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THERAPEAUTIC COMMUNICATION

HOME


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THERAPEUTIC COMMUNICATION

T ry expession

R eflection of wordsU se of silenceS et LimitsT ime with client


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THERAPEUTICCOMMUNICATIONS

ORIENTATION Broad Opening Recognition Giving information Silence Offering Self Do you want me to sit

beside you?


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THERAPEAUTIC COMMUNICATION


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THERAPEUTIC COMMUNICATIONSWORKING Focusing Let us discuss this topic more. Exploring Tell me more about it. Encourage Evaluation IS this what you want? Reflecting same idea Restating same statement Verbalizing Implied Are you going to kill

yourself? Seeking Clarification May you please repeat

that statement General lead Please continue.; And then? Limit setting Stop. Interpreting Maybe that thing is very significant

to you.


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TERMINATION Summarizing Let us now sum up.

You have stated earlieretc.

Do you have any questions? Our next therapy Look for changes in behavior Resistance is a common problem


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Therapeutic CommunicationTechniques

Accepting -indicating reception Eg .Yes

I follow what you said Nodding..


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Broad OpeningsAllowing the client to take the initiativein introducing the topic Eg. is there something youd like to talk

about?

Where would you like to begin?


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Consensual Validation

Searching for mutual understanding, for

accord in the meaning of the words Eg. Tell me whether my understanding of it

agrees with yours

Are you using this word to convey that . .?


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Encouraging Comparison

Asking that similarities and differences be

noted Eg. was it something like..?

Have you had similar experiences?


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Encouraging Description of

PerceptionsAsking the client to verbalize what he or

perceives Eg.Tell me when you feel anxious

What is happening?

What does the voice seem to be saying?


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Encouraging Expression

Asking client to appraise the quality of his

or her experience Eg. what are your feelings in regard to..?

Does this contribute to your distress?


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Exploring

Delving further into a subject or idea

Eg. Tell me more about that.Would you describe it more fully?What kind of work?


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F ocusing

Concentrating on a single point

Eg. This point seems worth looking at moreclosely

Of all the concerns youve mentioned,which is most troublesome?


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F ormulating a Plan of Action

-Asking the client to consider kinds of behavior likely to be appropriate in futuresituations Eg. What could you do to let your anger out

harmlessly?

Next time this comes up, what might youdo to handle it?


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General Leads

Giving encouragement to continue

Eg. Go onAnd then?Tell me about it


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Giving Information

Making available the facts that the client

needs Eg. My name isVisiting hours are

My purpose in being here is


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Giving Recognition

Acknowledging, indicating awareness

Eg. Good morning, Mr. SYouve finished your list of things todo.

I noticed that youve combed your hair


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Making Observations

Verbalizing what the nurse perceives

Eg. You appear tense..I notice that your biting your lips


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Offering Self

Making oneself available

Eg. Ill sit with you awhileIll stay here with youIm interested in what you think


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Placing Event in Time or

SequenceClarifying the relationship of events in time

Eg. what seemed to lead up to?Was this before or after?


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Presenting Reality

Offering for consideration that which is real

Eg. I see no one else in the room.Your mother is not here; I am a nurse.


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Reflecting

Directing client actions, thoughts, andfeelings back to client Eg. Client: Do you think I should tell the

doctor? Nurse: Do you think you should?


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Restating

Repeating the main idea expressed

Eg. Client: I cant sleep. I stay awake allnight.

Nurse:You have difficulty sleeping.Client:Im really mad, and upsetNurse: Youre really mad and upset.


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Seeking Information

Seeking to make clear that which is not

meaningful or that which is vague Im not sure that I follow.Have I heard you correctly?


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Silence

Absence of verbal communication, whichprovides time for for the client to putthoughts or feelings into words, regaincomposure, or continue talking Eg. Nurses says nothing but continues to

maintain eye contact and conveys interest.


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Suggesting Collaboration

Offering to share , to strive, to work with

the client for his or her benefit Eg. Perhaps you and I can discuss anddiscover the triggers for your anxiety


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Summarizing

Organizing and summing up that which

has gone before Eg. Have I got this straight?


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Translating into F eelings

seeking to verbalize clients feelings that

he or she expresses only indirectly Eg. Client: Im deadNurse: Are you suggesting that you feellifeless?


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Verbalizing the Implied

Voicing what the client has hinted at or

suggested Eg. Client: I cant talk to you or anyone. Its awaste of time. Nurse: Do you feel that noone understands


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Voicing Doubt

Expressing uncertainty about the reality of

the clients perceptions Isnt that unusual?Really?

Thats hard to believe.


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Nontherapeutic Communication

TechniquesAdvising-telling the client what to do

Agreeing- indicating accord with the

client Eg. I think you should.

Thats right

Indicating accord with the clientthats right. I agree

Agreeing


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Belittling F eelings expressed

Misjudging the degree of the clientscomfort Client: I have nothing to live for..I wish I was

deadNurse: Everybody gets down in the dumps.


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Challenging

Demanding proof from the client But how can you be President of the

Philippines?


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Defending

Attempting to protect someone or something from verbal attack This hospital has a fine reputation.


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Disagreeing

Opposing the clients ideas

Eg. Thats wrong


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Disapproving

Denouncing the clients behavior or ideas

Thats badId rather you wouldnt


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Giving approval

Sanctioning the clients behavior or ideas Thats good. Im glad that..


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Giving Literal Responses

Responding to a figurative comment asthough it were a statement of fact Client: Theyre looking in my head with

television camera.

Nurse: Try not to watch television.


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Indicating the existence of anexternal source

What makes you say that?


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Interpreting

Asking to make conscious that which isunconscious What you really mean is..


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Introducing an unrelated topic

Changing the subject Client: Id like to die.

Nurse: did you have visitors last night?


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Making stereotyped comments

Offering meaningless cliches or tritecomments

Keep your chin up.Just have a positive outlook.


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Probing

Persistent questioning of the clientNow tell me about this problem. I need to

know.


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Reassuring

Indicating there is no reason for anxietyEverything will be alright.


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Rejecting

Refusing to consider or showing contemptfor the clients behavior, ideas

Lets not discuss..


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Requesting an explanation

Asking the client to provide reasons for thoughts, feelings, behaviors, events

Why do you think that?


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Testing

Appraising the clients degree of insightDo you know what kind of hospital this

is?


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Using Denial

Refusing to admit that a problem existsClient: I am nothing.

Nurse: Of course, youre something.


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NONNON--THERAPEUTIC COMMUNICATIONSTHERAPEUTIC COMMUNICATIONS

Overloading blah, blah, blahUnderloading - ignoringValue Judgment use of adjectives

False Reassurance Dont worry, youwill be fine later.Focusing on Self I gave you medsso you are now feeling good

Internal Validation biased judgmentGiving Advice If I were you, illChanging Subject -


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ROLES OF THE PSYCHIATRIC NURSE

COUNSELOR -listens to the patientsverbalizationsPARENT SURROGATE - assists the patients inthe performance of activities of daily livingPATIENT ADVOCATE- enables the patient andhis relatives to know their rights andresponsibilities

TEACHER - assists the patient to learn moreadaptive ways of coping


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TECHNICIAN -facilitates the performance of nursing proceduresTHERAPIST -explores the patients needs,

problems and concerns through variedtherapeutic meansSOCIALIZING AGENT- assists the patient tofeel comfortable with others

WARD MANAGER- creates a therapeuticenvironment

HOME


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ASSESSING BEHAVIORAL SIGNS AND

SYMPTOMS


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ASSESSING BEHAVIORAL SIGNS ANDSYMPTOMS

ALWAYS S END M AIL THRU P OST O FF ICEA-Affect/AppearanceS-SpeechM-Motor Behavior/Mood/MemoryT-Thought ProcessP-Perception

O-Orientation


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General Appearance & Motor

Behavior What does the client look like? How is the clientdressed? Eye contact? Posture?

Speech- clarity, modulation, pitch, speed, barriersto communication

Motor Behavior:

Echopraxia- repeating the movements of another personEx. Everytime the nurse would move or gesture with her hands, the client would copyher gestures


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Echolalia -repeating the speech of another person

Ex. The nurse said to the client, Tell me your name. The client responded, Tell me your

name, Tell me your name.

Waxy Flexibility- having ones arms and legsplaced in a certain position and holding that

same position for hours.Ex. The nurse lifted the clients arm to check the

pulse, and the client left his arm extended inthe same position


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Parkinson-like symptoms- making

mask-like faces, drooling and havingshuffling gait, tremors and muscular rigidity. Seen in people who are onantipsychotic medication.

Ex. The nurse noticed that the clients faceheld no emotion. He walked very stiffly,leaning forward, almost robot-like


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Akathisia - displaying motor restlessness, feeling of muscular quivering; at its worst, patient isunable to sit or lie quietly

Ex. The clients leg kept jiggling upand down when he talked to thenurse. When his feet were still, hisarm would jiggle constantly during the

interview


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Thought ProcessTangentiality -association disturbance in whichthe speaker goes off the topic.

Ex. The nurse asks the client to talk more abouthis family. The client continuously left the topicand talked about boats, animals, his apartmentand so forth.Neologisms - words a person makes up thatonly have meaning for the person himself, oftenpart of a delusional system

Ex. I am afraid to go to the hospital because thenorks are looking for me there.


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Looseness of association- thinking is illogicaland confused. Connections in thought areinterrupted.

Ex. Cant go to the zoo, no money, OhI have ahat, these members make no sense,manWhats the problem?Flight of ideas- constant flow of speech inwhich the person jumps from one topic toanother in rapid succession. There is aconnection between topics although it issometimes hard to identify.

Ex. Say babe, hows it goinggoing to mysisters to get some moneymoney, honey,you got any breadbread and butter, staff of life, aint life grand?


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Blocking - sudden cessation of a thought in themiddle of a sentence. Person is unable tocontinue his train of thought.

Ex. I was going to get a new dress for theIforgot what I was going to say.

Perseveration- involuntary repetition of thesame thought, phrase or motor response todifferent questions or situations:

Ex. N: How are you doing Harry?P: F ine nurse, just fine.N: Did you go for a walk?P: F ine nurse, just fine.


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Confabulation - filling in a memory gapwith detailed believed by the teller tomaintain self-esteem

Ex.The nurse asked Harry who spentthe weekend at home, what he did thatweekend. Well, I just came back fromCalifornia after signing a contract with

MGM for a film on the life of Roosevelt.We have the most marvelous tour at thestudiowent to lunch with the director.


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Circumstantiality -before getting to the pointor answering a question, the person getscaught up in countless details andexplanationsEx.N: Where are you going for the weekendHarry?

P: Well, I first thought of going to mymothers but that was before I rememberedthat she was going to my sisters. My sister is

having a picnic. She always has picnics at thebeach. But I dont like the beach that shegoes to so I decided to some place elseIfinally decided to stay home.


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Word salad- mixture of words that hasno meaning

Ex. I am fineapple pienosalefurniture storetake itslowcellar door

Clang Association- stringing together of words because of their rhymingsounds without regard to their meaning

Ex. Good luck, buck, chuck, duck


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Affect

Flat -absence or near absence of emotional reactionBlunted -severe reduction in emotionalreactionInappropriate disharmony between thestimuli and the emotional reactionBizarre -grimacing, mumbling, giggling


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HALLUCINATIONSA sense perception for which no externalstimuli exist

Visual-seeing things that are not thereEx. During alcohol withdrawal he kept shouting,

I see snakes on the walls!

Auditory-Hearing voices when none ispresent(most common)Ex. I keep hearing my mothers voice telling

me I am bad. She died a year ago.


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Olfactory -smelling smells that do not existEx. I smell my stomach rotting

Tactile - feeling touched sensations in theabsence of the stimuli

Ex. A paranoid man feels electrical impulses fromouter space entering his body and controllinghis mind.

Gustatory -experiencing taste in the absence of stimuliEx. A paranoid woman tastes poison in her foodwhile eating at her sons wedding


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DELUSIONSA false belief held to be true even with evidence tothe contrary.

Persecution -the thought that one is being singledout for harm by others

Ex. An intern believes that the chief of staff is plotting tokill him to prevent the intern from becoming powerful

Grandeur - the false belief that one is a very powerful

and important personEx. A newly admitted patient told the nurse that she was

muse of the United Nations and that she is the mostbeautiful among women.


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Other areas to be assessed:

HistoryOrientationMemoryConcentrationSelf-conceptJudgment- the ability to make logical, rational decisions

Insight- understanding of the nature of a problemPhysiological needs

HOME


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LOSS AND GRIEVING

GRIEF - refers to the subjective emotionsand affect that are a normal response tothe experience of lossANTICIPATORY GRIEVING- when peoplefacing an imminent loss begin to grapplewith the very real possibility of the loss or

death in the near future


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LOSS

Physiologic LossSafe and Security Loss

Love and Belongingness LossSelf-Esteem LossSelf-actualization Loss


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GRIEVING PROCESSKUBLER-ROSSs

DenialAnger

BargainingDepressionAcceptance

Dysfunctional grieving grieving which extendsfrom 4 to 6 weeks leading to CRISIS


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Interventions

Explore clients perception and meaning of thelossAllow adaptive denial

Assist client to reach out for and accept supportEncourage client to examine patterns of copingin past and present situation of lossEncourage client to care for himself

Offer client food without pressure to eatUse effective communication

HOME


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CRISISsituation that occurs when an individualshabitual coping ability becomes ineffective

to merit demands of a situationTYPES O F CRISES:MATURATIONAL / DEVELOPMENTAL Normal expected crisis that runs through age

SITUATIONAL Unexpected and sudden event in life

ADVENTITIOUS Calamities, war

CRISIS AND ITS MANAGEMENT


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Characteristics of a Crisis state

Highly individualizedLasts for 4-6 weeks

Self-limitingPerson affected becomes passive andsubmissive

Affects a persons support system


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PHASES O F A CRISIS

Pre-crisis: State of equilibriumInitial Impact (may last a few hours to a fewdays): High level of stress, helplessness,

inability to function sociallyCrisis (may last a brief or prolonged period of time): Inability to cope, projection, denial,rationalization

Resolution: attempts to use problem-solvingskillsPost crisis: may have OLO F or may havesymptoms of neurosis, psychosis


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CRISIS MANAGEMENT

Role of the nurse is to return the client toits pre-crisis state by assisting and guidingthem until they achieved their OLO F .Goal: to enable patient to attain an OLO F

Nurses Primary Role: Active and Directive


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Steps in Crisis Intervention

Identify the degree of disruption the client isexperiencingAssess the clients perception of the event

F ormulate nursing diagnosesInvolve the patient and family if applicable withplanningImplement interventions- new and old coping

mechanismsEvaluate-reassessment, reinforcement


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TYPES OF THERAPIES

Treatment Modalities

I di id l P h h


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Individual Psychotherapy


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Milieu Therapy


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Milieu Therapy

Total environment has an effect on theindividuals behavior Components Physical Environment Interpersonal relationships Atmosphere of safety, caring, and mutual

respect F or alcoholics


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PROGRAMS FOR MILIEU SHOULD HAVE:

an emphasis on group and social interactionNo rules and expectations mediated by peer pressureA view of patients roles as responsible humanbeingsAn emphasis on patients rights for involvement in setting goalsF reedom of movement and informality of relationships with staff Emphasis on interdisciplinary participationGoal-oriented, clear communication


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G Th


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Group Therapy

Number of people coming together, sharing acommon goal, interest or concern, stayingtogether and developing relationshipsF or PTSD and Alcoholics

Phases Orientation- Purpose of the group is stated, Objectives

and expectations are laid out

Working - Leaders role is to keep the group focused,Support for each other to attain group goals

Termination- Leader acknowledges each memberscontribution and experience as a whole

Members prepare for separation


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Characteristics of Group Therapy

Universality You are not aloneInstilling hope and inspiration

Developing social skills by interacting withone another F eeling of acceptance and belongingAltruism Giving of ones self


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Psychoanalytically oriented group therapyPsychodrama

Family therapy


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Assumption of F amily Therapy F or alcoholic and schizophrenic


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Assumption of F amily TherapyClient: Whole familyConcepts: The family is the most fundamental unit of the society. Adaptive or maladaptive patterns of behavior are learned from

the family Dysfunction in the family = dysfunction in the individual

Purpose Improve relationships among family members Promote family function

Resolve family problems

OTHER TYPES O F


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OTHER TYPES O F

THERAPIESSUPPORT GROUPS F or those with AIDS, Mother-Against-Drug

Dependence

SELF -HELP GROUPS Alcoholic Anonymous


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RULES FOR PSYCHOTHERAPEUTIC

MANAGEMENTProvide support, treat patients with respectand dignity Do not place patients in situations wherein

they will feel inadequate or embarrassedTreat patients as individualsProvide reality testing

Handle hostility therapeutically Provide psychopharmacologic treatment

HOME


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BEHAVIORAL THERAPY

Pavlovs Classical Conditioning All behavior are learned

B.F . Skinners Operational Conditioning Reinforcements

B EHAVIORAL THERAPIES

Treatment Modalities

BEHAVIORAL THERAPY


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BEHAVIORAL THERAPY

Behavioral Modification Substance Abuse

Systematic Desensitization - Phobia


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PSYCHOSOMATIC

THERAPYTreatment Modalities

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Electroconvulsive Therapy


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Effective in most affective disordersThe induction of a grandmal seizure in thebrain.

Abnormal firing of neurons in the braincauses an increase in neurotransmittersNumber of Treatments: 6-12 ,3 times a

week, about .5-2secondsUnilateral or bitemporal

El t l i Th


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Electroconvulsive TherapyIndications:

Patients who require rapid responsePatients who cannot tolerate pharmacotherapy orcannot be exposed to pharmacotherapy Patients who are depressed but have not responded tomultiple and adequate trials of medication



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Electroconvulsive TherapyPreparations for ECT:

Pretreatment evaluation and clearanceConsentNPO from midnight until after the treatmentAtropine Sulfate-to decrease secretions,succinylcholine (Anectine)- to promote musclerelaxation, Methohexital Sodium(Brevital)-anesthethicEmpty bladderRemove jewelry, hairpins, dentures and otheraccessoriesCheck vital signsAttempt to decrease patients anxiety



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Care after ECT: O2 therapy of 100% until patient can breatheunassistedMonitor for respiratory problems, gag reflex

R eorient patientObserve until stableCareful documentation.

Male erectile dysfunction

OTHER THERAPIES

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