# Situation: A nurse in a psychiatric day-hospital program holds weekly one-to-one sessions with a 29-year-old woman who has borderline personality disorder. In their first meeting they agreed on 10 sessions. At the fifth session she hands the nurse a handmade card and an envelope containing ₱2,000, saying, "You are the only nurse here who really cares about me." Agency policy allows small tokens such as cards but not money. What should the nurse do FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630098  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A nurse in a psychiatric day-hospital program holds weekly one-to-one sessions with a 29-year-old woman who has borderline personality disorder. In their first meeting they agreed on 10 sessions.

At the fifth session she hands the nurse a handmade card and an envelope containing ₱2,000, saying, "You are the only nurse here who really cares about me." Agency policy allows small tokens such as cards but not money. What should the nurse do FIRST?

## 보기

1. Tell her that every nurse cares for her equally
2. Return the money kindly and accept the card
3. Ask her what giving these gifts means to her **✔ 정답**
4. Report the gift to the nurse supervisor

**정답: 3**

## 해설

When a client offers a gift, the nurse first explores its meaning with the client, then follows agency policy, such as accepting a card and kindly declining money. Here the gift comes with a statement that idealizes one nurse, which may signal splitting, so understanding what the gift means comes before acting on it.

## 심화 해설

Therapeutic use of self and limit-setting in BPD

When a client with borderline personality disorder offers a gift, the nurse’s first task is not to accept, refuse, or report it, but to explore the relational meaning the gift carries for the client before applying any agency policy. In this scenario, the client pairs the gift with the statement “You are the only nurse here who really cares about me.” That language is clinically significant because it suggests splitting—a core defense mechanism in BPD in which people and caregivers are rapidly divided into all-good and all-bad categories. The nurse has been placed in the all-good role, while other staff are implicitly devalued. Acting on the gift before understanding this dynamic would reinforce the split rather than address it.

Key point! The sequence matters: explore meaning first, then apply the boundary. Agency policy allows cards but not money, so the eventual action will be to accept the card and kindly return the money. However, jumping straight to returning the money would miss the therapeutic opportunity to understand why the gift is being given now, in this relationship, with this particular framing. Asking “What does giving these gifts mean to you?” is a mentalizing intervention—it invites the client to reflect on her own intention and the state of the therapeutic relationship, rather than simply reacting to the gift as a concrete transaction.

The qualitative literature on treatment for personality disorder supports this emphasis on relational process over concrete action. In a study exploring patients’ experiences of mentalization-based treatment, participants emphasized that useful therapeutic work involved the therapist’s consistent, curious, non-reactive stance toward interpersonal events, including moments that could otherwise provoke action or defensiveness [1]. The nurse’s first response, therefore, is not to correct the client’s perception (“every nurse cares for you equally”), which would feel invalidating and could intensify the split, but to open a reflective space about the gift’s meaning.

Stakeholder research on care systems for BPD similarly highlights that effective care depends on clinicians maintaining a predictable, non-punitive relational frame while explicitly addressing the interpersonal patterns that emerge in treatment . Gifts in this context are rarely only about the object—they are communications about attachment, idealization, fear of abandonment, or testing of boundaries. The nurse’s first move is to make that communication discussable.

Watch out! Reporting the gift to the supervisor before exploring its meaning would be premature and could rupture trust. Agency policy about money is important, but it is applied after the nurse understands the meaning, not before. The correct first action is option 3: ask the client what giving these gifts means to her. This preserves the therapeutic alliance, models curiosity instead of reactivity, and sets the stage for the boundary-setting that will follow—accepting the card and kindly declining the money in line with policy.

| Order of response | Action | Rationale |
| --- | --- | --- |
| First | Explore the meaning of the gift | Identifies splitting or idealization; maintains mentalizing stance [1] |
| Second | Apply agency policy | Accept card, return money kindly |
| Later if needed | Discuss the pattern with the treatment team | Prevents reinforcement of splitting across staff |

References (research sources)

- [1]Mentalization-Based Treatment From the Patients' Perspective - What Ingredients Do They Emphasize?Research articleMorken KTE, Binder PE, Arefjord NM, Karterud SW. (2019) · DOI: 10.3389/fpsyg.2019.01327

## 임상 시나리오

Gift-Giving in BPD: Explore Meaning Before ActingFirst assess for splitting, then apply agency policy
When a client with borderline personality disorder gives a gift, the first step is to explore its relational meaning, not to accept, refuse, or report it. The statement “You are the only nurse who really cares” suggests splitting, placing the nurse in an all-good role while devaluing others.

Use a mentalizing intervention such as asking what giving these gifts means to her. This invites reflection on her intention and the therapeutic relationship before any concrete action is taken.

After exploring meaning, follow agency policy. Because policy allows small tokens such as cards but not money, the eventual action is to accept the card and kindly return the money.

CautionActing on the gift before understanding the dynamic can reinforce the split. Jumping straight to returning the money misses the therapeutic opportunity to address why the gift is given now, in this relationship, with this framing.

## 핵심 개념

- **Splitting** — A defense mechanism in borderline personality disorder in which people or caregivers are viewed as all-good or all-bad.
- **Mentalizing intervention** — An approach that invites the client to reflect on intentions, feelings, and the state of the therapeutic relationship.
- **Therapeutic use of self** — Using the nurse-client relationship intentionally to promote insight, growth, and healthier interpersonal patterns.
- **Professional boundary** — The limits that protect the therapeutic relationship from becoming personal, financial, or otherwise exploitative.
- **Limit-setting** — Clearly and kindly maintaining rules or boundaries while preserving the therapeutic relationship.

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