COLLEGE OF NURSING

Resource Unit on Management of Patients with Manipulative Behaviors

Management of Patients with Manipulative BehaviorsSpecific ObjectivesContentT.A.T-L StrategyEvaluation

Prayer2 minOral evaluation:

It is a behavior in which a person controls others to fulfill his immediate desires.

It is the ethical component of the personality and provides the moral standards by which the ego operates.

What are the two types of manipulation according to Wiley?

What are the three groups of manipulative situations according to Bursten?

Give two nursing diagnoses of manipulative behavior.

At the end of the discussion, the learners will be able to:

I. Introduction

Case Scenario

John, age 26 years, has lost his third job as a salesman. He blames his boss for being against him and his co-workers for setting him up. He expresses a great deal of anger at all his former co-workers for being jealous of him. John relates that his whole life has been this way. External circumstances consistently stand in the way of his fulfillment. At present, John is hospitalized for elective surgery. He demands that his visiting hours be extended because he is expecting contacts for future employment. He is aware of his roommates condition and need for sleep but sees this as just another obstacle in his way. John continues to enlist the assistance of other patients in violating the visiting hours and appears to enjoy deceiving the staff. When confronted, John immediately appears sorrowful and states that he breaks rules only because his life has been so difficult.Socialized discussion with powerpoint presentation3 min

Define the different terms correctly.

II. Definition of terms

Manipulate - to control or play upon by artful, unfair, or insidious means especially to ones own advantage (Websters Dictionary)

Behaviour- the way in which one acts or conducts oneself, especially toward others (Websters Dictionary)

Manipulation/ Manipulative behavior- is a behavior in which a person controls others to fulfill his immediate desires

Superego- the superego is the ethical component of the personality and provides the moral standards by which the ego operates.

3 min

2. Differentiate the theories related to manipulative behavior satisfactorily.III. Theories related to Manipulative Behavior

Interpersonal Theory

A.1. Wiley

Wiley identified two different types of manipulation which are the constructive and destructive manipulation.

According to Wiley, constructive manipulation is using ones strengths to promote successful relationships. The constructive manipulator knows he is using manipulation and accepts responsibility for it. Communication continues consciously and maturely. Both parties in the interaction know what is occurring and can decide whether to participate.

Destructive criticism, on the other hand, occurs when a person uses other people for his/her own purposes.The manipulator promotes difficulties in or destroys relationships, and personal growth is stunted. Usually, communication is at an unconscious level. However, the victim responds negatively, often with anger and withdrawal, The manipulator may feel rejected, which increases his anxiety and need to manipulate.

A.2. Shostrom

Shostrom view manipulation as something that can never be eliminated. She claimed that all individuals use some degree of manipulation throughout their lives. The behaviour can be placed in a continuum from manipulative behaviour, wherein the person conceals emotion and serves own needs, to actualized behaviour, wherein the person trusts own emotions and openly communicates needs.

A.2.a. Continuum of manipulative behavior

Manipulative Behavior

Actualized Behavior

Conceals sincere emotions

Trusts own emotions

Serves own desires

Openly communicates desires

Disregard for others

Aware and trusts himself and others

Deceives by playing role to create impression

Shows honest and genuine emotion

Constant need to control others

Free and spontaneous in interaction

A.3. Kumler

According to Kumler, the term adaptive maneuvering may be used to describe the manipulative responses of newborns. It is an automatic behavioral pattern used to decrease anxiety without learning or interpersonal growth. In order to fulfill basic needs, newborns learn several adaptive maneuvers. They influence or manipulate without regard for others needs and without responsibility. Although this behavior is necessary for newborns, it is usually viewed as unacceptable in adults.

As the manipulative individual grows, he becomes trapped in a cycle wherein he has needs to be met, but he has learned to expect inconsistency and lack of fulfillment. Thus, he becomes anxious when faced with his needs or fears and begins to disregard the needs and rights of others. To gain fulfillment, adaptive behaviors learned in infancy, i.e. manipulation, is repeated. If the person gets a positive response and the needs are met, his anxiety temporarily decreases, but the use of manipulation is reinforced. On the other hand, if the person receives a negative response and his needs remains unfulfilled, his fears, insecurities, and anxiety significantly increase and he becomes angry and frustrated. To fulfill his needs and control his anxiety, he again tries to manipulate.

B. Psychoanalytical Theory

B.1. Freud

Psychoanalytical theory associates manipulation in the development of superego. The superego is the aspect of personality that holds all of our internalized moral standards and ideals that we acquire from both parents and society - our sense of right and wrong. The superego provides guidelines for making judgments. According to Freud, the superego begins to emerge at around age five and is influenced by various factors. A child who has strong aggressive feelings and fears retaliation from his parents may turn his aggressive feelings inward. The result may be an overly severe superego and conscience. Such as individual would probably manipulate very little. A child may develop a weak superego as a result of inability to internalize social expectations. The parents may be inconsistent in their morality or demands, giving the child a false impression of their actions. The resultant weak superego gives the child a decreased sense of guilt and weak conscience.

A person with manipulative personality often uses manipulation as his primary goal. Punishment or reward has no effect because the gain is from the act itself. Psychoanalytical theorists view the manipulative individual as a fragile form of a narcissistic personality. The narcissistic individual manipulates in response to a wound that causes shame. Through manipulation, the individual is relieved and exhilarated at pulling something over on someone and setting the balance right.

An individual with a manipulative personality puts his appearance before all his other aspects. Any threat to his appearance results in manipulative attempts to redeem his image, regardless of the impact on others or the violation of rights or rules.

B.2. Bursten

Bursten emphasized the conscious nature of manipulation in his psychoanalytical study of manipulation . The individual may not know the reason for his behavior, but he is usually aware that he is controlling another person to his own advantage. Bursten identified four essential components for manipulation:

1. Conflict of goal the manipulator must want something from the other person that he thinks the person does not want him to have.

2. Intentionality the manipulator must intend to influence the other person. This component requires planning by the manipulator with an intent that is conscious or readily accessible to consciousness.

3. Deception the manipulator knows his plan is to deceive the person.

4. Sense of satisfaction the manipulator must feel a sense of satisfaction in deceiving the other person.

The four components are related; in some instances one may be more easily recognized, and in other situations another component may be more obvious.

Bursten described three groups of manipulative situations.

1. A person in group 1 uses manipulation only occasionally to achieve a goal or attain satisfaction and pleasure. For example, the person may manipulate to get a special privilege or to draw attention to himself.

2. People in the second group may use manipulation to avoid danger and discomfort, as when the child does a special favor for a parent when he thinks punishment is forthcoming.

Persons in both groups do not manipulate repeatedly or chronically. Their reason for manipulation usually becomes obvious and the advantages are at a conscious level.

3. People in the third group seem to manipulate for the sake of manipulating. Manipulation is the persons life-style and he has a manipulative personality. The manipulative behavior may be silly, involving pranks that may lead to repeated punishment. The basis for the manipulation is primarily a need to pull something over on another person. People in this group may be classified as having an antisocial personality disorder.

22 min

3. Give at least 3 nursing diagnoses for a client with manipulative behavior and 3 nursing interventions for each diagnosis.

V. The Nursing Process

Assessment

1.Physical Dimension

The nurse first assesses the clients perception of the threat to his physical security. Any threat may increase anxiety and cause regression to maladaptive coping mechanisms. Physical illness often results in a sense of loss of control and a fear of becoming helpless and dependent. Within the health care system, a client often feels vulnerable and anxious and tries to manipulate the environment to increase his security. He may rely to manipulation to fulfill the physical needs that he has been able to meet independently in the past. The nurse assesses the clients stress level and past coping responses. Verbal and nonverbal behaviors tell the nurse that the client is feeling threatened or stress.

The clients manipulations may interfere with his ability to express his physical needs. The client may exaggerate a physical condition or need or withhold important information. For example, the client who exaggerates his pain to get extra medication ensures that his need (pain relief) will always be fulfilled and under his control. A client who wants to be discharged or to have special visiting privileges may also withhold information. To validate this clients condition, the nurse observes both verbal and nonverbal signals. Pain assessment, for example, includes both the clients perceptions of pain and observation of his appetite, sleeping pattern, ability to concentrate, and level of activity.

2.Emotional Dimension

The nurse tries to determine whether the clients manipulative behavior is a response to anxiety or an established, destructive pattern. A client who temporarily regresses may be aware of and disturbed by his behavior. The client may be able to discuss the fears or anxieties that triggered the behavior

A client who manipulates destructively as a pattern, as described by Wiley may appear pleased when his manipulations are successful; he does not show sincere remorse or embarrassment. The destructive manipulator often shows superficial emotions; the expression of sincere anxiety, guilt, or fear makes the client vulnerable. When the nurse explores the clients behavior, the client may respond with self-pity, anger or frustration instead of accepting responsibility. The nurse differentiates among assertive, aggressive, and manipulative behaviors. Many clients are encouraged to become assertively involved in their care and to question the health care providers. However, the system often remains rigid, and these attempts may be met with anger or power struggles. Clients may be negatively labeled because they have confronted the heath care system or changed a routine. The nurse who is aware of the differences between assertive, aggressive, and manipulative behaviors can identify whether the behavior is constructive or destructive.

3.Intellectual Dimension

Manipulative behaviors are often learned as survival skills in childhood, therefore a client who is cognitively impaired may still be a skillful manipulator. If the client has not learned to express his needs and to trust that they will be fulfilled, adaptive maneuvering may continue into a cognitively impaired individuals adulthood. The manipulator often gives seemingly rational reasons for his behaviors and may present a sound defense when challenged. The client may continually express a conflict between his perceived needs and the needs of others. The client may use flattery to get people on his side. He may request special privileges because of his special circumstances. When staffs do not respond positively to his manipulative behavior the client may get angry and frustrated. He may think that staff members are resistant because, as in his other relationships, they are against him. This behavior is an example of the vicious cycle manipulative clients perpetuate. The client who has been in the health care system for a long time may have learned several ways to gain control. He may use medical jargon, drop board members names, or refer to physicians and nurses as personal friends. The nurse assesses the clients motivation to change his behavior. She finds out how the client sees his behavior and whether his behavior has caused difficulties in the past. The nurse can ask directly whether he is willing to change his behavior. Manipulative behavior is repeated in search of fulfillment. If a positive response is received t?he manipulative behavior is reinforced.

4.Social Dimension

The nurse determines which of the three types of destructive manipulation the client is using. (1) Aggressive maneuvering exemplified by multiple demands, threats, requests for special consideration, and playing members of the health care team against each other; (2) distracting maneuvering, exemplified by changes of subject, flattery, expressions of helplessness, tearfulness, dawdling, and last minute stalling; and (3) disparaging maneuvers, exemplified by reprimands or self-pity.

The social life of a destructively manipulative client is often severely impaired and can be assessed by observing the clients present and past social interactions. A social interaction may reveal no sincere relationships. A social history may reveal no sincere relationships. The clients job history may show inconsistent work pattern, possibly resulting in financial instability. A manipulative pattern may be evident since early childhood. A review of the clients childhood and adolescence may show periods of aggressiveness and early sexual behaviors. What may initially appear to be manipulative behavior may actually be the clients cultural pattern. In such a case the nurse must be objective; an angry reaction can interfere with an accurate assessment.

5.Spiritual Dimension

A clients behavior can be influenced by religions that are manipulative rather than actualized. Manipulative religions encourage helplessness by stressing the inability of individuals to trust their own nature. The nurse may observe overdependence ,lon the religious community. The client may refuse to think through situations because he has learned to respond only as the religion demands. Such as client may resist helping himself, assuring the nurse that his religion will take care of him. He may rationalize that difficult events are Gods will or the will of some higher power. Actualized religions stress trust in ones own nature and encourage self-direction and growth. A client whose religion is actualized may rely on his religious community for support, guidance, and strength but accepts responsibility for his behavior and the direction of his future. The nurse remains objective by assessing the clients perception of the meaning of religion to his life. The client may blame God or his religion for his situation or his dissatisfaction in life. Such a client may also attempt to use religion in a manipulative pattern.

B. Analysis

Nursing Diagnosis

NANDA-accepted nursing diagnoses with causative statement appropriate for clients with manipulative behavior include the following:

Powerlessness related to altered ability to meet social responsibilities

Impaired social interaction related to inability to maintain enduring relationships

Ineffective individual coping related to disregard for social norms

Ineffective individual coping related to lack of impulse control

C. Planning

Goals

Outcome Criteria

Interventions

Rationale

Long Term

To replace manipulative behaviors with more actualized, mature patterns of relating

Demonstrate mature behaviors role modeled by the health care team.

Engages in long-term therapy as an outpatient to maintain support for new behaviors and patterns of relating.

Provide ongoing therapy sessions in which new behaviors and positive relating is practice, role modeled and supported.

Mature pattern of relating can be learned with consistent and long-term treatment

Short Term

To verbalize awareness of the use of manipulation and its effect on the ability to gain true fulfillment of ones needs and desires

Begins to identify own manipulative behavior.

Explores what it feels like to be manipulated.

Explores past uses of manipulation and assesses outcomes of those experiences.

Encourage open and honest discussion (1) clients manipulative behaviors, (2) how it would feel to him if he were manipulated, and (3) analysis of the outcomes of past manipulations

Gaining insight increases motivation and ability to change behavior.

To identify the stimuli that prompt the use of manipulative behaviors

Explores past situations that prompted the use of manipulation and identifies feelings experienced

Encourage identification of feelings or situations that trigger manipulative behaviors

Recognizing situations that trigger manipulative behavior promotes insight and ability to change behavior

To use alternative, more actualized methods of identifying and meeting needs

Substitutes new methods of relating while hospitalized.

Accepts feedback on new behaviors.

Role-play situations in which client may practice actualized methods of relating.

Provide feedback when client interacts without use of manipulation

Practicing new methods of mature relating will increase confidence and ability to use them long term.

Acknowledgement reinforces the use of nonmanipulative behavior

To self-evaluate behaviors and identify when support is needed to avoid relying on old patterns of communication

Identifies when old, manipulative patterns of relating are used and begins to accept responsibility for them.

Begins to request support when anxiety or stresses are high to avoid reliance on old patterns of relating.

Teach client to self-evaluate his behaviors and ask for support in a nonmanipulative way. Provide positive feedback when this behavior occurs.

Encourage and reinforce client as he requests support when anxiety and stress are high.

Self-evaluation and use of support will promote permanent use of new pattern of relating.

Encouragement and reinforcement will motivate clients to continue to request support as needed.

D. Implementation

Limit Setting

1. Expectations

Make expectations clear to the client and other staff members.

2. Client-Centered Limits

Be sure that limits are in the best interest of the client and not punitive.

3. Communication

Avoid using personal statements, such as I dont want you to drink alcohol while Im on duty. Offer the true rationale: Alcohol is not allowed in the hospital.

4. Consequences

When consequences are needed, avoid those that are absurd or cannot be enforced, such as Put the alcohol away or I wont come into your room, Offer only enforceable consequences, such as If you dont dispose of the alcohol, I will call security to dispose of it.

5. Testing

Remain firm and consistent as the client tests the limits that have been set.

6. Venting

Allow the client to vent feelings about limits, but do not engage in power struggles or attempt to rationalize (for example, The hospital policy was written because things would get out of control if all clients could drink alcohol ). Instead, verify the clients feelings and repeat the limit as necessary: I hear that you are angry about this, but alcohol is not allowed.

7. Positive Reinforcement

Return to the clients room when the affect has subsided to demonstrate that you are not angry and have not withdrawn. Offer positive reinforcement for strengths.

8. Clarifications for Staff

Explain the expectations, limits, and consequences discussed with the client to all staff members to provide consistency and avoid confusions.

Key Interventions for Manipulation

Ensure physical safety

Encourage client to assume responsibility for self-care

Set consistent limits on manipulative behavior

Encourage self-control

Be consistent in approaches to client

Role model constructive pattern of coping/mature interaction

Explore meaning of manipulative behavior

Explore the consequences of manipulative behavior

Support strengths

Reinforce constructive use of leadership abilities

Demonstrate to family techniques that do no reinforce manipulation

Discuss clients perception of his anxiety

Respond consistently to testing behavior

Encourage client to try out new communication techniques

Support clients request for religious assistance

Allow client to assume as much control as possible.

Channel request to primary nurse.

E. Evaluation

The evaluation of a change in a clients manipulative behaviors is based on the clients actions, not on his words. The nurse can base an evaluation on small changes in a clients behavior; more obvious, long-term changes will most likely result only from long-term therapy. The client is given the opportunity to learn and grow, and change is supported. (Varcarolis, E.M.)

The evaluation of the manipulative clients care can be divided into four areas for a thorough an objective review.

1. Adequacy

Was the clients behavior assessed objectively, or was he labeled negatively?

Did the behavior meet the criteria for destructive manipulation, or was it a regression because of stress?

Was a distinction made among aggressive, assertive, and manipulative behavior?

Did the treatment plan encourage the client to learn?

Were communication and limit setting clear and consistent, or was the cycle of manipulative behavior reinforced through inconsistency and anger?

2. Appropriateness

Were consistent limits and plans established early and communicated to the entire health care team?

Were interventions objective and punitive responses avoided?

Were the clients needs considered and met when possible?

Was the process of the clients interactions, not just their content, addressed?

3. Effectiveness

Did the clients behavior change?

Was the client able to see the need for learning and support?

Was the client able to identify manipulative communication patterns when his anxiety was low?

Were basic needs fulfilled by a supportive staff?

Efficiency

Was the health care teams communication clear and open?

Did members of the team support each other during the clients manipulative attempts?

Was the health care team able to identify the dynamics involved in interactions with the client and with each other?

Were limits and expectations consistent?

Was the manipulative behavior identified early?

Was the information shared with all persons involved with the client?

Has the health care team learned and grown from working with this client?

15 min

VI. Open Forum10 min

VII. Evaluation5 min

Resources:

Beck, C.K, Rawlins, R.P., & Williams, S.R. (1993). Mental-health psychiatric nursing: A holistic life-cycle approach (3rd ed). St. Louis, Missouri: Mosby.

Johnson, B.S. (1986). Psychiatric-mental health nursing: Adaptation and growth. Philadelphia, Pennsylvania: J.B. Lippincott Company.

Kneisl, C.R. & Trigoboff, E. (2012). Contemporary psychiatric mental health nursing. (3rd ed). New Jersey: Prentice Hall.

Potter, NN. (2006). What is manipulative behavior, anyway? Journal of Personality Disorder, 20 (2), 139-156.

Stuart, G.W. & Laraia, M.T. (2014). Principles and practice of psychiatric nursing (10th ed). St. Louis, Missouri: Mosby.

Varcarolis, E.M. (2010). Foundations of Psychiatric Mental Health Nursing: A clinical approach. USA: W.B. Saunders Company.

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