If they are successful in their

Anja Shanelle Fontelo & Shekinah Bromo

o
manipulation, they will continue to do so
until you are able to get out of the
CARE OF PATIENTS WITH MANIPULATIVE BEHAVIOR situation.
- Other signs of manipulation can also include
I. Definition of Manipulative Behaviors (Manipulation: 7 signs to look for, 2020):
- Manipulation is defined as the practice of using o Location Advantage
indirect tactics to control behavior, emotion and - A manipulator will try to bring you to
relationships (Manipulation, 2019). places that are not in your comfort
- This is also defined as the exercise of harmful zone and in which you are not familiar
influence over others in order to get what they to in order for them to have an
want. An individual who manipulates others is called advantage over you. This can be any
a manipulator. This type of individual seeks to place that the manipulator feels
create an imbalance of power, and take advantage ownership of or in control.
of a victim to get power, control, benefits and/or
privileges at the expense of the victim o Manipulation of Facts
(Manipulation: 7 signs to look for, 2020). - A manipulator will actively lie to you,
- Manipulation is often used by individuals who have make excuses, blame you, or
mental health problems, most particularly those strategically share facts about them
who have antisocial personality disorder, and withhold other truths. It is
narcissistic personality disorder, borderline through this that the manipulator
personality disorder, conduct disorder, addiction or would feel like they are gaining power
are in the manic phase of bipolar disorder (Zezo, and intellectual superiority over you.
2016).
o Exaggeration and Generalization
II. Characteristics of Manipulative Behaviors - Manipulators are experts in
- Maladaptive Manipulation is characterized by exaggeration and generalization and
(Zezo, 2016): they would use vague accusations to
o Disregard of the needs, goals and feelings make it harder to see the holes in
of others their arguments.
o Treating others as objects to fulfill the
needs of the manipulator o Cruel Humor
- Cruel Humor is a tactic used by
- Examples of manipulative behavior include manipulators to poke weakness and
(Manipulation, 2019): make an individual feel insecure. By
o Passive-aggressive behavior doing this manipulators would feel
o Implicit threats like they have a sense of psychological
o Dishonesty superiority.
o Withholding information
o Isolating a person from loved ones o Gaslighting
o Gaslighting - This tactic is used by the manipulator
o Verbal abuse to confuse you and make you
o Use of sex to achieve goals question your own reality. The
manipulation happens when you
III. Etiology of Manipulative Behaviors confront the abuse or lies and the
- Manipulation is particularly high among individuals manipulator tells you that it never
who (Zezo, 2016): happened.
o Have personality disorders (PD), especially
borderline, narcissistic and antisocial PDs) o Passive-Aggression
o Have a chemical dependence - Passive-aggression is another sign of
o Are in the manic phase of bipolar disorder manipulative behavior. Manipulators
o Have long histories of physical complaints will use this tactic to make you feel
without physical cause guilty, and give backhanded
o Are children or adolescents who have a compliments. They are doing this to
diagnosis of conduct disorder show anger without directly being
angry, making you feel confused.
IV. Signs and Symptoms
- Manipulation can occur in many forms. Kindness o Constant Judging
can even be a form of manipulation depending upon - Manipulators in this case would
the intent of the individual (Manipulation: 7 signs to openly judge, ridicule and dismiss
look for, 2020). you. They would want to make you
- People who manipulate others have common traits feel like you’re doing something
that you can look for, which includes (Manipulation: wrong, and that no matter what you
7 signs to look for, 2020): do you will be inadequate to them.
o They know your weaknesses and how to They would only focus on the
exploit them negative aspects and do not offer
o They use your insecurities against you constructive solutions.
o They convince you to give up something
important to you, to make you more
dependent on them
V. Disorders Associated with Manipulative Behaviors - Antisocial personality disorder is a pattern of
A. Antisocial Personality Disorder socially irresponsible, exploitative, and
a. Definition and Epidemiological Statistics guiltless behavior that reflects a general
- Antisocial personality disorder is characterized by disregard for the rights of others.sThese
a pervasive pattern of disregard for and violation individuals exploit and manipulate others for
of the rights of others and with the central personal gain and are unconcerned with
characteristics of deceit and manipulation obeying the law. They have difficulty
(Videbeck, 2011). sustaining consistent employment and in
- Manipulation, which is a hallmark of the antisocial developing stable relationships. They appear
client’s behavior, can be a normal, nondestructive cold and callous, often intimidating others with
method of meeting one’s needs. However, when their brusque and belligerent manner. They
used to control others, manipulation interferes tend to be argumentative and, at times, cruel
with interpersonal relationships. In antisocial and malicious. They lack warmth and
clients, the drive to manipulate others is compassion and are often suspicious of these
paramount, because these clients feel a need to qualities in others. Individuals with antisocial
be “number one” at all times. Manipulation may personality have a very low tolerance for
be evident in the client’s attempt to form alliances frustration, act impetuously, and are unable to
with the staff. (Kneisl, 2013) delay gratification. They are restless and easily
- Antisocial personality disorder is a pattern of bored, often taking chances and seeking thrills,
socially irresponsible, exploitative, and guiltless as if they were immune to danger (Townsend,
behavior that reflects a general disregard for the 2017).
rights of others. These individuals exploit and
manipulate others for personal gain and are
unconcerned with obeying the law. They have B. Borderline Personality Disorder
difficulty sustaining consistent employment and in a. Definition and Epidemiological Statistics
developing stable relationships (Townsend, 2017). - Borderline personality disorder is
- In the United States, prevalence estimates range characterized by a pattern of intense and
from 2 to 4 percent in men to about 1 percent in chaotic relationships, with affective instability
women (Townsend, 2017). Antisocial behaviors and fluctuating attitudes toward other people.
tend to peak in the 20s and diminish significantly These individuals are impulsive, are directly
after 45 years of age (Videbeck, 2011). The and indirectly self-destructive, and lack a clear
disorder is more common among the lower sense of identity (Townsend, 2017)
socioeconomic classes, particularly so among - Prevalence of borderline personality is
highly mobile inhabitants of impoverished urban estimated at 1 to 2 percent of the population.
areas. The ICD -10 identifies this disorder as It is more common in women than in men, with
dissocial personality disorder (Townsend, 2017). female-to-male ratios being estimated as high
as 4 to 1. The ICD-10 identifies this disorder as
b. Predisposing Factors emotionally unstable personality disorder
1. Biological Influence (Townsend, 2017).
- Studies have shown families of individuals with - Approximately 50% of individuals with BPD
the disorder show higher numbers of relatives also have other coexisting mental disorders,
with antisocial personality or alcoholism than in such as major depression, bipolar disorder,
the general population. The studies have shown eating disorders, and substance abuse
that children of parents with antisocial behaviors (National Alliance on Mental Illness [NAMI],
are more likely to be diagnosed with antisocial 2011). Research indicates that the risk is high
personality, even when they are separated at birth for substance abuse disorders in people
from their biological parents and reared by affected by BPD (Walter et al., 2009). (Kneisl,
individuals without the disorder. 2013)
- Individuals with borderline personality
2. Family Dynamics disorder may attempt to manipulate others to
- Antisocial personality disorder frequently arises gain immediate gratification of needs and at
from a chaotic home environment. Parental times sabotage their own treatment plans by
deprivation during the first 5 years of life appears purposely failing to do what they have agreed
to be a critical predisposing factor in the (Videbeck, 2011).
development of antisocial personality disorder.
Separation due to parental delinquency appears b. Predisposing Factors
to be more highly correlated with the disorder 1. Biological Influence (Townsend, 2017)
than is parental loss from other causes. The - Cummings and Mega (2003) have suggested a
presence or intermittent appearance of possible serotonergic defect in clients with
inconsistent impulsive parents, not the loss of a borderline personality disorder. In positron
consistent parent, is environmentally most emission tomography using methyl-L-
damaging. tryptophan, which reflects serotonergic
synthesis capability, clients with borderline
c. Clinical Picture personality demonstrated significantly
- Individuals with Antisocial personality disorder decreased methyl-L-tryptophan in medial
usually appear normal and these clients may be frontal, superior temporal, and striatal regions
quite engaging and even charming. They may of the brain.
exhibit signs of mild or moderate anxiety, - The decrease in serotonin also may have
especially if another person or agency arranged genetic implications for borderline personality
the assessment (Videbeck, 2011). disorder. It has been reported that depression
 is common in the family backgrounds of clients attention-seeking response patterns. Their seeming
with borderline personality disorder. lack of sincerity and emotional commitment
contributes to disturbances in interpersonal
2. Psychosocial Influence (Townsend, 2017) relationships. Individuals with HPD appear to be
- Studies have shown that many individuals with continually acting a role on stage. Their coping
borderline personality disorder were reared in patterns are based on repression, denial, and
families with chaotic environments. Lubit “Risk dissociation. (Kneisl, 2013)
factors [for borderline personality disorder] - Prevalence of the disorder is thought to be about 2
include family environments characterized by to 3 percent, and it is more common in women than
trauma, neglect, and/or separation; exposure in men.
to sexual and physical abuse; and serious
parental psychopathology, such as substance b. Predisposing Factors
abuse and antisocial personality disorder.” - Neurobiological correlates have been proposed in
Seventy percent of borderline personality the predisposition to histrionic personality disorder.
disorder clients report a history of physical Coccaro and Siever (2000) relate the characteristics
and/or sexual abuse (Gunderson, 2011). In of enhanced sensitivity and reactivity to
some Instances, this disorder has been likened environmental stimuli to heightened noradrenergic
to post traumatic stress disorder in response activity in the individual with histrionic personality
to childhood trauma and abuse. disorder.They suggested that the trait of impulsivity
may be associated with decreased serotonergic
c. Clinical Picture activity.
- Clients experience a wide range of dysfunction from - Heredity also may be a factor because the disorder
severe to mild. Initial behavior and presentation is apparently more common among first-degree
may vary widely depending on a client’s present biological relatives of people with the disorder than
status. When dysfunction is severe, clients may in the general population. Skodol and Gunderson
appear disheveled and may be unable to sit still, or (2008)report on research that suggests that the
they may display very labile emotions. In other behavioral characteristics of histrionic personality
cases, initial appearance and motor behavior may disorder may be associated with a biogenetically
seem normal (Videbeck, 2011). determined temperament. From this perspective,
- Individuals with borderline personality always seem histrionic personality disorder would arise out of
to be in a state of crisis. Their effect is one of “an extreme variation temperamental disposition”
extreme intensity, and their behavior reflects (p. 844).
frequent changeability. These changes can occur - From a psychosocial perspective, learning
within days, hours, or even minutes. Often these experiences may contribute to the development of
individuals exhibit a single, dominant affective tone, histrionic personality disorder. The child may have
such as depression, which may give way periodically learned that positive reinforcement was contingent
to anxious agitation or inappropriate outbursts of on the ability to perform parentally approved and
anger (Townsend, 2017). admired behaviors. It is likely that the child rarely
- The pervasive mood is dysphoric, involving received either positive or negative feedback.
unhappiness, restlessness, and malaise. Clients Parental acceptance and approval came
often report intense loneliness, boredom, inconsistently and only when the behaviors met
frustration and feeling “empty”. They rarely parental expectations.
experience periods of satisfaction of well-being
(Videbeck, 2011). c. Clinical Picture
- Chronic Depression- Depression occurs in response - People with histrionic personality disorder tend to
to feelings of abandonment by the mother in early be self-dramatizing, attention seeking, overly
childhood (see “Predisposing Factors”). Underlying gregarious, and seductive. They use manipulative
the depression is a sense of rage that is sporadically and exhibitionistic behaviors in their demands to be
turned inward on the self and externally on the the center of attention. They often demonstrate, in
environment. Seldom is the individual aware of the mild pathological form, what our society tends to
true source of these feelings until well into long- foster and admire. However, beneath these surface
term therapy (Townsend, 2017). characteristics is a driven quality—an all-consuming
- Inability to be alone- Because of this chronic fear of need for approval and a desperate striving to be
abandonment, clients with borderline personality conspicuous and to evoke affection or attract
disorder have little tolerance for being alone. They attention at all costs. Failure to evoke the attention
prefer a frantic search for companionship, no and approval they seek often results in feelings of
matter how unsatisfactory, to sitting with feelings of dejection and anxiety. Individuals with this disorder
loneliness, emptiness, and boredom (Townsend, are highly distractible and flighty by nature.
2017). - They have difficulty paying attention to detail. They
can portray themselves as carefree and
C. Histrionic Personality Disorder sophisticated on the one hand and as inhibited and
a. Definition and Epidemiological Statistics naive on the other. They tend to be highly
- Histrionic personality disorder is characterized by suggestible, impressionable, and easily influenced
colorful, dramatic, and extroverted behavior in by others. They are strongly dependent.
excitable, emotional people. They have difficulty
maintaining long lasting relationships, although VI. Assessment and Diagnostic Exams
they require constant affirmation of approval and A. Assessing the History (Zezo, 2016)
acceptance from others. - History of a personality disorder (PD) (borderline,
- People with histrionic personality disorder (HPD) antisocial, passive-agressive)
show a lifelong tendency for dramatic, egocentric, - History of Mania
 - History of substance use or dependence B. Nursing Interventions
- History of unreliable or immature behaviors marked Overall Guidelines for Nursing Interventions on
by instability and frequent changes in jobs, Manipulation
relationships and physicians 1. Anger is a natural response to being manipulated.
- Long history of unsubstantiated physical complaints Deal with your own feelings of anger toward the
patient. Peer supervision can be useful
B. Assessment Guidelines Manipulation (Zezo, 2016) 2. Assess your feelings towards patients who use
1. Assess for history of physical or psychosocial manipulation, and work on being assertive in
problems stating limits. Workshops in assertiveness can be
2. Identify patient’s usual coping responses very helpful for nurses.
3. Assess medications patient is taking 3. State limits and the behavior you expect from the
4. Assess for history of substance use, or dependence, patient in a matter-of-fact, non-threatening tone
spouse abuse, legal difficulties, and violent behavior 4. Ensure that limits are:
5. Assess patient’s strengths as well as weaknesses ○ Appropriate, not punitive
6. Who does the patient trust? ○ Enforceable
7. What does the patient do when he or she does not ○ Stated in a nonpersonal way (e.g.,
get his or her own way? “Alcohol is not allowed,” not “I don’t
8. Is the patient at risk for suicide? Homicide? want you to drink alcohol on the unit”.)
9. Is the patient abusing others? Child? Spouse? Elder? 5. State the consequences if behaviors are not
Other? forthcoming. Written limits and consequences can
be useful (one copy for the patient and one for the
VII. Medical Management staff).
A. Psychopharmacology (Townsend, 2017) 6. Ensure that all staff members understand the
- Psychopharmacology may be helpful in some expectations, limits and consequences discussed
instances. Although these drugs have no effect in with the patient to provide consistency. A written
the direct treatment of the disorder itself, some copy must be placed in the patient’s chart.
symptomatic relief can be achieved. Antipsychotic 7. Follow through with the consequences.
medications are helpful in the treatment of 8. Enforce all unit, hospital, group, or community
psychotic decompensation experienced by clients center policies. State reasons for not bending the
with paranoid, schizotypal, and borderline rules.
personality disorders. The selective serotonin 9. Be direct and assertive, if necessary, in a neutral,
reuptake inhibitors (SSRIs) and monoamine oxidase factual manner, not in anger.
inhibitors (MAOIs) have been successful in 10. Do not:
decreasing impulsivity and self-destructive acts in ○ Discuss yourself or other staff members
these clients with borderline personality disorders. with the patient
The MAOIs are not commonly used, however, ○ Promise to keep a secret for the patient
because of concerns about violations of dietary ○ Accept gifts from the patient
restrictions and the higher risk of fatality with ○ Attempt to be liked, “the favorite” or
overdose. The combination of an SSRI and an popular with the patient
atypical antipsychotic has been successful in 11. Withdraw your attention when the patient’s
treating dysphoria, mood instability, and impulsivity behavior is inappropriate.
in clients with borderline personality disorder. 12. Give attention and support when the patient’s
Antipsychotics have resulted in improvement in behavior is appropriate and positive.
illusions, ideas of reference, paranoid thinking, 13. Emphasize what the patient is feeling. Do not get
anxiety, and hostility in some clients. Lithium into a discussion about his or her rationalizations
carbonate and propranolol (Inderal) may be useful or intellectualizations.
for the violent episodes observed in clients with 14. Encourage the expression of feelings.
antisocial personality disorder (Coccaro & 15. Encourage identification of feelings or situations
Siever,2000). Caution must be given to prescribing that trigger manipulative behaviors.
medications outside the structured setting because 16. Role-play situations so that the patient can
of the high risk for substance abuse by these practice more direct and appropriate ways of
individuals. For the client with avoidant personality relating.
disorder, anxiolytics are sometimes helpful 17. Provide positive feedback when the patient
whenever previously avoided behavior is being interacts without the use of manipulation.
attempted. The mere possession of the medication 18. Where appropriate, see that patients and families
may be assurance enough to help the client through have names and numbers of appropriate
the stressful period. Antidepressants, such as community resources (e.g., Alanon, Alcoholics
sertraline (Zoloft) and paroxetine (Paxil), may be Anonymous, Parents Anonymous, Tough Love).
useful with these clients of panic disorder develops. 19. Keep detailed records in the patient’s chart as to
his or her responses to limit setting and any
VIII. Nursing Management increase or decrease in undesirable,
A. Nursing Diagnoses unacceptable, maladaptive manipulative
o Impaired Social Interaction r/t egocentric and behavior. Identify what seems to work and what
narcissistic behavior does not seem to work. Share information with all
o Anxiety r/t diminished autonomy as exhibited by staff members.
manipulative behaviors
o Ineffective coping r/t failure to intend to change IX. Treatment Modalities (Townsend, 2017)
behavior o Interpersonal Psychotherapy
- Depending on the therapeutic goals, interpersonal
psychotherapy with personality disorders is brief
 and time-limited, or it may involve long-term REFERENCES
exploratory psychotherapy. Interpersonal
psychotherapy may be particularly appropriate Brenner, A. (2016, October 27). 403 Forbidden. Psychology
because personality disorders largely reflect Today. https://www.psychologytoday.com/us/blog/in-
problems in interpersonal style. flux/201610/9-classic-strategies-manipulative-people
- Long-term psychotherapy attempts to understand
and modify the maladjusted behaviors, cognition, How to manage manipulative behavior in geriatric patients.
and effects of clients with personality disorders (2019, October 11). Retrieved February 09, 2021, from
that dominate their personal lives and https://www.myamericannurse.com/manage-
relationships. The core elements of treatment is manipulative-behavior-geriatric-
the establishment of an empathic therapist-client patients/#:~:text=An%20appropriate%20nursing%20di
relationship based on collaboration and guided agnosis%20associated,a%20psychiatric%20evaluation
discovery in which the therapist functions as a role %20as%20appropriate.
model for the client.
Kneisl, C. R., & Trigoboff, E. (2013). Contemporary psychiatric-
o Psychoanalytical Psychotherapy mental health nursing. 3rd ed. Boston: Pearson.
- The treatment of choice for individuals with
histrionic personality disorder has been Manipulation. (2019, March 26). Retrieved February 05, 2021,
psychoanalytical psychotherapy (Skodol & from
Gunderson, 2008). Treatment focuses on the https://www.goodtherapy.org/blog/psychpedia/mani
unconscious motivation for seeking total pulation
satisfaction from others and for being unable to
commit oneself to a stable, meaningful Manipulation: 7 signs to look for. (2020, November 19).
relationship. Retrieved February 05, 2021, from
https://www.webmd.com/mental-health/signs-
o Milieu or Group Therapy manipulation#1-2
- This treatment is especially appropriate for
individuals with antisocial personality disorder, Townsend, M. C., & Morgan, K. I. (2014). Psychiatric mental
who respond more adaptive to support and health nursing: Concepts of care in evidence-based
feedback from peers. In milieu or group therapy, practice (8th ed.). Philadelphia, PA: F.A. Davis Company.
feedback from peers is more effective than in one-
to-one interaction with a therapist. Group Videbeck, S. L. (2011). Psychiatric-Mental Health Nursing (5th
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groups that emphasize the development of social
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and developing interpersonal trust and rapport in Retrieved February 05, 2021, from
clients with avoidant personality disorder. https://nursekey.com/20-manipulative-behaviors/

o Cognitive Behavioral Therapy

- Behavioral strategies offer reinforcement for
positive change. Social skills training and
assertiveness training teach alternative ways to
deal with frustration. Cognitive Strategies help the
client recognize and correct inaccurate internal
mental schemata. This type of therapy may be
useful for clients with obsessive-compulsive,
antisocial, and avoidant personality disorders.

o Dialectical Behavioral Therapy

- Dialectical behavior therapy (DBT) is a type of
psychotherapy that was originally developed by
Marsha Linehan, PhD, as a treatment for the
chronic self-injurious and parasuicidal behavior of
clients with borderline personality disorder
(Sadock & Sadock,2007).It is a complex, eclectic
treatment that combines the concepts of
cognitive, behavioral, and interpersonal therapies
with Eastern mindfulness practices (Dimeff&
Linehan, 2001).

Take heart, deep breathe, you are stronger than you

think. 💕🌷