Psychiatric Mental Health Nursing by Videbeck

contract is not a promise to the nurse but is the

client’s promise to himself or herself to be safe. This

distinction is critical to avoid blurring the bound-

aries between nurse and client (Brown, Comtois, &

Linehan, 2002).

When clients are relatively calm and thinking

clearly, it is helpful for the nurse to explore self-harm

behavior. The nurse avoids sensational aspects of the

injury; the focus is on identifying mood and affect,

level of agitation and distress, and circumstances sur-

rounding the incident. In this way, clients can begin

to identify trigger situations, moods, or emotions that

precede self-harm and to use more effective coping

skills to deal with the trigger issues.

If clients do injure themselves, the nurse assesses

the injury and need for treatment in a calm, matter-

of-fact manner. Lecturing or chastising clients is puni-

tive and has no positive effect on self-harm behaviors.

Deflecting attention from the actual physical act is

usually desirable (Tredget, 2001).

PROMOTING THE THERAPEUTIC

RELATIONSHIP

Regardless of the clinical setting, the nurse must pro-

vide structure and limit-setting in the therapeutic re-

lationship. In a clinic setting, this may mean seeing

the client for scheduled appointments of a predeter-

mined length rather than whenever the client appears

and demands the nurse’s immediate attention. In the

hospital setting, the nurse would plan to spend a spe-

cific amount of time with the client working on issues

or coping strategies rather than giving the client ex-

clusive access when he or she has had an outburst.

Limit-setting and confrontation techniques, which are

described earlier, are also helpful.

ESTABLISHING BOUNDARIES IN

RELATIONSHIPS

Clients have difficulty maintaining satisfying inter-

personal relationships. Personal boundaries are un-

clear, and clients often have unrealistic expectations.

Erratic patterns of thinking and behaving often alien-

ate them from others. This may be true for both pro-

fessional and personal relationships. Clients easily

can misinterpret the nurse’s genuine interest and

caring as a personal friendship, and the nurse may

feel flattered by a client’s compliments. The nurse

must be quite clear about establishing the boundaries

of the therapeutic relationship to ensure that neither

the client’s nor the nurse’s boundaries are violated.

For example:

392 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS

tions often are used to manage these difficulties and

to stabilize the client’s condition.

PROMOTING THE CLIENT’S SAFETY

The client’s physical safety is always a priority. The
nurse must always seriously consider suicidal ideation
with the presence of a plan, access to means for en-
acting the plan, and self-harm behaviors and institute
appropriate interventions (see Chap. 15). Clients often
experience chronic suicidality or ongoing, intermittent
ideas of suicide over months or years. The challenge
for the nurse, in concert with the client, is to deter-
mine when suicidal ideas are likely to be translated
into action.
Clients may enact self-harm urges by cutting,
burning, or punching themselves, which sometimes
causes permanent physical damage. Self-injury can
occur when a client is enraged or experiencing dis-
sociative episodes or psychotic symptoms. They may
occur for no readily apparent reason. Helping clients
to avoid self-injury can be difficult when antecedent
conditions vary greatly. Sometimes clients may dis-
cuss self-harm urges with the nurse if they feel com-
fortable doing so. The nurse must remain nonjudg-
mental when discussing this topic. The nurse can
encourage clients to enter a no self-harm contract,
in which a client promises to not engage in self-harm
and to report to the nurse when he or she is losing
control. The nurse emphasizes that the no self-harm

◗ NURSINGINTERVENTIONS FOR THECLIENT

WITHBORDERLINEPERSONALITYDISORDER

• Promoting client’s safety
  No self-harm contract
  Safe expression of feelings and emotions


• Helping client to cope and control emotions
  Identifying feelings
  Journal entries
  Moderating emotional responses
  Decreasing impulsivity
  Delaying gratification


• Cognitive restructuring techniques
  Thought-stopping
  Decatastrophizing


• Structuring time


• Teaching social skills


• Teaching effective communication skills


• Therapeutic relationship
  Limit-setting
  Confrontation