The word “manipulation” has negative connotations. Usually, its use refers to someone attempting to exert influence or control with a conditional threat. Clinical examples include:

• “If you don’t prescribe that narcotic for me, I’m going to sue you for negligence.”
• “I don’t know if I’ll live or die if you discharge me from the hospital; the only way I know I’ll stay alive is if I stay here.”
• “But I need the full body MRI—what do you think the Local Television Station will report if it finds out that doctors aren’t providing appropriate care?”

Like I had mentioned previously, however, we are all manipulating each other all the time. In its less negative context, the word “manipulation” suggests skill and grace (e.g. “He manipulated the Rubix cube with ease”). We only realize when someone is manipulating us when the manipulation isn’t skillful. People successfully manipulate us all the time. Think of all of those feminine wiles that induce men to pursue women. Consider the tactics children exercise to maximize the likelihood that parents will purchase the Latest and Greatest toy for them. Ponder the strategies advertisements use to seduce those children to nag their parents to buy the Latest and Greatest toy.

You get my point.

Let’s review a non-clinical example, shall we?

Samuel is infatuated with Janet. When she shakes her head, her auburn locks sway across her back like gentle ocean waves lapping against the beach. He curses the physiological process of blinking, for when he blinks, he loses yet another moment to gaze upon her beautiful face. When she blinks, her aquamarine eyes disappear from his view for what seem like an eterntiy. Samuel is certain that her smile is radioactive, as he feels incredibly warm and tremulous when that lovely expression blooms across her face.

Samuel wants to spend time with Janet, to befriend her, to learn more about her, to secure the opportunity to touch her.

However, he’s not sure if she knows he exists.

Scenario 1: Samuel guesses that the direct approach will work best. He accosts Janet, grabs her shoulders, leans in, and hoarsely whispers, “I want to spend time with you. I want to know you. I’m in love with you. I think you’ll fall in love with me, too, and if you don’t, I’ll keep pursuing you until you do.” He then leans in further to kiss her.

We’ll give Samuel the benefit of the doubt. We’ll graciously assume that he doesn’t know how to ask women out on dates (successfully). We can call this a skills deficit.

Just because we know how to do something doesn’t mean that everyone else knows how to do it, too. Perhaps Samuel has never asked anyone out before. Perhaps he’s never learned that grabbing women who don’t know him may not actually be in his best interests. Maybe he’s never considered that women may not want to kiss him as much as he wants to kiss them.

Simply put, he just doesn’t know how to proceed. Women, however, may find his behavior atrocious and “manipulative”.

(By the way, Janet promptly screams, kicks him in the groin, and runs in the opposite direction.)

Scenario 2: Samuel waves at Janet from across the room and, upon her acknowledgment of him, approaches her. She looks at him; he clearly looks like he has something to say.

“Uh, hi, Janet,” he begins, wiping his palms against the pleats of his khakis. His eyes dart from her face to her shoes. She’s so beautiful. Oh. My. God. “I, uh, was wondering—um, actually, I don’t think you know me—my name—I’m, um, I mean, my name is Samuel. Samuel.”

He opens his mouth to continue, but nothing comes out.

Janet looks perplexed and begins to speak, but Samuel interrupts her.

“I almost make a six-figure salary, I don’t have any STDs, and I’m pretty sure that I can make you very, very happy,” he blurts out.

Poor Samuel. He’s apparently anxious and while he can approach women, his delivery is lacking. This might be a skills deficit, but maybe we can be more generous and suggest that he has not yet mastered skills acquisition.

Do you remember the first time you asked someone out? (You, too, ladies—don’t tell me that you’ve bought into the whole “Rules” thing, please.) It takes practice, right? Few, if any, people are “smooth” during that first invitation. (Indeed, few, if any, people are “smooth” upon responding to that first invitation!) Sometimes we know what to do and are motivated to do it… but we just haven’t had sufficient practice to do it skillfully.

Samuel may not have enough practice asking women out. Janet may be his prototype. And he may believe that his money will successfully induce her to accept his offer.

(Janet blinks at him and then curtly comments, “I already have a boyfriend.” She’s lying.)

Scenario 3: Samuel, on his way to the bathroom, spies Janet about to board the elevator and deduces that she is going home for the day. Realizing that this might be his opportunity to make his case, he dashes after her and slides into the elevator.

There are five other people in the elevator. And Samuel really needs to pee.

“Hi, Janet,” Samuel says quietly, hoping that only Janet will hear his greeting. Of course, everyone else hears him, too, but no one makes any eye contact.

“Hi,” Janet replies, smiling at Samuel. Between his full bladder and the radioactivity of her smile, he is sure that he will soon fall down and completely lose it.

“I’m Samuel. I work down the hallway from you,” he continues, shifting his weight between his feet. He feels the sweat pooling on his forehead.

“Oh, yeah,” Janet says. “I’ve seen you around. Nice to meet you.”

Samuel looks around the elevator. No one looks back at him. He curses his luck as he feels the pressure increase in his bladder. The elevator is stopping on every floor and no one is getting on or getting off the lift.

He’s about to pop.

“I’ve gotta go,” he hastily says as the elevator doors open. “Nice to meet you, too, Janet.”

And off he goes.

Samuel gets an “A” for effort, right? He presumably (1) knows the skills to ask a woman out and (2) has proficiency in them, but he’s never asked a woman out in a full elevator when he’s needed to pee. He’s never used these skills in this context.

Context matters. While we would all like to believe that we have integrity and behave in a predictable, consistent fashion across space and time, this is simply false. You didn’t act the same way in front of your parents as you did in front of your peers, did you? And have you ever looked at anonymous comments on weblogs? Do you think many people would leave such brazen comments if they actually confronted the writer in person?

This isn’t the best example of manipulation, but Samuel has at least planted the idea of himself in Janet’s head. That could potentially influence her in the future.

(Janet wonders what prompted Samuel to take off like that. We only travelled four floors….)

So how can we tie these ideas into a clinical context? If we refer back to our patient requesting narcotic medications:

1. He may not have the skills to calmly negotiate with the physician to obtain narcotics.
2. He may not have mastered the skills to calmly negotiate with the physician to obtain narcotics.
3. He might be in so much pain that he cannot exercise his usual calm negotiation skills with the physician.

“Yeah,” you might comment, “but he probably knows EXACTLY how to get narcotics: He probably knows what to say and how to say it. He’s just being willful and refusing to do it. He’s just being manipulative.”

Okay—if someone is fully aware of what he needs to do to maximize the likelihood of obtaining what he wants, why would he do anything else? If people know what they want, they’ll do the best they can to get it. The more important it is, the less likely they’ll schlep along and put forth a suboptimal effort.

Furthermore, it helps no one to describe a patient as “manipulative”. In using that word, you’ll increase the likelihood that you’ll feel angry at the patient, which will likely manifest itself either overtly or covertly in your interactions with the patient. If your patient senses that you’re angry at them (for reasons that may be invalid), that’ll increase the likelihood that the patient will become angry with you. Your professionalism will slide and other people (other attendings, nurses, medical students, residents, patients, etc.) will notice… and some might then infer that it’s totally appropriate and okay to label patients as “manipulative” and treat them as such.

Other people notice what you do. Be respectful.

Consider striking the word “manipulative” from your vocabulary. Just describe what people are doing. “She says that she will kill herself if I don’t give her Vicodin” is a lot more informative than “She’s manipulative”. Furthermore, brainstorming ideas and conferring with others (including the patient) to solve this dilemma is much easier when everyone knows the specific details of the dilemma. How does one solve a problem around an adjective?

And give people the benefit of the doubt. Time (and history) will soon illuminate the motives of others. But, until then, consider that people may simply not have the skills to effectively get what they want from you (or from anyone else). And, as you undoubtedly know, we all get frustrated (if not a little pissed) when we are stymied in achieving our goals.

Okay, off of my soapbox.