EMILIO AGUINALDO COLLEGE

Congressional East Ave. Burol Main, Dasmariñ as, Cavite

Bachelor of Science In Nursing

THERAPEUTIC COMMUNICATION

Submitted by:
Verano, Rome Kryss-Anne H.

Submitted to:
Obdulia Almarez RN, MaEd, MAN
Ma. Ann E. Crizaldo RN

January 28,2019
WHAT IS THERAPEUTIC COMMUNICATION?

Therapeutic communication is an interpersonal interaction between the nurse and the

client during which the nurse focuses on the client’s specific needs to promote an effective

exchange of information. Skilled use of therapeutic communication techniques helps the nurse

understand and empathize with the client’s experience. All nurses need skills in therapeutic

communication to effectively apply the nursing process and to meet standards of care for their

clients.

Therapeutic communication can help nurses to accomplish many goals:

• Establish a therapeutic nurse–client relationship.

• Identify the most important client concern at that moment (the client-centered goal).

• Assess the client’s perception of the problem as it unfolds.

• Facilitate the client’s expression of emotions.

• Teach the client and family necessary self-care skills.

• Recognize the client’s needs.

• Implement interventions designed to address the client’s needs.

• Guide the client toward identifying a plan of action to a satisfying and socially acceptable

resolution.

Privacy and Respecting Boundaries

Privacy is desirable but not always possible in therapeutic communication. An interview

or a conference room is optimal if the nurse believes this setting is not too isolative for the

interaction. The nurse also can talk with the client at the end of the hall or in a quiet corner of the
day room or lobby, depending on the physical layout of the setting. The nurse needs to evaluate

whether interacting in the client’s room is therapeutic. For example, if the client has difficulty

maintaining boundaries or has been making sexual comments, then the client’s room is not the

best setting. A more formal setting would be desirable.

Proxemics is the study of distance zones between people during communication. People feel

more comfortable with smaller distances when communicating with someone they know rather

than with strangers (DeVito, 2008). People from the United States, Canada, and many Eastern

European nations generally observe four distance zones:

• Intimate zone (0 to 18 inches between people): This amount of space is comfortable for

parents with young children, people who mutually desire personal contact, or people whispering.

Invasion of this intimate zone by anyone else is threatening and produces anxiety.

• Personal zone (18 to 36 inches): This distance is comfortable between family and friends who

are talking.

• Social zone (4 to 12 feet): This distance is acceptable for communication in social, work, and

business settings.

• Public zone (12 to 25 feet): This is an acceptable distance between a speaker and an audience,

small groups, and other informal functions (Hall, 1963).

 People from some cultures (e.g., Hispanic, Mediterranean, East Indian, Asian, and

Middle Eastern) are more comfortable with less than 4 to 12 feet of space between them while

talking. The nurse of European American or African American heritage may feel uncomfortable

if clients from these cultures stand close when talking.

Both the client and the nurse can feel threatened if one invades the other’s personal or

intimate zone, which can result in tension, irritability, fidgeting, or even flight. When the nurse

must invade the intimate or personal zone, he or she always should ask the client’s permission.

The therapeutic communication interaction is most comfortable when the nurse and client

are 3 to 6 feet apart. If a client invades the nurse’s intimate space (0 to 18 inches), the nurse

should set limits gradually, depending on how often the client has invaded the nurse’s space and

the safety of the situation.

Touch
As intimacy increases, the need for distance decreases. Knapp (1980) identified five types of

touch:

• Functional-professional touch is used in examinations or procedures such as when the nurse

touches a client to assess skin turgor or a masseuse performs a massage.

• Social-polite touch is used in greeting, such as a handshake and the “air kisses” some women

use to greet acquaintances, or when a gentle hand guides someone in the correct direction.

• Friendship-warmth touch involves a hug in greeting, and arm thrown around the shoulder of a

good friend, or the backslapping some men use to greet friends and relatives.

• Love-intimacy touch involves tight hugs and kisses between lovers or close relatives.

• Sexual-arousal touch is used by lovers.

Although touch can be comforting and therapeutic, it is an invasion of intimate and personal

space. Some clients with mental illness have difficulty understanding the concept of personal

boundaries or knowing when touch is or is not appropriate.

Active Listening and Observation

To receive the sender’s simultaneous messages, the nurse must use active listening and

active observation. Active listening means refraining from other internal mental activities and

concentrating exclusively on what the client says. Active observation means watching the

speaker’s nonverbal actions as he or she communicates.

Active listening and observation help the nurse to:

• Recognize the issue that is most important to the client at this time.

• Know what further questions to ask the client.

• Use additional therapeutic communication techniques to guide the client to describe his or her

perceptions fully.

• Understand the client’s perceptions of the issue instead of jumping to conclusions.

• Interpret and respond to the message objectively.

VERBAL COMMUNICATION SKILLS

Concrete Messages are clear, direct, and easy to understand. They elicit more accurate

responses and avoid the need to go back and rephrase unclear questions, which interrupts the

flow of a therapeutic interaction.

Abstract messages, in contrast, are unclear patterns of words that often contain figures of speech

that are difficult to interpret. They require the listener to interpret what the speaker is asking.

Using Therapeutic Communication Techniques

• The nurse can use many therapeutic communication techniques to interact with clients.

The choice of technique depends on the intent of the interaction and the client’s ability to

communicate verbally.

• Overall, the nurse selects techniques that facilitate the interaction and enhance

communication between client and nurse.

Therapeutic Communication Technique

• Accepting—indicating reception

• Broad openings—allowing the client to take the initiative in introducing the topic

• Consensual validation—searching for mutual understanding, for accord in the

meaning of the words

• Encouraging comparison—asking that similarities and differences be noted

• Encouraging description of perceptions—asking the client to verbalize what he or

she perceives
• Encouraging expression— asking the client to appraise the quality of his or her

experiences

• Exploring—delving further into a subject or an idea

• Focusing—concentrating on a single point

• General leads—giving encouragement to continue

• Formulating a plan of action—asking the client to consider kinds of behavior likely

to be appropriate in future situations

• Giving information— making available the facts that the client needs

• Giving recognition— acknowledging, indicating awareness

• Making observations— verbalizing what the nurse perceives

• Offering self—making oneself available

• Placing event in time or sequence—clarifying the relationship of events in time

• Presenting reality— offering for consideration that which is real

• Reflecting—directing client actions, thoughts, and feelings back to client]

• Restating—repeating the main idea expressed

• Seeking information—seeking to make clear that which is not meaningful or that

which is vague

• Silence—absence of verbal communication, which provides time for the client to put

thoughts or feelings into words, to regain composure, or to continue talking

• Suggesting collaboration— offering to share, to strive, and to work with the client

for his or her benefit

• Summarizing—organizing and summing up that which has gone before

• Translating into feelings— seeking to verbalize client’s feelings that he or she

expresses only indirectly

• Verbalizing the implied— voicing what the client has hinted at or suggested

• Voicing doubt—expressing uncertainty about the reality of the client’s perceptions

Avoiding Non-therapeutic Communication

• There are many non-therapeutic techniques that nurses should avoid

• These responses cut off communication and make it more difficult for the interaction to

continue

NON-THERAPEUTIC COMMUNICATION TECHNIQUES

• Advising—telling the client what to do

• Agreeing—indicating accord with the client

• Belittling feelings expressed—misjudging the degree of the client’s discomfort

• Challenging—demanding proof from the client

• Defending—attempting to protect someone or something from verbal attack?

• Disagreeing—opposing the client’s ideas

• Disapproving—denouncing the client’s behavior or ideas

• Giving approval— sanctioning the client’s behavior or ideas

• Giving literal responses—responding to a figurative comment as though it were a

statement of fact

• Indicating the existence of an external source—attributing the source of thoughts,

feelings, and behavior to others or to outside influences

 • Interpreting—asking to make conscious that which is unconscious; telling the client

the meaning of his or her Experience

• Introducing an unrelated topic—changing the subject

• Making stereotyped comments—offering meaningless clichés or trite comments

• Probing—persistent questioning of the client

• Reassuring—indicating there is no reason for anxiety or other feelings of discomfort

• Testing—appraising the client’s degree of insight

• Using denial—refusing to admit that a problem exists

Interpreting Signals or Cues

To understand what a client means, the nurse watches and listens carefully for cues. Cues

(overt and covert) are verbal or nonverbal messages that signal key words or issues for the

client. Finding cues is a function of active listening.

Overt cues are clear, direct statements of intent, such as “I want to die.” The message is clear

that the client is thinking of suicide or self-harm.

Covert cues are vague or indirect messages that need interpretation and exploration—for

example, if a client says, “Nothing can help me.”

NON-VERBAL COMMUNICATION SKILLS

Nonverbal communication is the behavior a person exhibits while delivering verbal

content. It includes facial expression, eye contact, space, time, boundaries, and body movements.

It is estimated that one third of meaning is transmitted by words and two thirds is communicated

nonverbally. Nonverbal communication involves the unconscious mind acting out emotions

related to the verbal content, the situation, the environment, and the relationship between the

speaker and the listener.

Facial Expression

The human face produces the most visible, complex, and sometimes confusing nonverbal

messages. Facial movements connect with words to illustrate meaning; this connection

demonstrates the speaker’s internal dialogue. Facial expressions can be categorized into

expressive, impassive, and confusing:

• An expressive face portrays the person’s moment-bymoment thoughts, feelings, and needs.

These expressions may be evident even when the person does not want to reveal his or her

emotions.

• An impassive face is frozen into an emotionless deadpan expression similar to a mask.

• A confusing facial expression is one that is the opposite of what the person wants to convey. A

person who is verbally expressing sad or angry feelings while smiling is exhibiting a confusing

facial expression.

Facial expressions often can affect the listener’s response. Strong and emotional facial

expressions can persuade the listener to believe the message.

Body Language

Body language (gestures, postures, movements, and body positions) is a nonverbal form

of communication. Closed body positions, such as crossed legs or arms folded across the chest,

indicate that the interaction might threaten the listener who is defensive or not accepting.

Hand gestures add meaning to the content. A slight lift of the hand from the arm of a

chair can punctuate or strengthen the meaning of words.

Vocal Cues

Vocal cues are nonverbal sound signals transmitted along with the content: voice volume,

tone, pitch, intensity, emphasis, speed, and pauses augment the sender’s message.

• Volume, the loudness of the voice, can indicate anger,fear, happiness, or deafness.

• Tone can indicate whether someone is relaxed, agitated, or bored.

• Pitch varies from shrill and high to low and threatening.

• Intensity is the power, severity, and strength behind the words, indicating the importance

of the message.

• Emphasis refers to accents on words or phrases that highlight the subject or give insight

into the topic.

• Speed is the number of words spoken per minute. Pauses also contribute to the message,

often adding emphasis or feeling.

Eye Contact

Looking into the other person’s eyes during communication, is used to assess the other

person and the environment and to indicate whose turn it is to speak; it increases during listening

but decreases while speaking

Although maintaining good eye contact is usually desirable, it is important that the nurse

doesn’t “stare” at the client.

Silence

Silence or long pauses in communication may indicate many different things. The client

may be depressed and struggling to find the energy to talk. Sometimes pauses indicate the client

is thoughtfully considering the question before responding.

Reference:
Videbeck, Sheila L./Psychiatric-mental health nursing 5th ed.
Townsend, Mary C., 1941/Psychiatric mental health nursing: concepts of care in evidence-based
practice 6th ed.