Principles techniques and elements of therapeutic communication 1

Principles, techniques, and elements of therapeutic communication 1

Therapeutic Communication • Therapeutic communication is the use of communication for the purpose of creating a beneficial outcome for the client. • Ruesch (1961), who originated the term therapeutic communication, stated that the purpose is to improve the client’s ability to function. • Furthermore, therapeutic communication facilitates the establishment of the nurse-client relationship and fulfills the purposes of nursing. 2

Therapeutic Communication • Interactive process between nurse, client • Helps client overcome temporary stress o To get along with other people o Adjust to the unalterable o Overcome psychological blocks • Established with purpose of helping client • Nurse responds to content o Verbal, nonverbal

Therapeutic Communication Characteristics • Is purposeful and goal-directed • Has well-defined boundaries • Is client-focused • Is nonjudgmental • Uses well-planned, selected techniques 4

The Elements of Therapeutic Communication 1. • Empathy: An emotional linkage between two or more people through which feelings are communicated; • involves trying to imagine what it must be like to be in another person’s situation Behaviors of the Nurse • Verbal comments: “This must make you feel sad. ” • Nonverbal actions: • A nod of the head to indicate understanding. • Mirroring the client’s facial expression in a genuine way. 5

• Empathizing o Empathy is process • People feel with one another • Embrace attitude of person who is speaking • Grasp idea that what client has to say important o NOT synonymous with sympathy o Interprets clients feelings without inserting own

• Empathy o Four phases of therapeutic empathizing • Identification • Incorporation • Reverberation • Detachment o On guard against over-distancing or burnout

Outcomes of empathy • Promotes understanding of the client’s feelings and condition. • Enables the nurse and client to relate better. • Provides the client with clues that the nurse is following and understanding what is being said. 8

2. Trust: The client’s belief that the nurse will behave predictably and competently while respecting the client’s needs Behaviors of the Nurse • Ensure confidentiality. • Be consistent. • Do exactly what you say you will do for the client. • Arrive on time. 9

• End the session on time. • Return when you say you will. • Be consistently friendly, open, and honest. Outcomes • Provides the basis for progress during future encounters. • Sets up the foundation of therapeutic relationship. • Makes the client feel comfortable with the nurse, rather than guarded or afraid. 10

Establish Trust • Establishing rapport o Include adolescent in discussion o Listen more than you talk o Avoid distractions o Be truthful with the child • Establishing trust o Follow through with promises o Respect confidentiality o Be truthful, even if it isn’t what they want

3. Honesty: The ability to be truthful, frank, and sincere Behaviors of the Nurse • Provide realistic reassurance. • Avoid false reassurance. • Develop insight into the way your feelings and reactions affect the client. • Accept yourself. Outcomes • Promotes the development of trust. • Enables the nurse to gain personal insight. Consequently, behavior with the client can be modified as needed. 12

4. Validation: Listening to the client and responding congruently in order to be sure that the nurse and client have the same understanding of a problem or issue Behaviors of the Nurse: Verbal comments: • “So you are saying that. . . ” • “Let me be sure I understand what you are saying. ” • “Tell me what you understand about what I just said. ” Outcomes: • Clarifies communication. • Helps the client to feel accepted, respected, and understood. 13

5. Caring: The level of emotional involvement between the nurse and the client. Behaviors of the Nurse: Nonverbal actions: • Seeking the client out each day. • Spending quality time with the client. • Paying attention to the client’s needs. • Using tactile messages, such as a pat on the back, to show support. Outcomes: • Makes the client feel accepted. • Provides the client with the knowledge that the nurse is willing to help. 14

6. Active listening: Hearing and interpreting language, noticing nonverbal and paraverbal enhancements, and identifying underlying feelings. Behaviors of the Nurse: • Taking time to listen. • Giving the client your undivided attention. • Making eye contact. • Responding to verbal and nonverbal leads, clues, and signals from the client. • Analyzing and validating throughout the conversation. • Suspending judgment. • Listening between the lines. 15

• Attentive listening o Mindful listening o Paying attention to verbal, nonverbal o Noting congruence o Absorbing content and feeling o Listening for key themes o Be aware of own biases o Highly developed skill

• Understanding the feelings behind the facts. • Noticing discrepancies between facts and feelings. • Noticing things omitted such as topics that the client should be discussing but avoids. • Using communication principles and techniques to be a sounding board. Outcomes: • Promotes understanding of the client. • Allows the client to express self more freely. • Helps the client gain a better understanding of the problem(s). • Promotes problem solving by the client. • Enhances the client’s self-esteem. 17

Blocks to Attentive Listening 1. 2. 3. 4. 5. 6. 7. Rehearsing Being concerned with oneself Assuming Judging Identifying Getting off track Filtering

Skills to achieve the maximum of listening: 1. Attending • Physical attending o Face the person squarely o Adopt an open posture o Lean toward the person o Maintain good eye contact o Try to be relatively relaxed

2. Silence • Using silence o Encouraging the client to communicate o Allowing client time to ponder what has been said o Allow client time to collect thoughts o Allow client time to consider alternatives o Look interested o Uncomfortable silence should be broken • Analyzed

3. Reflection • Reflecting o Repeating the client’s message • Verbal or nonverbal o Reflecting content repeats client’s statement • May be misused, overused • Use judiciously o Reflecting feelings • Verbalizing implied feelings in client’s comment o Encourages client to clarify

4. Just the Facts • Imparting information o Supplying additional data o Not constructive to withhold useful information o Line between information and advice o Avoid personal, social information o Client participation in decision making positive mental health outcomes • Take in and understand information • Educated empowered client

5. Deflection • Avoiding self-disclosure o Deflect a request for self-disclosure • Honesty • Benign curiosity • Refocusing • Interpretation • Clarification • Feedback and limit setting o Assess and evaluate responses

6. Clarification • Clarifying o Attempt to understand client’s statement o Ask client to give an example • Paraphrasing o Nurse assimilates or restates in own words o Fives nurse opportunity to test understanding • Checking perceptions o Sharing how one person perceives another

7. Question and Define • Questioning o Very direct way of speaking with clients o Open-ended questions focuses the topic o Close question limits choice of responses o Careful not to ask questions that steer answer • Structuring o Attempt to create order, establish guidelines o Define parameters of nurse-client relationship

8. Pinpoint and Link • Pinpointing o Calls attention to certain kinds of statements • Relationships o Point to inconsistencies o Similarities, differences • Linking o Nurse responds to client • Ties together two events, experiences, feelings • Connect past experiences with current behaviors

9. Giving Feedback • Nurse share reaction to what client said • Give in a way that does not threaten client • Risk of client experiencing feedback o Personal rejection • Nurses should be open, receptive to cues

10. Focus Feedback • • On behavior, observations, description On more-or-less, rather than either/or On here-and-now: what is said, not why Sharing of information, ideas Exploration of alternatives Value to client Amount of information client able to use Appropriate time and place

11. Confronting • Deliberate invitation to examine some aspect of personal behavior that indicates discrepancy between actions and words • Informational confrontation o Describes visible behavior • Interpretive confrontation o Draws inferences about the meaning of behavior

Six Skills in Confronting • • • Use of personal statements Use of relationship statements Use of behavior descriptions Use of description of personal feelings Use of responses aimed at understanding Use of constructive feedback skills

12. Summarize and Process • Summarizing o Highlighting the main ideas expressed o Conveys understanding o Reviews main themes of conversation o Use at different times during interaction o Don’t rush to summarize • Processing o Direct attention to interpersonal dynamics

Therapeutic Communication Mistakes • Common mistakes o Giving advice o Minimizing or discounting feelings o Deflecting o Interrogating o Sparring ﺗﺸﺘﻴﺖ ﺍﺳﺘﺠﻮﺍﺏ ﺍﻟﺴﺠﺎﻝ

Barriers and threats to effective Communication • Failure to listen • Improperly decoding intended message • Placing the nurse’s needs above client’s

The Therapeutic Relationship • Growth-facilitating process o Help client manage problems in living • More effectively • Develop unused, underused opportunities fully o Help client become better at helping self • May develop over weeks or within minutes • Influenced by nurse and client o Personal and professional characteristics

Therapeutic Relationship Characteristics • Characteristics of therapeutic relationship o Intellectual and emotional bond • Focused on client o Respects client as individual o Respects client confidentiality o Focuses on client’s well-being o Based on mutual trust, respect, acceptance

Therapeutic Relationship Phases • Preinteraction 1. Introductory 2. Working: stage 1 and stage 2 3. Termination

1. Introductory Phase • Preinteraction phase • Introductory phase o Orientation, pretherapeutic phase o Nurse and client observe each other o Open relationship o Clarify problem o Structure and formulate contract o Client may display resistive behaviors

• By end of this phase client begins to o Develop trust in nurse o View nurse as honest, open, concerned o Believe nurse will try to understand, respect o Believe nurse will respect client confidentiality o Feel comfortable talking about feelings o Understand purpose of relationship, roles o Feel an active participant in plan

2. Working Phase Stages • Stage One o Exploring and understanding thoughts and feelings o Empathetic listening and responding o Respect, genuineness o Concreteness o Reflecting, paraphrasing, clarifying, confronting o Intensity of interaction increases

• Stage two o Facilitate and take action o Collaborate o Make decisions o Provide support o Offer options

3. Termination Phase • • Difficult, ambivalent Summarizing Termination discussions Allow time for client adjustment to independence

Developing the Therapeutic Relationship • Set mutual goals with client • Discuss outcomes • Many ways of helping do not require training

Skills for the Therapeutic Relationship • • Listen actively Help identify the client’s feelings Be empathetic, honest, genuine, and credible Use ingenuity Be aware of cultural differences Maintain confidentiality Know your role and your limitations

Communication Techniques Working with Children and Families • • Accepting Broad openings Clarifying Focusing Observations Reflection Summarizing Active listening Collaborating Exploring Giving recognition Offering self Restatement or paraphrasing • Validating perceptions • • •

Developmental Considerations • Establish rapport with children o Sit or lower self to child’s eye level o Note what child is playing with or reading o If appropriate, agree with child/share feelings o Compliment a physical features, activity o Use calm tone of voice, appropriate language o Pace discussion, procedure in nonhurried manner o Preschoolers have limited concept of time

Conclusion • Nurse’s role requires communication skills • Effective communication large role o Ability to deliver highest quality of care • Nurse needs to be understood • Nurse needs to understand messages • Strong verbal, written communication skills • Monitor own nonverbal communication