Relationship Development and Therapeutic Communication Chapter 6 Relationship Development and Therapeutic Communication

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

The Therapeutic Nurse–Client Relationship (cont.) 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

The Therapeutic Nurse–Client Relationship (cont.) 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

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 See ATI mental health, 9th Ed. pg 5

Conditions Essential to Development of a Therapeutic Relationship Rapport Trust Respect Genuineness Empathy

Phases of a Therapeutic Nurse–Client Relationship Pre-interaction phase Obtain information about the client from chart, significant others, or other health-team members Examine one’s own feelings, fears, and anxieties about working with a particular client

Phases of a Therapeutic Nurse–Client Relationship (cont.) Orientation (introductory) phase Create an environment for trust and rapport Establish contract for intervention Gather assessment data Identify client’s strengths and weaknesses

Phases of a Therapeutic Nurse–Client Relationship (cont.) Orientation phase (cont.) Formulate nursing diagnoses Set mutually agreeable goals Develop a realistic plan of action Explore feelings of both client and nurse

Phases of a Therapeutic Nurse–Client Relationship (cont.) Working phase Maintain trust and rapport Promote client’s insight and perception of reality Use problem-solving model to work toward achievement of established goals Overcome resistance behaviors Continuously evaluate progress toward goal attainment

Phases of a Therapeutic Nurse–Client Relationship (cont.) Working phase (cont.) Transference Countertransference

Phases of a Therapeutic Nurse–Client Relationship (cont.) Termination phase Therapeutic conclusion of relationship occurs when Progress has been made toward attainment of the goals A plan of action for more adaptive coping with future stressful situations has been established Feelings about termination of the relationship are recognized and explored

Boundaries in the Nurse-Client Relationship Professional boundaries outline expectations for appropriate relationships Professional boundary concerns include issues associated with Self-disclosure Gift-giving Touch Friendship or romantic association

Boundaries in the Nurse-Client Relationship (cont.) Warning signs that indicate professional boundaries may be in jeopardy Favoring one client’s care over another’s Keeping secrets with a client Changing dress style for working with a particular client Swapping client assignments to care for a particular client Spending free time with a client

Boundaries in the Nurse-Client Relationship (cont.) Warning signs that indicate professional boundaries may be in jeopardy (cont.) Giving special attention to one client over others Frequently thinking about the client when away from work Sharing personal information with a client Receiving gifts or continuing contact with client after discharge

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

The Impact of Preexisting Conditions Both sender and receiver bring certain preexisting conditions to the exchange that influence the intended message and the way in which the message is interpreted Values, attitudes, and beliefs. The environment in which the transaction takes place. Culture or religion. Social status. Gender.

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

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 the 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

Active Listening To listen actively is to be attentive to what the 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

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 Is well timed

Milieu Therapy— The Therapeutic Community Chapter 8 Milieu Therapy— The Therapeutic Community

Introduction “The psychiatric-mental health nurse provides structures, and maintains a therapeutic environment in collaboration with the client and other health care clinicians” Standard 5c of the American Nurses Association Standards of Psychiatric– Mental Health Nursing Practice (2007) (Pg 39 ATI MH 9th ed. Therapeutic milieu)

Milieu Therapy Milieu therapy, or therapeutic community, is defined as “a scientific structuring of the environment to effect behavioral changes and to improve the psychological health and functioning of the individual” Within the therapeutic community setting, the client is expected to learn adaptive coping, interaction, and relationship skills that can be generalized to other aspects of his or her life

Current Status Milieu therapy blossomed during the 1960s, 1970s, and early 1980s, when psychiatric inpatient treatment provided sufficient time to implement programs of therapy aimed at social rehabilitation

Current Status (cont.) Although strategies for milieu therapy are still used, they have been modified to conform to the current short-term approach to care and to outpatient treatment programs

Basic Assumptions The health of each individual is to be realized and encouraged to grow Every interaction is an opportunity for therapeutic intervention The client owns his or her environment Each client owns his or her behavior Peer pressure is a useful and powerful tool Inappropriate behaviors are dealt with as they occur Restrictions and punishment are to be avoided

Conditions That Promote a Therapeutic Community Basic physiological needs are fulfilled The physical facilities are conducive to achievement of the goals of therapy A democratic form of self-government exists Responsibilities are assigned according to client capabilities A structured program of social and work-related activities is scheduled as part of the treatment program Community and family are included in the program of therapy in an effort to facilitate discharge from treatment

The Program of Therapeutic Community The treatment plan is directed by an interdisciplinary team The plan is formulated by the team Team members of all disciplines sign the plan and meet regularly to update the plan as needed Disciplines may include psychiatry, psychology, nursing, social work, occupational therapy, recreational therapy, art therapy, music therapy, dietetics, and chaplain’s service

Role of the Nurse Through use of the nursing process, nurses manage the therapeutic environment on a 24-hour basis Nurses have the responsibility for ensuring that the client’s physiological and psychological needs are met

Role of the Nurse (cont.) Nurses are also responsible for Medication administration Development of a one-to-one relationship Setting limits on unacceptable behavior Client education