The focus of Unit 7 is manipulative behaviour.

Dr Jeffrey Keller calls the art of dealing with manipulation verbal jiu-jitsu.

„We must first start with an analysis of what manipulation actually is. My definition of manipulation is this: in a 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. Then comes the manipulation, the attempt to coerce the practitioner into changing a “no” into a “yes.” Manipulation comes in many forms.”¹

The various manipulative behaviours that patients may use to influence medical staff, include exaggeration (making complaints seem more severe), belittling (criticizing medical staff), splitting (comparing staff to other practitioners), threatening (using physical or legal threats), fawning (excessive praise or flirtation), playing the victim (claiming discrimination), having external “champions” advocate for them, and self-harm (deliberately injuring themselves to gain attention or treatment). These tactics aim to manipulate staff into giving in to their demands.

This unit will explore effective communication techniques, recognizing verbal and non-verbal cues, developing a firm yet empathetic approach, maintaining professional boundaries and understanding the role of patient history and medical records in assessing their needs.

Learning Objectives:

By the end of this unit, you will be able to:

1. Apply effective communication techniques to manage potentially manipulative patients.
2. Recognize verbal and non-verbal cues associated with drug-seeking behaviour.
3. Develop an empathetic but firm approach to managing drug-seeking behaviours.

Communication is the foundation for managing patients who may be manipulative or attempting to manipulate the healthcare system.

Active listening: Show the patient that you are listening to their concerns. Sometimes, manipulative behaviour arises from unmet emotional or psychological needs.

Setting clear boundaries: Communicate clear guidelines about what is acceptable behaviour. For example, tell the patient that certain requests will not be met unless supported by appropriate medical evidence.

Assertive communication: Be firm but respectful in your response. For example, saying “I understand your concern, but I cannot prescribe medication without proper medical justification.”

Empathy with limits: Acknowledge their feelings (e.g., “I can understand that you are in pain”), but remind them of the importance of following proper medical procedures.

Pause for Thought

Think about a time when a patient tried to manipulate the system. What communication strategies did you use to address their behaviour? Were there any strategies you could have used that might have been more effective?

Drug-seeking behaviour can be subtle or overt, and understanding both verbal and non-verbal cues is essential. These behaviours should be assessed carefully and without judgment, allowing healthcare providers to make informed decisions based on clinical evidence, rather than being influenced by manipulation or undue pressure.

Verbal Cues:

• Frequent requests for specific medications: Patients may consistently ask for medications by name, particularly those with addictive properties.
• Desperation in tone, exaggeration of symptoms: They may use phrases like “I can’t live with this pain anymore” or “I need something stronger.”
• Inconsistent medical history: Their story about pain or past treatments may change frequently, which can be a red flag.

Non-Verbal Cues:

• Pacing or fidgeting: The patient may appear restless or agitated.
• Avoiding eye contact: Patients may avoid direct eye contact when talking about their pain or medications.
• Excessive physical gestures: Repeated touching or gesturing towards areas of their body where they claim to have pain.

Pause for Thought

Consider a situation where a patient exhibits drug-seeking behaviour. How can you empathize with them without compromising your professional boundaries? What language might you use to ensure they feel respected but not enabled?

It’s essential to address drug-seeking behaviour in a way that maintains empathy, while also remaining firm.

• Empathize with the patient’s situation: For instance, “I understand that chronic pain can be incredibly frustrating and challenging.”
• Set clear expectations: “However, we must follow proper procedures, and I cannot prescribe medication without confirming a medical need.”
• Offer alternatives: If appropriate, suggest alternative treatments or refer the patient to a specialist if their issue cannot be addressed by your unit.

Developing the Ability to Maintain Professional Boundaries in Emotionally Charged Situations

When emotions run high, it’s important to stay composed. Avoid becoming defensive or reactive. When responding to the patient, use neutral, non-judgmental language. For example, “I understand this situation is difficult, but I must follow our medical guidelines.”

Know when to walk away. If the situation becomes too heated or aggressive, it may be necessary to step away from the conversation, offering to continue later or with another member of staff if needed.

A thorough review of a patient’s medical history and records is crucial in managing drug-seeking behaviours. Understanding past treatments, diagnoses and prescribed medications can help you make informed decisions.

Check if the patient has a history of prescription medication misuse or if there are discrepancies in their reported history. Drug-seeking behaviour may involve repeated requests for specific drugs. Reviewing records over time can highlight patterns and inform your decision-making. If you are unsure, discuss the case with a colleague or supervisor to ensure you are approaching the situation appropriately.

Key Takeaways

1. Apply active listening, assertive communication and clear boundary-setting to manage manipulative patients.
2. Recognize verbal and non-verbal cues indicative of drug-seeking behaviour.
3. Develop an empathetic but firm approach to addressing drug-seeking behaviours.
4. Maintain professional boundaries in emotionally charged situations.
5. Use patient history and medical records to assess needs and guide decision-making.

Next Steps

• Do the exercises.
• Watch illustrative video accompanying Simulation 7.
• Participate in Role-play Simulation 7.
• Share reflections and key takeaways during debrief.

1. Keller J.E., “The Rules of Verbal Jiu-Jitsu with Patients – How to deflect and defuse manipulative conversations”, 2019, https://www.medpagetoday.com