Chapter 11 Therapeutic Communication and Relationships Copyright 2012

Chapter 11 Therapeutic Communication and Relationships Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Listen When I ask you to listen to me and you start giving advice, you have not done what I asked. When I ask you to listen to me and you begin to tell me why I shouldn’t feel that way, you are trampling on my feelings. When I ask you to listen to me and you feel you have to do something to solve my problem, you have failed me, strange as that may seem. Listen! All I asked was that you listen, not talk or do—just hear me. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

And I can do for myself; I’m not helpless. Maybe discouraged and faltering, but not helpless. When you do something for me that I can and need to do for myself, you contribute to my fear and weakness. But, when you accept as a simple fact that I do feel what I feel, no matter how irrational, then I can quit trying to convince you and can get about the business of understanding what’s behind this irrational feeling. And when that’s clear, the answers are obvious and I don’t need advice. So, please listen and just hear me. And, if you want to talk, wait a minute for your turn; and I’ll listen for you. Anonymous Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Learning Objectives After studying this chapter, you should be able to • Explain the process of communication • Distinguish the factors that influence communication • Describe the importance of assessing nonverbal communication • Articulate the relationship between comfort zones and effective communication skills Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Learning Objectives (cont. ) • Recognize factors that contribute to ineffective communication • Compare and contrast social and therapeutic communication • Formulate a list of therapeutic communication techniques • Demonstrate an understanding of the importance of confidentiality in the clinical setting Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Learning Objectives (cont. ) • Develop a sample interaction recording in the clinical setting • Construct a list of the essential conditions for a therapeutic relationship as described by Carl Rogers • Describe the six subroles of the psychiatric–mental health nurse identified by Hildegard Peplau • Discriminate the phases of a therapeutic one-toone relationship • Articulate a list of potential boundary violations that may occur during a therapeutic relationship Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Communication • Factors influencing communication: – Attitude – Sociocultural or ethnic background – Past experiences – Knowledge of subject matter – Ability to relate to others – Interpersonal perceptions – Environmental factors Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Communication • Verbal communication • Nonverbal communication – Vocal cues – Gestures – Physical appearance – Distance or spatial territory – Position or posture – Touch – Facial expression Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Zones of Distance Awareness Therapeutic communication occurs in the personal zone. Intimate Personal Social Public Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Communication • Effective therapeutic communication • Ineffective therapeutic communication – Failure to listen – Conflicting verbal and nonverbal messages – A judgmental attitude – Misunderstanding because of multiple meanings of English words – False reassurance – Giving of advice – Disagreement with or criticism of a person who is seeking support – The inability to receive information because of a preoccupied or impaired thought process – Changing of the subject if one becomes uncomfortable with the topic being discussed Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Social Versus Therapeutic Communication Purtilo & Haddad (2002) Social Communication Therapeutic Communication • It is doing a favor for another person or giving advice. • It promotes the functional use of one’s inner resources, encouraging verbalization of feelings or exploring ways to cope. • A personal or intimate relationship occurs. • The identification of needs may not occur. • Personal goals may or may not be discussed. • Constructive or destructive dependency may occur. • A variety of resources may be used during socialization. • A personal, but not intimate, relationship occurs. • Needs are identified by the client with the help of the nurse. • Personal goals are set by the client. • Constructive dependency, interdependency, and independence are promoted. • Specialized professional skills are used. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Approaches for Therapeutic Interactions (Purtilo, 1978) • Translate any technical information into layperson’s terms. • Clarify and restate any instructions or information given. Clients usually do not ask doctors or nurses to repeat themselves. • Display a caring attitude. • Exercise effective listening. • Do not overload the listener with information. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Conditions Essential for a Therapeutic Relationship • Empathy • Concreteness and specificity • Respect • Confrontation • Genuineness • Self-disclosure • Immediacy of relationship • Client self-exploration Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Roles of the Psychiatric Nurse • Nurse–teacher • Mother surrogate • Technical nurse • Nurse–manager • Socializing agent • Counselor or nurse–therapist Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Phases of a Therapeutic Relationship • Initiating or orienting phase – Building trust and rapport by demonstrating acceptance – Establishing a therapeutic environment, ensuring safety and privacy – Establishing a mode of communication acceptable to both the client and the nurse – Initiating a therapeutic contract by establishing a time, place, and duration for each meeting, as well as the length of time the relationship will be in effect – Assessing the client’s needs, coping strategies, defense mechanisms, strengths and weaknesses Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Phases of a Therapeutic Relationship (cont. ) • Working phase – Exploring the client’s perception of reality and providing constructive feedback – Helping the client develop positive coping behaviors – Identifying available support systems – Promoting a positive self-concept by focusing on what the client can do and not what the client cannot do – Encouraging verbalization of feelings – Promoting client independence by teaching new skills – Developing a plan of action with realistic goals – Implementing the plan of action – Evaluating the results of the plan of action Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Phases of a Therapeutic Relationship (cont. ) • Terminating phase – Provides self-care and maintains his or her environment – Demonstrates independence and works interdependently with others – Copes positively when experiencing feelings such as anxiety, anger, or hostility – Demonstrates emotional stability – Identifies the progress he or she has made Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Interacting with Difficult Clients • Do not take the client’s words personally. • Validate the client’s emotions. • Speak slowly in a soft, low voice. • Maintain a safe physical distance. • Ask simple questions such as “How can I help you? ” • Appear confident and speak in a firm, yet amicable, tone to maintain control of the situation. • Be familiar with the facility’s emergency plan, and do not hesitate to employ it if the situation warrants serious action. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Key Terms • Comfort zones • Social communication • Communication • Therapeutic communication • Countertransference • Nonverbal communication • Parataxic distortion • Process recording • Professional boundaries • Therapeutic relationship • Transference • Verbal communication • Zones of distance awareness Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Reflection Reflect on the quote at the beginning of the chapter. • Do any of the statements apply to you? • If so, which ones? • What actions can you take to improve your listening skills? Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins ?