that “no one can figure out what’s wrong with me. I
just have to suffer. It’s my bad luck!”
Nursing Interventions
The nurse may encounter much resistance from the
client in identifying feelings and expressing them di-
rectly. Often clients do not recognize that they feel
angry and may express it indirectly. The nurse can
help them examine the relationship between feelings
and subsequent actions. For example, a client may
intend to complete a project at work but then pro-
crastinates, forgets, or becomes “ill” and misses the
deadline. Or the client may intend to participate in a
family outing but becomes ill, forgets, or has “an
emergency” when it is time. By focusing on the be-
havior, the nurse can help the client to see what is so
annoying or troubling to others. The nurse also can
help the client to learn appropriate ways to express
feelings directly especially negative feelings such as
anger. Methods such as having the client write about
the feelings or role-play are effective. If the client is
unwilling to engage in this process, however, the
nurse cannot force him or her to do so.
COMMUNITY-BASED CARE
Caring for clients with personality disorders occurs
primarily in community-based settings. Acute psychi-
atric settings such as the hospital are useful for safety
concerns for short periods. The nurse will use skills to
deal with clients who have personality disorders in
clinics, outpatient settings, doctors’ offices, and many
medical settings. Often the personality disorder is not
the focus of attention; rather, the client may be seek-
ing treatment for a physical condition.
Most people with personality disorders are
treated in group or individual therapy settings, com-
munity support programs, or self-help groups. Others
will not seek treatment for their personality disorder
but may be treated for a major mental illness. Wher-
ever the nurse encounters clients with personality
disorders including in his or her own life, the inter-
ventions discussed in this chapter can prove useful.
MENTAL HEALTH PROMOTION
Recent research has focused on identifying behav-
iors in children and adolescents that correlate with
the development of personality disorders as adults
(Bleiberg, 2002; Johnson et al., 2000). These efforts
are designed to identify those at high risk for adult
personality disorders early enough to provide effec-
tive treatment and prevention strategies. Johnson
et al. (2000) found that adolescents exhibiting Clus-
ter A and Cluster B traits were more likely to com-
mit violent acts in adulthood. Bleiberg (2002) found
that children at risk for Cluster B personality dis-
orders demonstrate dramatic emotional responses
to other people, while paradoxically showing self-
centeredness and utter disregard for the feelings of
others. Bleiberg describes treatment for these chil-
dren as a collaborative effort with parents that pro-
motes the child’s ability to “mentalize,” which is the
capacity to interpret and to respond to human be-
havior and emotions (of self and others) in a human,
meaningful way.
Mahoney (2000) studied involvement in activities
rather than problem behaviors. The Carolina Longi-
tudinal Study, which followed 695 children from early
childhood to 24 years of age, provided the data. Chil-
dren who were involved in activities that were highly
structured, met regularly, involved skill mastery, and
were led by one or more adults were less likely to drop
out of school or participate in criminal activity. Higher
dropout rates and criminal activity in children and
adolescents are associated with the development of
adult personality disorders.SELF-AWARENESS ISSUES
Because clients with personality dis-
orders take a long time to change their behaviors, at-
titudes, or coping skills, nurses working with them
easily can become frustrated or angry. These clients
continually test the limits or boundaries of the nurse–
client relationship with attempts at manipulation.
Nurses must discuss feelings of anger or frustration
with colleagues to help them recognize and cope with
their own feelings.
The overall appearance of clients with personal-
ity disorders can be misleading. Unlike clients who
are psychotic or severely depressed, clients with per-
sonality disorders look as though they are capable of
functioning more effectively. The nurse can easily but
mistakenly believe the client simply lacks motivation
or the willingness to make changes and may feel frus-
trated or angry. It is easy for the nurse to think, “Why
does the client continue to do that? Can’t he see it only
gets him into difficulties?” This reaction is similar to
reactions the client has probably received from others.
Clients with personality disorders also challenge
the ability of therapeutic staff to work as a team. For
example, clients with antisocial or borderline person-
alities often manipulate staff members by splitting
them—that is, causing staff to disagree or to contra-
dict one another in terms of the limits of the treat-
ment plan. This can be quite disruptive. In addition,
team members may have differing opinions about in-
dividual clients. One staff member may believe that a
client needs assistance, while another may believe400 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS