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The term "manipulative" needs some clarification, as it has been rather overused. I will address that matter a little later in the chapter. First, though, I would like to tell you an entirely fictitious story, which I think will give a general idea of the territory I intend to explore in this chapter.
My story paints a rather extreme picture. I have made little use of pastel shades of meaning. However, I do not think any of the story's elements will be particularly difficult to imagine. Indeed, if you work with distressed patients, and find that this story does not remind you of one or two of them, I can only assume that you have led a charmed life, and be happy for you.
I am going to take you on a mythical journey with a mythical patient, whom I will call Mrs D. She has recently been admitted to a hospital ward, where you, dear reader, are kindly requested to imagine that you work. In case it is not already crystal clear, Mrs D is not her real name. Apart from being a very short name, it would be impossible – because the patient concerned does not exist.
Perhaps I should say, she exists in this chapter, but nowhere else. She is not a little mythical. She is entirely mythical. It follows that any resemblance to any real person or persons, living or dead, is certainly either an accidental disaster or a disastrous accident. Indeed, I suspect it is probably both.
Even before she has finished unpacking, Mrs D begins to be a nuisance. As soon as she arrives, she starts to make frequent demands, some of which are quite unreasonable. All attempts to satisfy those demands are extremely frustrating. Nothing is satisfactory. It is quite impossible to please her. Right now, her further demands are continuing so relentlessly, that there is hardly time to attend to the other patients.
Somehow, Mrs D also has a knack of making all concerned feel guilty about – well, about almost anything; indeed, often about nothing tangible at all. Even while feeling angry about her incessant demands and constant dissatisfaction, you find yourself feeling vaguely guilty and ashamed. You don't usually feel like that, but today, you do.
Other facilities and their staff members, incidentally, have always treated Mrs D with very great kindness. She has simply been blessed by encountering so many good people, wherever she has gone. Your colleagues, on the other hand, have been quite rude to her – which she doesn't understand at all. As for you – well, she knows you have done your best. At least she can see that you are trying, and she is grateful for that.
In due course, your patient shows herself to be capable of making trouble in various other ways. Usually, she contents herself with a little non-violent nastiness, such as lying about various staff members, to get them into trouble. She can get a bit physical sometimes, though. The other day, one of your colleagues asked her if she felt angry and if she would like to talk about it – and copped the contents of Mrs D's bedpan.
Next day, Mrs D tells you she was only angry with your colleague because of the terrible things she was saying about… you. She really hates to repeat them (but she does). She doesn't believe a word of it, but feels she must assure you that your secrets will be safe with her. You need not feel afraid at all.
She does not apply such benevolent restraint to your colleague. Instead, she files a formal complaint, stating that your colleague retaliated in a fury after a very slight accident with a bedpan, twisting her arm painfully and threatening to "see to her" unless she kept quiet about the whole thing.
Mrs D now tells you that she felt very diffident about making a complaint, but as she was a sick and defenceless patient, and had felt real fear for her life, she was forced to report the matter for her own protection. However, she would consider keeping the details from the press, and might not even involve the police, as long as your colleague was dismissed without delay.
I think I will take myself forward in time now (one of the great advantages of fiction) so that I can tell the rest of this story in the past tense. The next day, Mrs D was visited by a doctor. She immediately asked him to pull the curtains around her. She refused to have a nurse present during her examination, as that would embarrass her terribly. Some of the nurses were – well, she would rather not talk about it, it was all too distressing.
While the doctor was examining her, she cried out and told him (very loudly) to get away from her. She did not explain what had distressed her. She just said that misunderstandings could easily happen. She thought perhaps the whole thing had better remain their little secret. The doctor departed, shaking his head.
Whatever it was, it did remain their little secret – for the rest of the day. That night, though, she shared it with the night nurse, enjoining her to refrain at all costs from putting it in her report, as she did not wish any harm to come to such a nice doctor as a result of – well, it might all have been a misunderstanding.
Some days later, however, she spoke to that night nurse again, telling her that such matters really should be dealt with properly, and not just swept under the carpet. However, as it had been left out of the report at the time, she could see what a difficult position the nurse would find herself in – so perhaps the whole thing had better remain their little secret.
Mrs D continued to cause trouble, and to prepare the ingredients of future trouble, as long as she was in the ward. I could tell you a great deal more about her. However, so much of it is – well, misunderstandings can so easily occur. I am terribly afraid that you would think very, very badly of her, if you knew just a few of the things I know. Therefore, I think the rest of Mrs D's story had better remain… my little secret.
Although Mrs D's actions are often called manipulative behaviour, this term needs to be used with some care. This is, firstly, because everyone is manipulative to some extent. It is part of the process of trying to get what we want, so it can be difficult to distinguish exactly what is meant by the label.
Secondly, anyone we don't like, or whose behaviour we don't like, is at considerable risk of being labelled as manipulative – by us. Indeed, the more often the term is applied in appropriate cases, the more popular it seems to become as a convenient label for anyone we think is a bit unpleasant.
In some cases, manipulative behaviour is part of a larger syndrome. People with certain personality disorders intentionally exploit others in order to gratify their own desires, caring nothing for the pain they cause in the process. In addition, they show other features of their particular disorder.
Personality disorders which include abnormally manipulative behaviour include the antisocial, narcissistic and borderline personality disorders. However, in some cases, behaviour which is clearly suggestive of an abnormal personality does not fit the picture of any of the defined personality disorders.
Despite these difficulties, it is possible to list characteristic features that define abnormally manipulative behaviour – whatever its cause may be. Fortunately, not all are present in every case! However, abnormally manipulative people typically display a number of the following behaviours:
As a consequence of the behaviours described above, abnormally manipulative people progressively alienate their carers, who then tend to avoid them.
While it may be interesting to identify abnormally manipulative behaviour, it will only be of any practical use if something can be done about the behaviour or its effects. Fortunately, although there is no magical or perfect solution, a great deal can be done to reduce the damage caused by such behaviour, which may otherwise be very considerable.
The approach suggested below can be applied whether the problem is mild, moderate or severe. However, it takes a lot more effort when it is severe. Of course, the headings I have chosen for the ten steps that I suggest could easily be put in a different order, or given different names, or both.
1. Share information
Sharing information is the first essential whenever a team faces a problem. Some staff meetings waste a lot of time, but the time spent on this issue is never wasted. Nursing handover is another opportunity for making the situation known. The "grape vine" is also useful, but is not sufficient by itself.
Regardless of the method employed, every staff member needs to be aware that the team is, effectively, under attack – and that its resources are about to be tested to a considerable degree. However, written comments of a critical nature should either be avoided or worded very carefully. The same applies to spoken comments which might be overheard.
2. Support each other
Supporting each other is, hopefully, nothing new. It will be more difficult while this is going on, though, and it will be more vital than ever. Importantly, all accusations made must be shared with the whole team, and the innocence of those accused must be assumed by their colleagues. This is especially important when it is alleged that one colleague has transgressed against another (the quintessential "splitting" ploy).
Administrators should also support and be supported, but in some cases they may dig in with the "enemy". This is unfortunate, especially as many of them were carers once, and should therefore know better. Of course, some administrators are excellent, and their contribution is extremely valuable. However, if administrative support is lacking, peer support simply has an even greater task to fulfil than usual.
3. Agree on strategies
Agreeing on strategies is simply a matter of making plans and making sure that everyone knows them. One good plan is to have two staff members present when the patient is attended. Another good plan is to document everything carefully, as a contemporaneous record is the only reliable defence against any future accusations. As always, the documentation must be clear, unambiguous and emotionally neutral.
Some plans might have to do with setting limits on certain behaviours. These limits then need to be applied consistently by all staff members. Another good idea is to involve selected educators and clinicians with relevant expertise, and invite them to attend team meetings and suggest more solutions.
4. Keep draining the pool
Draining unfinished business from each person's pool of pain was discussed in the previous chapter, Communicating with the Dying, but it is relevant to any stressful situation. I am not suggesting that the problem is caused by your own unfinished business, but it is very likely to be stirred up by patients like Mrs D!
Unjust accusations are powerful triggers for many people. When a master troublemaker is looking for buttons to push, some will usually be found. There may also be official investigations into various allegations to add to the stress. As previously mentioned, dealing with these emotions is the subject of "Wanterfall", so I will not discuss the process here.
5. Plan ahead
Planning is not always possible as far as the problem itself is concerned. However, various aspects of your response to the situation can be planned in advance. For example, before entering the patient's room, decide what you choose to say and what you need to do. The patient will probably ask you to change your statements or your actions – perhaps both. This may be woven into the conversation very skilfully, so that you hardly notice it. Whenever possible, though, it is best to…
6. Stick to the plan
If someone asks you to change your plan, your first inclination may be to comply. Sometimes, this may be a very good idea, but this is almost certainly not one of those times. If you find yourself contemplating compliance, at least give yourself some time and space to consider the matter carefully.
Perhaps you could agree to think about it, but be sure to do that thinking somewhere else. Never deviate from your considered plan in the heat of the manipulative moment! If possible, also discuss the issue with a colleague. If a change involves previously agreed limits, of course, it will ultimately need to be discussed with the whole team.
Quite often, the result of this process will be that you decide to make no change at all, or perhaps to make some, but not all, of the requested changes. Report this decision to the patient in a matter of fact way, without displaying any apprehension about the storm of complaint you are probably expecting. If necessary, repeat the information using the "cracked record technique".
7. Charm the snake
Snake charming may seem like a strange addition to the present discussion. However, there are some parallels between caring for manipulative patients and managing dangerous animals. For example, it is generally best not to seem as terrified as you probably feel. Therefore, if possible, act as if you fully expect the patient to behave sensibly, rather than acting as if you are attending to the oral hygiene of a poisonous snake.
Don't be fooled by your own subterfuge, though. Always remember that (figuratively speaking) you actually are providing mouth care to a serpent. Therefore, remain alert with every sense. At the same time, watch your own feelings like a hawk. If you notice that you feel very bad, that is very good! (One of the chief dangers lies in not noticing that you feel bad.)
8. Be perfectly paranoid
Perfect paranoia may seem like another rather odd inclusion in our current context. You may even consider the term to be an oxymoron. Perhaps I should explain what I mean by it. By perfect paranoia, I actually mean two things. Firstly, I mean being suspicious of absolutely everything about the patient. Secondly, I mean processing that suspicion in a clear mind, by mixing it with equal parts of logic and equanimity.
In other words, I mean considering the possibility that absolutely anything might be yet another nasty, underhanded scheme, however much sweetness and light it is clothed in. At the same time, it is important to continue the patient's care in a methodical fashion, and to maintain as calm an atmosphere as possible. A calm atmosphere may not always deter the patient from creating further mischief, but perhaps it will help a bit. It will also make things less unpleasant for the carers involved.
For example, if the patient is kind to you, or praises your work, you should immediately suspect that you are being set up. You should also calmly consider that perhaps you are not being set up. In other words, assume that anything the patient says or does might be a barbed and baited hook. Sometimes, that will not be the case, which might be a sign of progress. Be glad of that – but don't forget to resume your perfect paranoia!
9. Be ready to duck
If you follow the above suggestions, such patients will not achieve their desired results, and this quite often causes a veritable avalanche of anger! It is often better if another person takes over at that point, as they may be able to address the anger without being a part of it. They will hear what a terrible person you are, but you will be spared the litany of your faults.
Next time you see the patient, just follow these same ten rules all over again; and always be ready to let go of the past, and start a new relationship which is not poisoned by what has gone before. While doing that, don't forget to remain perfectly paranoid, and always ready to duck!
10. Never retaliate
You may sometimes feel the urge to frown at such a patient, or perhaps even (gasp) speak sharply to them. OK, you will more likely want to swear and scream at them, though I won't mention homicide – oops, I did. If you blame yourself for such feelings, you will feel guilty as well as enraged. Now things are really proceeding according to plan (and no, it isn't your plan).
The two main things to remember about such feelings are (a) they are all "normal" and (b) many of them nevertheless need to be worked through, as mentioned under step 4, so that the urge to retaliate does not become overwhelming. If this urge is not well managed, retaliation of various sorts may well occur.
Perhaps the least specific form of retaliation is the most common. Often, such patients are moved to the bed furthest from the nurses' station, sometimes with their door kept shut. This is understandable, but it may place the patient at risk. It also makes it much less likely that anyone will be there to offer help if the patient is ever ready to accept it.
If you make the mistake of retaliating in a more specific way, all hell will break loose (and most of it will land on your own head). Retaliation is the only certain way of losing this game. In fact, it is one of the main things that you are being set up for. If you retaliate in an emotional way, you have no hope of winning. This patient is a master of psychological warfare, and you will be reeled in like a fish and roasted over a slow fire.
If you retaliate with physical violence, you will not only lose the game, you will probably lose your job as well. You might even feature on national television, face criminal charges, or both. Even though all you wanted to do was to care for patients, encountering this particular patient could make your life a misery. It is remarkably easy to get bitten, when caring for venomous snakes.
Fortunately, though, most cases do not go quite so far as that. Nevertheless, they are always difficult, and usually quite unpleasant. For those readers who are kind enough, and brave enough, to provide "mouth care for venomous snakes", I hope the above ideas will help you to avoid being bitten too often – and also help you to survive those bites that you do not avoid.
(Click the number of a footnote to return to its reference in the text)
 Of course, I could have told you about the equally mythical Mr D. He has rather more pronounced antisocial tendencies, and an even greater lack of impulse control, than Mrs D. In general, though, he is equally obnoxious.
 Coates, G.T. 2008. Wanterfall: A practical approach to the understanding and healing of the emotions of everyday life. Free e-book from www.wanterfall.com
 If you don't remember vinyl records, think of this as the looped sample technique. It is simply an answer that is repeated, calmly and politely, as often as necessary – instead of changing the answer on request.
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