COALINGA STATE HOSPITAL
NURSING POLICY AND PROCEDURE MANUAL
SECTION – Psychiatric Nursing Interventions
POLICY NUMBER: 1309
Effective Date: August 31, 2006
SUBJECT: APPROACHES FOR PASSIVE-AGGRESSIVE
(NEGATIVISTIC) OR MANIPULATIVE BEHAVIOR
1. PURPOSE:
The purpose of this policy is to assist the nursing staff member with the Individual
who is exhibiting passive-aggressive (negativistic) or manipulative behavior and to
provide a uniform approach to evaluation, intervention, and treatment.
2. POLICY:
Each Individual exhibiting passive-aggressive (negativistic) or manipulative behavior
shall receive appropriate individualized treatment to alleviate those symptoms in a
structured, safe, and secured environment. Each Individual diagnosed with passiveaggressive (negativistic) or manipulative behavior shall have an individualized
nursing care plan with short and long-term goals, which shall be compatible with the
Master Treatment Conference goals.
3. GENERAL INFORMATION:
It is especially important to remember your professional role when working with
Individuals who manifest passive-aggressive (negativistic) or manipulative behavior.
It is neither necessary nor particularly desirable for the Individual to like you
personally. It is not your purpose to be a friend to him. Maintaining your professional
role with the Individual will be a firm basis on which to establish a therapeutic
relationship in the best interest of the Individual.
4. DEFINITIONS:
Passive-aggressive (negativistic) - behavior is a type of indirect expression of
feelings whereby a Individual does not express aggressive (angry, resentful, etc.)
feelings verbally, but denies these feelings and reveals them instead through
behavior. This behavior may be indicative of a personality disorder "characterized by
use of passive behavior to express hostility. The behavior includes obstructionism,
pouting, procrastination, stubbornness, intentional inefficiency, and criticism and
scorn of authority.” These individuals are unaware that on going difficulties are the
results of their own behavior.
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Manipulative behavior - is characterized by the Individual's attempts to control his
interactions and relationships with others, often to satisfy some immediate desire or
need; or to avoid discomfort, change, or growth. Individual's who manifest
manipulative behavior may have little genuine motivation to change their ways of
relating to others and of dealing with situations in general. In seeking treatment, the
Individual may want to get out of a bind, crisis, or stressful situation (employing
manipulative behavior with regard to treatment).
Examples of abnormalities may include:
-Denial of problems or feelings
-Lack of insight
-Resistance to therapy; preoccupation
with other Individuals problems, with staff
members, or with unit dynamics to avoid
dealing with his own problems
-Inability or refusal to express emotions
directly
-Manipulation of staff, family, and other
Individuals
-Playing one person against another
-Attempting to gain special treatment or
privileges
-Attention-seeking behavior
-Somatic complaints
-Intellectualization or rationalization of
problems
-Seductive behavior or sexual acting out
-Refusal to participate in activities
-Dependency
-Low self-esteem/ low self-confidence
-Forgetfulness
-Dishonesty
-Anger or hostility
-Covert aggressive behaviors are chosen
over self-assertive behaviors
-Procrastination
-Stubbornness
5. PARTIAL LISTING OF POTENTIAL NURSING DIAGNOSES:
Manipulative behavior related to:
-Anger, hostility or resentment
-Fear of vulnerability
-Dishonesty
Disturbance in interpersonal communication related to:
-Decreased ability to express feelings
-Anger or hostility
-Dishonesty
Lack of insight related to:
-Denial of problems
-Denial of feelings such as anger
-Resistance to change
-Low self-esteem
-Early rejection by significant other
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Denial of problems or feelings related to:
-Fear of feelings
-Feelings unacceptable to the Individual
-Fear of dependency or inadequacy
-Feelings of helplessness
Powerlessness related to:
-Interpersonal interaction
-Lifestyle of helplessness
-Difficulty connecting own passive-resistive (negativistic) behaviors with
………… hostility or resentment
Resistance to treatment related to:
-Anger or hostility
-Lack of insight
Low self-esteem related to:
-Feelings of worthlessness
-Guilt
6. INDIVIDUAL OUTCOME/GOALS:
The Individual will be expected to:
-Verbalize increased insight into their behavior
-Express feelings verbally and non-verbally
-Express anger and hostility in a non-destructive manner
-Develop or increase feelings of self-worth
-Demonstrate decreased manipulative, attention-seeking, and/or passive-aggressive
(negativistic) behaviors
-Participate in the treatment program and activities
-Communicate directly and honestly with other Individuals and staff about self and
personal feelings
-Decrease somatic complaints
-Establish and maintain mature, non-manipulative relationships and patterns of
dealing
with other people and situations
7. IMPLEMENTATION AND INTERVENTION:
Deal effectively with the Individual who uses passive-aggressive (negativistic) and
manipulative behavior in interactions, relationships, and life situations:
NURSING ACTION
KEY POINTS
A. Be consistent. Set clear limits for
expected behavior. Do not debate,
A. To deal effectively with and to decrease
passive-aggressive (negativistic) and
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argue, or bargain with Individual.
manipulative behaviors
B. Be direct and confrontational if
necessary. Enforce all hospital policies
and regulations.
B. Explain; DO NOT apologize for
enforcing hospital policies and
regulations.
Decrease manipulation of staff members:
NURSING ACTION
KEY POINTS
A. Do not discuss yourself or other staff
members with this Individual. Set limits
on frequency and length of interactions
with Individual.
A. Sharing information about yourself or
others is inappropriate. To decrease
manipulative behaviors.
B. Withdraw your attention if Individual
begins saying that you are "the only staff
member I can talk to....” or “the only one
who understands" and so forth.
B. If you are "the only one" the Individual
may be too dependent or may be
flattering as a basis for manipulation.
Decrease the Individual's denial of problems, promote their insight:
NURSING ACTION
KEY POINTS
A. Discuss the Individual's behavior with
him in a non-judgmental manner.
A. To decrease denial of problems and
increase effectiveness of therapy and
increase insight.
B. Help identify the results and the
dynamics of their behavior and
relationships.
B. Reflection and feedback can be
effective in increasing insight.
Decrease the Individual's attention-seeking behavior, acting out, and secondary gains:
NURSING ACTION
KEY POINTS
A. Withdraw your attention when
Individual refuses to be involved in
activities or other therapies or when the
Individual's behavior is otherwise
inappropriate.
A. It is important to minimize attention
given to unacceptable behaviors.
Withdrawing attention can be more
effective than negative reinforcement in
decreasing unacceptable behaviors.
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Promote healthy and appropriate adult behavior and interactions; promote the
Individual's self-esteem:
NURSING ACTION
KEY POINTS
A. Give attention and support when
Individual exhibits appropriate behaviors.
A. To reinforce healthy and appropriate
adult interaction.
Decrease the Individual's somatic complaints:
NURSING ACTION
KEY POINTS
A. When the Individual voices somatic
complaint, treat the issue immediately
then tell the Individual that you will
discuss other things; do not engage in
lengthy
conversations about physical
complaints or physical condition.
A. Treating the somatic complaint in a
matter-of-fact consistent manner will
minimize reinforcement of attention
seeking behavior.
B. Observe and note patterns in somatic
complaints.
B. To decrease somatic complaints as
passive aggressive symptoms.
8. EVALUATION:
Documentation should reflect:
1. Individuals current status and progress towards meeting nursing objectives
and plans.
2. Changes in Individual condition.
3. Nursing interventions for unusual or sudden behavior changes.
4. Response to treatment program.
5. Attendance and participation in scheduled groups.
6. Response to medication.
7. Effect illness has on eating, sleeping, hygiene, elimination, and behavior.
8. Individual education.
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