Resource Unit on Management of Patients with Manipulative Behaviors

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Management of Patients with Manipulative Behaviors

Specific Objectives

Content

Prayer
At the end of the discussion, the I. Introduction
learners will be able to:
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.
1. Define
the
different
terms II. Definition of terms
correctly.
A. Manipulate - to control or play upon by artful, unfair, or insidious
means especially to ones own advantage (Websters Dictionary)
B. Behaviour- the way in which one acts or conducts oneself,
especially toward others (Websters Dictionary)
C. Manipulation/ Manipulative behavior- is a behavior in which a
person controls others to fulfill his immediate desires

T.A.

T-L Strategy
2 min
3 min

Socialized
discussion
with
powerpoint
presentation
3 min

Evaluation
Oral evaluation:
1. It
is
a
behavior
in
which a person
controls others
to fulfill his
immediate
desires.
2. It is the
ethical
component of
the personality
and provides
the moral
standards by
which the ego
operates.
3. What are the
two types of
manipulation
according to
Wiley?
4. What are the
three groups of
manipulative

D. Superego- the superego is the ethical component of the personality

and provides the moral standards by which the ego operates.
2. Differentiate the theories related to III. Theories related to Manipulative Behavior
manipulative behavior satisfactorily.
A. 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.

22 min

situations
according to
Bursten?
5. Give two
nursing
diagnoses of
manipulative
behavior.

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
Shows honest and genuine
emotion
Free and spontaneous in
interaction

Deceives by playing role to

create impression
Constant need to control others

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

V. The Nursing Process

A. 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

15 min

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 selfpity, 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:
1. Powerlessness related to altered ability to meet social
responsibilities
2. Impaired social interaction related to inability to maintain
enduring relationships
3. Ineffective individual coping related to disregard for social
norms
4. Ineffective individual coping related to lack of impulse control
C. Planning
Goals
Long Term
To replace
manipulativ
e behaviors
with more
actualized,
mature

Outcome
Criteria
Demonstrat
e mature
behaviors
role
modeled by
the health

Intervention
s
Provide
ongoing
therapy
sessions in
which new
behaviors

Rationale

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

patterns of
relating

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

Short Term
To verbalize
awareness
of the use of
manipulatio
n and its
effect on the
ability to
gain true
fulfillment
of ones
needs and
desires

Begins to
identify
own
manipulativ
e behavior.
Explores
what it feels
like to be
manipulated
.
Explores
past uses of
manipulatio
n and

and positive
relating is
practice, role
modeled and
supported.

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

Gaining
insight
increases
motivation and
ability to
change
behavior.

To identify
the stimuli
that prompt
the use of
manipulativ
e behaviors

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

assesses
outcomes of
those
experiences.
Explores
past
situations
that
prompted
the use of
manipulatio
n and
identifies
feelings
experienced
Substitutes
new
methods of
relating
while
hospitalized
.

Accepts
feedback on
new
behaviors.

manipulation
s
Encourage
identification
of feelings or
situations
that trigger
manipulative
behaviors

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

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

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

Provide
feedback
when client
interacts
without use
of
manipulation

Acknowledge
ment
reinforces the
use of
nonmanipulati
ve behavior

To selfevaluate
behaviors
and identify
when
support is
needed to
avoid
relying on
old patterns
of
communicat
ion

Identifies
when old,
manipulativ
e patterns of
relating are
used and
begins to
accept
responsibilit
y for them.

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

Teach client
to selfevaluate his
behaviors
and ask for
support in a
nonmanipula
tive 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.
Encouragemen
t 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
1. Ensure physical safety

2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

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, longterm 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?
VI. Open Forum
VII. Evaluation

10 min
5 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.