Nursing Interventions ^*denotes collaborative interventions

Rationale

Assess the client’s current level of functioning and communication, and begin to work with the client at that level.

To make contact with the client, you must begin where he or she is now.

Sit with the client for regularly scheduled periods.

Your physical presence conveys caring and acceptance.

Tell the client your name and that you are there to be with him or her.

By telling the client you are there to be with him or her, you convey interest without making demands on the client.

Remain comfortable with periods of silence; do not overload the client with verbalization.

The client’s ability to deal with verbal stimulation is impaired.

Use physical touch with the client (e.g., holding the client’s hand) as tolerated. If the client responds to touch negatively, remove your hand at that time, but continue attempts to establish physical touch.

Your physical touch presents reality and conveys acceptance.

Talk with the client in a soft voice. If the client remains unresponsive, continue to do this with the positive expectation of a response from the client.

A soft voice can be comforting and nonthreatening, and expresses your caring and interest in the client. Expecting the client to respond increases the likelihood that he or she will do so.

Ask the client to open his or her eyes and look at you when you are speaking to him or her.

You will facilitate reality contact and the client’s ability to attend by encouraging eye contact.

Be alert for subtle, nonverbal responses from the client.

The client’s initial responses usually will not be verbal or dramatic but rather very gradual and subtle (hand movement, eyes opening).

Give the client positive feedback for any response to you or to the external environment. Encourage him or her to continue to respond and reach out to others.

Your encouragement can foster the client’s attempts to re-establish contact with reality.

Use a radio, tape player, or television in the client’s room to provide stimulation as tolerated.

Media can provide stimulation during times that staff are not available to be with the client.

Assess the client’s tolerance of stimuli; do not force too much stimulation too fast.

Increasing stimuli too rapidly could result in the client’s further withdrawal.

Avoid allowing the client to isolate himself or herself in a room alone for long periods.

Isolation will foster continued withdrawal.

Initially encourage the client to spend short periods with one other person, e.g., have the client sit with one person for 15 minutes of each hour during the day.

At first, the client will be more successful with minimal stimulation (e.g., interactions for short time periods) and minimal changes (e.g., interacting with the same staff member).

Interact with the client briefly on a one-to-one basis initially; gradually increase the amount of time and the number of people with whom the client interacts.

A gradual increase in the amount and variety of stimulation can foster the client’s tolerance in a nonthreatening manner.

Talk with the client as though he or she will respond and avoid rapidly chattering at the client. Allow adequate time for the client to respond to you, either verbally or physically.

A positive expectation on your part increases the likelihood of the client’s response. A client who is withdrawn may need more time to respond due to slowed thought processes.

Refer to other people and objects in the immediate environment as you interact with the client.

You will promote the client’s contact with current reality by calling the client’s attention to his or her environment.

Initially, encourage the client to express himself or herself nonverbally (e.g., by writing or drawing).

Nonverbal communication usually is less threatening to the client than verbalization.

Encourage the client to talk about these nonverbal communications and progress to more direct verbal communication as tolerated. Encourage the client to express feelings as much as possible.

By asking the client about writings or drawings rather than directly about himself or herself or emotional issues, you minimize the perception of threat by the client. Gradually, direct verbal communication becomes tolerable to the client.

At first, walk slowly with the client. Progress gradually from gross motor activity (walking, gestures with hands) to activities requiring fine motor skills (jigsaw puzzles, writing).

The client will be able to use gross motor skills first. Fine motor skills require more of the client’s skill and attention.

See “Key Considerations in Mental Health Nursing: Nurse-Client Interactions” and other care plans as indicated.

Withdrawn behavior frequently is encountered with psychotic symptoms, depression, organic pathology, abuse, and post-traumatic stress disorder.

^*Teach the client and family and significant others about withdrawn behavior, safe use of medications, and other disease process(es) if indicated.

The client and family and significant others may have little or no knowledge of the client’s illness, care-giving responsibilities, or safe use of medications.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Initially encourage the client to spend short periods with one other person, e.g., have the client sit with one person for 15 minutes of each hour during the day.

At first the client will deal more readily with minimal stimulation (e.g., interactions for short time periods) and minimal changes (e.g., interacting with the same staff member).

Initially encourage the client to express himself or herself nonverbally (e.g., by writing or drawing).

Nonverbal communication usually is less threatening than verbalization.

Encourage the client to talk about these nonverbal communications and progress to more direct verbal communication as tolerated. Encourage the client to express feelings as much as possible.

By asking the client about writings or drawings rather than directly about himself or herself or emotional issues, you minimize the client’s perception of threat. Gradually, direct verbal communication becomes tolerable to the client.

Interact on a one-to-one basis initially, and then help the client progress to small groups, then larger groups as tolerated.

Gradual introduction of other people minimizes the threat perceived by the client.

Manage nursing assignments so that the client interacts with a variety of staff members, as the client tolerates.

Your social behavior provides a role model for the client. Interacting with different staff members allows the client to experience success in interactions within the safety of the staff-client relationship.

Teach the client social skills, such as approaching another person for an interaction, appropriate conversation topics, and active listening. Encourage him or her to practice these skills with staff members and other clients, and give the client feedback regarding interactions.

The client may lack social skills and confidence in social interactions; this may contribute to the client’s depression and social isolation.

Encourage the client to identify relationships, social, or recreational situations that have been positive in the past.

The client may have been depressed and withdrawn for some time and have lost interest in people or activities that provided pleasure in the past.

^*Encourage the client to pursue past relationships, personal interests, hobbies, or recreational activities that were positive in the past or that may appeal to the client. Consultation with a recreational therapist may be indicated.

The client may be reluctant to reach out to someone with whom he or she has had limited contact recently and may benefit from encouragement or facilitation. Recreational activities can serve as a structure for the client to build social interactions as well as provide enjoyment.

^*Encourage the client to identify supportive people outside the hospital and to develop these relationships (see Care Plan 2: Discharge Planning and Section 2: Community-Based Care).

In addition to reestablishing past relationships or in their absence, increasing the client’s support system by establishing new relationships may help decrease future withdrawn behavior and social isolation.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Withdraw your attention (ignore the client) when the client is verbally abusive. Tell the client that you are doing this and why (e.g., “I will not talk with you when you are being verbally abusive”), but you will give attention for appropriate behavior. If the client is physically abusive, provide for the safety of the client and others, and then withdraw your attention from the client.

Withdrawing attention can be more effective than negative reinforcement in decreasing unacceptable behaviors. The client may be seeking attention with this behavior. It is important to reinforce positive behaviors rather than unacceptable ones.

Be consistent and firm yet gentle and calm in your approach to the client.

As you provide limits, your behavior is a role model for the client.

Set and maintain firm limits.

Limits must be established by others when the client is unable to use internal controls effectively.

Remain calm. Control your own behavior, and communicate that control. If you are becoming upset, leave the situation in the hands of other staff members if possible.

Your behavior provides a role model for the client. If you behave in a hostile manner, it undermines limits and may exacerbate the client’s hostile behavior.

Make it clear that you accept the client as a person, but that certain specified behaviors are unacceptable.

The client is acceptable as a person regardless of his or her behaviors, which may or may not be acceptable.

Do not become insulted or defensive in response to the client’s behavior.

Remember that your relationship with the client is professional. It is not a personal relationship, and it is not necessarily desirable for the client to like you. It may help to view verbal abuse as a loss of control or as projection on the client’s part.

Do not argue with the client.

Arguing with the client can reinforce adversarial attitudes and undermine limits.

Be alert for a build-up of hostility in the client, such as increased verbal abuse or restless behavior.

Outbursts of hostility or aggression often are preceded by a period of increasing tension.

Be aware of and note situations and progression of events carefully, including precipitating factors, tension, level of stimuli, degree of structure, time, and staff members and others (clients, visitors) present.

Identifying patterns of behavior can be helpful in the anticipation of and early intervention in destructive behaviors.

Give support to those who are targets of the client’s abuse (other clients, visitors, staff members) rather than giving the client attention for abusive behavior.

Others may not understand the client’s behavior and may need support. If the client is seeking attention with hostile behavior, giving your attention to others may be effective in decreasing hostile behavior.

Do not attempt to discuss feelings when the client is agitated (see Care Plan 47: Aggressive Behavior).

Talking about feelings, especially anger, when the client is agitated may increase the agitation.

^*Remain aware of your own feelings. It may be helpful if staff members express their feelings in a client care conference or informally to each other in private (away from the client and other clients).

A client who is hostile may be difficult to work with and engender feelings of anger, frustration, and resentment in staff members. These feelings need to be expressed so that they are not denied and subsequently acted out with the client. They should be discussed with other staff members; it is not therapeutic for the client to deal with the staff’s feelings.

Encourage the client to seek a staff member when he or she is becoming upset or having strong feelings.

Seeking staff assistance allows intervention before the client can no longer control his or her behavior and encourages the client to recognize feelings and seek help.

Discuss with the client alternative ways of expressing emotions and releasing physical energy or tension.

The client needs to learn nondestructive ways to express feelings and release tension.

Encourage the client to increase his or her physical activity to release tension and plan to continue a regular exercise regimen after hospitalization. Encourage solitary or noncompetitive activities to avoid placing the client in competitive sports situations.

Physical activity provides many health benefits, including decreasing physical tension. Competitive situations may trigger or exacerbate hostile behavior.

As early as possible, give the client the responsibility for recognizing and appropriately dealing with his or her feelings. Expect the client to take responsibility for his or her actions; make this clear to the client.

Assuming responsibility for his or her feelings and actions may help the client to develop or increase insight and internal controls. It may diminish the client’s blaming others or feeling victimized.

Give the client positive feedback for controlling aggression, fulfilling responsibilities, and expressing feelings appropriately, especially angry feelings.

Positive feedback provides reinforcement for desired behaviors and can enhance self-esteem. It is essential that the client receive attention for positive behaviors, not only for unacceptable behaviors.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Involve the client in treatment planning and in decision making regarding his or her treatment as much as possible.

Participation in planning treatment can help reinforce the client’s participation and help prevent the client from assuming a victim role or feeling that he or she has no choice (and no responsibility) in his or her treatment.

One staff member may verbally review limits, rationale, and other aspects of the treatment program with the client, but this should be done only once and should not be negotiated after limits have been set. You may provide a written plan to the client.

The client is entitled to an explanation of the treatment program, but justification, negotiation, or repeated discussions can undermine the program and reinforce the client’s noncompliance.

Set and maintain firm limits. Do not argue with the client. Be specific and consistent regarding expectations; do not make exceptions.

Setting clear, specific limits lets the client know what is expected of him or her. Arguing with the client and making exceptions interject doubt and undermine limits.

It may be necessary to pay close attention to ensure the client ingests medication as ordered. Liquid medications, sprinkles, or dissolving tablets may be prescribed until the client accepts the need for medications.

The client may try to avoid taking prescribed medication. Using alternate forms of medications (when available) can prevent the client’s hiding oral medications in his or her mouth and discarding them unobserved.

Withdraw your attention if possible (and safe) when the client refuses to participate or exceeds limits. Give positive support for the client’s efforts to participate in treatment planning and treatment.

Withdrawing attention from unacceptable behavior can help diminish that behavior, but the client needs to receive attention for desired behaviors, not only for unacceptable behavior.

It may be helpful to have one staff person per shift designated for decision making regarding the client and special circumstances (see “Key Considerations in Mental Health Nursing: Therapeutic Milieu”).

Having one person designated as responsible for decisions minimizes the chance the client manipulating other staff members.

As the client’s hostile behavior diminishes, talk with the client about underlying problems and feelings; continue to include the client in treatment planning.

When the client is less agitated, he or she will be better able to focus on feelings and other problems and more receptive to participation in treatment.

Help the client to identify factors involved in his or her noncompliance and other behaviors. Provide or encourage continued treatment for these underlying factors.

The client may have underlying personal, social, or psychiatric conditions that contribute to his or her behaviors. Developing insight into and addressing these issues will help prevent reoccurrence.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Encourage the client to seek help from a staff member when he or she is becoming upset or having strong feelings.

Seeking staff assistance allows intervention before the client can no longer control his or her behavior and encourages the client to recognize feelings and seek help.

When the client is not agitated, discuss the client’s feelings and ways to express them.

The client may need to learn how to identify feelings and ways to express them.

^*Use role-playing and groups (formal and informal) to facilitate the client’s expression of feelings.

The client can practice new behaviors in a nonthreatening, supportive environment.

Discuss the client’s feelings about his or her hostile behavior, including past behaviors, their consequences, and so forth, in a nonjudgmental manner.

The client may be ashamed of his or her behavior, feel guilty, or lack insight into his or her behavior.

Discuss with the client alternative ways of expressing angry feelings and releasing physical energy or tension.

The client may need to learn other ways to express feelings and release tension.

Try to make physical activities available on a regular basis and when the client is becoming upset (e.g., running laps in a gymnasium). Encourage the client to use a regular exercise program to release tension.

Physical activity provides the client with a way to relieve tension in a healthy, nondestructive manner.

Provide opportunities for the client to succeed at activities, tasks, and interactions. Give positive feedback, and point out the client’s demonstrated abilities and strengths.

Activities within the client’s abilities will provide opportunities for success. Positive feedback provides reinforcement for the client’s growth and can enhance self-esteem.

Help the client set goals for his or her behavior; give positive feedback when the client achieves these goals.

Setting goals promotes the client’s sense of control and teaches goal-setting skills; achieving goals can foster self-confidence and self-esteem.

Be realistic in your feedback to the client; do not flatter the client or be otherwise dishonest.

Honesty promotes trust. Clients with low self-esteem do not benefit from flattery or undue praise.

^*Teach the client and his or her family or significant others about hostile behavior, other psychiatric problems, and medication use if any.

Information about psychiatric problems and medications can promote understanding, compliance with treatment regimen, and safe use of medications.

^*Encourage the client to follow through with continuing treatment for substance dependence or other psychiatric problems if appropriate.

Problems associated with hostile behavior may require long-term treatment.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Build a trust relationship with this client as soon as possible, ideally well in advance of aggressive episodes.

Familiarity with and trust in the staff members can decrease the client’s fears and facilitate communication.

Be aware of factors that increase the likelihood of violent behavior or agitation. Use verbal communication or PRN medication to intervene before the client’s behavior reaches a destructive point and physical restraint becomes necessary.

A period of building tension often precedes acting out; however, a client who is intoxicated or psychotic may become violent without warning. Signs of increasing agitation include increased restlessness, motor activity (e.g., pacing), voice volume, verbal cues (“I’m afraid of losing control.”), threats, decreased frustration tolerance, and frowning or clenching fists.

If the client tells you (verbally or nonverbally) that he or she feels hostile or destructive, try to help the client express these feelings in nondestructive ways (e.g., use communication techniques or take the client to the gym for physical exercise).

The client can try out new behaviors with you in a nonthreatening environment and learn nondestructive ways to express feelings rather than acting out.

Anticipate the possible need for PRN medication and seclusion or restraint orders.

In an aggressive situation, you will need to make decisions and act quickly. If the client is severely agitated, medication may be necessary to decrease the agitation.

^*Develop and practice consistent techniques of safe restraint as part of nursing orientation and continuing education.

Consistent techniques let each staff person know what is expected and will increase safety and effectiveness.

^*Develop instructions in safe techniques for carrying clients.

Consistent techniques increase safety and effectiveness.

Be familiar with restraint, seclusion, and staff assistance procedures and legal requirements.

You must be prepared to act and direct other staff in the safe management of the client. You are legally accountable for your decisions and actions.

Always maintain control of yourself and the situation; remain calm. If you do not feel competent in dealing with a situation, obtain assistance as soon as possible.

Your behavior provides a role model for the client and communicates that you can and will provide control. Not all situations are within nursing’s expertise or control; recognizing the need for outside assistance in a timely manner is essential.

Calmly and respectfully assure the client that you (the staff) will provide control if he or she cannot control himself or herself, but do not threaten the client.

The client may fear loss of control and may be afraid of what he or she may do if he or she begins to express anger or other feelings. Showing that you are in control without competing with the client can reassure the client without lowering his or her self-esteem.

^*Notify the charge nurse and supervisor as soon as possible in a (potentially) aggressive situation; tell them your assessment of the situation and the need for help, the client’s name, care plan, and orders for medication, seclusion, or restraint.

You may need assistance from staff members who are unfamiliar with this client. They will be able to help more effectively and safely if they are aware of this information.

^*Follow the hospital staff assistance plan (e.g., use paging system to call for assistance to your location); then, if possible, have one staff member familiar with the situation meet the additional staff at the unit door to give them the client’s name, situation, goal, plan, and so forth.

The need for help may be immediate in an emergency situation. Any information that can be given to arriving staff will be helpful in ensuring safety and effectiveness in dealing with this client.

If the client has a weapon:

If you are not properly trained or skilled in dealing safely with a client who has a weapon, do not attempt to remove the weapon. Keep something (like a pillow, mattress, or a blanket wrapped around your arm) between you and the weapon.

Avoiding personal injury, summoning help, leaving the area, or protecting other clients may be the only things you can realistically do. You may risk further danger by attempting to remove a weapon or subdue an armed client.

If it is necessary to remove the weapon, try to kick it out of the client’s hand. (Never reach for a knife or other weapon with your hand.)

Reaching for a weapon increases your physical vulnerability.

Distract the client momentarily to remove the weapon (e.g., throw water in the client’s face, or yell suddenly).

Distracting the client’s attention may give you an opportunity to remove the weapon or subdue the client.

^*You may need to summon outside assistance (especially if the client has a gun). When this is done, total responsibility is delegated to the outside authorities.

Exceeding your abilities may place you in grave danger. It is not necessary to try to deal with a situation beyond your control or to assume personal risk.

Remain aware of the client’s body space or territory; do not trap the client.

Potentially violent people have a body space zone up to four times larger than that of other people. That is, you need to stay farther away from them for them to not feel trapped or threatened.

Allow the client freedom to move around (within safe limits) unless you are trying to restrain him or her.

Interfering with the client’s mobility without the intent of restraint may increase the client’s frustration, fears, or perception of threat.

Decrease stimulation by turning television off or lowering the volume, lowering the lights, asking others to leave the area (or you can go with the client to another room).

If the client is feeling threatened, he or she can perceive any stimulus as a threat. The client is unable to deal with excess stimuli when agitated.

Talk with the client in a low, calm voice. Call the client by name, tell the client your name, where you are, and so forth.

Using a low voice may help prevent increasing agitation. The client may be disoriented or unaware of what is happening.

Tell the client what you are going to do and what you are doing as you actually do it. For example, “I will walk with you to another room to keep you safe” or “we are taking you to another room where you will be safe.” Use simple, clear, direct speech; repeat if necessary. Do not threaten the client, but state limits and expectations.

The client’s ability to understand the situation and to process information is impaired. Clear limits let the client know what is expected of him or her. Reassuring the client of his or her safety can lessen the client’s perception of threat or harm, especially if he or she is experiencing psychotic symptoms.

Do not use physical restraints or techniques without sufficient reason.

The client has a right to the fewest restrictions possible within the limits of safety and prevention of destructive behavior.

^*When a decision has been made to subdue or restrain the client, act quickly and cooperatively with other staff members. Tell the client in a matter-of-fact manner that he or she will be restrained, subdued, or secluded; allow no bargaining after the decision has been made. Reassure the client that he or she will not be hurt and that restraint or seclusion is to ensure safety.

Firm limits must be set and maintained. Bargaining interjects doubt and will undermine the limit. Reassuring the client of his or her safety can lessen the client’s perception of threat or harm, especially if he or she is experiencing psychotic symptoms.

^*While subduing or restraining the client, talk with other staff members to ensure coordination of effort (e.g., do not attempt to carry the client until everyone has verbally indicated they are ready).

Direct verbal communication will promote cooperation and safety.

Do not strike the client.

Physical safety of the client is a priority. The staff may subdue the client to prevent injury to the client or others but striking the client is not acceptable.

Do not help to restrain or subdue the client if you are angry (if enough other staff members are present). Do not restrain or subdue the client as a punishment.

Staff members must maintain self-control at all times and act in the client’s best interest. There is no justification for being punitive to a client.

Do not recruit or allow other clients to help in restraining or subduing a client.

Physical safety of all clients is a priority. Other clients are not responsible for controlling the behavior of a client and should not assume a staff role.

If possible, do not allow other clients to watch staff subduing the client. Take them to a different area, and involve them in activities or discussion.

Other clients may be frightened, agitated, or endangered by a client with aggressive behavior. They need safety and reassurance at this time.

Obtain additional staff assistance when needed. Have someone clear furniture and so forth from the area through which you will be carrying the client.

Transporting a client who is agitated can be dangerous if attempted without sufficient help and sufficient space.

When placing the client in restraints or seclusion, tell the client what you are doing and the reason (e.g., to regain control or protect the client from injuring himself, herself, or others). Use simple, concise language in a calm, nonjudgmental, matter-of-fact manner (see Nursing Diagnosis: Risk for Injury).

The client’s ability to understand what is happening to him or her may be impaired.

When the client is in restraints or seclusion, tell the client where he or she is, that he or she will be safe, and that staff members will continue to check on him or her. Tell the client how to summon the staff. Reorient the client or remind him or her of the reason for restraint as necessary.

Being placed in seclusion or restraints can be terrifying to a client. Your assurances may help alleviate the client’s fears.

Reassess the client’s need for continued seclusion or restraint according to the client’s condition and facility policies. Release the client or decrease restraint as soon as it is safe and therapeutic. Base your decisions on the client’s, not the staff’s, needs.

The client has a right to the least restrictions possible within the limits of safety and prevention of destructive behavior. The client’s safety and rights are priorities over staffing challenges or convenience.

Remain aware of the client’s feelings (including fear), dignity, and rights.

The client is a worthwhile person regardless of his or her unacceptable behavior.

Carefully observe the client and promptly complete documentation in keeping with hospital policy. Bear in mind possible legal implications.

Accurate, complete documentation is essential, as restraint, seclusion, assault, and so forth are situations that may result in legal action.

Administer medications safely; take care to prepare correct dosage, identify correct sites for administration, withdraw plunger to aspirate for blood, and so forth.

When you are in a stressful situation and under pressure to move quickly, the possibility of errors in dosage or administration of medication is increased.

Take care to avoid needlestick injury and other injuries that may involve exposure to the client’s blood or body fluids.

Hepatitis, HIV, and other diseases are transmitted by exposure to blood or body fluids.

Monitor the client for effects of medications, and intervene as appropriate.

Psychoactive drugs can have adverse effects, such as allergic reactions, hypotension, and pseudoparkinsonian symptoms.

Talk with other clients after the situation is resolved; allow them to express feelings about the situation.

Other clients have continued needs for therapeutic intervention in addition to their reactions to the acute situation. Be careful not to give attention only to the client who acts out or to withdraw to staff areas to discuss staff reactions and feelings.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Approach the client in a calm, matter-of-fact manner. Speak in a quiet, steady voice.

Your calm demeanor will communicate your confidence and sense of control to the client.

When the client is not agitated, encourage him or her to express feelings verbally, in writing, or in other nonaggressive ways.

The client will be most able to discuss emotional issues when he or she is not agitated. If the client is agitated, discussing emotional problems may increase agitation.

Teach the client about aggressive behavior, including how to identify feelings that may precede this behavior, such as increasing tension or restlessness. Help the client identify strategies that may help him or her avoid aggressive behavior.

The client may be unaware of the dynamics of aggressive behavior and feelings associated with it. Gaining this knowledge may help prevent aggressive behavior in the future.

Teach the client to use a problem-solving process: identifying the problem, evaluating possible solutions, implementing a solution, and evaluating the process.

The client may never have learned a systematic, effective approach to solving problems. Implementing a problemsolving process may help the client avoid frustration.

Encourage the client to identify and use nondestructive ways to express feelings or deal with physical tension.

The client may be able to avoid aggressive behavior using these techniques.

Talk with the client about coping strategies he or she has used in the past. Explore which strategies have been successful and which may have led to negative consequences.

The client may have had success using coping strategies in the past but may have lost confidence in himself or herself or in his or her ability to cope with stressors and feelings. Some coping strategies can be self-destructive (e.g., self-medication with drugs or alcohol).

Teach the client about positive coping strategies and stress management skills, such as increasing physical exercise, expressing feelings verbally or in a journal, or meditation techniques. Encourage the client to practice this type of technique while in the hospital.

The client may have limited or no knowledge of stress management techniques or may not have used positive techniques in the past. If the client tries to build skills in the treatment setting, he or she can experience success and receive positive feedback for his or her efforts.

^*Teach the client and family or significant others about other disease process(es) and medication use if any.

The client’s significant others may lack understanding of the client’s behavior; they also can be supportive as the client attempts to change behavior.

Help the client set goals for his or her behavior; give positive feedback when the client achieves these goals.

Achieving goals can foster self-confidence and self-esteem. Allowing the client to set goals promotes the client’s sense of control and teaches goal-setting skills.

^*Include the client’s significant others in setting goals and planning strategies for change, as appropriate.

Including significant others can promote compliance with treatment and support for the client.

Provide opportunities for the client to succeed at activities, tasks, and interactions. Give positive feedback, and point out the client’s demonstrated abilities and strengths.

Activities within the client’s abilities will provide opportunities for success. Positive feedback provides reinforcement for the client’s growth and can enhance self-esteem.

Be realistic in your feedback to the client; do not flatter the client or be otherwise dishonest.

Honesty promotes trust. Clients with low self-esteem do not benefit from flattery or undue praise.