16 PERSONALITYDISORDERS 393
Client: “You’re better than my family and the
doctors. You understand me more than anyone else.”
Nurse: “I’m interested in helping you get better,
just as the other staff are.”(establishing boundaries)
TEACHING EFFECTIVE
COMMUNICATION SKILLS
It is important to teach basic communication skills
such as eye contact, active listening, taking turns
talking, validating the meaning of another’s commu-
nication, and using “I” statements (“I think... ,” “I
feel... ,” “I need.. .”). The nurse can model these
techniques and engage in role-playing with clients.
The nurse asks how clients feel when interacting and
gives feedback about nonverbal behavior such as “I
notice you were looking at the floor when discussing
your feelings.”
HELPING CLIENTS TO COPE AND TO
CONTROL EMOTIONS
Clients often react to situations with extreme emo-
tional responses without actually recognizing their
feelings. The nurse can help clients to identify their
feelings and learn to tolerate them without exagger-
ated responses such as destruction of property or
self-harm. Keeping a journal often helps clients gain
awareness of feelings. The nurse can review journal
entries as a basis for discussion.
Another aspect of emotional regulation is de-
creasing impulsivity and learning to delay gratifi-
cation. When clients have an immediate desire or re-
quest, they must learn that it is unreasonable to ex-
pect it to be granted without delay. Clients can use
distraction such as taking a walk or listening to music,
to deal with the delay or they can think about ways
to meet needs themselves. Clients can write in their
journals about their feelings when gratification is
delayed.RESHAPING THINKING PATTERNS
These clients view everything, people and situations,
in extremes—totally good or totally bad. Cognitive
restructuringis a technique useful in changing pat-
terns of thinking by helping clients to recognize neg-
ative thoughts and feelings and to replace them with
positive patterns of thinking. Thought-stoppingis
a technique to alter the process of negative or self-
critical thought patterns such as “I’m dumb, I’m stu-
pid, I can’t do anything right.” When the thoughts
begin, the client may actually say, “Stop!” in a loud
voice to stop the negative thoughts. Later, more sub-
tle means such as forming a visual image of a stop
sign will be a cue to interrupt the negative thoughts.
The client then learns to replace recurrent, negative
thoughts of worthlessness with more positive think-
ing. In positive self-talk,the client reframes nega-
tive thoughts into positive ones: “I made a mistake,
but it’s not the end of the world. Next time, I’ll know
what to do” (Alper & Peterson, 2001).
Decatastrophizingis a technique that involves
learning to assess situations realistically rather than
always assuming a catastrophe will happen. The
nurse asks, “So what is the worst thing that could
happen?” or “How likely do you think that is?” or
“How do you suppose other people might deal with
that?” or “Can you think of any exceptions to that?” In
this way, the client must consider other points of view
and actually think about the situation; in time, his or
her thinking may become less rigid and inflexible
(Harvard Mental Health Letter, 2002).STRUCTURING THE CLIENT’S
DAILY ACTIVITIES
Feelings of chronic boredom and emptiness, fear of
abandonment, and intolerance of being alone are com-
mon problems. Clients often are at a loss about how to
manage unstructured time, become unhappy and ru-
minative, and may engage in frantic and desperate be-
haviors (e.g., self-harm) to change the situation. Min-
imizing unstructured time by planning activities can
help clients to manage time alone. Clients can make a
written schedule that includes appointments, shop-
ping, reading the paper, or going for a walk. They are◗ CLIENT/FAMILYTEACHING FOR
BORDERLINEPERSONALITYDISORDER- Teaching social skills
Maintaining personal boundaries
Realistic expectations of relationships - Teaching time structuring
Making written schedule of activities
Making a list of solitary activities to combat
boredom - Teaching self-management through cognitive
restructuring
Decatastrophizing situation
Thought-stopping
Positive self-talk - Assertiveness techniques such as “I” statements
- Use of distraction such as walking or listening to
music