1. Chapter 11Therapeutic Communication and Relationships

2. Listen! All I asked was that you listen, not talk or do—just hear me.
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. 2

3. 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 3

4. 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 4

5. 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 5

6. 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-to- one relationship
Articulate a list of potential boundary violations that may occur during a therapeutic relationship 6

7. Communication Factors influencing communication: – Attitude
– Sociocultural or ethnic background
– Past experiences
– Knowledge of subject matter
– Ability to relate to others
– Interpersonal perceptions
– Environmental factors 7

8. Types of Communication
Verbal communication
Nonverbal communication
– Vocal cues
– Gestures
– Physical appearance
– Distance or spatial territory
– Position or posture
– Touch
– Facial expression 8

9. Zones of Distance Awareness
Therapeutic communication occurs in the personal zone.
Intimate
Personal
Public
Social

10. 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 10

11. Social Versus Therapeutic Communication Purtilo & Haddad (2002)
Social Communication
It is doing a favor for another person or giving advice.
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.
Therapeutic Communication
It promotes the functional use of one’s inner resources, encouraging verbalization of feelings or exploring ways to cope.
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. 11

12. 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. 12

13. Conditions Essential for a Therapeutic Relationship
Empathy
Respect
Genuineness
Self-disclosure
Concreteness and specificity
Confrontation
Immediacy of relationship
Client self-exploration 13

14. Roles of the Psychiatric Nurse
Nurse–teacher
Mother surrogate
Technical nurse
Nurse–manager
Socializing agent
Counselor or nurse–therapist 14

15. 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 15

16. 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 16

17. 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 17

18. 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. 18

19. Key Terms Social communication Comfort zones Therapeutic communication
Therapeutic relationship
Transference
Verbal communication
Zones of distance awareness
Comfort zones
Communication
Countertransference
Nonverbal communication
Parataxic distortion
Process recording
Professional boundaries 19

20. ? 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? ?