of their actions and do not consider morals or ethics
when making decisions. Their behavior is determined
primarily by what they want, and they perceive their
needs as immediate. In addition to seeking immedi-
ate gratification, these clients also are impulsive.
Such impulsivity ranges from simple failure to use
normal caution (waiting for a green light to cross a
busy street) to extreme thrill-seeking behaviors such
as driving recklessly.
Clients lack insight and almost never see their
actions as the cause of their problems. It is always
someone else’s fault: some external source is respon-
sible for their situation or behavior.
SELF-CONCEPT
Superficially clients appear confident, self-assured,
and accomplished, perhaps even flip or arrogant.
They feel fearless, disregard their own vulnerability,
and usually believe they cannot be caught in lies, de-
ceit, or illegal actions. They may be described as ego-
centric (believing the world revolves around them);
but actually the self is quite shallow and empty; these
clients are devoid of personal emotions. They realisti-
cally appraise their own strengths and weaknesses.
ROLES AND RELATIONSHIPS
Clients manipulate and exploit those around them.
They view relationships as serving their needs and
pursue others only for personal gain. They never think
about the repercussions of their actions to others. For
example, a client is caught scamming an older person
out of her entire life savings. The client’s only com-
ment when caught is, “Can you believe that’s all the
money I got? I was cheated! There should have been
more.”
These clients often are involved in many rela-
tionships sometimes simultaneously. They may marry
and have children, but they cannot sustain long-
term commitments. They usually are unsuccessful
as spouses and parents and leave others abandoned
and disappointed. They may obtain employment read-
ily with their adept use of superficial social skills, but
over time their work history is poor. Problems may re-
sult from absenteeism, theft, or embezzlement, or they
may simply quit out of boredom.
Data Analysis
People with antisocial personality disorder generally
do not seek treatment voluntarily unless they per-
ceive some personal gain from doing so. For example,
a client may choose a treatment setting as an alter-
native to jail or to gain sympathy from an employer;
they may cite stress as a reason for absenteeism or
poor performance. Inpatient treatment settings are
not necessarily effective for these clients and may, in
fact, bring out their worst qualities.
Nursing diagnoses commonly used when work-
ing with these clients include the following:- Ineffective Coping
- Ineffective Role Performance
- Risk for Other-Directed Violence
Outcome Identification
The treatment focus often is behavioral change. Al-
though treatment is unlikely to affect the client’s in-
sight or view of the world and others, it is possible to
make changes in behavior. Treatment outcomes may
include the following:- The client will demonstrate nondestructive
ways to express feelings and frustration. - The client will identify ways to meet his or
her own needs that do not infringe on the
rights of others. - The client will achieve or maintain satisfac-
tory role performance (e.g., at work, as a
parent).
Intervention
FORMING A THERAPEUTIC RELATIONSHIP
AND PROMOTING RESPONSIBLE BEHAVIOR
The nurse must provide structure in the therapeutic
relationship, identify acceptable and expected be-
haviors, and be consistent in those expectations. The
nurse must minimize attempts by these clients to
manipulate and to control the relationship.
Limit-settingis an effective technique that in-
volves three steps:- Stating the behavioral limit (describing the
unacceptable behavior) - Identifying the consequences if the limit is
exceeded - Identifying the expected or desired behavior
Consistent limit-setting in a matter-of-fact, non-
judgmental manner is crucial to success. For exam-
ple, a client may approach the nurse flirtatiously and
attempt to gain personal information. The nurse
would use limit-setting by saying, “It is not accept-
able for you to ask personal questions. If you continue,
I will terminate our interaction. We need to use this
time to work on solving your job-related problems.”
The nurse should not become angry or respond to the
client harshly or punitively.
Confrontationis another technique designed
to manage manipulative or deceptive behavior. The
nurse points out a client’s problematic behavior while
remaining neutral and matter-of-fact; he or she avoids
accusing the client. The nurse also can use confronta-
tion to keep clients focused on the topic and in the pre-
384 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS