Managing Disruptive Patients _ ________________________________________________________________
what is asked of them. However, examining their feelings is not always the easiest thing for healthcare professionals to do. Because patients present with many different issues, it is likely that situations will arise when the patients’ problems match ones that healthcare professionals, themselves, are experiencing. Self-awareness is critical for successful interactions in these situations. Healthcare professionals are not perfect, and they may have unsolved problems and issues, but knowing what they are is important. There is also the recognition that patients do have the right to nonadherence. Sometimes the patient is making choices for reasons the healthcare professional has not considered. It is essential to examine why the patient stopped (or never started) the treatment as prescribed. There is also a time when patients will have to live with the consequences of their own actions. The self-aware healthcare professional knows that there are limits to what teaching and explaining can do to change the health behaviors of others.
The use of manipulation as an adaptive, need-gratifying mechanism starts early in life. It is defined as an automatic behavioral pattern that infants use to get their basic needs met. They manipulate without any regard for the needs of others. In newborns, who are utterly dependent on others, the use of manipulation is acceptable and, in fact, vital. It is a matter of survival. As children grow and develop, they test a variety of adaptive maneuvers to manipulate the environment to gratify their needs. If a child’s unacceptable behaviors are met with clear and consistent limits delivered by primary caretakers with unconditional love and acceptance (of the child if not of the behavior), then the child will gradually develop a sense of self-esteem and self-control. Slowly, children learn to replace manipulation with more independent, adaptive behaviors. If, on the other hand, a child’s first limit-testing manipulative efforts are met with inconsistent limits or with no limits at all, with conditional love, and with lack of acceptance of the child, then the child will not learn how to fulfill their needs and how to gain love and acceptance from others (Townsend & Morgan, 2017).
Some technology-based interventions, such as reminder apps on a cell phone or digital patient education are becoming more common, but do they really work?
ADAPTIVE VERSUS MALADAPTIVE MANIPULATION
Manipulation, learned early in life, is a process that occurs consciously or unconsciously in virtually all interpersonal interactions. When manipulation is used in an adaptive sense, it is just one of many behaviors that a person can call on to ensure that their needs are fulfilled. It is neither the only need- gratifying behavior nor the dominant one. For manipulation to be considered maladaptive, it depends on the: • Extent to which it is used as a dominant need- gratifying mechanism. • Degree to which a person is aware of using it. • Degree to which the person is self-oriented and not oriented to others. • Degree to which others are treated as objects. • Effect on others, such as the person who has been manipulated feeling angry but not necessarily being certain as to why. Unquestionably, the word manipulator has taken on a deroga- tory or pejorative connotation. However, the fact is that every- one manipulates at times as a way of ensuring that needs are met. It is important to understand that isolated instances of manipulation do not make a person a manipulator. It is when manipulation as a need-gratifying mechanism becomes an adult behavioral pattern that it is viewed negatively. When it is adopted as the primary means of decreasing anxiety without the opportunity of learning or experiencing personal growth, then it is problematic.
Some clinical trials have been examining the effective- ness of smart phone reminders and education for mental health patients. One meta-analysis (Gan et al., 2021) examined numerous clinical trials, and the adherence and improvement in behavior was not con- sistently improved. Mental health patients often drop out of programs or trials, and low levels of adherence are seen as common for this population. Healthcare professionals can only continue to offer education and support for the patient and their family. MANIPULATIVE BEHAVIORS Illness poses a severe threat to a person’s security, self-esteem, and autonomy. It results in a loss of self-control and a fear of becoming helpless and dependent. The healthcare system may also place patients in child-like positions. The resulting anxiety may prompt a regression to manipulation as a coping mechanism, even in patients who do not typically demonstrate manipulative behaviors.
A DEVELOPMENTAL VIEW OF MANIPULATIVE BEHAVIORS
Before healthcare professionals can intervene effectively, they must understand not only what manipulation is and how they respond to it but also where it begins. How does manipulation become entrenched as a need-gratifying mechanism?
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