THERAPEUTIC

COMMUNICATION
vNurse-Patient Relationship
vBoundaries

vTherapeutic Communication
Techniques
 THERAPEUTIC
RELATIONSHIPS

¢ Primary mode of implementing

interventions in psychiatric nursing
¢ Phases:
-Orientation
-Working
-Termination
¢ Students may have a pre- interaction
phase
 EFFECTIVE NURSE
BEHAVIOR
¢Active Listening
¢Focus on Client
¢Self Awareness
¢Professional Caring:
-Genuine
-Interest
-Acceptance
 INEFFECTIVE NURSE
BEHAVIOR
¢ Excessive Self- Disclosure
¢ Anxiety
¢ Distracting non-verbal
mannerisms of behavior
¢ Excessive talking
¢ Asking multiple questions

¢ Rushing the interaction process

 BOUNDARIES
¢ General Principles of
Boundaries in professional
relationships
¢ Special issues in mental health:

-Client’s perception of Nurse’s

action
-Setting for the interaction
-Use of touch
 ISSUES
¢ Confidentiality

¢ Privacy and dignity

¢ Student Concerns:
-What if no one will talk to me?
-What if I say the wrong thing?
-What if I can’t think of anything
to say?
-How can I ask personal questions
without prying?
 THERAPEUTIC
COMMUNICATION
¢Purpose and Goals:
-Expressing feelings
-Clarifying problems
-Addressing Client’s concern
-Resolving problems
-Role playing alternatives
 VERBAL SKILL AND
BEHAVIOR
¢ Specific clear messages
¢ Therapeutic Communication
Techniques
¢ Finding and responding to cues
¢ Open ended questions vs. Close
ended questions
¢ Directive vs. non- Directive
interaction
 NON-VERBAL SKILLS AND
BEHAVIOR

¢ Distance

¢ Posture
¢ Eye Contact
¢ Facial Expression
¢ Tone and Volume of Voice
¢ Use of touch

¢ Involvement in activity
DISTANCE ZONES
¢ Intimate zone (0 to 18 inches between people):
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): comfortable
between family and friends who are talking.
¢ Social zone (4 to 12 feet): acceptable for
communication in social, work, and business
settings.
¢ Public zone (12 to 25 feet): acceptable distance
between a speaker and an audience, small groups,
and other informal functions
PRINCIPLES GUIDING THERAPEUTIC
COMMUNICATION

¢ Establishing trust
¢ Be honest
¢ Acceptance of person, not necessarily
behavior
¢ Be emphatic, not sympathetic
¢ Non-judgmental attitude, be matter-
of-fact
¢ Avoid usual social responses or
clichés
¢ Client usually talks more than Nurse
 NONTHERAPEUTIC
RESPONSES OR QUESTIONS
¢ Giving approval/disapproval or advice
¢ Use of good, bad, right or wrong

¢ Asking WHY questions

¢ Changing the subject due to Nurse’s

discomfort
¢ Stereotyped comments

¢ Challenging, probing

¢ Defending

¢ Belittling client’s feelings

 BASIC THERAPEUTIC
COMMUNICATION TECHNIQUES
¢ Broad Openings, general Leads
¢ Offering Self, giving information, placing in
time or sequence, consensual validation
¢ Encouraging expression of feelings

¢ Exploring, Focusing

¢ Reflecting, Restating

¢ Encouraging Description of perceptions,

making comparisons, suggesting
collaboration
¢ Purposeful use of silence

¢ Summarizing
 ADVANCED OR SPECIALIZED
TECHNIQUES
¢ Verbalizing the implied
¢ Clients with Psychotic symptoms
-Presenting reality
-Voicing doubts
-Translating into feelings
¢ Clients with Dementia and psychotic symptoms
-Avoid correcting misperceptions if possible
-Going along
-Distraction and Diversion
-Promoting interaction and involvement
 RESPONSE TO
INAPPROPRIATE BEHAVIOR

¢ Giving feedback
¢ Limit-setting
¢ Confronting incongruencies

¢ Promoting appropriate behavior

 ANGER AND HOSTILITY
¢ Verbalde- escalation techniques
-Ask what Client wants or need
-Avoid use of “NO”
-Offer alternatives encourage to
verbalize feelings
-Offer prn medications if
indicated
-Suggest time out to regain
control
 CONFLICT
¢ Assertive communication techniques allow
honest expression of thoughts, feelings and
opinions without infringing on the rights of
others
¢ The goal of conflict resolution is a
negotiated resolution in which each party
feels they have been heard and gets at least
some of what they want
¢ Conflicts may involve clients, staff, or both
EXAMPLE OF ASSERTIVE
COMMUNICATION
¢ Use of “I” statements
¢ Avoid use of “you” statements

¢ Be specific, avoid generalization

¢ Make clear statements

¢ Validate other person’s feelings or

position
¢ Include statement of the problem of
conflict
¢ Include outcome that is desired
 THERAPEUTIC
COMMUNICATION TECHNIQUES
¢ Using Silence
-utilizing absence of verbal
communication

¢ Accepting
-giving indication of reception
¢ Example:

“Yes”
“I follow what you said.”
Nodding
¢ Giving Recognition
-Acknowledging, indicating awareness

Example:
“Good Morning Mr. S..”
“You’ve finished your list of things to
do”
“I noticed that you’ve combed your
hair.”
¢ OfferingSelf
-Making one’s self available

Example:
“I’ll sit with you for a while.”
“I’ll stay here with you.”
“I’m interested in what you’re
thinking.”
¢ Giving Broad Openings
-Allowing a client to take the initiative
of introducing the topic

Example:
“Is there something you’d like to talk
about?”
“What are you talking about?”
“Where would you like to begin?”
¢ OfferingGeneral Leads
-Giving encouragement to
continue

Example:
“Go on.”
“And then?”
“Tell me about it.”
¢ Placing the Event in time and Sequence
-clarifying the relationship of events in
time

Example:
“What seemed to lead to…?”
“Was this before or after…?”
“When did this happen?”
¢ Making Observations
-Verbalizing the implied

Example:
“You appear tense.”
“Are you comfortable when you…?”
“I notice that your biting your lip.”
¢ Encouraging description of perception
-Asking the client to verbalize what he
or she perceives

Example:
“Tell me when you feel anxious.”
“What is happening?”
“What does the voice seem to be
saying?”
¢ Encouraging Comparison
-Asking that similarities and
differences be noted

Example:
“Was this something like…”
“Have you had similar experiences?”
¢ Restating
-Repeating the main idea expressed

Example;
Client: “I can’t sleep. I stay awake all night.”
Nurse: “You have difficult sleeping.”
Client: “I’m really. I’m so upset.”
Nurse: “You’re really mad and upset.”
¢ Reflecting
-directing questions, feelings, or ideas back
to the client

Example:
Client: “Do you think I should tell the doctor…?”
Nurse: “Do you think you should?”
Client: “My brother spends all my money and then
has the nerve to ask for more.”
Nurse: “This cause you to feel angry.”
¢ Focusing
-Concentrating on a single point

Example:
“This point seems worth looking at more
closely.”
“Of all the concerns you’ve mentioned,
which one is most troublesome?”
¢ Exploring
-delving further into a subject or idea

Example:
“Tell me more about that.”
“Would you like to describe it more fully?”
“What kind of work?”
¢ Giving Information
-making available the facts the
client needs

Example:
“My name is…..”
“Visiting hours are…”
“My purpose in being here is……..”
“I’m taking you to…”
¢ Seeking information
-Seeking to make clear that which is not
meaningful or that is vague

Example:
“I’m not sure that I follow.”
“What would you say is the main point of
what you just said?”
“Have I heard you correctly?”
¢ Presenting Reality
-Offering for consideration that which
is real

Example:
“I see no one else in the room.”
“That sound was a car backfiring.”
“Your mother is not here. I’m a Nurse.”
¢ Voicing Doubt
-Expressing uncertainty about the
reality of the client’s perceptions.

Example:
“Isn’t that unusual?”
“That’s hard to believe?”
¢ Seeking consensual validation
-searching for mutual understanding,
for accord in the meaning of the words.

Example:
“Tell me whether my understanding of it
agrees with yours.”
“Are you using the word to convey the idea
that…?”
¢ Verbalizing the implied
-voicing what the client has hinted at or
suggested

Example:
Client: “I can’t talk to you or anyone. It’s a
waste of time.”
Nurse: “You’re feeling that no one
understands?”
Client: “My wife pushes me around just like
my mother and sister did.”
Nurse: “Is it your impression that women
are domineering?”
¢ Encouraging Expression
-Asking the client to appraise the
quality of his or her experiences

Example:
“What are your feelings in regards to….?”
“Does this contribute to your discomfort?”
¢Attempting to translate into feelings
-Seeking to verbalize feelings that are
only expressed indirectly
Example:
Client: “I’m Dead.”
Nurse: “Are you suggesting that you feel
lifeless? Or is it that life seems to have no
meaning?”
Client: “I’m way out in the ocean.”
Nurse: “You seem to feel lonely or
deserted.”
¢ Suggesting collaboration
-Offering to share, to strive, to work
together with the client for his or her
benefit

Example:
“Perhaps you and I can discuss and
discover what produces your anxiety.”
“Let’s go to your room, and I’ll help you find
what you’re looking for.”
¢ Summarizing
-Organizing and summing up that which
has gone before

Example:
“Have I got this straight?”
“You’ve said that..”
“During the past hour you and I have
discussed…”
¢ Encouraging formulation of a plan of action
-Asking the client to consider kinds of
behavior likely to be appropriate in future
situations.

Example:
“What could you do to let your anger out
harmlessly?”
“Next time it comes up, what might you do
to handle it?”
 NON-THERAPEUTIC
RESPONSES

¢ Reassuring
-Indicating that there is no cause for
anxiety

Example:
“I wouldn’t worry about that.”
“Everything will be alright.”
“You’re coming along just fine.”
¢ Giving Approval
-Sanctioning the client’s behavior
or ideas

Example:
“That’s good.”
“I’m glad that you…”
¢ Rejecting

-Refusing to consider or showing

contempt for the client’s ideas or
behavior.

Example:
“Let’s not discuss…”
“I don’t want to hear about…..”
¢ Disapproving

-Denouncing the client’s behavior

or ideas

Example:
“That’s bad.”
“I’d rather you wouldn’t…”
¢ Agreeing

-Indicating accord with the

client

Example:
“That’s right.”
“I agree.”
¢ Disagreeing

-Opposing the client’s ideas.

Example:
“That’s wrong.”
“I definitely disagree with…”
“I don’t believe that.”
¢ Advising

-Telling the client what to do.

Example:
“I think you should…..”
“Why don’t you…”
¢ Probing

-Persistent questioning of the

client

Example:
“Now tell me about…”
“Tell me your life history.”
¢ Challenging

-demanding proof from the client

Example:
“But how can you be President of the
United States?”
“If you’re dead, why is your heart
beating?”
¢ Testing
-Appraising the client’s degree of
insight

Example:
“Do you still have the idea that..”
“Do you know what kind of hospital
this is?”
¢ Defending
-Attempting to protect someone or
something from verbal attack

Example:
“This hospital has a fine reputation.”
“No one here would lie to you.”
“I’m sure that your doctor has your best
interests in mind.”
¢ Requestingan explanation
-Asking the client to provide reasons
for thoughts, feelings, behaviors and
events

Example:
“Why do you think that?”
“Why do you feel this way?”
“Why did you do that?”
¢ Indicating the existence of an external
force
-Attributing the source of thoughts, feelings
and behavior to others, or to outside
influences

Example:
“What makes you say that?”
“Who told you that you were Jesus?”
“What made you do that?”
¢ Belittling feelings expressed
-Misjudging the degree of the client’s
discomfort

Example:
Client: “I have nothing to live for… I wish I
was dead.”
Nurse: “Everybody gets down in dumps.” Or
“I’ve felt that way sometimes.”
¢ Using Denial
-Refusing to admit that a problem exists

Example:
Client: “I’m nothing.”
Nurse:”Of course you’re something.
Everybody’s something.”
Client: “I’m dead.”
Nurse:”Don’t be silly.”
¢ Interpreting
-Seeking to make conscious that which is
unconscious, telling the client the meaning
of his or her experience

Example:
“What you really mean is……”
“Unconsciously you’re saying….”
¢ Introducingan unrelated topic
-changing the subject

Example:
Client: “I’d like to die.”
Nurse: “Did you have visitors this
weekend?”
BEHAVIORAL APPROACHES
¢ Depressed, withdrawn Clients
-Spend time developing rapport
-involve periods of silence
-Use of moderate tone of voice
-Avoid being overly cheerful
-Observe carefully for any cues or expressions of
suicidal ideation or intent
-Be alert to sudden mood swings
-Any suspicion about suicide should be reported
immediately
-Expect slow, gradual improvements
-Do not force clients to progress rapidly
¢ Manic,Hyperactive Clients
-Maintain calm, low-key matter of
fact approach to effectively de-
escalate manic behaviors
-Do not encourage the client’s antics
-Decrease stimulation
-Distract clients to less provocative
topics and activities to help calm
manic behavior
¢ Manipulative, demanding behavior
-Maintain consistent approach with these
clients
-Limits must be stated clearly and
reinforced in a non-punitive manner
-Do not attempt to be liked, popular or the
favorites of these clients
-Withdraw attention if the client begins
saying; “you are the only on I can talk to” or
“You are the only one who understands”.
-Be kind but firm
-Present the idea that all members of the
health care team are involved in his care
¢ Delusional Clients
-Do not convey the idea that the
Nurse accepts the delusion as a
reality
-Do not argue with the client
-Present a factual account of the
situation as you see it
¢ HallucinatingClients
-Avoid conveying that the
hallucinations are real
-Do not converse with the voices, or
reinforce client’s beliefs in the
hallucination as reality
-Focus on the feeling surrounding the
hallucination
-Closely observe the client to ensure
his safety
¢ Paranoid Clients
-Be non-threatening
-Answer the client’s questions with little or
no hesitation
-Do not be secretive with these clients
-Do not whisper in front of a paranoid client
-Avoid joking
-Avoid discussion of controversial issues
-Do not argue with the client about paranoid
delusions but interject reality when
appropriate
-Do not give any indication that you believe
as the client does
-Do not touch them without thorough
explanation
¢ Hypersexual, seductive clients
-Maintain a non-judgmental attitude
-Acknowledge that sexual feelings and
needs are important while setting limits on
sexual acting-out or inappropriate behavior
-Avoid placing yourself in a potentially
compromising position
-Confront the client about the
inappropriate behavior and let him or her
know the behavior is unacceptable
¢ Aggressive, Violent clients
-Avoid isolating yourself or being alone
with a client who has a potential for
violence
-If a client become aggressive- Give the
client space and keep some distance away;
DO NOT MOVE AWAY CLOSER; DO NOT
TURN YOUR BACK on the client; slowly
and deliberately leave the area
-Use a calm, quiet tone of voice
-Encourage the client to verbalize feelings
instead of acting them out
-Avoid threatening the client in a
judgmental, punitive attitude
 POST-TEST
1.Which of the following questions is an example of
a closed-ended question?
¢ a. Would you like help?
¢ b. How can I help you?
¢ c. Which game would you like to play?
¢ d. Tell me more about yourself.
2. The client says “I can’t go in that room. It’s
full of rats.” The best response by the nurse
is:

a. “Are you sure there are rats in your room?”

b. “I don’t see any rats in your room.”
c. “Tell me about rats.”
d. “I’ll see that someone gets rid of them for
you.”
3. The client says; “I’m so mixed up. I can’t
think straight. What do you think I should
do?” The best response by the nurse is:

a. “I think you’ll have to decide that for

yourself.”
b. “Maybe things will seem better tomorrow.”
c. “We can talk about that later when you’re
not so upset.”
d.”What do you think you should do?”
4. The client tells the nurse “I’m so upset. My
parents are getting a divorce and I don’t
know what to do.”

a. “I know what you mean. That is really bad

news.”
b. “Tell me about it.”
c. “Maybe they’ll get back together.”
d. “There’s probably nothing you can do
about it.”
¢ 5. The nurse who is planning to have therapeutic
communication with a client must, as a first
priority, do which of the following things that
serves as the foundation of therapeutic
communication?
a.establish rules c. get eye contact
b.develop rapport d. sit within arm’s length
¢ 6. When working with a client, you decide you
need to maintain a personal distance from this
client. Using the distances identified by Hall,
who introduced the concept, you would stand how
far from the client?
¢ a. 6 to 12 inches c. 4.5 to 5 feet
¢ b. 18 inches to 4 feet d. 5.5 feet
7. The nurse enters a client’s room on the
morning before surgery. The client has
been crying. The best response by the nurse
is:
a. “Good morning. Why are you crying?”

b. “I see you need some private time. I’ll be

back in 15 minutes.”
c. “Try not to cry. It will all be over soon.”

d. “It seems you’ve been crying. How are you

feeling?”
8. A client with terminal metastatic cancer
says to the nurse; “My family makes me so
mad. They keep talking about a cure or a
miracle. I wish they’d stop. I’m the one
who’s dying.” The best response by the
nurse is:
a. “Have you told your family how you’re
feeling?”
b. “Let’s talk about your family and their
attitude.”
c. “Well, your family sounds like they have
positive attitude.”
d. “You’re feeling angry that your family
keeps hoping for a cure?”
9.A nurse is engaging in a therapeutic
relationship with a client. Which of the
following describe a therapeutic
relationship. Select all that apply.
a. Identify and meet the needs of the client
and nurse.
b. Assist the client to explore feelings.

c. Encourage the practice of coping skills.

d. Give advice if the client requests it.

e. Exchange personal information with the

client
f. Discuss the client’s issues with family
members.
10. The following interaction is an example of
which therapeutic communication
technique?
Client: “I had an accident?”
Nurse: “Tell me about your accident.”
a) Accepting

b) General lead

c) Making an observation

d) Offering Self
1. The nurse is interviewing a newly admitted
psychiatric client. Which nursing statement
is an example of offering a "general lead"?

A. "Do you know why you are here?"

B. "Are you feeling depressed or anxious?"
C. "Yes, I see. Go on."
D. "Can you chronologically order the events
that led to your admission?
2. A nurse is assessing a client diagnosed with
schizophrenia for the presence of
hallucinations. Which therapeutic
communication technique used by the nurse
is an example of making observations?

A. "You appear to be talking to someone I do

not see."
B. "Please describe what you are seeing."
C. "Why do you continually look in the corner
of this room?"
D. "If you hum a tune, the voices may not be
so distracting."
3. A client tells the nurse, "I feel bad because
my mother does not want me to return home
after I leave the hospital." Which nursing
response is therapeutic?

A. "It's quite common for clients to feel that

way after a lengthy hospitalization."
B. "Why don't you talk to your mother? You
may find out she doesn't feel that way."
C. "Your mother seems like an understanding
person. I'll help you approach her."
D. "You feel that your mother does not want
you to come back home?"
4. A student nurse tells the instructor, "I'm
concerned that when a client asks me for
advice I won't have a good solution." Which
should be the nursing instructor's best
response?

A. "It's scary to feel put on the spot by a

client. Nurses don't always have the answer."
B. "Remember, clients, not nurses, are
responsible for their own choices and
decisions."
C. "Just keep the client's best interests in
mind and do the best that you can."
D. "Set a goal to continue to work on this
aspect of your practice."
5. A client states, "You won't believe what my
husband said to me during visiting hours. He
has no right treating me that way." Which
nursing response would best assess the
situation that occurred?

A. "Does your husband treat you like this very

often?"
B. "What do you think is your role in this
relationship?"
C. "Why do you think he behaved like that?"
D. "Describe what happened during your time
with your husband."
¢ 6. A client is admitted to the inpatient unit of the
mental health center with a diagnosis of paranoid
schizophrenia. He's shouting that the
government of France is trying to assassinate
him. Which of the following responses is most
appropriate?

A. "I think you're wrong. France is a friendly

country and an ally of the United States. Their
government wouldn't try to kill you."
B. "I find it hard to believe that a foreign
government or anyone else is trying to hurt you.
You must feel frightened by this."
C. "You're wrong. Nobody is trying to kill you."
D. "A foreign government is trying to kill you?
Please tell me more about it."
¢
7. Every day for the past 2 weeks, a client with
schizophrenia stands up during group therapy
and screams, "Get out of here right now! The
elevator bombs are going to explode in 3
minutes!" The next time this happens, how
should the nurse respond?

A. "Why do you think there is a bomb in the

elevator?"
B. "That is the same thing you said in yesterday's
session."
C. "I know you think there are bombs in the
elevator, but there aren't."
D. "If you have something to say, you must do it
according to our group rules."
¢ 8. A client with a history of major depression tells
the nurse "I wish I weren't alive. I have been a
failure my entire life and I am totally useless to
anyone." The most therapeutic response to the
client is:

a. "You shouldn't talk like that. You're not a

failure."
b. "Once the antidepressants start working you
will feel better about yourself."
c. "Things could be worse. You should be grateful
for what you have."
d. "You've been feeling like a failure your entire
life?"
¢ 9. The nurse is completing the sexual history
section of the admission assessment. The client
tells the nurse "I don't want to talk about this.
This is private between my spouse and me."
Which nurse response reflects empathy?

a. "I am a professional nurse and I know what I

am doing."
b. "I understand this is difficult for you to talk
about, but I have to complete the admission
assessment."
c. "Yes, I know just how you feel."
d. "I know some of these questions are difficult
for you."
¢ 10. The father of a 16 year old who has
just been diagnosed with Hodgkin’s
disease tells the nurse he does not want
his child to know the diagnosis. The
nurse’s best response would be?
a. “It is best if he knows the diagnosis.”
b. “The cure rate for Hodgkin’s disease is
high.”
c. “Let’s talk about why you don’t want him
to know.”
d. “Would you like someone with Hodgkin’s
to talk to you?”