Healthy manipulation is essentially purposeful behavior directed at getting needs met. It (1) is goal oriented and used only when appropriate, (2) considers others’ needs, and (3) is only one of several coping mechanisms used.

Most of us manipulate/organize events every day to manage our lives (e.g., carry out financial obligations, optimize social activities, ensure the welfare of a family, or plan a work/study schedule). This keeps our lives and the lives of those we care about as secure and as stable as possible. Most nurses are good at organizing their daily schedules to provide optimum care to their patients. This includes consults with other health care professionals, changing time schedules, organizing care into priorities, and countless other ways to ensure quality care. These are all healthy uses of manipulation. Nurses manipulate situations and events not just to complete their assignments but to best serve their patients.

Maladaptive manipulation is characterized by:

• Treating others as objects to fulfill the needs of the manipulator.

Maladaptive manipulation is often used by individuals who have mental health problems, most particularly those who have antisocial personality disorder, narcissistic personality disorder, borderline personality disorder, conduct disorder, addiction, or are in the manic phase of bipolar disorder. However, hurtful maladaptive manipulation is not always a health care issue. It can be used by children against parents, students against teachers, teachers against each other or against their students, adults in business, in politics, by the news media, by bloggers, and anywhere by anyone who disregards how they gain power over others. When manipulation is used in a maladaptive manner, individuals say or do almost anything to get what they want, even if it is at the expense of others.

Maladaptive manipulation in the health care system presents a real challenge to staff. The staff is most effective when all are working together on intervention for manipulation. One situation in which staff members should be alert to possible manipulation is when each staff member views and experiences the patient in extremely different ways. This inevitably results in staff confusion and disagreements. Infighting can result when discussing care for the patient. Variations in experiences can occur between nurses and physicians, shifts, individuals on the nursing staff, and/or administrators and staff.

Potential for staff manipulation is particularly high among individuals who:

• Have a chemical dependence

• Are in the manic phase of bipolar disorder

• Have long histories of physical complaints without physical cause

• Are children or adolescents who have a diagnosis of conduct disorder

Individuals who manipulate might be trying to gain a variety of different things, although a need for control is usually the underlying force. For example, some individuals might manipulate to get nurturance, power over a situation or person, possessions, or another material gratification.

A common form of maladaptive manipulation is the use of pitting one person or group against another person or group. In the health care setting, it might look something like this:

Or, when talking to a member of the day staff, a manipulative patient might say something like:

Once staff is all stirred up and angry with each other, the patient is better able to get what he or she wants without interference. Staff splitting is a real challenge in the health care setting. Patients also manipulate when they flatter and behave in such a way as to give the impression of sincerity, caring, and appreciation when their only goal is to get their needs met in any manner possible:

Patients with chemical dependence problems are used to soothing anxiety and denying or postponing unattractive realities through use of their substance. Patients learn to manipulate others through anger, threatening, swindling, cajoling, instilling guilt, flattering, or any other method to get their drugs. For most individuals who are dependent on a drug, the drug is the only thing in the world they care about.

Another form of manipulation is seen in patients who are profane, fault finding, and adept at exploring others’ vulnerabilities. They constantly push limits. Their manipulative behaviors often alienate family, friends, employers, health care providers, and others.

A positive history might include some of the following:

• History of mania

• History of substance use or dependence

• History of unreliable or immature behaviors marked by instability and frequent changes in jobs, relationships, and physicians

• Long history of unsubstantiated physical complaints

• Plays one person against another (nurse against nurse, family member against staff, therapist against family member)

• Attempts to get special treatment or privileges

• Uses attention-seeking behaviors

• Uses somatic complaints to get out of doing things

• Lacks insight

• Denies problems

• Focuses on other people’s problems (patients, staff, unit dynamics)

• Uses intimidation to control or feel superior

• Demanding (the more staff try to cater to the patient’s demands, the more they escalate)

• Frustration causes more intense manipulative behavior

• Lies, cheats, steals

• Exploitive with little concern for others

• Quick to recognize vulnerability in others

• Devalues others to feel good about self

• Resists limits set on negative behaviors

2. Identify patient’s usual coping responses.

3. Assess medications patient is taking.

4. Assess for a history of substance use or dependence, spouse abuse, legal difficulties, and violent behavior.

5. Assess patient’s strengths as well as weaknesses.

6. Who does the patient trust?

7. What does the patient do when he or she does not get his or her own way?

8. Is the patient at risk for suicide? Homicide?

9. Is the patient abusing others? Child? Spouse? Elder? Other?

Individuals who employ manipulation as a primary means of getting their needs met often have no motivation to change as long as they can get what they want when they want it, even if it is at the expense of others. Impaired Social Interaction is usually present because the patient’s actions often have a negative impact on others. Patients who employ maladaptive manipulation in their relationships with others usually present with a history of interpersonal difficulties and unstable relationships. The manipulative individual feels no compunction about lying, stealing, cheating, threatening, tormenting, devaluing, demeaning, or swindling to get what he or she wants.

Staff working with manipulative patients are best prepared when they establish firm rules that are rigidly interpreted and consistently enforced among all members of the health care team. Frequent discussions regarding the patient’s progress can help reduce staff frustration and isolation and minimize the patient’s attempts at staff splitting. Smith (1994) identifies important guidelines when intervening with manipulative behaviors:

• Interventions such as employing limit-setting techniques help reduce stress and hostility for both patient and staff.

• To successfully limit problem behavior, limits must be consistent and reinforced by everyone, including the family and all health care personnel.

Therefore, confronting unacceptable, inappropriate, or harmful behavior needs to be done immediately, and setting limits on patient behaviors is the pivotal intervention when working with manipulative patients. Clear, enforceable consequences of continuing unacceptable behaviors need to be spelled out and consistently and matter-of-factly enforced by all staff involved in the patient’s care.

It is neither the nurse’s purpose to be a friend to the patient nor the patient’s purpose to be a friend to the nurse. The most effective approach with the patient is to maintain a professional therapeutic relationship with clear boundaries. A professional relationship is based on the patient’s therapeutic needs, not on being liked or the nurse’s personal feelings. People who manipulate others need clear and firm boundaries with clear and firm consequences identified for overstepping those boundaries.

2. Assess your feelings toward patients who use manipulation, and work on being assertive in stating limits. Workshops in assertiveness can be very helpful for nurses.

3. State limits and the behavior you expect from the patient in a matter-of-fact, nonthreatening tone.

4. Ensure that limits are:

• Enforceable

• Stated in a nonpersonal way (e.g., “Alcohol is not allowed,” not “I don’t want you to drink alcohol on the unit.”)

5. State the consequences if behaviors are not forthcoming. Written limits and consequences can be useful (one copy for the patient and one for the staff).

6. Ensure that all staff members understand the expectations, limits, and consequences discussed with the patient to provide consistency. A written copy must be placed in the patient’s chart.

7. Follow through with the consequences.

8. Enforce all unit, hospital, group, or community center policies. State reasons for not bending the rules.

9. Be direct and assertive, if necessary, in a neutral, factual manner, not in anger.

10. Do not:

• Promise to keep a secret for the patient

• Accept gifts from the patient

• Attempt to be liked, “the favorite,” or popular with the patient

11. Withdraw your attention when the patient’s behavior is inappropriate.

12. Give attention and support when the patient’s behavior is appropriate and positive.

13. Emphasize what the patient is feeling. Do not get into a discussion about his or her rationalizations or intellectualizations.

14. Encourage the expression of feelings.

15. Encourage identification of feelings or situations that trigger manipulative behaviors.

16. Role-play situations so that the patient can practice more direct and appropriate ways of relating.

17. Provide positive feedback when the patient interacts without use of manipulation.

18. Where appropriate, see that patients and families have names and numbers of appropriate community resources (e.g., Alanon, Alcoholics Anonymous, Parents Anonymous, Tough Love).

19. Keep detailed records in the patient’s chart as to his or her responses to limit setting and any increase or decrease in undesirable, unacceptable, maladaptive manipulative behavior. Identify what seems to work and what does not seem to work. Share information with all staff members.