Therapeutic relationship and the orientation phase
The nurse is in the
orientation phase of the nurse–client relationship with a client who has
borderline personality disorder. This phase is not only about building rapport; it is the time to establish the
contract, which includes the purpose of the sessions, the number of meetings, and the
limits of confidentiality. The client explicitly asks the nurse to promise not to tell anyone on the team.
The nurse cannot make that promise because information indicating danger to self or others must be shared with the treatment team. The correct response is to explain the boundaries of confidentiality before the client decides what to disclose.
Key point! A promise of absolute secrecy would be unsafe and unethical. The nurse must clarify the limits of confidentiality before the client shares sensitive material, not after.
Why the other options are incorrect
| Option | Why it is not the best response |
|---|
| 1. Promise to keep it private | This creates a boundary violation and a false contract. If the client later reveals self-harm or harm to others, the nurse would be forced to break the promise, damaging trust and potentially endangering the client. |
| 2. Tell her secrets are not allowed | This is overly restrictive and shuts down communication. Confidentiality is part of the therapeutic relationship, but it has defined exceptions. The nurse should not imply that no private information can be shared. |
| 3. Ask her to share it with the psychiatrist | This deflects the nurse’s responsibility and does not address the client’s request. The nurse is the appropriate person to clarify the limits of confidentiality within the nurse–client relationship. |
Applying the evidence to borderline personality disorder
Clients with borderline personality disorder often test boundaries and may experience intense fears of abandonment or rejection, which can lead them to seek exclusive alliances with one clinician.
The caregiver must build a clear structure that serves as the basis for the therapeutic relationship, even when the client’s emotional dependency makes the bond feel fragile. Setting limits on confidentiality is part of that structure. The nurse maintains the relationship by being honest about what can and cannot remain private, rather than by making an impossible promise.
Watch out! A client with borderline personality disorder may interpret a refusal to promise secrecy as rejection. The nurse should explain the limits calmly and matter-of-factly, without becoming defensive or apologetic, so the client understands this is a professional standard, not a personal judgment.
What the nurse should say
The nurse can respond by stating that most information shared in sessions is confidential, but there are exceptions. For example, if the client reveals a plan to harm herself or someone else, or if there is a legal requirement to report, that information must be shared with the team to keep her safe.
The client should know these limits before deciding what to share, so she can make an informed choice. This approach preserves trust while maintaining safety and professional boundaries.
Key point! The limits of confidentiality are established in the orientation phase, not discovered later when a crisis occurs. Explaining them early protects both the client and the nurse.