“The ailment” revisited: Are “manipulative” patients really the most difficult?

Abstract

Background: In 1957 Main's paper “The Ailment” described the so-called “manipulative” patient and the disruptive effect such patients might have on staff. Today, with mental health services under increasing pressure, the possibility remains that certain patterns of patient behaviour, combined with particular staff attitudes or “ward culture”, could lead to conflict and staff stress.

Aims: To investigate clusters of behaviours that mental health staff might find difficult and stressful.

Methods: In the first study staff rated 48 types of patient behaviour in terms of the extent to which they made work difficult or distressing. Factor analysis revealed several clusters of behaviours, one of which resembled the traditional image of the “manipulative” client. In the second study staff provided difficulty and distress ratings, together with possible coping strategies, for seven patient vignettes based on the identified clusters.

Results: Staff rated the “manipulative” patient as less difficult and distressing than aggressive or self-harming patients. Coping strategies included supervision and boundary setting.

Conclusions: Patients who are aggressive or self-harming may induce a sense of powerlessness in staff operating in a risk averse and resource limited environment. Implications for management and staff training are considered.

Declaration of interest: None.

• Staff stress
• behaviour problems
• patient management
• personality disorder