Manipulative Behaviour of Prisoners and Abuse of Psychotropic Drugs from the Nurse's Perspective

Introduction

Abuse of psychotropic drugs represents a specific risk in psychiatric care, which is particularly significant in the prison environment. Increased consumption of psychotropic drugs raises the risk of their inappropriate prescribing, polypharmacy, and the development of addiction (Baldessarini, 2014; Mahesarajah, El Asmar, Irwin, 2024). Insufficient assessment of the condition, incorrect dosing, or risky interactions lead to prescribing cascades (Soerensen, Nielsen, Poulsen et al., 2016). In prisons, the consumption of psychotropic drugs is higher than in the general population, and their abuse for drug substitution or trafficking is common (Hassan, Senior, Webb et al., 2016). Pregabalin, benzodiazepines, and opioids, which have high addictive potential, are most often the subject of manipulative behaviour. Some prisoners deliberately simulate mental distress and use sophisticated verbal and non-verbal manipulative behavioural patterns. Recognising them is challenging and requires a balance between the ethical duty to treat and the prevention of abuse (Calabrò, Perissinotto, Scalorbi et al., 2023). Systematic observation and analysis of behaviour are tools for protecting psychiatric treatment from abuse. The situation is complicated by prison specifics, such as staff turnover, poor record linkage, and insufficient monitoring of medication consumption (Magola-Makina, Abuzour, Ashcroft et al., 2022).

Objective

To analyse patterns of prisoner behaviour associated with the risk of abusing psychotropic drugs.

Sample and Methodology

The study was an observational descriptive study conducted in the real conditions of outpatient psychiatric care in a prison. The research problem focused on answering the question of what behavioural patterns in prisoners a nurse in a psychiatric outpatient clinic may encounter in connection with attempts to obtain psychotropic drugs with a risk of their abuse. The data collection method was structured observation. The occurrence of observed phenomena was recorded in a protocol, which was compiled by combining professional knowledge and the results of a pilot study (2020-2024). We observed the influence of the nurse's presence on prisoners' behaviour when requesting medication and other phenomena (frequency of visits, medical history, motivation for psychiatric examination). In the pilot study, the most common verbal and non-verbal behavioural patterns of prisoners when requesting a prescription for psychotropic drugs were identified. These patterns were subsequently systematically arranged into categories of manipulative behaviour according to the practical-theoretical framework of Edmüller and Wilhelm. This is a recognised framework for analysing argumentation, moderating discussions, and defending against manipulation. It combines knowledge from formal logic, philosophy of language, and social psychology into a coherent system of effective communication.

The observation protocol contained eight categories of manipulative behavioural patterns and one additional category "truly ill" (SN), with specific verbal and non-verbal examples defined for each category. Emotional appeal to fear (EASt) included threats of self-harm, legal consequences, or physical attack, accompanied by an aggressive tone and dominant posture. Emotional appeal to compassion (EASo) manifested by emphasising suffering, dramatic gestures, and dejected facial expressions. Appeal to guilt (EAPV) involved blaming the healthcare professional, crying, or urgent pleas. False dilemma (FD) consisted of presenting only two alternatives without admitting other options. Appeal to authority (AA) was based on referring to another doctor or institution ("Doctor XY always prescribed it for me"). The tactic of obvious fact (TES) presented the problem as self-evident and indisputable, without room for discussion. Suggested confidentiality (SD) created the impression of a special relationship, often accompanied by a quiet voice, nervousness, and avoidance of eye contact. Slippery slope (S) consisted of predicting a chain of negative consequences of refusal ("if you don't give it to me, I'll get beaten"). A contrast to the mentioned techniques was the additional category truly ill (SN), which included prisoners with a proven psychiatric diagnosis. Their behaviour was characterised by calmness, cooperation, and consistent information about treatment without signs of manipulation.

The occurrence of observed patterns was recorded using a tally method in the protocol throughout the entire visit, from the start of the conversation with the doctor until leaving the outpatient clinic. The frequency of repeated occurrence of individual patterns within one visit was recorded. Data were processed using descriptive statistics, determining the absolute and relative frequency of occurrence of individual behavioural patterns and their verbal and non-verbal manifestations. A complete list of specific manifestations assigned to each category is provided in Table 1.

Table 1 Observation protocol__: categories and behavioural patterns (Source: Author)

Legend: EASt - emotional appeal to fear, EASo - emotional appeal to compassion, EAPV - appeal to guilt, FD - false dilemma, AA - appeal to authority, TES - tactic of obvious fact, S - slippery slope, SD - suggested confidentiality, SN - truly ill

Ethical aspects of the study

The study was conducted in accordance with the principles of ethical research when working with a vulnerable population. The observation was non-interventional in nature and did not interfere with the physician's diagnostic or therapeutic decision-making. Entry into the prison environment was made possible with the consent of the contributory organization Healthcare Facilities of the Ministry of Justice, which provides healthcare in the prison. To protect anonymity, the name of the prison is not disclosed. The observation was carried out during the regular operation of the psychiatric outpatient clinic. At the beginning of the examination, prisoners were informed about the presence of the nurse conducting the observation and were informed that participation in the observation was voluntary and that they could refuse cooperation at any time or request the termination of the examination without any negative impact on the scope or quality of the healthcare provided. Informed consent was obtained orally after instruction, and refusal did not affect the provision of healthcare. All data were anonymized – no names or identifying information of prisoners were recorded in the observation protocols, and the results are presented in aggregated form to prevent the retrospective identification of individuals. An objective and unbiased approach was maintained during both the planning and implementation of the study; data were not selectively edited or adjusted to fit the researchers' expectations.

Results

Graph 1 Sum of verbal and non-verbal behavior patterns over 6 weeks (Source: Author)

During the monitored period from January 6 to February 14, 2025, 165 male prisoners attended the prison psychiatric outpatient clinic. Due to repeated check-ups, a total of 265 visits were recorded, with each visit considered a separate case. The unit of analysis was the occurrence and frequency of verbal and non-verbal behavioral expressions during the entire visit. Over the six-week systematic observation, a total of 1,029 behavioral expressions (100%) were recorded. Graph 1 illustrates the relative representation of individual behavior categories. Emotional appeals (appeals to fear, guilt, and sympathy) constituted approximately two-thirds of all recorded expressions, indicating the dominance of emotionally charged strategies in attempts to influence the decision to prescribe psychotropic medications. Less frequent were rationally appearing argumentation techniques (false dilemma, appeal to authority, tactic of the obvious fact, slippery slope) and the strategy of suggested confidentiality. A separate category was designated for the genuinely ill (SN), which represented authentic psychiatric difficulties without an apparent manipulative intent.

In a more detailed analysis, we divided visits according to the number of recorded manipulative expressions during a single examination. Three categories emerged. The most numerous group consisted of visits with two to three manipulative expressions (56.6%), followed by visits with four or more expressions (28.3%). Visits in which only one manipulative expression was recorded were the least represented (15.1%). This picture suggests that for a significant portion of prisoners, it is not an isolated attempt to influence medication prescribing, but rather the repeated and cumulative use of multiple strategies within a single contact with the psychiatrist. In addition to the frequency of individual categories, we also monitored combinations of manipulative behavior patterns during a single visit. In several cases, two or more strategies were combined by the same prisoner within one examination, thereby increasing the complexity and sophistication of the manipulative behavior. The most common was the emotional appeal to fear (n = 354; 34.4%), with both verbal (n = 184) and non-verbal forms (n = 170) being approximately equally represented. This category points to the frequent use of intimidation and threats to influence the treatment decision. The second most common category was the emotional appeal to guilt (n = 188; 18.3%), in which verbal expressions (n = 102) slightly predominated over non-verbal ones (n = 86). The emotional appeal to sympathy (n = 146; 14.2%), on the other hand, was more frequently expressed non-verbally (n = 84) than verbally (n = 62), which may indicate a specific manipulative tactic based more on facial expressions, gestures, and overall demeanor than on the content of words. Other categories – false dilemma (n = 115; 11.2%), appeal to authority (n = 61; 5.9%), tactic of the obvious fact (n = 48; 4.7%), and slippery slope (n = 11; 1.1%) – occurred exclusively in verbal form and had the character of rationally appearing, yet manipulatively constructed arguments. Suggested confidentiality (n = 56; 5.4%) was represented by an almost equal number of verbal (n = 29) and non-verbal (n = 27) expressions, indicating the combined use of this strategy, often associated with creating a feeling of a "secret" or a special relationship with the healthcare professional. A separate category was designated for the genuinely ill (n = 50; 4.9%), which represents authentic behavior patterns of prisoners with a confirmed psychiatric diagnosis – verbal (n = 28) and non-verbal (n = 22). This group differed from manipulatively motivated strategies by calmness, cooperation, and consistent information about treatment, with behavioral expressions related to the actual health condition and not to the intent to obtain psychotropic medications for other purposes.

Discussion

The results of the presented study confirm that manipulative behavior associated with attempts to influence the prescribing of psychotropic medications is a frequent phenomenon in the prison environment, representing a significant risk factor for their potential misuse. In line with Hassan et al., a high frequency of manipulative behavior (n = 1,029) was also recorded in the studied sample in attempts to influence the prescribing of psychotropic medications (Hassan, Senior, Webb et al., 2016). Most often, these were emotional appeals, primarily an appeal to fear, followed by an appeal to guilt and sympathy, which corresponds to the conclusions of Tamburella, Kathpala, and Reeves (2017). The analysis of combinations of manipulative strategies confirmed that prisoners do not use only individual techniques but purposefully combine them to amplify the pressure on the healthcare professional and increase the likelihood of prescribing the desired medication group. The most frequently recorded was the simultaneous use of an emotional appeal to fear and an appeal to guilt (41.5%), which links the threat of negative consequences with shifting responsibility for the condition onto the healthcare professional.

The second most frequent combination was an appeal to guilt and an appeal to compassion (32.1%), in which prisoners dynamically switch between blaming and dramatizing suffering, thereby multiplying the emotional pressure. Three-strategy combinations (17.0%), often linked to an argument from authority or a false dilemma, represent a highly sophisticated form of manipulative behavior, in which prisoners rapidly change communication tactics based on the healthcare professional's reaction. This pattern may indicate a high motivation to obtain psychotropic drugs with addictive potential and is consistent with the findings of Semahegn et al. (2020), who point to a link between complex manipulative manifestations and the risk of inappropriate prescribing of medications (Semahegn, Torpey, Man et al., 2020). These findings are consistent with the observations of Mert, Turgut, Kelleci et al. (2015), who draw attention to manipulative patient behavior and its association with non-adherence to treatment. In the prison environment, this phenomenon is further intensified by the unavailability of legal and illegal drugs and their replacement with psychotropic medications (Rousselet, Guerlais, Caillet et al., 2019).

The high prevalence of addictions in prisons is also highlighted by Marek (2020), Fazel, Yoon, Hayes (2017). Chomynová, Grohmannová, Dvořáková et al. (2023) emphasize that psychotropic drugs often serve as a substitute for unavailable addictive substances. These findings also highlight the risk of polypharmacy and prescribing cascades in insufficiently coordinated treatment (Soerensen, Nielsen, Poulsen et al., 2016). In this context, during the observation of prisoner behavior during psychiatric examinations, it was also noted that among the requested psychotropic drugs were medications with a sedative effect, including chlorprothixene. Butcher, Packham, Williams et al. (2021) point to the overestimation of depression prevalence and excessive prescribing of psychotropic drugs when relying solely on prisoners' subjective statements. According to Chang, Lichtenstein, Långström et al. (2016), properly set pharmacotherapy in combination with psychological and resocialization programs can reduce the risk of recidivism. Scott (2016) emphasizes that the psychiatrist or nurse must be, to some extent, "detectives" who verify the credibility of reported symptoms, while Kupers (2020) warns that excessive suspicion can lead to neglecting real needs and the risk of suicide. Wood (2021) emphasizes that nurses should actively assess prisoners and use innovative tools, such as screening for manipulative behavior patterns, thereby contributing to the detection of psychotropic drug abuse and improving the quality of care. Their role in detecting simulation and inconsistencies in behavior is crucial (Jenkins, 2023). The results therefore support the need to align pharmacological and non-pharmacological approaches, introduce monitoring, and strengthen control mechanisms in prison facilities.

Limitations of the Study

The presented study has several limitations that need to be considered when interpreting the results. First and foremost, it is an observational investigation conducted in a specific prison facility, which may limit the possibilities of generalization to other prisons with a different organizational structure or a different composition of the prison population. Another limitation of the study is that, due to its non-interventional design, it did not systematically monitor whether and which psychotropic drugs were actually prescribed during individual visits. Although psychotropic drugs with a sedative effect, including chlorprothixene, did occur in the clinical context of psychiatric care, their prescription was not the subject of systematic data collection or analysis. The presented results therefore reflect exclusively the frequency and nature of observed verbal and non-verbal behavioral manifestations, and not the subsequent decisions regarding pharmacotherapy. For the future, it would be beneficial to link behavioral data with prescription data, which would allow for a more detailed assessment of the relationship between manipulative strategies, psychiatric diagnosis, and the indication for pharmacotherapy.

Conclusion

The results of the study confirm that manipulative behavior of prisoners in obtaining psychotropic drugs represents a significant risk for safe and high-quality psychiatric care in the prison environment. The observed high incidence of both verbal and non-verbal manipulative patterns emphasizes the need for active monitoring of behavior by the nursing staff. Systematic monitoring and documentation of behavioral changes, consultation of suspicious manifestations with the expert team, and strengthening of effective communication and education of prisoners about treatment and its risks are recommended. The consistent application of these measures can contribute to health protection, limit drug abuse, and increase the safety of psychiatric care in prisons.

Authors:

prof. PhDr. Mária Kilíková, PhD., MPH
St. Elizabeth University of Health and Social Work in Bratislava, n.o.,
Detached workplace of Bl. Sára Salkaházi in Rožňava
ORCID 0000 0001 5248 835X
PhDr. Katriňáková Tatiana
St. Elizabeth University of Health and Social Work in Bratislava, n.o.,
Detached workplace of Bl. Sára Salkaházi in Rožňava
MUDr. Dagmar Štefanová

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