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9 Types of Manipulative Patients

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Specializes in Clinical Leadership, Staff Development, Education. Has 28 years experience.

Does a patient’s manipulative behavior easily turn your good day to bad?

Read on to learn how you can be better prepared when you become the target of a patient’s relentless demands.

9 Types of Manipulative Patients

After 23 years of nursing, very few things drain my energy like a manipulative patient. This has been a constant regardless of the position or setting I was working. I expect to be hoodwinked when caring for someone with a substance use, personality or eating disorder. But, in reality, a patient with any diagnosis can hustle their healthcare team.

Manipulation Defined

I recently read an article, written by Dr. Jeffrey E. Keller, who works where some of the most skilled patient manipulators live- jails and prisons. Dr. Keller defined manipulation as:

Quote

“In the medical encounter, it’s what happens after a patient wants something he shouldn’t have-- like a narcotic, a special diet, gabapentin, an MRI, a double mattress-- and won’t take “no” for an answer. Manipulation comes into play when the patient attempts to engineer a “yes” out of your “no”.

Recognition Leads to Preparedness

The best way to keep your sanity when dealing with a manipulative person is to recognize common tactics they may throw your way. In his article, Dr. Keller describes 9 types of manipulative patients and their behaviors.

Exaggeration

This tactic is used when someone tries to make their circumstances special when compared to other patients. The patient will attempt to make their need or want worthy of your “special consideration”.

  • “I have never experienced pain this bad”
  • “I can’t go on hurting like this”
  • “It’s so much worse now than it was last night”

Belittling

Manipulative patients will often attempt to make your contribution or job role seem unimportant or undervalued.

  • “Nurse X knew exactly what to do to help me sleep”
  • “The nursing care at Hospital X was so much better!”
  • “The day-shift nurse would have called the doctor by now”

Belittling is usually paired with splitting.

Splitting

This is when you're compared to another nurse who would (or did) give the patient what they wanted. It may be the nurse in another facility or on a different shift.

  • “The other nurse pulled strings so I could move to a larger room”
  • “I never had to wait longer than 2 minutes for Nurse X to respond to my calls”.

Threatening

Threatening behavior from patients can come in several different forms. Patients may communicate threats of physical violence either verbally or nonverbally.

  • Verbal: “I will come right off this bed and at you if I do not get something for pain.”
  • Non-verbal: Patient may clench fists, tense muscles or narrow eyes.
  • A patient may also make threats in the form of complaints.
    • “If you don’t give me what I want, I will go all the way to the hospital administrator.”
    • “I have a lawyer and you will be hearing from her!”

Fawning

Sometimes patients use exaggerated flattery (fawning) as a way to manipulate you into getting what they want. We do not always know when we are being manipulated because fawning can be very subtle.

“I am so glad you are here tonight! I sleep so good when you are my nurse and I brag about you to everyone.”

Fawning can also take on a flirty or sexual innuendo.

  • “You look so fit. You must work out every day.”
  • “I love your cologne. What is that scent?”

Filibustering

Filibustering is especially exhausting because the patient is so relentless in their demands, you finally just give in.

  • “I am going to continue to push this call light until I get what I want!”
  • “I will come back to your office every day until I get a prescription for gabapentin.”

The Straw-Man Victim

A manipulator sometimes accuses the nurse of acting against a protected class instead of their clinical assessment or findings.

Champions

A champion is someone that pleads the patient’s case from the outside and is usually a family member. I recently cared for a patient who demanded a doctor look at his rash in the middle of the night. Even though the rash was barely visible and not causing discomfort, the patient’s granddaughter called the front desk also demanding that a doctor visit the patient within the next hour.

Champions can be challenging since they often combine manipulative techniques, such as splitting, exaggeration and intense filibustering.

Self-harm

There are patients who deliberately harm themselves to force you to do something they want. Examples would include:

  • A patient who deliberately falls
  • A diabetic who intentionally causes severe hypo or hyperglycemia
  • A patient who refuses venipuncture for lab work necessary for care

Stay One Step Ahead

It takes training, practice and experience to successfully deal with patient manipulation. If you are a new nurse, ask for help before you become overwhelmed by tactics your patients may use to get what they want. You can practice staying “one step ahead” by recognizing the different types of manipulation and having your response ready.

What types of manipulative behavior have you encountered recently?

References

9 Types of Manipulative Patients- Know Their Tactics and Be Prepared

J. Adderton MSN has over 20 years experience in clinical leadership, staff development, project management and nursing education.

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21 Comment(s)

Emergent, RN

Specializes in ER. Has 28 years experience.

That was an excellent and accurate list. Bravo!

Excellent. I need tips on working with them!

Daisy4RN

Specializes in Travel, Home Health, Med-Surg. Has 20 years experience.

Great article! Manipulative pts are the worst, they are sooo draining and especially when you have multiples.

I think it’s a slippery slope to talk so overtly about patients being manipulative. HUMANS are manipulative, period. And we have the honor and difficult job of caring for them at their worst. I tend to err on the side of compassion, while maintaining firm but loving boundaries which I keep to myself so as not to make the people we care for feel as though we are villianizing them. People who are in pain &/or mental anguish do things that don’t always appear rational or make our jobs easy - but luckily we didn’t go into the art of caregiving because we wanted an easy ride, right?

FolksBtrippin, BSN, RN

Specializes in Psychiatry, Pediatrics, Public Health.

Maintaining boundaries is important. Labeling people as manipulative doesn't help you do that and can sometimes lead to neglect or abuse.

Self harm especially should not be categorically defined as manipulative behavior. Self harm is only rarely manipulative.

People sick enough for hospital admission are going to have strong feelings. It's not correct to presume exaggeration.

Splitting is a complex maladaptive coping behavior.

There are practical ways nurses can respond to maladaptive behaviors without gaslighting the patient or compromising care.

Maybe I should write an article. 🤔

CommunityRNBSN, BSN, RN

Specializes in Community health. Has 3 years experience.

I agree with the above— humans are manipulative! Including me when I am at my worst, including you when circumstances turn you that way. I try not to lose my compassion for people.

That being said: flirtation makes me uncomfortable and I hate when a patient uses it to “manipulate”. (I sometimes find that people who are physically attractive are in the habit of being constantly flirtatious, so they aren’t consciously manipulating; it’s just how they get their needs met.). I had a young male patient today flirting, and I felt like I was walking a tightrope to convey that I am friendly and kind, but I am NOT flirting back or being impressed by that behavior.

J.Adderton, BSN, MSN

Specializes in Clinical Leadership, Staff Development, Education. Has 28 years experience.

52 minutes ago, FolksBtrippin said:

There are practical ways nurses can respond to maladaptive behaviors without gaslighting the patient or compromising care.

Maybe I should write an article.

I enjoy reading different perspectives and think ways for responding would make a great article.

Serhilda, ADN, RN

Specializes in Cardiac Telemetry, ICU.

You're spot on. These patients often times become verbally abusive when all else fails too. Been there, done that. Extending further sympathy for someone disrespectful, aggressive, and/or abusive is completely inappropriate and ineffective. I'm glad my last manager supported us taking an assertive approach with these patients instead of asking us to simply understand, grin and bear it.

Given our ANA Nurses' Code of Ethics and our role as the Patient's Advocate, I think more is expected of us as nurses than to label patients who behave in ways we consider unreasonable.

When we label people as a) or b) we objectify them and erroneously think that we are perceiving the whole situation when in actuality we are only seeing a tiny snapshot of their lives during the time we are caring for them. It becomes very difficult to relate to people as individuals once we have conveniently categorized them, and real listening on our part stops.

Labelling patients/family members is ultimately unproductive and can actually be harmful for the patient and their family member.

Treating a patient (or their family member) as a type a) manipulative problem or a type b) manipulative problem may assuage our ego but the result is that it is actually impossible for the patient or their family member to communicate in a real way with the nurse once this happens. I'll give an example: My family member was admitted to hospital and hadn't eaten since early morning of the prior day. I happen to know that my family member becomes hypoglycemic - this is on their chart - and I could see that they were showing symptoms of low blood sugar, so I went to look for their nurse to ask them if my family member could have something to eat now as they hadn't eaten since yesterday and to let them know that I was concerned that my family member was showing symptoms of hypoglycemia. As I was making my request to the nearest staff member I could find (my family member's nurse was no-where to be seen) and was about to express my concern for my family member, another nurse informed me that a meal had been ordered and that we had to wait. So, case in point, the nurse who told us we had to wait failed to listen to me and had already decided what the situation was as soon as they heard me begin to speak - a demanding, unreasonable family member - and was treating us as though their perception was true when it wasn't. Some family members, being on the receiving end, would have escalated the situation in order to be heard and to try to advocate for the patient's needs, and this would have been due to the nurse's snap judgement and failure to listen and learn what the situation required.

While nurses need to be able to set boundaries with patients who are truly unreasonable, it is important to remember that patients who are hospitalized are usually very sick, sometimes lack a good support system, and are often unable to articulate their needs or concerns in the most polite manner even if they would like to.

Also, a number of medical problems are known to result in an altered mental status. It is also important to consider the stress of hospitalization, the stress of a patient's particular illness and it's affect on the other medical problems the patient has, and the effects of medications on patients.

Labelling patients and their family members negates relationships when in order for a patient and their family member to trust the nurses who provide their care it is important to build relationships with them. Being on the patient/family member end of a nurse who shows no compassion or kindness in dealing with the patient and their family member, who is unwilling to listen to them, and who treats the patient and their family member as a problem, is a truly horrible experience in my experience for the patient and their family member and is one where I will talk to administration and/or request medical records.

Edited by Susie2310

scribblz, BSN, CNA, LPN

Specializes in Med Surg, Tele, Geriatrics, home infusion. Has 14 years experience.

I think the OP's article was pretty spot on for common, manipulative behaviors that we nurses have to navigate in practice. To all those who feel we are stereotyping our patients and that this is an unethical way to talk about them... you are making an excellent observation that we need to keep in mind. That being said these are real behaviors which like "non compliance" or "aggressive" behaviors can harm us and do the patient no favors. So we would be wise to focus on recognition of these behaviors and how to manage them rather than how we feel about the patient. Because these patients are tough, especially if they roll through your unit every few months. They should be rotated through nurses, and the team needs to set fair limits and provide a united front. These patients are utilizing maladaptive coping mechanisms, and it's unlikely you can change that. But you can be kind and fair without being used if you can set boundaries and ground rules if you people demonstrate these red flag behaviors that the OP mentioned.

TriciaJ, RN

Specializes in Psych, Corrections, Med-Surg, Ambulatory. Has 40 years experience.

7 hours ago, Serhilda said:

You're spot on. These patients often times become verbally abusive when all else fails too. Been there, done that. Extending further sympathy for someone disrespectful, aggressive, and/or abusive is completely inappropriate and ineffective. I'm glad my last manager supported us taking an assertive approach with these patients instead of asking us to simply understand, grin and bear it.

This hits the nail on the head. Manipulative behaviour is much easier to deal with when management is on board and appropriate boundaries are part of the treatment plan. When one person gets roped in or management is not supportive, it makes the manipulative patient ten times harder to care for. That's when you feel your compassion draining and that's when the patient is at the highest risk for neglect.

All of this is less common and less problematic overall when the nurse's personal self esteem and nurse-identity don't hinge upon constant reassurance and/or being approved and adored by anyone/everyone. Instead, let kindness, professional prudence and fairness/neutrality be the things that reinforce one's self-esteem. Encountering these situations in patient care should not bring on a personal existential or self-esteem crisis.

If you know that you are acting with competence and genuine kindness then you will not feel validated (manipulated) by things like fawning, and will not be intimidated (manipulated) by belittling, splitting, filibustering and the like.

Threats of complaints are easily handled: Immediately refer the complaint or threat to a member of administration. Get a witness with some authority.

Threats of physical contact or violence of any kind are also to be dealt with immediately by security and admin.

Basically the nurse's job is simply to practice in a competent/prudent, and kind manner. It is possible to build a decent and genuine professional rapport with difficult people--but all of it begins with understanding oneself. Avoid what I call emotional flailing, which leads to grasping around for acceptance and reassurance from any source as if these are some sort of effective lifeline--which they are not; they are flimsy and not anchored to anything. Another useful picture is that of the tumbleweed being blown this way or that by the direction and force of the wind. Don't be that. Instead, do what is kind and right and when difficulty arises handle it as kindly, neutrally and efficiently as possible.

-My unsolicited $.02 which I think is useful for many areas of life, not just nursing.

FolksBtrippin, BSN, RN

Specializes in Psychiatry, Pediatrics, Public Health.

21 hours ago, CommunityRNBSN said:

I agree with the above— humans are manipulative! Including me when I am at my worst, including you when circumstances turn you that way. I try not to lose my compassion for people.

That being said: flirtation makes me uncomfortable and I hate when a patient uses it to “manipulate”. (I sometimes find that people who are physically attractive are in the habit of being constantly flirtatious, so they aren’t consciously manipulating; it’s just how they get their needs met.). I had a young male patient today flirting, and I felt like I was walking a tightrope to convey that I am friendly and kind, but I am NOT flirting back or being impressed by that behavior.

This is tough for me too. Culturally, women are often held responsible for a man's attraction to them, so when a patient flirts with me I instantly feel shame.

A male psychiatrist once told me a story about a patient who invited him to partake in a threesome with her and her boyfriend. He says "Of course I declined. But that was a good day..." I was taken aback by his irreverence. He went on to explain that our patients can feel a kind of love for us that is sometimes expressed romantically or sexually, and that it doesn't really matter as long as we don't respond similarly.

I'm not sure I see it exactly the way that psychiatrist does. But his attitude helped me feel better about the patient who asked me to make out with him twice in one visit, once after being told not to do that.

mmc51264, ADN, BSN, MSN, RN

Specializes in orthopedic; Informatics, diabetes. Has 9 years experience.

there are some that are legitimately manipulative. I do not usually play into people trying some behaviors.

When I was a new nurse, I had a pt that accused me of not giving her narcotic pain medication. I scanned her and the medication but she had her brother in the room and he stated that he never saw me actually give the medication.

I was so upset, it was the first time I had encountered someone being like that to me. I documented it, wrote a safety report, notified my charge nurse and the physician. I take issues about narcotics very seriously. From then on, I brought another nurse in with me to witness medication administration.

It was scary. I don't get "got" very much anymore, but it is hard when they try.

perc71, BSN, MSN, APRN, NP

Has 14 years experience.

You summed up an informative post (OP), thank you. Patent's with Borderline PD are good in splitting and gaslighting. Identifying patients with manipulative tendencies is great but try not to loose your objectivity to the patent's problem to be able to be an effective nurse. It is a delicate balance indeed.

I disagree with exaggeration. It could be the worst pain they’ve ever felt. How do we know? I suffer from anxiety and, after caring for my mom in my home who has Alzheimer’s, started having panic attacks. It was, and is, the worst anxiety I have felt. Should a doctor refuse to help me because he/she thinks I’m exaggerating? I think that’s an irresponsible conclusion to come to with a patient.

LibraNurse27, BSN, RN

Specializes in Community Health, Med/Surg, ICU Stepdown. Has 8 years experience.

I used to get stressed out by some of these behaviors, especially sick patients refusing care. I have learned that I cannot force someone to care about their health and I cannot care about them more than they care about themself. I provide them with compassion, educate them on all treatments ordered and offer the meds, blood draw, etc once or twice, then respect their right to refuse, let them know I will notify the MD, not in retaliation but just so they know what’s going on.

I don’t neglect patients, I still check on them. But if a patient is verbally or physically aggressive I refuse to return to their room, argue with them or try to convince them to receive care. I call management and security. I will not get injured trying to force people to do things they don’t want to do. Often the patients want to get a reaction from you and see you upset that they are refusing. If you don’t buy into it sometimes they later want the care and it is a win for both of you 😊As someone with a severe mental health issue I give people the benefit of the doubt for behaviors but I do not tolerate abuse.