Victorian Institute of Forensic Mental Health, Office of the Health Services Commissioner, Department of Psychological Medicine, Monash University, Victoria, Australia
Correspondence: Professor Paul E. Mullen, Thomas Embling Hospital, Locked Bag 10, Fairfield, Victoria 3078, Australia. E-mail: paul.mullen{at}dhs.vic.gov.au
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ABSTRACT |
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Aims To investigate the unusually persistent complainants who lay waste to their own lives and place inordinate demands and stress on complaints organisations.
Method Complaints officers completed questionnaires on both unusually persistent complainants and matched controls.
Results Persistent complainants (distinguished by their pursuit of vindication and retribution) consumed time and resources and resorted to both direct and veiled threats. Attempts to distinguish these people from a control group on the basis of the manner in which their claims were initially managed failed.
Conclusions Persistent complainants pursuit of vindication and retribution fits badly with complaints systems established to deliver reparation and compensation. These complainants damaged the financial and social fabric of their own lives and frightened those dealing with their claims. The study suggests methods of early detection and alternative management strategies.
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INTRODUCTION |
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Complaints organisations and the courts continue to be plagued by a small group of unusually persistent people who consume enormous amounts of resources. This study addressed the nature of this group, whether its members resembled those described in the old literature on querulousness, and if there was evidence that the way in which their claims had been dealt with initially had launched them on this disastrous course.
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METHOD |
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The questionnaire
The questionnaire was compiled through consultation with focus groups of
complaints officers and a review of the existing literature on the querulous
(a copy of the questionnaire is available from the authors upon request). The
human research ethics committee of the Department of Human Services, Victoria,
approved the study.
Statistical analysis
Fishers exact test (two-sided) with P<0.05 as a cut-off
was employed with the odds ratio to measure the size of the effect, and simple
one-way analysis of variance (ANOVA) for the association or explained
variance.
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RESULTS |
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Factors defining persistence
The mean period of involvement with the complaint organisations for the
persistent group was longer (35 months v. 8.3 months,
P<0.01), and a significantly smaller proportion of the persistent
cases were resolved at closure (23% v. 87%, P<0.01),
compared with the control group. There was no significant difference between
the two groups in whether the person registered the complaint by letter
(persistent group 81% v. control group 82%) or telephone (90%
v. 77%), or made an appointment to see someone personally (23%
v. 23%). The persistent complainants were more likely to turn up
without an appointment (31% v. 4.5%, odds ratio 9.3, 95% CI
2.043.4; P<0.01) and to communicate by e-mail (19%
v. 4%, OR 5.0, 95% CI 1.0324.2; P<0.05) and fax
(56% v. 32%, OR 2.7, 95% CI 1.26.2; P<0.05). In
the persistent group, 71% used three or more methods to communicate, compared
with only 34% of controls (OR 3.43, 95% CI 1.478.0;
P<0.01). Persistent complainants communicated more frequently and
at far greater length (Table 1) and demanded changes in case worker more often (52% v. 9%, OR 19.4,
95% CI 4.588.8; P<0.01).
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Nature and aim of the complaints
The persistent and control groups were equally likely to complain of
specific losses and damage to finances (71% v. 72%; NS),
relationships (25% v. 18%; NS) and physical functioning (15%
v. 5%; NS). The persistent more frequently complained of damage to
their overall social and economic functioning (35% v. 9.5%, OR 5.3,
95% CI 1.617.2; P<0.01), self-esteem (40% v. 14%,
OR 4.3, 95% CI 1.511.9; P<0.01) and general health (44%
v. 23%, OR 2.6, 95% CI 16.6; P<0.05). The
professionals, in contrast, judged the persistent group less likely to have
incurred actual financial loss (39% v. 59%, OR 0.5, 95% CI
0.21.01; P<0.05) and no more or less likely to have
sustained damage to their health or relationships. Overall, the professionals
judged some 31% of the persistent group to have sustained no substantial loss
compared with only 9% of the control group (OR 2.8, 95% CI 997.98;
P<0.05).
Compensation, usually financial, was frequently sought by those in both persistent and control groups (61% v. 58%; NS), as were improved services (42% v. 47%; NS). Acknowledgement that they had been mistreated and some form of specific apology were more often sought by the persistent (67% v. 32%, OR 4.4, 95% CI 1.910.4; P<0.01).
The differences between the two groups objectives became clearer when issues of personal vindication and retribution were considered. The persistent sought acknowledgement of the wider social implications of their complaint (39% v. 9%, OR 6.3, 95% CI 1.920.1; P<0.01) and public recognition of their struggles (25% v. 0%; P<0.01). Retribution, in terms usually of the dismissal or prosecution of those they held responsible, was sought more frequently by the persistent (43% v. 11%, OR 5.7, 95% CI 1.916.9; P<0.01). More extreme forms of revenge, such as public exposure and humiliation, were demanded exclusively by the persistent (14% v. 0%; P<0.01). The persistent more often demanded justice for themselves based on claims of principle (60% v. 18%, OR 9.98, 95% CI 3.726.8; P<0.01) and insisted on their day in court (25% v. 4%, OR 7.0, 95% CI 1.433.0; P<0.01). The professionals found that the persistent were more likely to vary the nature and grounds of their complaint over time (31% v. 0%; P<0.01).
Form of the complaints
The form in which the complaints were expressed showed more idiosyncrasies
in the persistent group. Persistent complainants were more likely to use
medical and legal terms inappropriately: legal, 42% v. 2%, OR 31.5,
95% CI 4.03246 (P<0.01); medical, 19% v. 2%, OR
10.24, 95% CI 1.383.5 (P<0.01). The use of rhetorical
questions, such as Should any reasonable person be made to accept such
treatment? in written communications was more common among the
persistent: 56% v. 7%, OR 17.2, 95% CI 4.762.8
(P<0.01).
The written material from the persistent complainants showed unusual methods of attempting to emphasise their words (Table 1). The use of highlighters to accentuate certain words occurred in both the persistent and control groups, but the use of several different colours to highlight words was significantly more common in the persistent group: 19.2% v. 2.3%, OR 10.2, 95% CI 1.383.5 (P<0.01). The more traditional methods of emphasis were also employed significantly more frequently, including repeated underlining, using inverted commas and inserting marginal notes. Three or more of these typographical forms of emphasis were found in over half of the persistent (57% v. 11%). The professionals judged that the methods used by the persistent of expressing their written complaints, compared with the control group, were inappropriately lengthy and difficult to follow (95.5% v. 17%, OR 0.01, 95% CI 0.0020.049; P<0.01); the various oddities of writing also on occasion rendered parts of the letters from the persistent group unintelligible (42% v. 2%; P<0.01). The persistent complainants showed a greater propensity to attach supporting materials to their written complaints, including copies of letters, almost invariably with added comments and copies of supporting documents (35% v. 9%; P<0.01). The enclosing of endorsements of their good character and personal diaries was confined to the persistent (15.4% v. 0%).
Behaviour of complainants
Complaints officers judged the persistent complainants to be more difficult
and intimidating. Interestingly, only people from the persistent group were
judged to have behaved in an overly ingratiating manner (42% v. 0%;
P<0.01). Written threats against the complaints professionals were
made exclusively by the persistent, 17% of whom made direct threats and 32%
veiled threats, such as I know where you live and Careful
you dont find yourself losing your family like me. Threats over
the telephone or in person were also made exclusively by the persistent (52%).
Similarly, only the persistent made threats to kill themselves (16%) if their
complaint were not settled to their satisfaction. Overtly offensive (22%
v. 0%; P<0.01) and overly dramatic expressions (77%
v. 7%, OR 45.5, 95% CI 11.9173.6; P<0.01) were
employed more frequently by the persistent, as were unnecessary repetitions
(71% v. 11%, OR 19.2, 95% CI 6.358.2; P<0.01). In
interviews only about 10% of the persistent group were found by professionals
to be able to express their complaints in a coherent and rational manner
(10.5% v. 82%, OR 0.03, 95% CI 0.0030.21; P<0.01).
Complaints officers experienced a positive rapport, or at least active
sympathy, less frequently with the persistent complainants (12% v.
86%, OR 0.02, 95% CI 0.010.07; P<0.01). Professionals
acknowledged attempting more frequently to avoid contact with these
complainants (48% v. 0%; P<0.01) and seeking help from
senior colleagues (52% v. 2%, OR 54.2, 95% CI 6.9424.0;
P<0.001). The persistent complainants themselves were more likely
to involve other agencies as the complaints procedure progressed, with 77%
contacting at least one other agency (v. 21%; P<0.001),
and 37% contacting four or more (v. 0%; P<0.01).
Management of the initial complaint
The complaints professionals attempted to evaluate how the complaint had
been handled initially. In their view, only about half of all the complaints
from both the case and the control groups had been dealt with appropriately
and reasonably by the agency, or individual, receiving the initial complaint
(53% v. 46%; NS). Unreasonable delay had occurred on occasion for
both persistent and control complainants (25% v. 30%; NS), and people
in both groups had on occasion been met with overt hostility (8% v.
2%; NS), a blanket denial (23% v. 18%; NS) or suggestions they had
only themselves to blame (8% v. 2%; NS). Subsequently there was not
judged to be any significant difference in how often unreasonable expectations
were fostered about the likely nature of the settlement (4% v. 2%;
NS).
Impact on the complainants
Persistent complainants were reported as having a far greater investment in
their claim, being far less likely to view a failure as
disappointing (19% v. 91%, OR 0.024, 95% CI
0.0070.082; P<0.01) and more likely to describe the
consequences as a disaster (81% v. 9%, OR 42, 95% CI
12.1144; P<0.01) or even life-threatening
(23% v. 0%; P<0.01), compared with the control group. By
pursuit of their claim, those in the persistent category were more likely than
controls to have damaged their close relationships (31% v. 2%, OR
19.1, 95% CI 2.415.1; P<0.01) and their social lives (25%
v. 0%; P<0.01), and to have seriously impaired their
financial position (29% v. 7%, OR 5.5, 95% CI 1.520.6;
P<0.01).
Analysis of variance
The ANOVA demonstrated that 31% of the variance in the persistence of the
claimants was predicted by variables related to the methods of expressing the
grievance, including the style and language of the complaints, which was
present from the outset, and the volume of materials, which accumulated as the
complaints procedure progressed.
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DISCUSSION |
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Vindication and retribution
The persistent complainants focused on issues of personal vindication and
retribution. This fits badly with the functions of complaints organisations,
and even court-based litigation, which are geared to provide conciliation
through reparation and compensation. These people are searching for outcomes
that a modern complaints resolution process cannot deliver. A more formal
orientation for complainants at the outset, reinforced if necessary over time,
about what can (and what cannot) be provided in the complaints process might
militate against the pursuit of such unrealisable goals.
Form of the complaints
The increased frequency and the voluminous nature of the material generated
by the persistent group were to be expected. Less predictable were the
dramatic differences in the form in which complaints were registered. Unusual
methods of emphasis included multiple underlinings, putting words in capital
letters, and the liberal use of exclamation marks and inverted commas, as well
as copious marginal notes. Interestingly, exactly these types of emphasis are
reported in descriptions of querulants in the 19th and early 20th centuries
(Krafft-Ebing, 1879;
Kraepelin, 1904). Emphasising
words with multiple-coloured highlighting pens is a modern variant, which we
have also seen clinically among our querulant patients, some of whom produce a
riot of colour on every page of their voluminous complaints. Other features
described in the earlier literature were the frequent misuse of technical
legal and medical terms, and the attachment to the complaints of copies of
letters, reports of legal decisions, personal endorsements and diaries. These
visible and easily quantifiable similarities between the forms in which
todays persistent complainants and yesterdays querulants express
their grievances is a strong argument for an overlap between the two groups.
These peculiarities in the form in which the complaints are presented
accounted for over a third of the variance between cases and controls in our
study. As these idiosyncrasies are usually present from the outset, they
potentially provide an early warning sign.
Threats and damages
Over half of the persistent complainants made some form of threat of
violence directed at the complaints professionals. Equally troubling was the
frequency of suicide threats. These threats explain the apprehensiveness about
personal safety expressed by many of the professionals when dealing with the
unusually persistent. We had assumed the group we saw clinically differed from
the vast majority of unusually persistent complainants in having resorted to
threats and violence. The study indicates, however, that threats are very much
a part of the behaviour of the querulant. Whether or not the person is
prosecuted and referred to a forensic clinic is at least in part a function of
the tolerance of the complaints officers. The fears expressed in the focus
groups about the social and interpersonal damage suffered by the persistent
complainants were also confirmed by the study. These findings underline the
importance of complaints organisations both making strenuous efforts to
protect and support their staff who deal with such cases, and doing all in
their power either to prevent or to extricate persistent complainants from
their damaging progress.
Creating the persistent complainant
One of our hopes in conducting this study was to establish that inept and
socially insensitive responses early in the progress of the complaint
contributed to the chronicity and recalcitrance of the persistent group. If
such provocations could be identified, they might be remediable. The failure
to obtain direct evidence that persistent complainants were more likely to be
subjected to hostile, rejecting or blaming responses may reflect our
dependence on the second-hand, and potentially partial, impressions of the
professionals. Had we been able to obtain direct access to the
complainants experiences of their initial contacts, a different picture
might have emerged. This area merits further research.
Assessing the risk of unusual persistence
The behaviours that differentiated the persistent cases from the controls
were nearly always apparent by the time the complaint reached an agency of
accountability, although the severity often escalated over time, as the
frustrations and distress mounted. Even on the basis of this preliminary
study, it should be possible to identify at an early stage many of those at
risk of becoming abnormally persistent. This capacity is worse than useless,
however, unless it leads to a response that could decrease the damage suffered
by the complainant worse than useless, because in the absence of
effective interventions then identification would amount to stigmatisation.
The next phase of research needs, therefore, to include properly controlled
trials of methods of complaint management aimed at preventing the emergence of
these destructive forms of persistence. Better induction of clients into the
complaints process is one possibility. Another is actively identifying and
attempting to counter unrealistic and essentially unrealisable goals. A trial
might be worthwhile using teams of professionals trained specifically for
managing the abnormally persistent complainant. The conventional wisdom is
that difficult clients should be managed by a single experienced professional,
to avoid splitting and confusion. This conventional wisdom is probably correct
for the difficult complainant, but not necessarily for the unusually
persistent: here, a team of professionals who can share the load and protect
each other from becoming the specific focus of the clients ire might be
more effective. These possibilities need proper evaluation.
Mental health professionals have, over recent decades, stepped back from involvement with those once viewed as querulous or have been pushed back. There are good reasons for caution in introducing concepts of personal pathology into social processes such as complaining, but equally it is cavalier to ignore the possibility that knowledge and approaches developed in the mental health field might offer help to organisations and individuals in avoiding the damaging and distressing effects of unusually persistent complaining. Perhaps it is time to restore querulousness to a legitimate place among the problem behaviours that mental health professionals study and manage.
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Clinical Implications and Limitations |
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LIMITATIONS
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Received for publication June 2, 2003. Revision received October 27, 2003. Accepted for publication November 12, 2003.
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