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Territoriality, density, and distance are aspects of environment that communicate messages.

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The nurse-client relationship is the foundation on which psychiatric nursing is established. The therapeutic interpersonal relationship is the process by which nurses provide care for clients in need of psychosocial intervention. Mental health providers need to know how to gain trust and gather information from the patient, the patient's family, friends and relevant social relations, and to involve them in an effective treatment plan.

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Proxemics: Use of Space

Territoriality - the innate tendency to own space Density - the number of people within a given environmental space Distance - the means by which various cultures use space to communicate

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Therapeutic use of self is the instrument for delivery of care to clients in need of psychosocial intervention. Interpersonal communication techniques are the tools of psychosocial intervention.

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Intimate distance - the closest distance that individuals allow between themselves and other Personal distance -the distance for interactions that are personal in nature, such as close conversation with friends Social distanc - the distance for conversation with strangers or acquaintances Public distance - the distance for speaking in public or yelling to someone some distance away


Therapeutic relationships are goal- oriented and directed at learning and growth promotion.

Therapeutic Use of Self

Nonverbal Communication: Body Language Components of nonverbal communication

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Definition - ability to use ones personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions. Nurses must possess self-awareness, self-understanding, and a philosophical belief about life, death, and the overall human condition for effective therapeutic use of self.

Requirements for Therapeutic Relationship

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Rapport Trust Respect Genuineness Empathy

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Physical appearance and dress Body movement and posture Touch Facial expressions Eye behavior Vocal cues or paralanguage

THERAPEUTIC COMMUNICATION TECHNIQUES Using silence - allows client to take control of the discussion, if he or she so desires Accepting - conveys positive regard Giving recognition - acknowledging, indicating awareness Offering self - making oneself available Giving broad openings - allows client to select the topic Offering general leads - encourages client to continue Placing the event in time or sequence - clarifies the relationship of events in time Making observations - verbalizing what is observed or perceived Encouraging description of perceptions - asking client to verbalize what is being perceived Encouraging comparison - asking client to compare similarities and differences in ideas, experiences, or interpersonal relationships Restating - lets client know whether an expressed statement has or has not been understood Reflecting - directs questions or feelings back to client so that they may be recognized and accepted Focusing - taking notice of a single idea or even a single word Exploring - delving further into a subject, idea, experience, or relationship Seeking clarification and validation - striving to explain what is vague and searching for mutual understanding Presenting reality - clarifying misconceptions that client may be expressing Voicing doubt - expressing uncertainty as to the reality of clients perception Verbalizing the implied - putting into words what client has only implied Attempting to translate words into feelings - putting into words the feelings the client has expressed only indirectly Formulating plan of action - striving to prevent anger or anxiety escalating to unmanageable level when stressor recurs THERAPEUTIC COMMUNICATION AND PROBLEM-SOLVING Goals are often achieved through use of the problem-solving model:

Phases of a Therapeutic Nurse-Client Relationship Pre-interaction phase Orientation/Introductory Period Working Termination

INTERPERSONAL COMMUNICATION Interpersonal communication is a transaction between the sender and the receiver. Both persons participate simultaneously. In the transactional model, both participants perceive each other, listen to each other, and simultaneously engage in the process of creating meaning in a relationship, focusing on the patients issues and assisting them learn new coping skills.

Both sender and receiver bring certain preexisting conditions to the exchange that influence the intended message and the way in which message is interpreted.

CONTEXT OF THERAPEUTIC COMMUNICATION Values, attitudes, and beliefs.

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Social status

Example: attitudes of prejudice are expressed through negative stereotyping.

Culture or religion Cultural mores, norms, ideas, and customs provide the basis for ways of thinking.

High-status persons often convey their high-power position with gestures of hands on hips, power dressing, greater height, and more distance when communicating with individuals considered to be of lower social status.


Masculine and feminine gestures influence messages conveyed in communication with others.

Age or developmental level

Example: The influence of developmental level on communication is especially evident during adolescence, with words such as cool, awesome, and others.

The environment

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Identify the clients problem. Promote discussion of desired changes. Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively.

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Discuss alternative strategies for creating changes the client desires to make. Weigh benefits and consequences of each alternative. Help client select an alternative. Encourage client to implement the change. Provide positive feedback for clients attempts to create change. Help client evaluate outcomes of the change and make modifications as required.

Self-awareness and ability to collaborate with other health care providers are also skills that will facilitate accurate inquiry into the patient's true concerns and the context in which they occur.

REFERENCES 1. Epstein RM, Borrell F, Caterina M . Communication and mental health in primary care. In New Oxford Textbook of Psychiatry (Edrs. Gelder MG, Lpez-Ibor JJ, Andreasen NC), Oxford University Press, 2000.


To listen actively is to be attentive to what client is saying, both verbally and nonverbally.

Therapeutic Technique 1. Offering Self

Several nonverbal behaviors have been designed to facilitate attentive listening.

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S Sit squarely facing the client. O Observe an open posture. L Lean forward toward the client. E Establish eye contact. R Relax.


making self-available and showing interest and concern. I will walk with you 2. Active listening paying close attention to what the patient is saying by observing both verbal and non-verbal cues. Maintaining eye contact and making verbal remarks to clarify and encourage further communication. 3. Exploring Tell me more about your son 4. Giving broad openings What do you want to talk about today? 5. Silence Planned absence of verbal remarks to allow patient and nurse to think over what is being discussed and to say more. 6. Stating the observed

Process Recordings Written reports of verbal interactions with clients A means for the nurse to analyze the content and pattern of interaction A learning tool for professional development How do I give a Patient Feedback

Feedback is useful when it is descriptive rather than evaluative and focused on the behavior rather than on the client is specific rather than general is directed toward behavior that the client has the capacity to modify imparts information rather than offers advice. Nontherapeutic Communication Techniques

verbalizing what is observed in the patient to, for validation and to encourage discussion You sound angry 7. Encouraging comparisons y asking to describe similarities and differences among feelings, behaviors, and events. y Can you tell me what makes you more comfortable, working by yourself or working as a member of a team? 8. Identifying themes asking to identify recurring thoughts, feelings, and behaviors. When do you always feel the need to check the locks and doors? 9. Summarizing

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Giving reassurance - may discourage client from further expression of feelings if client believes the feelings will only be downplayed or ridiculed Rejecting - refusing to consider clients ideas or behavior Approving or disapproving - implies that the nurse has the right to pass judgment on the goodness or badness of clients behavior Agreeing or disagreeing - implies that the nurse has the right to pass judgment on whether clients ideas or opinions are right or wrong Giving advice - implies that the nurse knows what is best for client and that client is incapable of any self-direction Probing - pushing for answers to issues the client does not wish to discuss causes client to feel used and valued only for what is shared with the nurse Defending - to defend what client has criticized implies that client has no right to express ideas, opinions, or feelings Requesting an explanation - asking why implies that client must defend his or her behavior or feelings Indicating the existence of an external source of power - encourages client to project blame for his or her thoughts or behaviors on others Belittling feelings expressed - causes client to feel insignificant or unimportant Making stereotyped comments, clichs, and trite expressions - these are meaningless in a nurse-client relationship Using denial - blocks discussion with client and avoids helping client identify and explore areas of difficulty Interpreting - results in the therapists telling client the meaning of his or her experience Introducing an unrelated topic - causes the nurse to take over the direction of the discussion

reviewing the main points of discussions and making appropriate conclusions. During this meeting, we discussed about what you will do when you feel the urge to hurt your self again and this include 10. Placing the event in time or sequence asking for relationship among events. When do you begin to experience this ticks? Before or after you entered grade school? 11. Voicing doubt voicing uncertainty about the reality of patients statements, perceptions and conclusions. I find it hard to believe 12. Encouraging descriptions of perceptions asking the patients to describe feelings, perceptions and views of their situations. What are these voices telling you to do? 13. Presenting reality or confronting stating what is real and what is not without arguing with the patient. I know you hear these voices but I do not hear them. I am Lhynnelli, your nurse, and this is a hospital and not a beach resort. 14. Seeking clarification asking patient to restate, elaborate, or give examples of ideas or feelings to seek clarification of what is unclear. I am not familiar with your work, can you describe it further for me. I dont think I understand what you are saying. 15. Verbalizing the implied rephrasing patients words to highlight an underlying message to clarify statements. Patient: I wont be bothering you anymore soon. Nurse: Are you thinking of killing yourself? 16. Reflecting throwing back the patients statement in a form of question helps the patient identify feelings. Patient: I think I should leave now.

Effective communication is the core skill in mental health care in primary care settings.


Nurse: Do you think you should leave now? 17. Restating repeating the exact words of patients to remind them of what they said and to let them know they are heard. Patient: I cant sleep. I stay awake all night. Nurse: You cant sleep at night? 18. General leads using neutral expressions to encourage patients to continue talking. Go on You were saying 19. Asking question using open-ended questions to achieve relevance and depth in discussion. How did you feel when the doctor told you that you are ready for discharge soon? 20. Empathy recognizing and acknowledging patients feelings. Its hard to begin to live alone when you have been married for more than thirty years. 21. Focusing pursuing a topic until its meaning or importance is clear. Let us talk more about your best friend in college You were saying 22. Interpreting providing a view of the meaning or importance of something. Patient: I always take this towel wherever I go. Nurse: That towel must always be with you. 23. Encouraging evaluation asking for patients views of the meaning or importance of something. What do you think led the court to commit you here? Can you tell me the reasons you dont want to be discharged? 24. Suggesting collaboration offering to help patients solve problems. Perhaps you can discuss this with your children so they will know how you feel and what you want. 25. Encouraging goal setting asking patient to decide on the type of change needed. What do you think about the things you have to change in your self? 26. Encouraging formulation of a plan of action probing for step by step actions that will be needed. If you decide to leave home when your husband beat you again what will you do next? 27. Encouraging decisions asking patients to make a choice among options. Given all these choices, what would you prefer to do. 28. Encouraging consideration of options asking patients to consider the pros and cons of possible options. Have you thought of the possible effects of your decision to you and your family? 29. Giving information providing information that will help patients make better choices. Nobody deserves to be beaten and there are people who can help and places to go when you do not feel safe at home anymore. 30. Limit setting discouraging nonproductive feelings and behaviors, and encouraging productive ones. Please stop now. If you dont, I will ask you to leave the group and go to your room. 31. Supportive confrontation acknowledging the difficulty in changing, but pushing for action. I understand. You feel rejected when your children sent you here but if you look at this way 32. Role playing practicing behaviors for specific situations, both the nurse and patient play particular role. Ill play your mother, tell me exactly what would you say when we meet on Sunday. 33. Rehearsing asking the patient for a verbal description of what will be said or done in a particular situation. Supposing you meet these people again, how would you respond to them when they ask you to join them for a drink?. 34. Feedback pointing out specific behaviors and giving impressions of reactions. I see you combed your hair today. 1. 2. 3. 4. 5. 6. 7. 8. 9. 1. 2. 3. 4. 5. 6. 7. 8. 9.

35. Encouraging evaluation


asking patients to evaluate their actions and their outcomes. What did you feel after participating in the group therapy?. 36. Reinforcement giving feedback on positive behaviors. Everyone was able to give their options when we talked one by one and each of waited patiently for our turn to speak. Avoid pitfalls: Giving advise Talking about your self Telling client is wrong Entering into hallucinations and delusions of client False reassurance Clich Giving approval Asking WHY? Changing subject Defending doctors and other health team members.


Non-therapeutic Technique 1. Overloading


talking rapidly, changing subjects too often, and asking for more information than can be absorbed at one time. Whats your name? I see you like sports. Where do you live? 2. Value Judgments giving ones own opinion, evaluating, moralizing or implying ones values by using words such as nice, bad, right, wrong, should and ought. You shouldnt do that, its wrong. 3. Incongruence sending verbal and non-verbal messages that contradict one another. The nurse tells the patient Id like to spend time with you and then walks away. 4. Underloading remaining silent and unresponsive, not picking up cues, and failing to give feedback. The patient ask the nurse, simply walks away. 5. False reassurance/ agreement Using clich to reassure client. Its going to be alright. 6. Invalidation Ignoring or denying anothers presence, thoughts or feelings. Client: How are you? Nurse responds: I cant talk now. Im too busy. 7. Focusing on self responding in a way that focuses attention to the nurse instead of the client. This sunshine is good for my roses. I have beautiful rose garden. 8. Changing the subject introducing new topic inappropriately, a pattern that may indicate anxiety. The client is crying, when the nurse asks How many children do you have? 9. Giving advice telling the client what to do, giving opinions or making decisions for the client, implies client cannot handle his or her own life decisions and that the nurse is accepting responsibility. If I were you Or it would be better if you do it this way 10. Internal validation making an assumption about the meaning of someone elses behavior that is not validated by the other person (jumping into conclusion). The nurse sees a suicidal clients smiling and tells another nurse the patient is in good mood. Other ineffective behaviors and responses: Defending Your doctor is very good. Requesting an explanation Why did you do that? Reflecting You are not suppose to talk like that! Literal responses If you feel empty then you should eat more. Looking too busy. Appearing uncomfortable in silence. Being opinionated. Avoiding sensitive topics Arguing and telling the client is wrong Having a closed posture-crossing arms on chest


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Making false promises Ill make sure to call you when you get home. Ignoring the patient I cant talk to you right now Making sarcastic remarks Laughing nervously Showing disapproval You should not do those things.