CHAPTER 8 r Therapeutic Communication isg
statement implies: "He kept staring at me, and I a message is verbalized can be as impoftarrt asbegan to wonder if I was dressed inappropriately or wbat is verbalized,.had mustard on my face!"
Gazing at another's eyes arouses strong emo- E ^^__ *-_.r-*_tions. Thus, eye conta ct rarety tasrs longer than I COne CoNCEPT3 seconds before one or both viewers experience 4 Therapeutic Communicatiana powerful urge to glance away' Bteaking eye caregiver verbal and nonverlcal techniques that focuscontact lowers stress levels (Givens, 2010c).
,,, on the care receiver,s needS and advance the promo_
vocar cues, or paratansuase E :::""J,.[*3;t1,:;[T3i,*:ffi:]T",Hffi5]1""
Paralangaage is the gestural component of the # standing of behavioral motivation. lt is nonjudgmental,
spoken *ord. lt consisis of pitch, tone, and loud- ffi discourages defensiveness, and promotes trust.
ness of spoken messages; the rate of speaking;expressively placed pauses; and emphasis assigned
? to c€r:lin words. rhese vocal cuel greatly ilnflu- ThefapeUtiC COmmgnicatign TeChniqUeSil ence the way individuals interpret verbal mes-
Xffi *i",tr"1'#;ou,f;";:*T::I"-f T:[:il:,1l:,:r::]J?#lJfJ','f ::,"1.1#;":i}{ p"T:-i*d as being anxious or tense' therapeutically with clients. These are the "techni-
^S) .. '"t"t.t""t vocal emphases can alter interpreta- cal piocedures" carried out by the nurse working
. {X tion of the message. Three examples follow: in fsychiatry and they should serye to enhance
iF t 1. "I felt SURE you would notice the change." development of a therapeutic nurse-client relation-
\ d Interpreta.tion: I was SURE you would, but ship. Table 8-2 includes a list of rhese techniques,
S S you didn't. a short explanation of their usefulness, and
A * 2. "I felt sure YoU would notice the change.D examples of each'
t N Interpreta.tion: I thought yOU would, even if\d I nobodv else did. NOntherapeuti' GOmmuni'ati'nI \ 3. "I felt sure you would norice the CHANGE.,, TeChniqUeSg i fnturlrretation: Even if you didn,t notice
\ g Tf^119 else, I thought you would notice the several approaches are considered to be barrierstl Sr' r;- CHAI\IGE' to open communication befween the nurse and
..'l l\ \' Verbal cues play a maior role in determining client. Hays and Larson (1,g6, identified a number
,t- Ua f,esRonses in human communication situations. How of these techniques, which are presented in
ts\\r$q$$l
Q't1',S*u;N:"s
Fi$
Using silence
Accepting
Giving recognition
Offering self
Gives the client the opportunity tocollect and organize thoughts, tothink through a point, or to considerintroducing a topic of greater con-cern than the one being discussed.
Conveys an attitude of reception andregard.
Acknowledging and indicatlng aware-ness; better than complimenting,which reflects the nurse's judgment.
Making oneself available on anunconditional basis, increasingclient's feelings of self-worth.
"Yes, I understand what you said."Eye contact; nodding.
"Hello, Mr. J. I notice that you made aceramic ashtray in OT."
"l see you made your bed."
"l'll stay with you awhile.""We can eat our lunch together.""l'm interested in you."
Continued
Giving broad openings
Offering general leads
Placing the event in timeor sequence
Making observations
Encouraging descriptionof perceptions
Encouraging comparison
Restating
Reflecting
Focusing
Allows the client to take the initiative
in introducing the topic; emphasizesthe importance of the client's role inthe interaction.
Offers the client encouragement tocontinue.
Clarifies the relationship of events intime so that the nurse and client canview them in perspective.
Verbalizing what is observed or per-
ceived. This encourages the client torecognize specific behaviors andcompare perceptions with the nurse.
Asking the client to verbalize what is
being perceived; often used withclients experiencing hallucinations.
Asking the client to compare similari-ties and differences in ideas, experi-ences, or interpersonal relation-
ships. This helps the client recog-nize life experiences that tend torecur as well as those aspects of life
The main idea of what the client has
said is repeated. This lets the clientknow whether or not an expressed
statement has been understood andgives him or her the chance to con-tinue, or to clarify if necessary.
Questions and feelings are referred
back to the client so that they may
be recognized and accepted, and
so that the client may recognize thathis or her point of view has value-agood technique to use when theclient asks the nurse for advice.
Taking notice of a single idea or even
a single word; works especially well
with a client who is moving rapidlyfrom one thought to another. This
technique is not therapeutic,however, with the client who is very
anxious. Focusing should not bepursued until the anxiety level has
subsided.
"What would you like to talk abouttoday?"
"Tell me what you are thinking."
"Yes, I see." "Go on,""And after that?"
"What seemed to lead up to . . .?""Was this before or after . . .?""When did this happen?"
"You seem tense.""l notice you are pacing a lot.""You seem uncomfortable whenyou..."
"Tell me what is happening now."
"Are you hearing the voices again?"
"What do the voices seem to besaying?"
"Was this something like . . .?""How does this compare with the time
when . . .?""What was your response the last time
this situation occurred?"
Cl: "l can't study. My mind keeps
wandering."Ns: "You have difficulty concentrating."Cl: "l can't take that new job. What if I
can't do it?"Ns: "You're afraid you will fail in this
new position."
Cl: "What do you think I should doabout my wife's drinking problem?"
Ns: "What do youthink you should do?"Cl: "My sister won't help a bit toward
my mother's care. I have to do it all!"
Ns: "You feel angry when she doesn'thelp."
"This point seems worth looking at
more closely. Perhaps you and I can
discuss it together."
CHAPTER 8 r Therapeutic Communication 15S
Exploring
Seeking clarificationand validation
Presenting reality
Voicing doubt
Verbalizing the implied
Attempting to translatewords into feelings
Formulating a plan ofaction
Delving further into a subject, idea,experience, or relationship; especiallyhelpfulwith clients who tend toremain on a superficial level of com-munication. However, if the clientchooses not to disclose fufiher infor-mation, the nurse should refrain frompushing or probing in an area thatobviously creates discomforl.
Striving to explain that which is vagueor incomprehensible and searchingfor mutual understanding. Clarifyingthe meaning of what has been saidfacilitates and increases understand-ing for both client and nurse.
When the client has a misperceptionof the environment, the nurse definesreality or indicates his or her percep-tion of the situation for the client.
Expressing uncertainty as to the realityof the client's perceptions; oftenused with clients experiencingdelusional thinking.
Putting into words what the client hasonly implied or said indirectly; it canalso be used with the client who ismute or is otherwise experiencingimpaired verbal communication. Thisclarifies that which is implicitraiherlhan explicit.
When feelings are expressed indirectly,the nurse tries to "desymbolize"what has been said and to find cluesto the underlying true feelings.
When a client has a plan in mind fordealing with what is considered to bea stressful situation, it may serve toprevent anger or anxiety from esca-lating to an unmanageable level.
"Please explain that situation in moredetail."
"Tell me more about that particularsituation."
"l'm not sure that I understand. Wouldyou please explain?"
"Tell me if my understanding agreeswith yours."
"Do I understand correctly that yousaid . . .?"
"l understand that the voices seemreal to you, but I do not hear anyvoices."
"There is no one else in the room butyou and me."
"l find that hard to believe.""That seems rather doubtful to me.""l understand that you believe thisto be true, but I see this situationdifferently than you."
Cl: "lt's a waste of time to be here. I
can't talk to you or anyone."Ns: "Are you feeling that no one
understands?"Cl:(Mute)Ns: "lt must have been very difficult
for you whgn your husband died inthe fire."
Cl: "l'm way out in the ocean."Ns: "You must be feeling very lonely
now."
"What could you do to let your angerout harmlessly?"
"Next time this comes up, whatmight you do to handle it moreappropriately?"
Adapted frcn Hays, J. 5., & Larson, K. H. (1 963). Interacting with patients. New york: Macniilan.
raDre o-r. -L\urscs slruurq recugrlrzc arl(r errlllrllalcthe use of these patterns in their relationships withclients. Avoiding these communication barriers willmaxtrnize the effectiveness of communication andenhance the nurse-client relationship.
Active Listening
To listen actively is to be attentiveclient is saying, both verbally andAttentive listening creates a climateclient can communicate. With activenufse communicates acceptance
lLrt LrrE urlgrrl, allLt urestablished within the relationship that promotesopenness and honest expression.
Several nonverbal behaviors have been designatedas facilitative skills for attentive listening. Thoselisted here can be identified by the acronymSOLER:
S-Sit squarely facing the client. This gives themessage that the nurse is there to listen and isinterested in what the client has to say.
O-Observe an open posture. Posture is consid-ered "open" when arms and legs remainuncrossed. This suggests that the nurse is
to what thenonverbally.
in which thelistening theand respect
Giving reassurance
Rejecting
Approving or disapproving
Agreeing or disagreeing
lndicates to the client that there is no
cause for anxiety, thereby devaluing the
client's feelings; may discourage theclient from further expression of feelings ifhe or she believes they will only be down-played or ridiculed.
Refusing to consider or showing contemptfor the client's ideas or behavior. This may
cause the client to disdontinue interaction
with the nurse for fear of further rejection.
Sanctioning or denouncing the client'sideas or behavior; implies that the nurse
has the right to pass judgment on whetherthe client's ideas or behaviors are "good"or "bad," and that the client is expected
to please the nurse. The nurse's accept-ance of the client is then seen as condi-tional depending on the client's behavior.
lndicating accord with or opposition to the
client's ideas or opinions; implies that the
nurse has the right to pass judgment onwhether the client's ideas or opinions are
"right" or "wrong." Agreement prevents the
client from later modifying his or her point
of view without admitting error.
Disagreement implies inaccuracy, provok-
ing the need for defensiveness on the part
of the client.
Telling the client what to do or how tobehave implies that the nurse knows
what is best, and that the client is inca-pable of any self-direction. lt nurtures
the client in the dependent role by dis-couraging independent thinking.
"l wouldn't worry about that if I
were you.""Everything will be all right."Better to say: "We will work on
that together."
"Let's not discuss . . .""l don't want to hear about . . ."Better to say: "Let's look at that a
little closer."
"That's good. I'm glad that you . . .""That's bad. l'd rather you
wouldn't . . ."Better to sayr "Let's talk about
how your behavior invoked angerin the other clients at dinner."
"That's right. I agree.""That's wrong. I disagree.""l don't believe that."Better to say: "Let's discuss what
you feel is unfair about the new
community rules."
"l think you should . . .""Why don't you . . ."Better to say: "What do you think
you should do?" or "What do you
think would be the best way tosolve this problem?"
Giving advice
CHAPTER 8 r Therapeutic Communication 157
Probing
Defending
Requesting an explanation
lndicating the existenceof an external sourceof power
Belittling feelingsexpressed
Making stereotypedcomments
Persistent questioning of the client; push-ing for answers to issues the client doesnot wish to discuss. This causes theclient to feel used and valued only forwhat is shared with the nurse andplaces the client on the defensive.
Attempting to protect someone or some-thing from verbal attack. To defend whatthe client has criticized is to imply thathe or she has no right to express ideas,opinions, or feelings. Defending doesnot change the client's feelings and maycause the client to think the nurse istaking sides against the client.
Asking the client to provide the reasonsfor thoughts, feelings, behavior, andevents. Asking "why" a client didsomething or feels a certain way canbe very intimidating, and implies that theclient must defend his or her behavioror feelings.
Attributing the source of thoughts, feelings,and behavior to others or to outside influ-ences. This encourages the client toproject blame for his or her thoughts orbehaviors on others rather than accept-ing the responsibility personally.
When the nurse misjudges the degree ofthe client's discomfort, a lack of empathyand understanding may be conveyed.The nurse may tell the client to "perk up"or "snap out of it." This causes the clientto feel insignificant or unimportant. Whenone is experiencing discomfort, it is norelief to hear that others are or havebeen in similar situations.
Clich6s and trite expressions are mean-ingless in a nurse-client relationship.When the nurse makes empty conversa-tion, it encourages a like response fromthe client.
"Tell me how your mother abusedyou when you were a child."
"Tell me how you feel toward yourmother now that she is dead."
"Now tell me about . . ."Better technique: The nurse should
be aware of the client's responseand discontinue the interaction atthe first sign of discomfort.
"No one here would lie to you.""You have a very capable physician.
l'm sure he only has your bestinterests in mind."
Better to say: "l will try to answeryour questions and clarify someissues regarding your treatment.
"Why do you think that?""Why do you feel this way?""Why did you do that?"Better to say! "Describe what
you were feeling just before thathappened."
"What makes you say that?""What made you do that?""What made you so angry last night?"Better to say: "You became angry
when your brother insulted yourwife."
Cl: "l have nothing to live for.I wish lwere dead."
Ns: "Everybody gets down in thedumps at times. I feel that waymyself sometimes."
Betterto say: "You must be veryupset. Tell me what you are feelingright now."
"l'm fine, and how are you?""Hang in there. lt's for your own
good.""Keep your chin up."Better to say: "The therapy must
be difficult for you at times. Howdo you feel about your progress atthis point?"
Continued
158 UNIT 3 r Therapeutic Approaches in Psychiatric Nursing Care
Using denial When the nurse denies that a problem
exists, he or she blocks discussion withthe client and avoids helping the clientidentify and explore areas of difficulty.
With this technique the therapist seeks tomake conscious that which is uncon-scious, to tell the client the meaning of
his or her experience.
lnterpreting
lntroducing an unrelatedtopic
Changing the subject causes the nurse totake over the direction of the discussion.This may occur in order to get to some-thing that the nurse wants to discusswith the client or to get away from atopic that he or she would prefer not todiscuss.
Cl: "l'm nothing."Ns: "Of course you're something.
Everybody is somebody.Better to say: "You're feeling like no
one cares about you right now."
"What you really mean is . . .""Unconsciously you're saying . . ."Better technique: The nurse must
leave interpretation of the client'sbehavior to the psychiatrist. Thenurse has not been prepared toperform this technique, and inattempting to do so, may endangerother nursing roles with the client.
Cl: "l don't have anything to live for."Ns: "Did you have visitors this
weekend?"Better technique: The nurse must
remain open and free to hear the
client, to take in all that is being con-veyed, both verbally and nonverbally.
Adapted from Hays, J. 5., & Larson, K. H. 0963). lnteructing with patients. New York: Macmillan.
"open" to what the client has to say..With a
"closed" position, the nurse can convey asomewhat defensive stance, possibly invokinga similar response in the client.
L-Lean forward toward the client. This conveysto the client that you are involved in theinteraction, interested in what is being said,and making a sincere effort to be attentive.
E-Establish eye contact. Eye contact, intermit-tently directed, is another behavior thatconveys the nurse's involvement and willing-ness to listen to what the client has tosay. The absence of eye contact or the con-stant shifting of eye contact elsewhere inthe environment gives the message that thenurse is not really interested in what isbeing said.
R-Relax. V/hether sitting or standing during theinteraction, the nurse should communicate a
sense of being relaxed and comfortable withthe client. Restlessness and fidgetiness cofirmu-nicate a lack of interest and may convey a feel-ing of discomfort that is likely to be transferredto the client.
Process Recordings
Process recordings are written reports of verbalinteractions with clients. They are verbatim (to theextent that this is possible) accounts, written by thenurse or student as a tool for improving interper-sonal communication techniques. The processrecording can take many forms, but usuallyincludes the verbal and nonverbal communicationof both nurse and client. The exercise provides a
means for the nurse to analyze both the contentand the pattern of the interaction. The processrecording, which is not considered documentation,is intended to be used as a learning tool for profes-sional development. An example of one type ofprocess recording is presented inTable 8-4.
