When you're on the receiving end of a client's difficult behavior, you may worry about job performance, feel burned out, and have trouble handling the client and his treatment. Learning how to effectively manage difficult behavior implicitly teaches you how to prevent being taken advantage of. It also helps you limit the intense feelings associated with emotional fatigue.

Difficult behavior can take the form of manipulative behavior, excessive dependence, symptom focusing, resistance, emotional disengagement, denial, difficulty with rapport and trust, or hostility. You may encounter more than one such behavior in a single client, but let's take a look at managing one of the toughest — manipulative behavior.

A Look at Underhanded Methods
In general, manipulative behavior refers to underhanded efforts to maintain control or have one's own way when interacting with others. For example, a client may:

• strive for a desired social, emotional, or material resource at your expense or when you aren't willing to provide it.
• pretend to be cordial, compliant, ingratiating, sincere, or charming toward you to achieve an immediate end when his underlying feelings are actually judgmental, aggressive, or otherwise negative. The result? He'll treat you very well and very badly.
• fabricate stories or distort reality to coax you to believe or do something you might not do spontaneously.
• try to strongly influence your thinking or convince you to assume a perspective he wants.
• behave in a way that makes you feel responsible or even guilty about his thoughts, actions, or overall well-being so he doesn't have to take responsibility.
• try to elicit your pity or sympathy for something that resulted from his own actions.
• engage in an intense or intimate interaction with you so you feel obligated to be present for him even when he behaves inappropriately.

What's Behind the Behavior?
Someone who engages in manipulative behavior may have difficulty distinguishing between the reality of a given situation and his own perceptions and distortions. He may be trying to free himself from the burdens of everyday life or to improve or preserve feelings of self-worth. He might also be trying to maintain the upper hand in your relationship, to ensure an ongoing connection, or to avoid the risk of being judged poorly. If a manipulative strategy is effective, he'll continue to use it without regard for the potential consequences.

However, once you've been the victim of manipulative behavior, you may come to distrust the client and become uncertain about his goals and preferences during therapy. Trying to understand his behavior offers the best chance of deciding how you can preserve your relationship and help him work toward the ultimate goals of therapy. Failing to manage the behavior could make you either limit how much effort you put into your work with him or disengage emotionally to protect yourself from the manipulative interactions.

Respond with Intentionality
When a client behaves in manipulative ways, respond with intentionality using various modes. For example, you might try:

• collaborating to remind a power-seeking client of adaptive ways to retain and use power within the therapeutic relationship.
• empathizing, which is best used if his manipulative behavior is interfering with therapy and you pause to try to understand the reasons behind his need to act this way.
• instructing him that the manipulative behavior is interfering with therapy or the therapeutic relationship; you can also teach him alternative ways to have his needs fulfilled.
• problem-solving, If he accepts the fact that he's behaving inappropriately and you can help him independently think through the pitfalls and alternatives to the behavior.

Unfortunately, in certain circumstances, nothing you do will manage a client's negative behavior. For example, if the client is interpersonally hostile, sexually inappropriate, or even subtly abusive and unresponsive to limit setting and redirection, don't try to initiate or continue communication. Instead, remove yourself from his presence and document the nature of the behavior in his chart, your specific attempts at intervention, and the reasons that treating him wasn't possible.

To Learn More
DavisPTnetwork offers a variety of online continuing-education courses for PTs. This article is based on content written by Renee R. Taylor in her book The Intentional Relationship. To learn more about managing manipulation and other difficult client behaviors, access this online continuing-education course on DavisPTnetwork: The Therapeutic Relationship: The Intentional Relationship Model and the Therapeutic Use of Self.