presence is also a function of experiences, both good and bad.
However, while specific definitions of presence may evade us, 2 qualities exist in those who have it. The first is that these practitioners generate an aura of genuine caring for their patients and clients. The second is that they simultaneously also create just enough space between themselves and the animal and client to maintain their integrity and objectivity under the most emotionally challenging and seductive circumstances. A worthy standard for any client-practitioner interaction.