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Therapeutic Communication Techniques

Communication is the most powerful tool a psychiatric nurse should have. It is the basis of therapeutic–nurse patient relationship. Communication is a complex process and needs practice to use it effectively. Therapeutic communication techniques are methods used to encourage patients to interact in a manner that promotes their growth and moves them toward their treatment goals. All the communication must be aimed at preserving the self respect of both the helper and helpee.

1. Listening

Listening is an active process of receiving information and examining reaction to the messages received. It is not simply hearing. It is essential to reach any understanding of the patient. It is the first rule of therapeutic-nurse relationship. The patient should be talking more than the nurse during the interaction. Listening is sign of respect and is powerful reinforcer. Active listening involves all the nurse’s senses. E.g. maintaining eye contact and receptive nonverbal communication which helps to convey the nurse’s interest and acceptance.

2. Broad Openings

Here the nurse is encouraging the patient to select topics for discussion. Patient should be welcomed to the communication with warmth and respect. Patient should feel that nurse is ready to listen. Open-ended questions result in fuller, more revealing answers.

E.g. 

What are you thinking about?

Can you tell me more about that?

What shall we discuss today?

Domination of the interaction by the nurse or rejecting the responses by the nurse results in poor therapeutic relationship.

3. Questioning

The nurse skillfully asks open-ended questions during the initial admission. Interviewing skills are necessary to avoid asking too many personal questions in one session. Questions should be to achieve relevance and depth.

How come you stopped taking your medication?

Tell me how you feel now?

4. Restating

 Nurse is repeating of the main thought the patient has expressed.  It also indicates that the nurse is listening, validating, reinforcing or calling attention to what has been said. Usually a part of patient’s statement is repeated. When restating patient should not feel the nurse is reassuring, judgmental or defending.

E.g. “Your mother left you when you were 5 year old?

5. Clarification

Here, the nurse makes specific questions to help clear up a specific point patient makes by attempting to put in to words vague ideas or unclear ideas of the patient. Patient’s verbalizations may not be clear when overwhelmed with emotions. Nothing should be allowed to pass to the patient that nurse does not hear or understand.

“I am not sure what you mean. Could do tell me about it again?”

Failure to probe and assumed understanding result in poor communication.

6. Reflection

By reflection nurse is directing back the patient’s ideas, feeling, questions or content. Reflection lets the patient know that the nurse has heard what was said and understand the content. Reflection of the feelings let the patient know that the nurse is aware of what the patient is feeling. It signifies understanding, empathy, interest and respect for the patient. Other techniques may not represent empathetic understanding.

        “ You are looking sad and tense. Is it related to what you have explained?”

Reflecting techniques can be used incorrectly, when stereotyping patient’s response, inappropriate timing of reflections and inappropriate cultural experience and educational level of the patient.

7. Focusing

Focusing helps the patient expand o a topic of importance and also helps in analysing in detail. It helps the patient talk about life experiences or problem areas and accepts the responsibility for improving them. If the goal is to change thoughts, feelings or beliefs, the patient must first identify and down them. It allows the patient discuss central issues and keeps the communication goal-directed.

        “ I think you should talk more about your relationship with your husband?”

8. Sharing Perceptions

It involves asking the patient to verify the nurse’s understanding of what the patient is thinking or feeling. For example, nurse is interviewing an alcoholic patient:

Patient: My wife and children are so good. They love me. But I do not know what happened to me. I can’t care tem. I can’t stop drinking.

Nurse: You seem to be very disappointed with your drinking. Am right about that?

If used inappropriately sharing perceptions can make the patient feel challenging, reassuring, testing

9. Theme Identification

Themes are underlying issues or problems experienced by the patient that emerge repeatedly during the course of the nurse-patient relationship, like anxiety, depression.

“It sounds like that is very important to you. You have mentioned it a very few times.”

10.  Silence

Here, the nurse use lack of verbal communication for a therapeutic reason. It allows the patient to think and gain insights. Silence on the part of nurse has varying effects, depending on how the patient perceives it. To a vocal patient silence on the part of nurse may be welcome, but with a depressed or withdrawn patient, the nurse’s silence may convey support, understanding, and acceptance.

11.  Humour

Humour is basic part of our personality and has a place in therapeutic nurse-patient relationship. It is the discharge of energy through the comic enjoyment of imperfect. It may be helpful with a patient experiencing mild to moderate anxiety. Humour should be consistent with social and cultural values.

12.  Informing

Informing or giving information is nurse shares simple facts with the patient. This skill is use in patient education like when to take medication, necessary precautions and side effects.

        “I think you need to know more about your medication works”

Informing should not fall in to giving advice.

13.  Suggesting

Suggesting is the presentation of alternate ideas. As a therapeutic technique, it is useful intervention in the working phase of the relationship. Suggesting or giving advice can be non-therapeutic. Patient may take nurse’s advice and still have an unsuccessful outcome, the patient returns to blame nurse.

14. Confrontation

Confrontation involves anger and aggression. The therapeutic dimension is  assertiveness rather than aggression. Confrontation is an attempt by the nurse to make the patient aware of incongruence in is or her feelings, attitudes, beliefs, and behaviours. It may also help in discovery of ambivalent feelings in the patient. The nurse must be ready to work with the patient through the crisis after confronting the patient. With out this commitment the confrontation lack therapeutic potential and may damage nurse-patient relationship.

15. Role playing

Role playing involves acting out a particular situation. It increases patient’s insight in to human relations can deepen the ability to see the situation from another person’s point of view. Role playing can be used for attitude change and to promote self-awareness.

One of the specific ways in which role playing can be used to resolve conflicts and increase self-awareness is through a dialogue that requires the patient to take the part of each person  or each side of the problem. If the conflict is internal, the dialogue occurs in the present tense between the conflicting selves until one part of the conflict outweighs the other. If second person is involved , the patient is told to begin the dialogue by expressing wants and resentments about the other person. Then, the patient changes chairs assume the role other person, and responds to what was said. This way patient can express feelings and opinions and gives reality base for the probable response from the other party involved in the conflict.

Therapeutic Impasses

For variety of reasons therapeutic communication can be hindered. Therapeutic impasses are blocks in th progress of nurse-patient relationship. They arise for variety of reasons, but the all crates stall in the process of nurse-patient relationship.  Impasse provokes variety of emotions in both he patient and nurse ranging from anxiety and apprehension to frustration, love, or intense anger. The commonest four impasses are discussed here: resistance, transference, counter transference and boundary violations.

1. Resistance

Resistance is the patent’s reluctance or avoidance of verbalizing or experiencing troubling aspects of oneself. The term was first coined by Freud. Resistance is often caused by patient’s unwillingness to change when the need for change is recognized. Patient usually displays resistance during the working phase of nurse-patient relationship, because greater part of problem-solving occurs during this phase. Resistance may be due to:

• nurse who has moved too quickly or too deeply into  the patient’s feelings in to the patient’s feelings
• intentional or unintentional communication of lack of respect
• nurse who is an inappropriate role model for therapeutic behaviour
• Secondary gain– favourable environmental, interpersonal, and situational changes occur and material advantages as a result of the illness (secondary gain can become a powerful force in perpetuating an illness because it makes environment more comfortable)

2. Transference

Transference is an unconscious response in which the patient experiences feelings and attitudes toward the nurse that were originally associated with other significant figures I his or her life.

• They may be triggered by superficial similarity, such as facial features or speech, or by personality style or trait.
• These reactions are the patient’s attempt to reduce anxiety.
• The nurse may be viewed as an authority figure from the past such as parent figure, or lost loved object, such as former spouse
• Transference reactions are harmful to the therapeutic relationship only if they are ignored and unexplained.

Two types of transference are particularly problematic in nurse-patient relationship: hostile transference and dependent reaction transference

1. Hostile transference

Patient may express hostility by uncooperativeness, negativism and hostile silence. If the hostility and anger are internalized, this resistance is expressed as depression and discouragement. Patient may terminate the relationship on the grounds that there is no chance of getting well. If hostility is externalized the, the patient may become critical, defiant, and irritable and may express doubts about nurse’s training, experience or competence. Patient may attempt to compete with the nurse by reading books on psychology and debating intellectual issues rather than working on real life problems.

2. Dependent reaction transference

This resistance is characterised by patient who are submissive, subordinate, and irritating and who regard nurse as godlike figure. Patient continues to demand more of the nurse.

Management of Transference and resistance

Resistance and transference can be difficult problems for the nurse. The psychiatric nurse must be ready to be exposed to such powerful positive and negative emotional responses from the patient.

• Resistance may be due to the nurse and patient have not arrived a mutually acceptable goals or plans of action. The appropriate action here is to return to the goals, purposes and roles of the nurse and patient relationship.

• The analysis of the resistance or transference should be directed toward the patient gaining awareness of these motivations and learning about being completely responsible for all actions or behaviour.

• The first thing nurse must listen to the patient.

• When transference or resistance is recognised clarification and reflection of feelings can be used. Clarification gives the nurse a more focussed idea of what is happening. Reflection of the content ma help patients become aware of what has been going on their own mind.

E.g. Nurse may say” I sense you are struggling with yourself. Part of you want to explore the issue of your of your marriage and another part says ‘No-I’m not ready yet”.

3. Countertransfernce

It is a therapeutic impasse created by the nurse’s specific emotional response to the qualities of the patient. This is inappropriate to the content and context of therapeutic nurse-patient relationship. It is transference applied to the nurse. It is natural that nurse feels warmth toward or liking for some patients more than others. The nurse also will be genuinely angry about the actions of some patient. But in countertransfernce, the nurse’s responses are not justified by reality. Here nurse identify the patient with individuals from their past, and personal needs interfere with their therapeutic relationship.

Types

1.  Reactions of intense love or caring

2.  Reactions of intense disgust or hostility

3.  Reactions of intense anxiety often in response to resistance by the patient

Examples:

• Difficulty in empathizing with the patient in certain problem areas

• Feeling of depression during or after a session

• Feeling or anger or impatience because of the patient’s unwillingness to change

• Argument with the patient or a tendency to push before the patient is ready

• Personal or social involvement with the patient

• Dreams about or preoccupation with the patient

• Sexual or aggressive fantasies about the patient

Other forms include staff involve in countertransfernce

• when they over-react the patient’s aggressive behaviour, ignore available patient data that would promote understanding

• Ignoring patient’s behaviour that does not fit the staff’s diagnosis, minimising a patent’s behaviour, joking about or criticizing a patient or becoming in caught up in intimidation.

The nurse must be constant look out for countertransfernce, become aware when it occurs and work with it to promote therapeutic goals. The nurse must use self-examination throughout the relationship. Following questions are helpful:

• How do I feel about the patient?

• Do I feel sorry or sympathetic for the patient?

• Am I afraid of the patient?

• Do I get extreme pressure out of seeing the patient?

• Do I want to protect, reject, or punish the patient?

Countertransfernce can be harmful to the relationship; it should be dealt as soon as possible. The nurse should discover the source of the problem. When it is recognized the nurse can exercise control over it. If required help, the nurse can seek individual or group supervision.

‘Problem patients’ may elicit strong negative feelings such as anger, fear and helplessness in the mind of nurse. Such patients should be dealt with patience and action should be directed to making patient responsible for his own behaviour. Nurse should review patient’s needs and problems and use responsive dimensions of genuineness, respect, empathetic understanding, and concreteness.

4. Boundary Violations

Here the nurse goes beyond the boundaries of therapeutic relationship and establishes a social, economic, or personal relationship with a patient. Boundary violation is involved whenever a nurse is doing or thinking of doing something special, different or unusual for a patient. Situations where possible boundary violations can happen:

1. The patient takes the nurse to a lunch or dinner
2. the nurse regularly reveals personal information to the patient
3. The nurse accepts free gifts from the patient
4. The nurse agrees to meet the patient for treatment  outside the usual therapeutic setting without therapeutic justification

Types:

1. Role boundaries-problems with role boundaries require the insight of the nurse and the setting of firm therapeutic limits with the patient
2. Time boundaries-odd and unusual hours that have no therapeutic necessity
3. Place and space boundaries-usually in an office or a hospital unit, outside that requires strong therapeutic rationale
4. Money boundaries-regarding fee
5. Gift and service boundaries-gift acceptance may place undue obligations to the patient
6. Clothing boundaries-dress appropriately in a therapeutic manner
7. Language boundaries-addressing the patient and nurse’s choice of words in implementing care. Too familiar, sexual, off-colour or leading language are boundary violations.
8. Self-disclosure boundaries-inappropriately timed self-disclosure and that lacking therapeutic value
9. Post-discharge social boundaries-post-discharge social contact raise the question of boundary violation
10. Physical contact boundaries- sexual contact

Reference

1. Dexter, G. Psychiatric Nursing skills- A patient-Centred approach. 2^nd edn. Chapmal & Hall London, 1995.
2. Fertinash, M, K. & Hooldey A P. Psychiatric Mental Health Nursing. 3^rd edn. Mosbey Philadelphia 2003.
3. Teyler, M.C. Eessentials of Psychiatric Nursing. 14^th edn. Mosbey London, 1994.
4. Gail.W.Stuart, Michal T. Laraiya. Principles and Practice of Psychiatric Nursing 1998: Chapter 10, Page 178.
5. Mohr, K W. Psychiatric Mental Health Nursing. 6^th edn. LWW Philadelphia 2006

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