Managing Disruptive Patients _ ________________________________________________________________
Active manipulation may involve any of the following behav- iors: • Making demands : “I want my medication at 9 o’clock, not 8 o’clock. I don’t care about your rules!” • Violating rules and routines : “Oops! I forgot I was supposed to be measuring my urine. Guess I’ll need to stay another day so you can get a complete sample.” • Making threats : “If you don’t get that guy and his obnoxious family out of my room this minute, I’m going to tear up this place – and you along with it!” Manipulative behaviors can also be passive and more subtle: • Eliciting pity : “Can’t you understand how hard it’s been for me lately? My husband is leaving me for another woman, my two kids are out every night until 1:00 a.m., and my son wrecked a brand-new car last weekend. Wouldn’t you drink too?” • Ingratiating and flattering : “You’re the only one on this unit who can possibly understand me. I don’t even know why you’re working here – you’re so much smarter than the rest of them. And prettier too.” • Evoking guilt feelings : “Well, if you had come in here to talk to me at 2:15, when you said you would, I wouldn’t have gotten so depressed, and I wouldn’t have had to cut my wrist.” • Abusing compassion : “You said you understood how hard it was for me to be in this hospital, so I was sure you’d understand why I needed to sneak out this morning. I’m back now, so take it easy. Why do you have to search me? You said you trusted me!” • Attempting to exchange roles and become the helper’s helper : “I heard you tell one of the healthcare professionals that you’re having trouble with your son. I can’t believe he doesn’t appreciate having a mother like you. I’m about his age, I’ll bet. Tell me what he’s doing. Maybe I can help.” • Pitting staff members against each other : “I couldn’t get that other healthcare professional to understand why she should persuade the doctor to discharge me tomorrow. She said not to discuss it with you because you’re too new to understand the rules yet. But I know you understand my situation. Will you explain it to my doctor? And pick a time when she’s not around to interfere.” • Questioning competence or authority : “My doctor said that I could have another sleeping pill if the first one didn’t work. Can’t you even read a chart? Well, you’re not in charge around here anyway. We’ll see what happens to your job when the unit manager comes in tomorrow.”
In each of the foregoing examples, patients seized on a par- ticular need of the healthcare professional (the need to be professionally competent; to maintain a safe, consistent envi- ronment; to be viewed as empathic and understanding) and geared their behavior to exploit the healthcare professional’s weaknesses or therapeutic vulnerability. When healthcare professionals realize they have been success- fully manipulated, their likely response is a range of negative feelings and behaviors, including anger, frustration, indiffer- ence, and withdrawal. Although patients with manipulative behaviors will enjoy these responses as signs of their power, they will also feel an inward sense of increasing anxiety because once again they have successfully managed to manipulate someone. Can no one be trusted? Will no one ever be able to see through them and give them what is truly needed – a sense of realistic limits and a genuine feeling of self-control? The vicious cycle of manipulation can play out repeatedly between healthcare professional and patient when manipulative behaviors are not accurately identified, and healthcare professional interventions are not put in place to halt the cycle. It is essential that firm, realistic limits be set and then followed with all patients. The limits should be communicated clearly and openly, with an appropriate rationale. Although there should be consequences for nonadherence, they should not be punitive but should be set to reflect the best interests of the patients. Table 4 sum- marizes steps that are helpful in setting limits for patients who act in a manipulative manner. If healthcare professionals are to stop the cycle, self-awareness is vital. If they have difficulty with their own self-esteem, they will be vulnerable to manipulative behavior. The key is for healthcare professionals to be aware of their needs so they will know when they are being exploited. They also need to be aware of their own responses, such as feelings of anger, the need to withdraw, frustration, or loss of objectivity, as indica- tors that they are being manipulated. Only then can they be effective in helping patients find more adaptive ways of getting their needs met.
INTERVENTIONS FOR MANIPULATIVE BEHAVIORS
Patients who use manipulation as a means to have their needs met present a challenge for healthcare professionals. Patients may be unable and unwilling to recognize their maladaptive manipulative coping mechanism. Even when the healthcare professional points it out, the patient may not be willing to change. As noted previously, manipulation is inherently rewarding. However, manipulation also has a way of alienating others and making it impossible for the patient to form mean- ingful relationships. The healthcare professional who can help patients recognize the effects of their manipulative behavior and find alternative need-gratifying mechanisms will do much to improve their patients’ quality of life. Role-modeling straight- forward behavior is an effective way to encourage patients to lessen their manipulative behaviors.
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