based activity at the same time, so this technique of
distracting the client is often useful.
It also may be useful to work with the client to
identify certain situations or a particular frame of
mind that may precede or trigger auditory halluci-
nations (Lakeman, 2001). Intensity of hallucinations
often is related to anxiety levels; therefore, monitoring
and intervening to lower anxiety may decrease the in-
tensity of hallucinations. Clients who recognize that
certain moods or patterns of thinking precede the onset
of voices may eventually be able to manage or control
the hallucinations by learning to manage or avoid par-
ticular states of mind. This may involve learning to
relax when voices occur, engaging in diversions, cor-
recting negative self-talk, and seeking out or avoiding
social interaction.
Teaching the client to talk back to the voices
forcefully also may help him or her manage auditory
hallucinations. The client should do this in a rela-
tively private place rather than in public. There is an
international self-help movement of “voice-hearer
groups” developed to assist people to manage audi-
tory hallucinations. One group devised the strategy
of carrying a cell phone (fake or real) to cope with
voices when in public places. With cell phones, mem-
bers can carry on conversations with their voices in
the street—and tell them to shut up—while avoiding
ridicule by looking like a normal part of the street
scene (Hagen & Mitchell, 2001). Being able to ver-
balize resistance can help the client feel empowered
and capable of dealing with the hallucinations.
COPING WITH SOCIALLY
INAPPROPRIATE BEHAVIORS
Clients with schizophrenia often experience a loss of
ego boundaries, which poses difficulties for themselves
and others in their environment and community.
Potentially bizarre or strange behaviors include touch-
ing others without warning or invitation, intruding
into others’ living space, and talking to or caressing
inanimate objects, and engaging in such socially in-
appropriate behaviors as undressing, masturbating,
or urinating in public. Clients may approach others
and make provocative, insulting, or sexual statements.
The nurse must consider the needs of others as well as
the needs of clients in these situations.
Protecting the client is a primary nursing re-
sponsibility and includes protecting the client from
retaliation by others who experience the client’s in-
trusions and socially unacceptable behavior. Re-
directing the client away from situations or others
can interrupt the undesirable behavior and keep the
client from further intrusive behaviors. The nurse
also must try to protect the client’s right to privacy
and dignity. Taking the client to his or her room or a
quiet area with less stimulation and fewer people
often helps. Engaging the client in appropriate ac-
tivities also is indicated. For example if the client is
undressing in front of others, the nurse might say,
“Let’s go to your room and you can put your clothes
back on”(encouraging collaboration/redirecting to
appropriate activity). If the client is making verbal
statements to others, the nurse might ask the client
to go for a walk or move to another area to listen to
music. The nurse should deal with socially inappro-
priate behavior nonjudgmentally and matter-of-factly.
This means making factual statements with no over-
tones of scolding or talking to the client as if he or she
were a naughty child.
Some behaviors may be so offensive or threaten-
ing that others respond by yelling at, ridiculing, or
even taking aggressive action against the client. Al-
though providing physical protection for the client is
the nurse’s first consideration, helping others affected
by the client’s behavior also is important. Usually
the nurse can offer simple and factual statements
to others that do not violate the client’s confiden-
tiality. The nurse might make statements such as
“You didn’t do anything to provoke that behavior.
Sometimes people’s illnesses cause them to act in
strange and uncomfortable ways. It is important not
to laugh at behaviors that are part of someone’s ill-
ness”(presenting reality/giving information).
The nurse reassures the client’s family that these
behaviors are part of the client’s illness and not per-
sonally directed at them. Such situations present an
opportunity to educate family members about schizo-
phrenia and to help allay their feelings of guilt, shame,
or responsibility.
Reintegrating the client into the treatment milieu
as soon as possible is essential. The client should not
feel shunned or punished for inappropriate behavior.
Health care personnel should introduce limited stim-
ulation gradually. For example, when the client is
comfortable and demonstrating appropriate behavior
with the nurse, one or two other people can be en-
gaged in a somewhat structured activity with the
client. The client’s involvement is gradually increased
to small groups and then to larger, less structured
groups as he or she can tolerate the increased level of
stimulation without decompensating (regressing to
previous, less effective coping behaviors).TEACHING CLIENT AND FAMILY
Coping with schizophrenia is a major adjustment
for both clients and their families. Understanding
the illness, the need for continuing medication and
follow-up, and the uncertainty of the prognosis or re-
covery are key issues. Clients and families need help14 SCHIZOPHRENIA 315