Mental Health

Nursing II
NURS 2310
Unit 3
Therapeutic
Communication

Objective 1

Defining therapeutic milieu

The therapeutic milieu is a scientific

structuring of the environment in
order to effect behavioral changes and
to improve the psychological health
and functioning of the individual.
Within this structured environment,
the client is expected to learn
adaptive coping, interaction, and
relationship skills that can be
generalized to other aspects of his or
her life.

Objective 2

Analyzing the nurses role in

maintaining the therapeutic
milieu in an inpatient
psychiatric/mental health setting

The nurse maintains the therapeutic milieu in

the inpatient setting by:

Encouraging health promotion

Providing therapeutic interaction
Allowing clients to participate in governing the
unit
Expecting the client to take responsibility for his or
her own behavior
Utilizing peer pressure or peer support as a tool to
bring about acceptable group norms
Dealing with inappropriate behaviors as they occur
Avoiding restrictions and punishments

Objective 3

Reviewing the components

of nurse-client relationship
development and
therapeutic communication

Therapeutic use of self:

Ability to use ones personality consciously and

in full awareness in an attempt to establish
relatedness and to structure nursing
interventions

Therapeutic communication:

Consists of verbal and nonverbal techniques

that focus on the clients needs and advance
the promotion of healing and change
Encourages the exploration of feelings and
fosters understanding of behavioral motivation
Promotes trust, discourages defensiveness,
and is nonjudgmental

Active listening:

Being attentive to what the client is saying

both verbally and nonverbally
Facilitative skills include
facing the client squarely
observing an open posture
leaning toward the client
establishing eye contact
maintaining a relaxed demeanor

Feedback:

Communication method that helps the

client consider a modification of behavior

Therapeutic relationship:

Interaction between two people in which

input from both participants contributes to a
climate of healing, growth promotion, and/or
illness prevention
Goal-oriented
goal of the relationship determined jointly
by nurse and client
goal is most often directed at learning and
growth promotion in an effort to bring
about some type of change in the clients
life
may be based on a problem-solving model

Conditions essential to the development of

a
therapeutic relationship include:
Rapport
special feelings on the part of both the client
and nurse based on acceptance, warmth,
friendliness, common interest, a sense of
trust, and a nonjudgmental attitude
establishing rapport may be accomplished
by discussing non-health-related topics
Genuineness

the ability to be open, honest, and real in

interactions

Developing therapeutic relationships

(contd)
Trust

confidence in another persons

presence, reliability, integrity,
veracity, and sincere desire to provide
assistance when requested
providing a blanket when the client is cold
providing food when the client is hungry
keeping promises
being consistent
ensuring confidentiality

Developing therapeutic relationships

(contd)
Respect
unconditional positive regard
calling the client by name
spending time with the client
allowing sufficient time to answer the clients
questions or concerns
always being open and honest
striving to understand the motivation behind
the clients behavior

Empathy

process in which one is able to see

beyond outward behavior and accurately
sense anothers inner experience

Objective 4
Exploring the
phases of the
therapeutic
relationship

Phases of the therapeutic relationship:

Preinteraction

phase

Preparation for the first encounter with

the client
Orientation

(Introductory) phase

The nurse and client become acquainted

Working

phase

Accomplishment of the therapeutic work

of the relationship
Termination

phase

Bringing a therapeutic conclusion to the

relationship

Boundary issues within a professional

relationship may include:
Transference
When the client unconsciously attributes to
the nurse feelings and behavioral
dispositions formed toward a person from
his or her past
Countertransference

The nurses behavioral and emotional

response to the client which may be related
to unresolved feelings toward significant
others from the nurses past, or may be
generated in response to transference
feelings on the part of the client

Boundary issues (contd)

Self-disclosure

May be appropriate when the

information to be shared is judged to be
therapeutically beneficial to the client
Never used for the purpose of meeting
the nurses own needs
Gift-giving

Professional judgment
Institutional policy
Never financial
suggest a donation elsewhere

Boundary issues (contd)

Touch

Caring touch with no associated physical

need can be therapeutically appropriate
Beware of situations in which touch may
be misinterpreted, culturally
unacceptable, or dangerous
paranoid patient
psychotic client

Warning signs that may indicate a potential

breech in professional boundaries in the
nurse-client relationship include:
Favoring one clients care over anothers
Swapping assignments with another nurse to
care for a particular client
Giving special attention or treatment to one
client over others
Spending free time with one particular client
Sharing personal information or work
concerns with a client
Continuing contact/communication with a
client after discharge

Objective 5
Correlating appropriate modes
of therapeutic communication
with specific psychiatric
behaviors

Modes of therapeutic communication:

Using silence

gives the client the opportunity to collect and

organize thoughts

Accepting

conveys an attitude of reception and regard

Giving recognition
acknowledging

Offering general leads

offers the client encouragement to continue

Making observations

verbalizing what is observed or perceived

Restating

repeating the main idea of what the client has said

Encouraging description of perceptions

asking the client to verbalize what is being
perceived

Therapeutic communication (contd)

Reflecting

referring questions and feelings back to the

client so that they may be recognized and
accepted

Focusing

taking notice of a single idea or a single word

works well with the client who is moving
rapidly from one thought to another
not to be used with a client who is anxious

Presenting reality

when a client has a misperception of the

environment, the nurse defines reality

Voicing doubt

expressing uncertainty as to the reality of

percpetions

Objective 6
Exploring the
concept of
therapeutic
community

The therapeutic community holds that

everything that happens to the client
or within the clients environment is
considered to be part of the treatment
program.
Community factors, such as social
interactions, the physical structure of
the treatment setting, and schedule of
activities may generate negative
responses which are used as
examples to help the client learn how
to manage stress more adaptively in
real-life situations.

Conditions that promote the therapeutic

community include:
The fulfillment of basic physiological
needs
The conduciveness of the physical
facilities to achievement of the goals of
therapy
The existence of a democratic form of
self-governance
The assignment of responsibilities based
on each clients capabilities
The scheduling of a structured program
of social and work-related activities
The inclusion of community and family
with regards to discharge planning

Objective 7

Examining the use of groups as

a therapeutic tool

Group:
Collection of individuals whose association
is founded on shared commonalities of
interest, values, norms, or purpose
Membership is generally
by chance (born into the group)
by choice (voluntary affiliation)
by circumstance (the result of life-cycle events
over which an individual may or may not have
control)

Group Therapy = a form of psychosocial

treatment in which a number of clients meet
together with a therapist for purposes of
sharing, gaining personal insight, and
improving interpersonal coping strategies.

Use of a group as a therapeutic tool:

Instillation of hope
Universality
Imparting of information
Altruism
Corrective recapitulation of the primary
family group
Development of socializing techniques
Imitative behavior
Interpersonal learning
Group cohesiveness
Catharsis
Existential factors

Objective 8

Identifying group types, roles,

functions, development and
stages

Functions of a group:

Socialization
Support
Task completion
Camaraderie
Informational
Normative
enforcement of established norms

Empowerment
Governance
rules committees

Types of groups:

Task Groups
accomplishing a specific outcome or task
focus on problem-solving and decision-making

Teaching Groups
exist to convey knowledge and information to a
number of individuals

Supportive/Therapeutic Groups
concerned with preventing future upsets by
teaching effective ways of dealing with emotional
distress

Self-Help Groups
allow clients to talk about their fears and relieve
feelings of isolation while receiving comfort and
advise from others undergoing similar experiences

Member roles within groups:

Maintenance Roles
Task Roles
Compromiser
Coordinator
Encourager
Evaluator
Follower
Elaborator
Gatekeeper
Energizer
Harmonizer
Initiator
Orienter
Individual Roles
Monopolizer
Aggressor
Recognition
Blocker
Seeker
Dominator
Seducer
Mute/Silent member

Phases of group development:

Phase I
Initial or Orientation Phase
Group activities leader and members work
together to establish the rules that will
govern the group
Leader expectations leader expected to
orient members to specific group processes,
encourage members to participate without
disclosing too much too soon, promote an
environment of trust, and ensure group
rules dont interfere with goal fulfillment
Member behaviors members have not yet
established trust; fear of not being
accepted by the group

Phases of group development (contd)

Phase II
Middle or Working Phase
Group activities productive work toward
completion of the task is undertaken;
problem-solving and decision-making occur
Leader expectations role diminishes and
becomes one of facilitator
Member behaviors trust established among
members; members turn to each other more
often, and less so to the leader; members
accept criticism from others and use it
constructively to create change

Phases of group development (contd)

Phase III
Final or Termination Phase
Group activities termination process
discussed in depth for several meetings
before the final session
Leader expectations the leader encourages
group members to reminisce about what has
occurred, review the goals, and discuss
actual outcomes
Member behaviors grief response may be
evident; may lead to discussion of previous
losses; successful termination of the group
may help members develop the skills
needed when losses occur in other
dimensions of their lives.