Therapeutic Communication Techniques

in Psychiatric Nursing
Responsible, Assertive, and Caring Interactions in Practice

Sheila L. Videbeck, PhD, RN

THERAPEUTIC RELATIONSHIPS
• Primary mode of implementing interventions in psychiatric nursing • Phases – Orientation – Working – Termination – Students may have a preinteraction phase

EFFECTIVE NURSE BEHAVIOR • • • • Active listening Focus on client Self-awareness Professional caring
– Genuine – Interest – Acceptance

INEFFECTIVE NURSE BEHAVIOR • Excessive self-disclosure • Anxiety • Distracting nonverbal 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 actions – 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 COMMUNICATIONS

• Purposes and Goals
– Expressing feelings – Clarifying problems – Addressing client concerns – Resolving problems – Role playing alternatives

VERBAL SKILLS & BEHAVIOR
• Specific clear messages • Therapeutic communication techniques • Finding and responding to cues • Open-ended vs. close- ended questions • Directive vs. nondirective interaction

NONVERBAL SKILLS & BEHAVIOR
• • • • • • • Distance Posture Eye contact Facial expression Tone and volume of voice Use of touch Involvement in activity

PRINCIPLES GUIDING THERAPEUTIC COMMUNICATIONS
• Establish trust • Be honest • Acceptance of person, not necessarily behavior • Be empathetic, not sympathetic • Nonjudgmental attitude, be matter-offact • Avoid usual social responses or cliches • Client usually talks more than nurse

NONTHERAPEUTIC RESPONSES or QUESTIONS
• Giving approval/disapproval or advice • Use of good, bad, right, 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 doubt – Translating into feelings

ADVANCED or SPECIALIZED TECHNIQUES
• Clients with dementia and psychotic symptoms
– Avoid correcting misperceptions if possible – Going along – Distraction and diversion – Promoting interaction and involvement

RESPONSES TO INAPPROPRIATE BEHAVIOR

• Giving feedback • Limit-setting • Confronting incongruencies • Promoting appropriate behavior

ANGER AND HOSTILITY
• Verbal de-escalation techniques
– Ask what client wants or needs – Avoid use of “No” – Offer alternatives encourage to verbalize feelings – Offer prn medication 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

EXAMPLES OF ASSERTIVE COMMUNICATION

• • • • •

Use of “I…” statements Avoid use of “You..” statements Be specific, avoid generalizations Make clear statements Validate other person’s feelings or position • Include statement of the problem of conflict • Include outcome that is desired

FACTORS INFLUENCING THERAPEUTIC COMMUNICATIONS

• Cultural • Spiritual • Individual personal beliefs

NCLEX-RN
Communication Questions

• Context is a variety of settings, not just mental health • Principles used to answer questions are the same as those used to respond to clients • Assess context of situation and desired outcome • Not always I therapeutic and 3 nontherapeutic statements

Current Developments in Nursing
• In a variety of health care settings
– Electronic medical records – Hand held devices in the clinical setting – Evidence-based practice – Use of nurse practitioners and physician assistants as primary care providers

TRENDS IN PSYCHIATRIC PRACTICE
• • • • Medication for children and adolescents ADHD vs. Bipolar disorder Increased incidence of autism Early identification and treatment for schizophrenia • Out-patient commitments – forced medication vs. individual rights in the community • Use of restraint and seclusion • Increased incidence of mental illness among incarcerated population

THERAPEUTIC COMMUNICATION TECHNIQUES
Dr. Sheila Videbeck

THERAPEUTIC COMMUNICATION TECHNIQUES

Using silence
.... utilizing absence of verbal communication.

• Silence often encourages the client to verbalize if it is an interested, expectant silence. It gives the client time to organize his or her thoughts and to direct the topic of the interaction. The client can focus on the issues that are most pressing. Much nonverbal communication occurs during periods of silence. The nurse needs to be aware of his or her nonverbal behavior and what is being conveyed to the client. The client's nonverbal behavior may indicate mood, feelings, thoughtfulness, or any variety of behaviors.

THERAPEUTIC COMMUNICATION TECHNIQUES

Accepting
... giving indication of reception. "Yes." "I follow what you said." Nodding • An accepting response, such as "I'm with you" or "I follow what you're saying" indicates that the nurse has heard and has followed the trend of thought. Accepting does not indicate agreement, but is non-judgmental in nature. The nurse should not use accepting if the client's meaning is unclear. Facial expression, tone of voice and so forth must also convey acceptance, or the words will lose their meaning.

THERAPEUTIC COMMUNICATION TECHNIQUES

Giving recognition
... .Acknowledging, indicating awareness. "Good morning, Mr. S ... " “You've finished your list of things to do." "I notice that you've combed your hair." • Greeting the client by name, indicating awareness of change, noting efforts the client has made - all these show that the nurse recognizes the client a person, as an individual. Such recognition does not carry the notion of value, that is, of being "good" or "bad". The nurse is simply stating aloud some thing that is a fact.

THERAPEUTIC COMMUNICATION TECHNIQUES Offering self
.... making one's self available. "I'll sit with you awhile." "I'll stay here with you." "I'm interested in what you're thinking." • Sometimes clients are unable to verbalize or make themselves understood. Or the client may not be ready to talk. The nurse can offer his or her presence, interest, and desire to understand. It is important that this offer is unconditional, that is, the client doesn't have to respond verbally to get the nurse's attention.

THERAPEUTIC COMMUNICATION TECHNIQUES
Giving broad openings
.... allowing the client to take the initiative in introducing the topic. “Is there something you'd like to talk about?" "What are you talking about?“ "Where would you like to begin?" • Broad openings make explicit the idea that the client has the lead in the interaction. For the client who is hesitant about talking, broad openings may stimulate him or her to take the initiative.

Offering general leads
.... giving encouragement to continue. "Go on." "And then?" "Tell me about it." • General leads indicate the nurse is listening and following what the client is saying without taking away the initiative for the interaction. It encourages the client to continue if he or she is hesitant or uncomfortable about the topic.

THERAPEUTIC COMMUNICATION TECHNIQUES
Placing the event in time or sequence
.... clarifying the relationship of events in time. “What seemed to lead up to ... ?" "Was this before or after..?" "When did this happen?" • Putting events in proper sequence helps both the nurse and the client to see them in perspective. The client may gain insight into cause-and -effect behavior and consequences, or likewise help the client to see that perhaps some things are not related to each other. The nurse may gain information about recurrent patterns or themes in the client's behavior or relationships.

Making observations
.... verbalizing what is perceived. "You appear tense." "Are you uncomfortable when you ... ?" "I notice that you're biting your lip.'.' • The nurse often makes observations which can be called to the client's attention. The client may be showing signs of anxiety of which he or she is unaware. Or the client may have begun to hallucinate. Or the nurse may be uncertain what the client is thinking or feeling. Making an observation gives the client the opportunity to agree or disagree with the nurse's observation. The client might say, "Yes, now that you mention it, I am feeling anxious." Or the client might say "No, I'm not aware of being anxious.'''' Either way, the nurse and client can then discuss how the client is feeling.

THERAPEUTIC COMMUNICATION TECHNIQUES
Encouraging description of perception
.... Asking the client to verbalize what he or she perceives. "Tell me when you feel anxious." "What is happening?" "What does the voice seem to be saying?" • If the nurse is to understand the client, he or she must come to see things from the client's perspective. The client should feel free to describe his perceptions to the nurse. Nurses sometimes believe that encouraging the client to describe his or her ideas will fix them more firmly in his or her mind. This may be especially difficult for the nurse if the ideas are suicidal or aggressive in nature. However, the client may feel less inclined to act on ideas once they are spoken aloud.

Encouraging comparison
… Asking that similarities and differences be noted. "Was this something like…” "Have you had similar experiences?" • Comparing ideas or experiences or relationships brings out many recurrent themes. The client benefits from making these comparisons. He or she might recall coping strategies that were effective in the past, and can be used again. Or the client might recall having survived a similar situation, so is ready to believe that things might improve again.

THERAPEUTIC COMMUNICATION TECHNIQUES
Restating .... repeating the main idea expressed. Client: "I can't sleep. I stay awake all night." Nurse: "You have difficulty sleeping." Client: "I'm really. I'm so upset." Nurse: "You're really mad and upset." • What the client has said is repeated in approximately or nearly the same words used by the client. This restatement lets the client know that the idea was communicated effectively. The client is encouraged to continue. Or if the client has been misunderstood, he or she can clarify their thoughts.

Reflecting .... directing questions, feelings, or ideas back to the client. 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 causes you to feel angry." Reflection encourages the client to recognize and accept his or her own feelings. The nurse indicates that the client's point of view has value, and that the client has the right to have opinions, make decisions, and think independently.

THERAPEUTIC COMMUNICATION TECHNIQUES Focusing
.... concentrating on a single point.
"This point seems worth looking at more closely. "Of all the concerns you've mentioned, which one is most troublesome?" • The client can be encouraged to concentrate his or her energies on a single point, and may avoid being overwhelmed by a multitude of factors or problems. It is also a useful technique when the client jumps from on topic to another.

Exploring
.... delving further into a subject or idea.
"Tell me more about that." "Would you like to describe it more fully?" "What kind of work?" • When clients tend to deal with topics in a superficial manner, exploring can help them examine the issue more fully. Any problem or concern can be better understood if explored in depth. However, if the client states an unwillingness to explore a subject, the nurse must respect his or her wishes.

THERAPEUTIC COMMUNICATION TECHNIQUES
Giving information
.... making available the facts the client needs.
"My name is ... " "Visiting hours are ... " "My purpose in being here is ... " "I'm taking you to ... " • Informing the client of facts increases his or her knowledge about a topic or lets the client know what to expect. The nurse is functioning as a resource person. Giving information can also build trust with the client.

Seeking information
... seeking to make clear that which is not meaningful or that which is vague.
"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?" • Clarification should be sought throughout interactions with clients. This can help the nurse avoid making assumptions that understanding has occurred when it has not. It helps the client articulate thoughts, feelings and ideas more clearly.

THERAPEUTIC COMMUNICATION TECHNIQUES
Presenting reality
.... offering for consideration that which is real.

"I see no one else in the room." "That sound was a car backfiring." "Your mother is not here; I'm a nurse." • When it is obvious that the client is misinterpreting reality, the nurse can indicate that which is real. The nurse does this not by way of arguing with the client or belittling the client's own experience, but rather by calmly and quietly expressing the nurse's own perceptions or the facts of the situation. The intent here is to indicate an alternative line of thought for the client to consider, not to "convince" the client that he or she is wrong.

Voicing doubt
... expressing uncertainty about the reality of the client's perceptions.

"Isn't that unusual?" "Really?" "That's hard to believe." • Another means of responding to distortions of reality is to express doubt. Such expression permits the client to become aware that others do not necessarily perceive events in the same way or draw the same conclusions as the client does. This does not mean the client will alter this point of view, but at least the client will be encouraged to re-consider or re-evaluate what has occurred. The nurse has neither agreed nor disagreed, however, the nurse has not let the misinterpretations and distortions of reality pass without comment.

THERAPEUTIC COMMUNICATION TECHNIQUES
Seeking consensual validation
... searching for mutual understanding, for accord in the meaning of the words. "Tell me whether my understanding of it agrees with yours." "Are you using this word to convey the idea that ... ?"
• For verbal communication to be meaningful, it is essential that the words being used have the same meaning for both (or all) participants. The client and the nurse may use the same phrase, but it could have different meaning for both of them. In addition, it is important to avoid slang or popular words or phrases that are more easily misunderstood.

Verbalizing the implied
.... voicing what the client has hinted at or suggested.
Client: "I can't talk to you or anyone. It's a waste of time." Nurse: "Is it your 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?"
• Putting into words what has been implied or said indirectly tends to make the discussion less obscure. The nurse should be as direct as possible without being unfeelingly blunt or obtuse. The client may have difficulty communicating in a direct manner. The nurse should take care to express only what is fairly obvious; otherwise the nurse may be jumping to conclusions or interpreting the client's communication.

THERAPEUTIC COMMUNICATION TECHNIQUES
Encouraging expression
.... asking the client to appraise the quality of his or her experiences. "What are your feelings in regard to ... ?" "Does this contribute to your discomfort?" • The client is asked to consider people and events in the light of his or her own values. The client is encouraged to make his or her own appraisal rather than accepting the opinions of others.

Attempting to translate into feelings
... Seeking to verbalize feelings that are only expressed indirectly. 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." • Often what the client says, when taken literally, seems meaningless or far removed from reality. To understand, the nurse must concentrate on what the client might be feeling in order to express him or herself in this manner.

THERAPEUTIC COMMUNICATION TECHNIQUES
Suggesting collaboration
.... offering to share, to strive, to work together with the client for his or her benefit.
"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 your looking for."
• The nurse seeks to offer the client a relationship in which the client can identify problems in living with other, grow emotionally, and improve the ability to form satisfactory relationships. The nurse offers to do things with the client, rather than doing things for the client.

Summarizing
.... organizing and summing up that which has gone before.
"Have I got this straight?" "You've said that..." "During the past hour you and I have discussed ... "
• Summarization seeks to bring out the important points of the discussion and to increase the awareness and understanding of both participants. It omits the irrelevant and organizes the pertinent aspects of the interaction. It allows both the nurse and client to depart with the same ideas in mind and provides the sense of closure at the completion of each discussion.

THERAPEUTIC COMMUNICATION TECHNIQUES
Encouraging formulation of a plan of action
.... asking the client to consider kinds of behavior likely to be appropriate in future situations.
"What could you do to let your anger out harmlessly?" "Next time this comes up, what might you do to handle it?"
• It may be helpful for the client to plan what he or she might do to handle various interpersonal situations that arise in the future. Talking over the situation and making defmite plans increases the likelihood that the client will cope more effectively in similar situations. Any plans that are made must be those of the client, not the nurse. In addition, the nurse and client might roleplay the situation so the client can put the plan into practice.

NON-THERAPEUTIC RESPONSES

NON THERAPEUTIC RESPONSES
Reassuring
.... indicating that there is no cause for anxiety. "I wouldn't worry about that." "Everything will be all right." "You're coming along just fine." • To attempt to dispel the client's anxiety by implying that there is not sufficient reason for concern is to completely devalue the client's feelings. Vague reassurance without accompanying facts is meaningless to the client.

Giving approval
... Sanctioning the client's behavior or ideas. "That's good." "I'm glad that you ... "
• Saying what the client thinks or feels is "good" , implies that the opposite is "bad". Approval, then, tends to limit the client's freedom to think, speak, or act in a certain way. This can lead to the client's acting in a particular way just to please the nurse.

NON THERAPEUTIC RESPONSES Rejecting
.... refusing to consider or showing contempt for the client's ideas or behavior.
"Let's not discuss ... " "I don't want to hear about...."
• When any topic is rejected, it is closed off from exploration. In turn, the client may feel rejected by the nurse along with his or her ideas.

Disapproving
.... denouncing the client's behavior or ideas.
"That's bad.' "I'd rather you wouldn't ..... "
• Disapproval implies that the nurse has the right to pass judgment on the client's thoughts and actions. It further implies that the client is expected to please the nurse.

NON THERAPEUTIC RESPONSES
Agreeing
.... indicating accord with the client.
"That's right." • "I agree." While approval indicates that the client is "good" rather than "bad", agreeing indicates that the client is "right" rather than "wrong". This gives the client the impression that he or she is "right" because of agreement with the nurse. Opinions and conclusions should be exclusively the client's. When the nurse agrees with the client, there is no opportunity for the client to change his or her mind without being "wrong" .

Disagreeing
.... opposing the client's ideas.
"That's wrong." "I definitely disagree with .. ." • "I don't believe that." Disagreeing implies the client is "wrong". Consequently, the client feels as if he or she has to defend their point of view or ideas.

NON THERAPEUTIC RESPONSES
Advising
.... telling the client what to do. "I think you should ... " "Why don't you ... ?"

Giving advise implies that only the nurse knows what is best for the client, instead of the client him- or herself.
.... persistent questioning of the client. "Now tell me about. .. " "Tell me your life history."

Probing

Probing tends to make the client feel used or invaded. Clients have the right not to talk about issues or concerns if they choose. Pushing and probing by the nurse will not encourage the client to talk.

NON THERAPEUTIC RESPONSES
Challenging
... demanding proof from the client. "But how can you be President of the United States?" "If you're dead, why is your heart beating?“ • Often, the nurse feels that if he or she can challenge the client to prove unrealistic ideas, the client will realize there is no "proof', and will then recognize reality. Actually, challenging causes the client to become defensive, and the client defends the delusions or misperceptions more strongly than before.

Testing
... appraising the client's degree of insight. "Do you stilI have the idea that. .. " "Do you know what kind of hospital this is?" • These types of questions are forcing the client to try to recognize their problems. Having the client acknowledge that he or she doesn't know these things meets the need of the nurse, but is not helpful for the cIient.

NON THERAPEUTIC RESPONSES
Defending
... Attempting to protect someone or something from verbal attack.

"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."
• Defending what the client has criticized implies that the client has no right to express his or her impressions, opinions, or feelings. Telling the client that his criticism is unjust or unfounded does not change the client's feelings.

Requesting an explanation
... asking the client to provide reasons for thoughts, feelings, behaviors, and events. "Why do you think that?" "Why do you feel this way?" "Why did you do that?"

There is a difference between asking the client to describe what is occurring or has taken and asking him to explain why. More often than not a "why" question has an intimidating effect. In addition, the client is not likely to know "the reason why" and may become defensive trying to explain him or herself.

NON THERAPEUTIC RESPONSES
Indicating the existence of an external source
.... Attributing the source of thoughts, feelings, and behavior to others, or to outside influences.
"What makes you say that?" "Who told you that you were Jesus?" "What made you do that?" • The nurse can ask, "What happened?" or "What events led you to draw such a conclusion?" But to question "What made you think that?" seems to imply that the client was made or compelled to think in a certain way. Usually, the nurse does not intend to suggest that the source is external, but that is often the client's interpretation.

Belittling feelings expressed
.... misjudging the degree of the client's discomfort.
Client: "I have nothing to live for. .. I wish I was dead." Nurse: "Everybody gets down in the dumps." OR "I've felt that way sometimes." • When the nurse tries to equate the intense and overwhelming feelings expressed by the client to "everybody" or the nurse's own feelings, the nurse implies that the discomfort is temporary, mild, self-limiting or not important. The client is focused on his or her own worries and feelings - hearing about the problems or feelings of others is not helpful.

NON THERAPEUTIC RESPONSES
• • • • • • • • • • • • • Making stereotyped comments .... offering meaningless clichés or trite expressions. "Nice weather we're having." "I'm fine and how are you?" "It's for your own good." "Keep your chin up." "Just listen to your doctor and take part in activities - you'll be home in no time." Social conversation contains a lot of clichés or meaningless chitchat. Such comments are of no value in the nurse-client relationship. Any automatic responses will lack the nurse's considered reflection or thoughtfulness. Giving literal responses ... responding to a figurative comment as though it were a statement of fact. Client: I'm an Easter egg." Nurse: "What color?" OR "You don't look like one." Client: "There looking in my head with a television camera.” Nurse: "Try not to watch television." OR "With what channel?" Often, the client is at a loss to describe his or her feelings, so comments like this are the best the client can muster. Usually it is helpful for the nurse to focus on the client's feelings in response to statements such as these.

NON THERAPEUTIC RESPONSES
Using denial.
... refusing to admit that a problem exists.
Client: "I'm nothing." Nurse: "Of course you're something. Everybody's something." Client: "I'm dead." Nurse: "Don't be silly."

The nurse is denying the client's feelings or the seriousness of the situation by dismissing the comments without attempting to discover the feelings or meaning behind such statements.

Interpreting
... seeking to make conscious that which is unconscious, telling the client the meaning of his or her experience.
"What you really means is ... " "Unconsciously you're saying ... "

The client's thoughts and feelings are his or her own, not to be interpreted by the nurse, or interpreted for hidden meaning. Only the client can identify or confirm the presence of feelings.

NON THERAPEUTIC RESPONSES
Introducing an unrelated topic
... changing the subject.
Client: "I'd like to die." Nurse: "Did you have visitors this weekend?" • The nurse takes the initiative for the interaction away from the client. This is usually done because the nurse is uncomfortable, doesn't know how to respond, or has a topic that the nurse wants to discuss.

BEHAVIORAL APPROACHES
The following approaches may be helpful to nursing students during initial contacts with psychiatric clients. With all clients, avoid becoming the “only one” the client will talk to about feelings or problems. This can be flattering, but it is manipulative on the part of the client. Let the client know that pertinent information will be communicated to other team members. DO NOT promise to keep information a secret as a way of obtaining information, or for any other reason.

BEHAVIORAL APPROACHES
Depressed, withdrawn clients
Working with depressed, withdrawn clients can be difficult and challenging. These clients can have overwhelming, hopeless feelings, and they can display helplessness and dependency. Spending time developing rapport with a depressed client will involve periods of silence as these clients often have trouble expressing themselves. Use a moderate tone of voice and avoid being overly cheerful. Observe carefully for any cues or expressions of suicidal ideation or intent. Also be alert to any sudden mood swings. Any suspicion about suicide should be reported to the team/caregiver immediately to assure safety. To avoid becoming frustrated with depressed or withdrawn clients, expect slow, gradual improvement. Trying to force clients to progress too rapidly is unrealistic and further lowers the client’s self-esteem.

BEHAVIORAL APPROACHES
Manic, hyperactive clients
Manic, hyperactive clients have extremely labile moods. They may be hostile, angry, sarcastic, and critical one moment, and playful, humorous, and witty the next. They may express grandiose schemes and ideas, or tell unbelievable stories. A calm, low-key matter-of-fact approach is effective in de-escalating manic behavior. While clients may be funny or entertaining to observe, encouragement of their antics by staff or students will escalate the client’s behavior, causing more outlandish behavior. Later, when the client has improved, he or she may feel shame or embarrassment about their behavior. Decreasing stimulation and distracting these clients to less provocative topics and activities can help calm manic behavior.

BEHAVIORAL APPROACHES
Manipulative, demanding behavior
Many clients, especially those with personality disorders, attempt to manipulate staff and students to serve their own purposes. Problem behaviors with these clients include denial of problems, lack of insight, playing staff against on another, attempting to gain special treatment or privileges, and inappropriate attention seeking. It is imperative that the entire team present a consistent approach with these clients. Limits must be stated clearly and reinforced in a nopunitive manner. Do not attempt to be liked, popular, or the favorite of these clients. Withdraw your attention if the client begins saying “you are the only one I can talk to” or “you are the only one who understands”. Be kind but firm with the client, presenting the idea that all team members are involved in his care.

BEHAVIORAL APPROACHES Delusional clients
Delusions are fixed, false ideas that have no basis in reality, yet cannot be changed by information or logical reasoning. It is important to remember that delusions are not within the client’s conscious control. When interacting with a delusional client, never convey the idea that you accept the delusion as reality. Do not argue with the client, but present a factual account of the situation as you see it.

BEHAVIORAL APPROACHES
Hallucinating clients
Hallucinations are perceptions involving any of the senses that have no basis in reality. Auditory and visual hallucinations are most common in psychiatric clients. It is important to remember that hallucinations seem very real to the client, and can be extremely disturbing. However, when interacting with the client who is hallucinating, avoid conveying that the hallucinations are real. Do not converse with the voices, or otherwise reinforce the client'’ belief in the hallucinations as reality. Communicate verbally in direct, concrete, specific terms and avoid gesturing or abstract ideas that may be misinterpreted by the client. Focus on the feeling surrounding the hallucination. “The voices you are hearing must be very frightening for you” is a therapeutic response to a client with auditory hallucinations. Remember, clients frequently act on command hallucinations (voices giving orders) and close observation is important for the safety of the client and others.

BEHAVIORAL APPROACHES
Paranoid clients
Paranoid clients are extremely suspicious and believe people are against them. They have low self-esteem and lack trust in others. To build rapport with a paranoid client, be non-threatening and answer the client’s questions with little or no hesitation. Do not be secretive with these clients, and be aware of their presence around the staff when other clients are being discussed. Do not whisper in the presence of a paranoid client. Avoid joking (they will not see the humor) and avoid discussion of controversial issues. Do not argue with the client about paranoid delusions, but do interject reality when appropriate and do not give any indication that you believe as the client does. Do not touch paranoid clients without a thorough explanation, such as “I’m going to take your blood pressure and pulse.” Sudden of personal touch may be misinterpreted as an aggressive or sexual overture.

BEHAVIORAL APPROACHES
Hypersexual, seductive clients
Some clients may display hypersexual or seductive behavior toward other clients, students, or staff. With these clients, it is important to maintain a non-judgmental attitude and acknowledge that sexual feelings and needs are important while setting limits on sexual acting-out or inappropriate behavior. When dealing with seductive clients, avoid placing yourself in a potentially compromising position, such as being alone with the client in a secluded area or the client’s room. Recognize that the seductive behavior is a way of testing limits, getting attention, or expressing anger. Confront the client about the inappropriate behavior and let him or her know the behavior is unacceptable, seeking assistance from instructor or staff if needed. Anytime this type of behavior occurs, it should be reported to the team or caregiver, so it can be dealt with consistently and therapeutically.

BEHAVIORAL APPROACHES
Aggressive, violent clients
Avoid isolating yourself or being alone with a client who has a potential for violence. Remember that a history of violence is the best predictor of future violent episodes. If a client becomes aggressive while you are with him or her, give the client space and keep some distance away – DO NOT move closer to the client. Do not turn your back on the client, but slowly and deliberately leave the area. Use a calm, quiet tone of voice, and encourage the client to verbalize feelings instead of acting them out. Avoid threatening the client or expressing a judgmental, punitive attitude as this will set up a power struggle and result in increased agitation. Call for nursing staff assistance as soon as possible if a client becomes increasingly agitated or begins acting out in any way.

TEST YOUR KNOWLEDGE

1. Which of the following statements would be an empathetic response in a client interaction?
A. “You must have been embarrassed when your father yelled at you in the grocery store.” B. “You really should find your own housing and get out of the situation with your father.” C. Well, It sounds like your father has difficulty controlling his temper.” D. “Why do you think your father chose that time and place to yell at you?”

2. The client says to the nurse, “I have special powers because I am the mother of God. I can heal everyone in the hospital.” The nurse’s best response would be:
A. “That sounds interesting. What can you do?” B. “It would be unusual for anyone to have that kind of power.” C. “You could not heal everyone. No one has that much power.” D. “Well, you can certainly try.”

3. During the admission interview, the nurse asks the client what led to their hospitalization. The client responds, “They lied about me. They said I murdered my mother. You’re the killers. You all killed my mother. She died before I was born.” The best initial response by the nurse would be: A. “I just saw your mother. She’s fine.” B. “You’re having very frightening thoughts.” C. “We’ll put you in a private room until you’re in better control.” D. “If your mother died before you were born, you wouldn’t be here.”

4. 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.

5. Client: “I was so upset about my sister ignoring me when I was talking about being ashamed.” Nurse: “How are your stress reduction classes going?”
This is a nontherapeutic response because the nurse has:

A. Changed the topic. B. Offered advice. C. Challenged the client. D. Demonstrated disapproval.

6. During the mental status assessment, the client expresses the belief that the CIA is stalking him and plans to kidnap him. The best response by the nurse would be:
A. “That makes no sense at all.” B. “You can tell me about that after I finish asking these questions.” C. “What kind of things have been happening?” D. “Why would the CIA be interested in you?”

7. The nurse says to the client, “You become very anxious when we start talking about your drinking.” Which of the following techniques is the nurse using? A. Confronting behavior. B. Making an observation. C. Translating into feelings. D. Verbalizing the implied.

8. The nurse enters the client’s room and finds the client anxiously pacing the floor. The client begins shouting at the nurse to “get out of my room!” The best intervention by the nurse would be to:
– Approach the client and ask “What’s wrong?” – Call for help and say “Calm down.” – Say “I’m leaving now, but I’ll be back.” – Stand at the doorway and say “You seem upset.”

9. A depressed client states, “I’m such a burden to everyone. I’m not worth all the trouble.” The best response by the nurse would be:
A. “I am sure you have led a good life.” B. “I care about you and want to work with you.” C. “Try to forget those thoughts and join our card game.” D. “Your family loves you very much.”

10. A client with depression is hospitalized following a suicide attempt. The client tells the nurse “I’m such a failure – I can’t even commit suicide. I can’t do anything right.” The best response by the nurse is: – – – – “Feeling like this is part of being ill.” “I don’t see you as a failure.” “You have everything to live for.” “You’ve been feeling like a failure for a while?”

11. During an admission assessment, the client tells the nurse “I haven’t slept at all the last few nights.” The best response by the nurse is:
A. “Go on.” B. “Sleeping?’ C. “Sometimes I have trouble sleeping too.” D. “You’re having difficulty sleeping?”

12. 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 attitudes.” C. “Well your family sounds like they have a positive attitude.” D. “You’re feeling angry that your family keeps hoping for a cure?”

TEST YOUR KNOWLEDGE
Questions – Set 2

1. Which statement by the nurse encourages the client to evaluate the current situation?
A. “That must have been difficult for you.” B. “How do you get along with your family?” C. “Describe how you feel about taking your medication.” D. “I think it would be a good idea to talk about your medication.”

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 the 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 is caring for a client who is anxious. The client says “I have something to tell you, but it’s a secret. Do you promise not to tell?”. The appropriate response by the nurse is:
A.“You know you can trust me.” B.“I promise I won’t tell anyone.” C.“I cannot promise to keep a secret.” D.“If you tell, I’ll have to report it to your psychiatrist.”

6. A nurse employed at a local mental health
clinic is approached by a neighbor who says “How is Mrs. Jones doing? She is my best friend and I know she comes to the clinic every week.” The appropriate response by the nurse is:
A.“I cannot discuss any client situation with you.” B.“If you want to know how she’s doing, you should ask her yourself.” C.“I’m not supposed to say anything, but Mrs. Jones is really doing well.” D.“Since you already know her problems, I can tell you she’s making progress.”

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 nurse is engaging in a therapeutic relationship with a client. Which of the following describe a therapeutic relationship? Select all that apply.
» Identify and meet the needs of the client and the nurse. » Assist the client to explore feelings. » Encourage the practice of coping skills. » Give advice if the client requests it. » Exchange personal information with the client. » Discuss the client’s issues with family members.

9. The nurse is caring for a client with a terminal illness. Put the stages of grief as described by Kubler-Ross in the order they occur. A.Bargaining B.Denial C.Acceptance D.Anger E.Depression

10. The physician has prescribed fluphenazine decanoate (Prolixin) 37.5 mg IM. The vial is labeled 25 mg/ml. How many ml will the nurse need to administer?

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