Chapter 5

Relationship Development and Therapeutic Communication

Professor Fickley

Introduction

• 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.

Introduction (cont.)

• 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.

The Therapeutic Nurse-Client Relationship

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

• How do Social Relationships differ from Therapeutic Relationships?

Therapeutic Use of Self

• Definition - ability to use one’s 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

Conditions Essential to Development
of a Therapeutic Relationship

• Rapport

• Trust

• Respect

• Genuineness

• Empathy

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.

The Impact of Who “YOU” Are

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

• Values, attitudes, and beliefs.

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.

The Impact of “YOU” (cont.)

• Social status. 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.

• Gender. Masculine and feminine

gestures influence messages conveyed in communication with others.

The Impact of “YOU” (cont.)

• 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.

Proxemics

• The environment in which the transaction takes place. Territoriality, density, and distance are aspects of environment that communicate messages.

• 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

Proxemics: Use of Space

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 distance - the distance

for conversation with strangers

or acquaintances

• Public distance - the distance for speaking in

public or yelling to someone some distance away

Nonverbal Communication: Body Language

Components of nonverbal communication

• 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

Therapeutic Communication Techniques (cont.)

• 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

Therapeutic Communication Techniques (cont.)

• 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

Therapeutic Communication Techniques (cont.)

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

Therapeutic Communication Techniques (cont.)

• Voicing doubt - expressing uncertainty as to the reality of client’s 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

How do I use Therapeutic Communication to Help Problem Solve??

• Goals are often achieved through use of the problem-solving model:

• Identify the client’s problem.

• Promote discussion of desired changes.

• Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively.

• Discuss alternative strategies for creating changes the client desires to make.

Problem solving(con’t)

• Weigh benefits and consequences of each alternative.

• Help client select an alternative.

• Encourage client to implement the change.

• Provide positive feedback for client’s attempts to create change.

• Help client evaluate outcomes of the change and make modifications as required.

How do I set limits on inappropriate behavior?

• Best approach is to be firm, but accepting

• Reject the behavior

• Accept the person

• “Mr D, I really enjoy playing monopoly with you, but I don’t like when you swear. I am wondering if you can express your angry feeling in another manner?

Active Listening

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

• Several nonverbal behaviors have been designed to facilitate attentive listening.

Active Listening (cont.)

• S – Sit squarely facing the client.

• O – Observe an open posture.

• L – Lean forward toward the client.

• E – Establish eye contact.

• R – Relax.

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

• Ex;

Nontherapeutic Communication Techniques

• 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 client’s ideas or behavior

• Approving or disapproving - implies that the nurse has the right to pass judgment on the “goodness” or “badness” of client’s behavior

Nontherapeutic Communication Techniques (cont.)

• Agreeing or disagreeing - implies that the nurse has the right to pass judgment on whether client’s 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

Nontherapeutic Communication Techniques (cont.)

• 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

Nontherapeutic Communication Techniques (cont.)

• Belittling feelings expressed - causes client to feel insignificant or unimportant

• Making stereotyped comments, clichés, 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

Nontherapeutic Communication Techniques (cont.)

• Interpreting - results in the therapist’s telling client the meaning of his or her experience

• Introducing an unrelated topic - causes the nurse to take over the direction of the discussion

QUESTIONS:

• I. CONDITIONS ESSENTIAL TO DEVELOPMENT OF A THERAPEUTIC RELATIONSHIP

• Situation: Pam comes to the psychiatric clinic for assistance with more adaptive coping. Nurse Jones will be her therapist.

• Match the behaviors described on the right with the essential condition for therapeutic relationship development listed .

• RAPPORT; TRUST; RESPECT; GENUINENESS; EMPATHY

• _____1. Nurse Jones does not approve of Pam’s gay lifestyle but accepts her unconditionally nonetheless.

• _____2. Nurse Jones and Pam develop an immediate mutual regard for each other.

• _____3. Pam knows that Nurse Jones is always honest with her and will tell her the truth even if it is sometimes painful.

• _____4. Pam knows that Nurse Jones will not tell anyone else about what they discuss in therapy.

• _____5.When Pam talks about her problems, Nurse Jones listens objectively and encourages

Questions:Phases of the Relationship

• Identify the appropriate phase of relationship development for each of the following tasks. The four phases include:

• a. Preinteraction phase: b. Orientation phase

• c. Working phase; d. Termination phase

• _____ 1. Pam and Nurse Jones set goals for their time together.

• _____ 2. Nurse Jones reads Pam’s previous medical records.

• _____ 3. Having identified Pam’s problem, they discuss aspects for possible change and ways to accomplish them.

• _____ 4. They establish a mutual contract for intervention.

• _____ 5. The established goals have been met.

What technique is being used?

• 1. Ct: “The FBI wants to kill me.

• Ns: “I find that hard to believe.” _

• _________________________

• 2. Ns Asst: “Mr. J. always calls me sweetie pie. I get so angry when he does that.”

• Ns: “Perhaps you should consider how he is feeling.” ___________________________________________

• 3. Ct: “My daddy always tucked me into bed at night.”

• Ns: “I’d like to talk more about your relationship with your father.” _______________________________

• 4. Ns to Ct: “Good morning, Sue. I see you are wearing the hair bow you made in OT.”

• _______________

• 5. Ct: “I didn’t really mean it when I said I wanted to die.”

• Ns: “What makes you say those kinds of things?” ______________________________________________

Modified FA Davis