Personality is the emotional and behavioral characteristics that make up a person. Personality traits are said to be present at birth or develop early in life. Personality influences the way we see and relate to the world. Correctional patients often have disordered personalities that have led to criminality and incarceration. Although there are many forms of personality disorders such as paranoid, narcissistic, and obsessive-compulsive, the most common forms in the correctional patient populations are antisocial personality disorders. Prisoners are ten times as likely to have an antisocial personality disorder as the general population. So, correctional nurses need to know how to recognize and respond to individuals who have these conditions.

Consider this patient situation:

Lynn is a new nurse in a medium security state prison. One morning on treatment rounds in one of the housing units she gets distracted while George is using the nail clippers. Clippers are available for use by inmates in the presence of a nurse. When she returns her attention to George, the clippers are nowhere to be found and George responds “What clippers? You must have left them somewhere.” He smiles charmingly at Lynn as she frantically searches for the missing implement. Although afraid of losing her job for carelessness, Lynn reports the situation to the housing officer who initiates a lock down and cell search. The clippers are found in George’s shoe and he is placed in administrative segregation. Later it is discovered that George owed another inmate a large gambling debt and wanted to move out of general population for protection.

Antisocial Personality Disorder (ASPD)

Antisocial Personality Disorder involves characteristics of social irresponsibility, exploitation of others, and lack of guilt or shame in these behaviors. These traits make ASPD patients dangerous to the emotional and psychological well-being of the correctional nurses who care for them.

What to Look For

Here is a list of common ASPD characteristics. How many of them describe patients arriving at your sick call or medication line?

• Superficial charm
• Self-centered and self-important
• Need for stimulation and prone to boredom
• Deceptive behavior and lying
• Conning and manipulative
• Little remorse or guilt
• Shallow emotional response
• Callous with a lack of empathy
• Living off others or predatory attitude
• Poor self-control
• Promiscuous sexual behavior
• Early behavioral problems
• Lack of realistic long term goals
• Impulsive lifestyle
• Irresponsible behavior
• Blaming others for their actions
• Short term relationships

George demonstrated several of these characteristics in the situation with Lynn. He took advantage of her and felt no shame or guilt about it. He was superficially charming while being deceptive and lying about the situation.

A patient with antisocial personality disorder, in general, is manipulative, irresponsible, deceitful, and guiltless. Correctional nurses must be careful to protect themselves while setting clear behavioral boundaries for the nurse-patient relationship.

Protect Yourself from Manipulation

Unless you are working specifically in the correctional mental health department, your job is not to ‘treat’ the antisocial behavior, but to be aware of it and protect yourself. These patients will use every interaction to their advantage. They are astute at discerning another person’s vulnerabilities and they prey on people who are hurting. Staff members who are lonely, insecure, or self-involved are good candidates for the manipulation of an inmate with an antisocial personality disorder. Correctional nursing careers have ended when nurses have been drawn into sexual relationships or illegal activities like smuggling contraband or diverting narcotics for these individuals. Protect yourself. Learn to identify the characteristics typically seen in these individuals. Keep yourself and your teammates accountable to stop potential issues before they move to a dangerous level.

Protect yourself from manipulation by treating all patients with consistent, professional behavior and demeanor. Follow all security rules of conduct. Here are a few tips.

• Don’t get personal. If a patient comments about your hair or your figure, call them on it. If the comments continue, report them.
• Do not perform even the smallest ‘extra’ activity for a patient. Giving him/her/they a cotton ball, extra gauze or extra antibiotic ointment is the first step down a slippery slope.
• Treat all inmates with equal respect and professional distance. Do not show any favoritism and do not allow any in return.
• If you think you may have already been compromised, report it immediately to your supervisor and take actions to halt the progression. This may include reassignment to another duty or area to break the connection.

Control the Situation

When working with ASPD patients, it is important to maintain control of the situation.

• Keep your distance: A somewhat detached therapeutic stance will help establish the professional nature of the interaction. This patient will not appropriately respond to empathy or compassion.
• Keep control of the relationship: Set clear limits about your availability, frequency of encounters, and appropriate patient behavior during medical visits.
• Keep your cool: Monitor your own feelings when entering into a patient encounter with an ASPD patient. Be mindful of words and actions. For example, avoid responding in kind to verbal attacks or manipulation.

Establish Behavior Accountability

All patients, but those with ASPD in particular, need to be held accountable for their behavior. While it is difficult to maintain positive regard for a patient who is deceitful or manipulative, it can be done. Here are some ways to remain therapeutic in patient encounters with ASPD patients.

• Maintain an attitude that projects that it is not the patient, but the patient’s behavior, that is unacceptable.
• When the patient exhibits unacceptable behavior, identify it as such and redirect the patient to appropriate behavior.
• Do not attempt to convince the patient to do the right thing. Instead of saying “You should” or “You shouldn’t,” say “You are expected to.”  This establishes normative behavior and depersonalizes required actions.

Interacting with patients who have ASPD can be the most frustrating part of your correctional nursing practice. However, with mindfulness toward self-protection and behavioral boundary setting, you can feel confident that you have done your best to provide quality healthcare in a difficult situation.

For more information about inmate manipulation, check out The Correctional Nurse Educator class “Inmate Manipulation for the Correctional Nurse.”  

Have you struggled with a difficult patient like Lynn’s? Share your experience in the comments section of this post.