1. Relationship Development and Therapeutic Communication
Chapter 6
Relationship Development and Therapeutic Communication

2. 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

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. 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

10. 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

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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

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

32. 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)

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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