THERAPEAUTIC COMMUNICATION

HOME
THERAPEUTIC COMMUNICATION

• T – ry expession
• R – eflection of words
• U – se of silence
• S – et Limits
• T – ime with client
 THERAPEUTIC
COMMUNICATIONS
• ORIENTATION
– Broad Opening
– Recognition
– Giving information
– Silence
– Offering Self – “Do you want me to sit
beside you?”
THERAPEAUTIC COMMUNICATION
THERAPEUTIC COMMUNICATIONS
• WORKING
– Focusing – “Let us discuss this topic more.”
– Exploring – “Tell me more about it.”
– Encourage Evaluation – “IS this what you want?”
– Reflecting – same idea
– Restating – same statement
– Verbalizing Implied – “Are you going to kill
yourself?”
– Seeking Clarification – “May you please repeat
that statement”
– General lead – “Please continue.”; “And then?”
– Limit setting – “Stop.”
– Interpreting – “Maybe that thing is very significant
to you.”
• TERMINATION
– Summarizing – “Let us now sum up.
You have stated earlier…etc.”
– “Do you have any questions?”
– “Our next therapy…”
– Look for changes in behavior
– Resistance is a common problem
 Therapeutic Communication
Techniques

• Accepting-indicating reception
– Eg.”Yes”
“I follow what you said”
Nodding..
 Broad Openings
• Allowing the client to take the initiative
in introducing the topic
– Eg. “is there something you’d like to talk
about?”
“Where would you like to begin?”
 Consensual Validation

• Searching for mutual understanding, for

accord in the meaning of the words
– Eg. “Tell me whether my understanding of it
agrees with yours”
“Are you using this word to convey that . .?”
 Encouraging Comparison

• Asking that similarities and differences be

noted
– Eg. “was it something like..?”
“Have you had similar experiences?”
 Encouraging Description of
Perceptions

• Asking the client to verbalize what he or

perceives
– Eg.”Tell me when you feel anxious”
“What is happening?”
‘What does the voice seem to be saying?”
 Encouraging Expression

• Asking client to appraise the quality of his

or her experience
– Eg. “what are your feelings in regard to..?”
“Does this contribute to your distress?”
 Exploring

• Delving further into a subject or idea

– Eg. “Tell me more about that.”
“Would you describe it more fully?”
“What kind of work?”
 Focusing

• Concentrating on a single point

– Eg. “This point seems worth looking at more
closely”
“Of all the concerns you’ve mentioned,
which is most troublesome?”
Formulating a Plan of Action
-Asking the client to consider kinds of
behavior likely to be appropriate in future
situations
– Eg. “What could you do to let your anger out
harmlessly?”
“Next time this comes up, what might you
do to handle it?”
 General Leads

• Giving encouragement to continue

– Eg. “Go on”
“And then?”
“Tell me about it”
 Giving Information

• Making available the facts that the client

needs
– Eg. “My name is…”
“Visiting hours are…”
“My purpose in being here is… “
 Giving Recognition

• Acknowledging, indicating awareness

– Eg. “Good morning, Mr. S…”
“You’ve finished your list of things to
do.”
“I noticed that you’ve combed your
hair”
 Making Observations

• Verbalizing what the nurse perceives

– Eg. “You appear tense..”
“I notice that your biting your lips”
 Offering Self

• Making oneself available

– Eg. “I’ll sit with you awhile”
“I’ll stay here with you”
“I’m interested in what you think”
 Placing Event in Time or
Sequence

Clarifying the relationship of events in time

Eg. “what seemed to lead up to…?
“Was this before or after?”
 Presenting Reality

• Offering for consideration that which is real

– Eg. “I see no one else in the room.”
“Your mother is not here; I am a nurse.”
 Reflecting

• Directing client actions, thoughts, and

feelings back to client
– Eg. Client: “Do you think I should tell the
doctor…? Nurse: “Do you think you should?”
 Restating

• Repeating the main idea expressed

– Eg. Client: I can’t sleep. I stay awake all
night.”
Nurse:You have difficulty sleeping.”
Client:”I’m really mad, and upset”
Nurse: You’re really mad and upset.”
 Seeking Information

• Seeking to make clear that which is not

meaningful or that which is vague
– “I’m not sure that I follow.”
“Have I heard you correctly?”
 Silence
• Absence of verbal communication, which
provides time for for the client to put
thoughts or feelings into words, regain
composure, or continue talking
– Eg. Nurses says nothing but continues to
maintain eye contact and conveys interest.
 Suggesting Collaboration

• Offering to share , to strive, to work with

the client for his or her benefit
– Eg. Perhaps you and I can discuss and
discover the triggers for your anxiety
 Summarizing

• Organizing and summing up that which

has gone before
– Eg. “Have I got this straight?”
 Translating into Feelings

• seeking to verbalize client’s feelings that

he or she expresses only indirectly
– Eg. Client: “I’m dead”
Nurse: “Are you suggesting that you feel
lifeless?”
 Verbalizing the Implied

• Voicing what the client has hinted at or

suggested
– Eg. Client: I cant’ talk to you or anyone. It’s a
waste of time.” Nurse: “Do you feel that no
one understands”
 Voicing Doubt

• Expressing uncertainty about the reality of

the client’s perceptions
– “Isn’t that unusual?”
“Really?”
“That’s hard to believe.”
Nontherapeutic Communication
Techniques
• Advising-telling the client what to do
Agreeing- indicating accord with the
client
– Eg. “I think you should….”
“That’s right”

Agreeing
 Indicating accord with the client
 “that’s right.” “I agree”
 Belittling Feelings expressed
• Misjudging the degree of the client’s
comfort
– Client: “I have nothing to live for..I wish I was
dead”
Nurse: “Everybody gets down in the dumps.”
 Challenging
• Demanding proof from the client
– “But how can you be President of the
Philippines?”
 Defending
• Attempting to protect someone or
something from verbal attack
– “This hospital has a fine reputation.”
 Disagreeing

• Opposing the client’s ideas

– Eg. “That’s wrong”
 Disapproving

• Denouncing the client’s behavior or ideas

– “That’s bad”
“I’d rather you wouldn’t”
 Giving approval
• Sanctioning the client’s behavior or ideas
– “ That’s good.” “I’m glad that..”
 Giving Literal Responses
• Responding to a figurative comment as
though it were a statement of fact
– Client: “They’re looking in my head with
television camera.”
Nurse: “Try not to watch television.”
 Indicating the existence of an
external source

• “What makes you say that?”

 Interpreting
• Asking to make conscious that which is
unconscious
– “What you really mean is..”
 Introducing an unrelated topic
• Changing the subject
– Client: “I’d like to die.”
Nurse: “did you have visitors last night?”
 Making stereotyped comments
• Offering meaningless cliches or trite
comments
• “Keep your chin up.”
• “Just have a positive outlook.”
 Probing
• Persistent questioning of the client
• “Now tell me about this problem. I need to
know.”
 Reassuring
• Indicating there is no reason for anxiety
• “Everything will be alright.”
 Rejecting
• Refusing to consider or showing contempt
for the client’s behavior, ideas
• “Let’s not discuss..”
 Requesting an explanation
• Asking the client to provide reasons for
thoughts, feelings, behaviors, events
• ‘Why do you think that?”
 Testing
• Appraising the client’s degree of insight
• “Do you know what kind of hospital this
is?”
 Using Denial
• Refusing to admit that a problem exists
• Client: “I am nothing.”
Nurse: “Of course, you’re something.”
NON-THERAPEUTIC COMMUNICATIONS
• Overloading – “blah, blah, blah”
• Underloading - ignoring
• Value Judgment – use of adjectives
• False Reassurance – “Don’t worry, you
will be fine later.”
• Focusing on Self – “I gave you meds
so you are now feeling good”
• Internal Validation – biased judgment
• Giving Advice – “If I were you, ill…
• Changing Subject -
 ROLES OF THE PSYCHIATRIC NURSE

• COUNSELOR-listens to the patient’s

verbalizations
• PARENT SURROGATE- assists the patients in
the performance of activities of daily living
• PATIENT ADVOCATE- enables the patient and
his relatives to know their rights and
responsibilities
• TEACHER- assists the patient to learn more
adaptive ways of coping
• TECHNICIAN-facilitates the performance of
nursing procedures
• THERAPIST-explores the patient’s needs,
problems and concerns through varied
therapeutic means
• SOCIALIZING AGENT- assists the patient to
feel comfortable with others
• WARD MANAGER- creates a therapeutic
environment

HOME
ASSESSING BEHAVIORAL SIGNS AND
SYMPTOMS
 ASSESSING BEHAVIORAL SIGNS AND
SYMPTOMS
• ALWAYS SEND MAIL THRU POST OFFICE
• A-Affect/Appearance
• S-Speech
• M-Motor Behavior/Mood/Memory
• T-Thought Process
• P-Perception
• O-Orientation
 General Appearance & Motor
Behavior
– What does the client look like? How is the client
dressed? Eye contact? Posture?
– Speech- clarity, modulation, pitch, speed, barriers
to communication

Motor Behavior:

• Echopraxia- repeating the movements of

another person
Ex. Everytime the nurse would move or
gesture with her hands, the client would copy
her gestures
• Echolalia-repeating the speech of another
person
Ex. The nurse said to the client, “Tell me your
name.” The client responded, “Tell me your
name, Tell me your name.”

• Waxy Flexibility- having one’s arms and legs

placed in a certain position and holding that
same position for hours.
Ex. The nurse lifted the client’s arm to check the
pulse, and the client left his arm extended in
the same position
• Parkinson-like symptoms- making
mask-like faces, drooling and having
shuffling gait, tremors and muscular
rigidity. Seen in people who are on
antipsychotic medication.
Ex. The nurse noticed that the client’s face
held no emotion. He walked very stiffly,
leaning forward, almost robot-like
Akathisia- displaying motor
restlessness, feeling of muscular
quivering; at its worst, patient is
unable to sit or lie quietly
Ex. The client’s leg kept jiggling up
and down when he talked to the
nurse. When his feet were still, his
arm would jiggle constantly during the
interview
 Thought Process
• Tangentiality-association disturbance in which
the speaker goes off the topic.
Ex. The nurse asks the client to talk more about
his family. The client continuously left the topic
and talked about boats, animals, his apartment
and so forth.
• Neologisms- words a person makes up that
only have meaning for the person himself, often
part of a delusional system
Ex. “I am afraid to go to the hospital because the
“norks” are looking for me there.”
• Looseness of association- thinking is illogical
and confused. Connections in thought are
interrupted.
Ex. “Can’t go to the zoo, no money, Oh…I have a
hat, these members make no sense, man…
What’s the problem?”
• Flight of ideas- constant flow of speech in
which the person jumps from one topic to
another in rapid succession. There is a
connection between topics although it is
sometimes hard to identify.
Ex. “Say babe, how’s it going…going to my
sister’s to get some money…money, honey,
you got any bread…bread and butter, staff of
life, ain’t life grand?”
• Blocking- sudden cessation of a thought in the
middle of a sentence. Person is unable to
continue his train of thought.
Ex. “I was going to get a new dress for the…I
forgot what I was going to say.”

• Perseveration- involuntary repetition of the

same thought, phrase or motor response to
different questions or situations:
Ex. N: How are you doing Harry?
P: Fine nurse, just fine.
N: Did you go for a walk?
P: Fine nurse, just fine.
• Confabulation - filling in a memory gap
with detailed believed by the teller to
maintain self-esteem
Ex.The nurse asked Harry who spent
the weekend at home, what he did that
weekend. “Well, I just came back from
California after signing a contract with
MGM for a film on the life of Roosevelt.
We have the most marvelous tour at the
studio…went to lunch with the director.
• Circumstantiality-before getting to the point
or answering a question, the person gets
caught up in countless details and
explanations
Ex.N: Where are you going for the weekend
Harry?
P: Well, I first thought of going to my
mother’s but that was before I remembered
that she was going to my sister’s. My sister is
having a picnic. She always has picnics at the
beach. But I don’t like the beach that she
goes to so I decided to some place else…I
finally decided to stay home.
• Word salad- mixture of words that has
no meaning
Ex. “I am fine…apple pie…no sale…
furniture store…take it slow…cellar
door”

• Clang Association- stringing together

of words because of their rhyming
sounds without regard to their meaning
Ex. “Good luck, buck, chuck, duck”
 Affect
• Flat-absence or near absence of
emotional reaction
• Blunted-severe reduction in emotional
reaction
• Inappropriate –disharmony between the
stimuli and the emotional reaction
• Bizarre-grimacing, mumbling, giggling
 HALLUCINATIONS
• A sense perception for which no external
stimuli exist

• Visual-seeing things that are not there

Ex. During alcohol withdrawal he kept shouting,
“I see snakes on the walls!”

• Auditory-Hearing voices when none is

present(most common)
Ex. “I keep hearing my mother’s voice telling
me I am bad. She died a year ago.”
• Olfactory-smelling smells that do not exist
Ex. “I smell my stomach rotting”

• Tactile- feeling touched sensations in the absence

of the stimuli
Ex. A paranoid man feels electrical impulses “ from
outer space” entering his body and controlling his
mind.

• Gustatory-experiencing taste in the absence of

stimuli
Ex. A paranoid woman tastes poison in her food
while eating at her son’s wedding
 DELUSIONS
• A false belief held to be true even with evidence to
the contrary.

• Persecution-the thought that one is being singled

out for harm by others
Ex. An intern believes that the chief of staff is plotting to
kill him to prevent the intern from becoming powerful

• Grandeur- the false belief that one is a very powerful

and important person
Ex. A newly admitted patient told the nurse that she was
muse of the United Nations and that she is the most
beautiful among women.
 Other areas to be assessed:
• History
• Orientation
• Memory
• Concentration
• Self-concept
• Judgment-the ability to make logical, rational decisions
• Insight-understanding of the nature of a problem
• Physiological needs

HOME
 LOSS AND GRIEVING
• GRIEF- refers to the subjective emotions
and affect that are a normal response to
the experience of loss
• ANTICIPATORY GRIEVING- when people
facing an imminent loss begin to grapple
with the very real possibility of the loss or
death in the near future
• DISENFRANCHISED GRIEF-grief over a
loss that is not or cannot be acknowledged
openly, mourned publicly or supported
socially
• COMPLICATED GRIEVING-when a
person is void of emotion, grieves for
prolonged periods, has expressions of grief
that seem disproportionate to the event
 LOSS
• Physiologic Loss
• Safe and Security Loss
• Love and Belongingness Loss
• Self-Esteem Loss
• Self-actualization Loss
 GRIEVING PROCESS
KUBLER-ROSS’s
• Denial
• Anger
• Bargaining
• Depression
• Acceptance

• Dysfunctional grieving – grieving which extends

from 4 to 6 weeks leading to CRISIS
 Interventions
• Explore client’s perception and meaning of the
loss
• Allow adaptive denial
• Assist client to reach out for and accept support
• Encourage client to examine patterns of coping
in past and present situation of loss
• Encourage client to care for himself
• Offer client food without pressure to eat
• Use effective communication

HOME
 CRISIS AND ITS MANAGEMENT
CRISIS
• situation that occurs when an individual’s
habitual coping ability becomes ineffective to
merit demands of a situation
• TYPES OF CRISES:
• MATURATIONAL / DEVELOPMENTAL
– Normal expected crisis that runs through age
• SITUATIONAL
– Unexpected and sudden event in life
• ADVENTITIOUS
– Calamities, war
 Characteristics of a Crisis state
• Highly individualized
• Lasts for 4-6 weeks
• Self-limiting
• Person affected becomes passive and
submissive
• Affects a person’s support system
 PHASES OF A CRISIS
• Pre-crisis: State of equilibrium
• Initial Impact (may last a few hours to a few days):
High level of stress, helplessness, inability to
function socially
• Crisis (may last a brief or prolonged period of
time): Inability to cope, projection, denial,
rationalization
• Resolution: attempts to use problem-solving skills
• Post crisis: may have OLOF or may have
symptoms of neurosis, psychosis
 CRISIS MANAGEMENT
• Role of the nurse is to return the client to
its pre-crisis state by assisting and guiding
them until they achieved their OLOF.
• Goal: to enable patient to attain an OLOF
• Nurse’s Primary Role: Active and Directive
 Steps in Crisis Intervention
• Identify the degree of disruption the client is
experiencing
• Assess the client’s perception of the event
• Formulate nursing diagnoses
• Involve the patient and family if applicable with
planning
• Implement interventions- new and old coping
mechanisms
• Evaluate-reassessment, reinforcement
TYPES OF THERAPIES

Treatment Modalities
Individual Psychotherapy
Milieu Therapy
 Milieu Therapy
• Total environment has an effect on the
individual’s behavior
• Components
– Physical Environment
– Interpersonal relationships
– Atmosphere of safety, caring, and mutual
respect
– For alcoholics
PROGRAMS FOR MILIEU SHOULD HAVE:
• an emphasis on group and social interaction
• No rules and expectations mediated by peer
pressure
• A view of patients’ roles as responsible human
beings
• An emphasis on patients’ rights for involvement
in setting goals
• Freedom of movement and informality of
relationships with staff
• Emphasis on interdisciplinary participation
• Goal-oriented, clear communication
Group Therapy
 Group Therapy
• Number of people coming together, sharing a
common goal, interest or concern, staying
together and developing relationships
• For PTSD and Alcoholics
• Phases
– Orientation-Purpose of the group is stated, Objectives
and expectations are laid out
– Working -Leaders role is to keep the group focused,
Support for each other to attain group goals
– Termination-Leader acknowledges each member’s
contribution and experience as a whole
–  Members prepare for separation
 Characteristics of Group Therapy
• Universality  “You are not alone”
• Instilling hope and inspiration
• Developing social skills by interacting with
one another
• Feeling of acceptance and belonging
• Altruism “Giving of one’s self”
• Psychoanalytically oriented group therapy
• Psychodrama
• Family therapy
Assumption of Family Therapy
– For alcoholic and schizophrenic
 Assumption of Family Therapy
• Client: Whole family
• Concepts:
– The family is the most fundamental unit of the society.
– Adaptive or maladaptive patterns of behavior are learned from
the family
– Dysfunction in the family = dysfunction in the individual
• Purpose
– Improve relationships among family members
– Promote family function
– Resolve family problems
 OTHER TYPES OF
THERAPIES
• SUPPORT GROUPS
– For those with AIDS, Mother-Against-Drug
Dependence

• SELF-HELP GROUPS
– Alcoholic Anonymous
RULES FOR PSYCHOTHERAPEUTIC
MANAGEMENT
• Provide support, treat patients with respect
and dignity
• Do not place patients in situations wherein
they will feel inadequate or embarrassed
• Treat patients as individuals
• Provide reality testing
• Handle hostility therapeutically
• Provide psychopharmacologic treatment

HOME
 BEHAVIORAL THERAPIES
Treatment Modalities
BEHAVIORAL THERAPY
• Pavlov’s Classical Conditioning
– All behavior are learned

• B.F. Skinner’s Operational Conditioning

– Reinforcements
 BEHAVIORAL THERAPY

• Behavioral Modification – Substance

Abuse

• Systematic Desensitization - Phobia

 ATTITUDE THERAPY
Treatment Modalities

ATTITUDE THERAPY
1. Paranoid – Passive Friendliness
2. Withdrawn – Active Friendliness
3. Depressed / Anorexia – Kind Firmness
4. Manipulative – Matter of Fact
5. Assaultive – No Demand
6. Anti-social – Firm, consistent
HOME
 PSYCHOSOMATIC
THERAPY
Treatment Modalities

HOME
Electroconvulsive Therapy
 Electroconvulsive Therapy
• Effective in most affective disorders
• The induction of a grandmal seizure in the
brain.
• Abnormal firing of neurons in the brain
causes an increase in neurotransmitters
• Number of Treatments: 6-12 ,3 times a
week, about .5-2seconds
• Unilateral or bitemporal
 Electroconvulsive Therapy
Indications:
• Patients who require rapid response
• Patients who cannot tolerate pharmacotherapy or
cannot be exposed to pharmacotherapy
• Patients who are depressed but have not responded to
multiple and adequate trials of medication
Electroconvulsive Therapy
Preparations for ECT:
• Pretreatment evaluation and clearance
• Consent
• NPO from midnight until after the treatment
• Atropine Sulfate-to decrease secretions,
succinylcholine (Anectine)- to promote muscle
relaxation, Methohexital Sodium(Brevital)-
anesthethic
• Empty bladder
• Remove jewelry, hairpins, dentures and other
accessories
• Check vital signs
• Attempt to decrease patient’s anxiety
 Electroconvulsive Therapy
Care after ECT:
• O2 therapy of 100% until patient can breathe unassisted
• Monitor for respiratory problems, gag reflex
• Reorient patient
• Observe until stable
• Careful documentation.
• Male erectile dysfunction

OTHER THERAPIES
NEUROSURGERY