_________________________________________________________________ Managing Disruptive Patients
patient’s interaction or request. Sensing that something does not ring true can assist the healthcare professional to suspect manipulative behavior. Universally, healthcare professionals, like most of the population, want to avoid interaction with patients who regularly use manipulation. CYCLE OF MANIPULATION A person has needs to be met but cannot trust the environ- ment to meet them consistently. The ensuing anxiety causes the person to fall back on the earliest need-gratifying mecha- nism-–adaptive maneuvering and manipulation to ensure that their needs are met. If the manipulative behavior is effective, then the anxiety temporarily decreases. The person’s needs have been met. However, the pattern of manipulation has been reinforced. When the same person gets a negative response, they may become angry and frustrated, and anxiety skyrockets. The person again tries desperately to manipulate the environment in an effort to regain control. The pattern is set, especially when the manipulative behaviors work. Lacking basic trust, the person is caught in an endless cycle of having to resort to manipulative behaviors to ensure that their needs are met. In the process, however, individuals are likely to alienate those around them and generate mistrust from other people. The issue of this loss of trust is key to understanding the pathology of manipulation. The patient who uses manipulation in a maladaptive way has little concern for the wants and needs of other people. Because individuals who use manipulation do not trust their own feelings, they cannot trust others. This lack of trust leads to a sense of loss of control, and the individual tries to regain a sense of self- mastery by controlling others.
HEALTHCARE CONSIDERATIONS For the same reasons younger patients are prone to manipu- lation, anxiety, lack of control in their environment, low self-esteem, and feelings of insecurity, the elderly are also likely to use such behavior to meet their needs. Although healthcare professionals working with geriatric patients may understand why it is happening, it is no less frustrating to manage. It is important for the healthcare professional to provide information to this population about reasonable expectations and then make every effort to meet those expectations. If something has been promised that cannot happen, the healthcare professional should explain to the patient why this change must be made. Open and honest communication is important in establishing trust and modeling straightforward behavior. One healthcare profes- sional (Kemerer, 2016) notes that consistent therapeutic communication and remaining accountable decreases the likelihood of allegations of neglect or abuse. IDENTIFYING MANIPULATIVE BEHAVIORS Healthcare professionals may overuse the term manipulative. After a difficult day or after caring for a string of patients with particularly taxing behaviors, a healthcare professional may be prone to assign the label manipulator to the patient who makes that one final demand that sends the healthcare professional over the edge or to the patient who is just a little too insistent in their self-advocacy. Patients who use manipulation have many requests that begin to seem unreasonable. Asking for a fresh beverage is understandable but asking for another within an hour and then needing more ice, then a pain pill, and then wanting to have a pillow fluffed becomes too much (Riley, 2020). Healthcare professionals who work in correctional or psychiatric settings often experience this manipulation as a stressor (Schoenly, 2017). If the term manipulative is to have clinical meaning, its characteristics must be understood.
There are a variety of measurement tools available to attempt to decipher personality traits. Exploring manipulative behavior is of interest to many, especially because of its
MANIPULATION IS NOT ALWAYS EASY TO RECOGNIZE
apparent connection with delinquent and/or criminal behavior later in life. Bergstrom and Farrington (2018) investigated whether the use of one or more scales could be predictive of psychopathology in adulthood. The data were supportive of a connection between high scores on callous-unemotional traits combined with high scores on daring-impulsive ones, pointing to a higher risk in childhood and outcomes as adults that were below normal. PROVIDER-PATIENT CYCLE OF MANIPULATION The patient who exhibits manipulative behaviors is uncannily adept at seeking out the unique weaknesses and vulnerabilities of others and using those weaknesses and vulnerabilities to gain control. Their manipulative behavior can be active or passive.
Patients who use manipulation are often charming, entertain- ing, and intelligent. They rarely see themselves as having a problem and are unlikely to seek help on their own. In fact, many individuals who demonstrate manipulative behaviors are loathe to change, even when confronted, because these behaviors get their needs met (Halter, 2021). When the harm- ful effect on others is pointed out, these patients may feign guilt or remorse because they are aware that these are the socially acceptable responses. They will not actually feel those feelings, however. Patients with dominant manipulative traits do not have a superego (concerned with moral behavior) strong enough for pangs of conscience to be genuine. The reaction of healthcare professionals faced with such situ- ations is, understandably, negative. It is sometimes possible to detect manipulation by virtue of a negative reaction to a
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