for special favors or attempts to alter treatment goals
or behavioral expectations.
Whether there is a written contract or treatment
plan, staff must be consistent with these clients. They
will attempt to bend or break rules, blame others for
noncompliance, or make excuses for behavior. Con-
sistency in following the treatment plan is essential
to decrease manipulation.
Time-outis retreat to a neutral place so clients
can regain self-control. It is not a punishment. When a
client’s behavior begins to escalate, such as yelling
at or threatening someone, a time-out may prevent
aggression or acting out. Staff may need to institute
a time-out for clients if they are unwilling or unable to
do so. Eventually the goal is for clients to recognize
signs of increasing agitation and take a self-instituted
time-out to control emotions and outbursts. After the
time-out the nurse should discuss the events with the
client. Doing so can help clients to recognize situa-
tions that trigger emotional responses and to learn
more effective ways of dealing with similar situations
in the future. Providing positive feedback for success-
ful efforts at avoiding aggression helps to reinforce
new behaviors for clients.
It helps for clients to have a schedule of daily
activities including hygiene, school, homework, and
leisure time. Clients are more likely to establish pos-
itive habits if they have routine expectations about
tasks and responsibilities. They are more likely to fol-
low a daily routine if they have input concerning the
schedule.IMPROVING COPING SKILLS
AND SELF-ESTEEM
The nurse must show acceptance of clients as worth-
while persons even if their behavior is unacceptable.
This means that the nurse must be matter-of-fact
about setting limits and must not make judgmental
statements about clients. He or she must focus only
on the behavior. For example, if a client broke a chair
during an angry outburst, the nurse would say,
“John, breaking chairs is unacceptable behavior. You
need to let staff know you’re upset so you can talk about
it instead of acting out.”The nurse must avoid saying
things like, “What’s the matter with you? Don’t you
know any better?”Comments such as these are per-
sonal and do not focus on the specific behavior; they
reinforce the client’s self-image as a “bad person.”
Clients with a conduct disorder often have a tough
exterior and are unable or reluctant to discuss feel-
ings and emotions. Keeping a diary may help them
to identify and express their feelings. The nurse can
discuss these feelings with clients and explore bet-
ter, safer expressions than through aggression or
acting out.498 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS
Intervention
DECREASING VIOLENCE AND INCREASING
COMPLIANCE WITH TREATMENT
The nurse must protect others from the manipulation
or aggressive behaviors common with these clients.
He or she must set limits on unacceptable behavior
at the beginning of treatment. Limit settinginvolves
three steps:
- Inform clients of the rule or limit.
- Explain the consequences if clients exceed
the limit. - State expected behavior.
Providing consistent limit enforcement with no ex-
ceptions by all members of the health team including
parents is essential. For example, the nurse might
say, “It is unacceptable to hit another person. If you
are angry, tell a staff person about your anger. If you
hit someone, you will be restricted from recreation
time for 24 hours.”
For limit setting to be effective, the consequences
must have meaning for clients—that is, they must
value or desire recreation time (in this example). If a
client wanted to be alone in his or her room, then this
consequence would not be effective.
The nurse can negotiate with a client a behav-
ioral contract outlining expected behaviors, limits,
and rewards to increase treatment compliance. The
client can refer to the written agreement to remem-
ber expectations, and staff can refer to the agreement
should the client try to change any terms. A contract
can help staff to avoid power struggles over requests
◗ INTERVENTIONS FORCONDUCTDISORDER
- Decreasing violence and increasing compliance
with treatment
Protect others from client’s aggression and
manipulation.
Set limits for unacceptable behavior.
Provide consistency with client’s treatment plan.
Use behavioral contracts.
Institute time-out.
Provide a routine schedule of daily activities. - Improving coping skills and self-esteem
Show acceptance of the person, not necessarily
the behavior.
Encourage the client to keep a diary.
Teach and practice problem-solving skills. - Promoting social interaction
Teach age-appropriate social skills.
Role-model and practice social skills.
Provide positive feedback for acceptable
behavior. - Providing client and family education