Therapeutic Communication CH 6 Videbeck

Nontherapeutic Communication Techniques Giving approval

-sanctioning the client's behavior or ideas "That's good." "I'm glad that"...." Saying what the client thinks or feels is "good" implies that the opposite is "bad." Approval, then, tends to limit the client's freedom to think, speak, or act in a certain way. This can lead to the client's acting in a particular way just to please the nurse.

Goals of Therapeutic Communication

Establish a therapeutic nurse-client relationship. Identify the most important client concern at that moment (the client-centered goal). Assess the client's perception of the problem Facilitate the client's expression of emotions. Teach the client and family necessary self-care skills. Recognize the client's needs. Implement interventions designed to address the client's needs. Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution.

5 identified types of touch

Functional—professional touch is used in examinations or procedures such as when the nurse touches a client to assess skin turgor or a masseuse performs a massage. Social—polite touch is used in greeting, such as a handshake and the "air kisses" some women use to greet acquaintances, or when a gentle hand guides someone in the correct direction. Friendship—warmth touch involves a hug in greeting, an arm thrown around the shoulder of a good friend, or the backslapping some men use to greet friends and relatives. Love—intimacy touch involves tight hugs and kisses between lovers or close relatives. Sexual—arousal touch is used by lovers.

nonverbal communication:

the behavior that accompanies verbal content, such as body language, eye contact, facial expression, tone of voice, speed and hesitations in speech, grunts and groans, and distance from the listener

Active listening and observation help the nurse to

Recognize the issue that is most important to the client at this time Know what further questions to ask the client Use additional therapeutic communication techniques to guide the client to describe his or her perceptions fully Understand the client's perceptions of the issue instead of jumping to conclusions Interpret and respond to the message objectively

spirituality:

a client's beliefs about life, health, illness, death, and one's relationship to the universe; involves the essence of a person's being and his or her beliefs about the meaning of life and the purpose for living

body language:

a nonverbal form of communication: gestures, postures, movements, and body positions

social zone:

a space of 4 to 12 feet, which is the distance acceptable for communication in social, work, and business settings

assertive communication:

ability to express positive and negative ideas and feelings in an open, honest, and direct way

distance zones:

amount of physical space between people during communication; in the United States, Canada, and many Eastern European nations, four distance zones are generally observed: intimate zone, personal zone, social zone, and public zone

therapeutic communication:

an interpersonal interaction between the nurse and the client during which the nurse focuses on the client's specific needs to promote an effective exchange of information

directive role:

asking direct, yes/no questions and using problem-solving to help the client develop new coping mechanisms to deal with present, here-and-now issues

intimate zone:

space of 0 to 18 inches between people; the amount of space comfortable for parents with young children, people who mutually desire personal contact, or people whispering; invasion of this intimate zone by anyone else is threatening and produces anxiety

active listening:

concentrating exclusively on what the client says, refraining from other internal mental activities

process:

in communication, denotes all nonverbal messages that the speaker uses to give meaning and context to the message

public zone:

space of 12 to 25 feet; the acceptable distance between a speaker and an audience, between small groups, and among others at informal functions

personal zone:

space of 18 to 36 inches; a comfortable distance between family and friends who are talking

eye contact:

looking into the other person's eyes during communication

closed body positions:

nonverbal behavior such as crossed legs and arms folded over chest that indicate the listener may be failing to listen, defensive, or not accepting

context:

the environment in which an event occurs; includes the time and the physical, social, emotional, and cultural environments cues (overt and covert): verbal or nonverbal messages that signal key words or issues for the client

communication:

the processes that people use to exchange information

proxemics:

the study of distance zones between people during communication

circumstantiality:

the use of extraneous words and long, tedious descriptions

verbal communication:

the words a person uses to speak to one or more listeners

3 -6 feet

therapeutic communication interaction is most comfortable when the nurse and client are _ _ _ feet apart. If a client invades the nurse's intimate space (0 to 18 inches), the nurse should set limits gradually

abstract messages:

unclear patterns of words that often contain figures of speech that are difficult to interpret

nondirective role:

using broad openings and open-ended questions to collect information and help the client to identify and discuss the topic of concern

content:

verbal communication; the literal words that a person speaks

active observation:

watching the speaker's nonverbal actions as he or she communicates

congruent message:

when communication content and processes agree

incongruent message:

when the communication content and process disagree

concrete message:

words that are as clear as possible when speaking to the client so that the client can understand the message; concrete messages are important for accurate information exchange

Silence Therapeutic Communication Technique

—absence of verbal communication, which provides time for the client to put thoughts or feelings into words, to regain composure, or to continue talking Nurse says nothing but continues to maintain eye contact and conveys interest. Silence often encourages the client to verbalize, provided that it is interested and expectant. Silence gives the client time to organize thoughts, direct the topic of interaction, or focus on issues that are most important. Much nonverbal behavior takes place during silence, and the nurse needs to be aware of the client and his or her own nonverbal behavior.

Giving recognition Therapeutic Communication Technique

—acknowledging, indicating awareness "Good morning, Mr. S."..." "You've finished your list of things to do." "I notice that you've combed your hair." Greeting the client by name, indicating awareness of change, or noting efforts the client has made all show that the nurse recognizes the client as a person, as an individual. Such recognition does not carry the notion of value, that is, of being "good" or "bad."

Broad openings Therapeutic Communication Technique

—allowing the client to take the initiative in introducing the topic "Is there something you'd like to talk about?" "Where would you like to begin?" Broad openings make explicit that the client has the lead in the interaction. For the client who is hesitant about talking, broad openings may stimulate him or her to take the initiative.

Nontherapeutic Communication Techniques Testing

—appraising the client's degree of insight "Do you know what kind of hospital this is?" "Do you still have the idea that"...?" These types of questions force the client to try to recognize his or her problems. The client's acknowledgment that he or she doesn't know these things may meet the nurse's needs but is not helpful for the client.

Encouraging comparison Therapeutic Communication Technique

—asking that similarities and differences be noted "Was it something like"...?" "Have you had similar experiences?" Comparing ideas, experiences, or relationships brings out many recurring themes. The client benefits from making these comparisons because he or she might recall past coping strategies that were effective or remember that he or she has survived a similar situation.

Encouraging expression Therapeutic Communication Technique

—asking the client to appraise the quality of his or her experiences "What are your feelings in regard to"...?" "Does this contribute to your distress?" The nurse asks the client to consider people and events in light of his or her own values. Doing so encourages the client to make his or her own appraisal rather than to accept the opinion of others.

Formulating a plan of action Therapeutic Communication Technique

—asking the client to consider kinds of behavior likely to be appropriate in future situations "What could you do to let your anger out harmlessly?" "Next time this comes up, what might you do to handle it?" It may be helpful for the client to plan in advance what he or she might do in future similar situations. Making definite plans increases the likelihood that the client will cope more effectively in a similar situation.

Nontherapeutic Communication Techniques Requesting an explanation

—asking the client to provide reasons for thoughts, feelings, behaviors, events "Why do you think that?" "Why do you feel that way?" There is a difference between asking the client to describe what is occurring or has taken place and asking him to explain why. Usually, a "why" question is intimidating. In addition, the client is unlikely to know "why" and may become defensive trying to explain himself or herself.

Encouraging description of perceptions Therapeutic Communication Technique

—asking the client to verbalize what he or she perceives "Tell me when you feel anxious." "What is happening?" "What does the voice seem to be saying?" To understand the client, the nurse must see things from his or her perspective. Encouraging the client to describe ideas fully may relieve the tension the client is feeling, and he or she might be less likely to take action on ideas that are harmful or frightening.

Nontherapeutic Communication Techniques Interpreting

—asking to make conscious that which is unconscious; telling the client the meaning of his or her experience "What you really mean is"...." "Unconsciously you're saying"...." The client's thoughts and feelings are his or her own, not to be interpreted by the nurse for hidden meaning. Only the client can identify or confirm the presence of feelings.

Nontherapeutic Communication Techniques Defending

—attempting to protect someone or something from verbal attack "This hospital has a fine reputation." "I'm sure your doctor has your best interests in mind." Defending what the client has criticized implies that he or she has no right to express impressions, opinions, or feelings. Telling the client that his or her criticism is unjust or unfounded does not change the client's feelings but only serves to block further communication.

Nontherapeutic Communication Techniques Indicating the existence of an external source

—attributing the source of thoughts, feelings, and behavior to others or to outside influences "What makes you say that?" "What made you do that?" "Who told you that you were a prophet?" The nurse can ask, "What happened?" or "What events led you to draw such a conclusion?" But to question, "What made you think that?" implies that the client was made or compelled to think in a certain way. Usually, the nurse does not intend to suggest that the source is external, but that is often what the client thinks.

Nontherapeutic Communication Techniques Introducing an unrelated topic

—changing the subject Client: "I'd like to die." Nurse: "Did you have visitors last evening?" The nurse takes the initiative for the interaction away from the client. This usually happens because the nurse is uncomfortable, doesn't know how to respond, or has a topic he or she would rather discuss. The client's thoughts and feelings are his or her own, not to be interpreted by the nurse for hidden meaning. Only the client can identify or confirm the presence of feelings.

Placing event in time or sequence Therapeutic Communication Technique

—clarifying the relationship of events in time "What seemed to lead up to"...?" "Was this before or after"...?" "When did this happen?" Putting events in proper sequence helps both the nurse and the client to see them in perspective. The client may gain insight into cause-and-effect behavior and consequences, or the client may be able to see that perhaps some things are not related. The nurse may gain information about recurrent patterns or themes in the client's behavior or relationships.

Focusing Therapeutic Communication Technique

—concentrating on a single point "This point seems worth looking at more closely." "Of all the concerns you've mentioned, which is most troublesome?" The nurse encourages the client to concentrate his or her energies on a single point, which may prevent a multitude of factors or problems from overwhelming the client. It is also a useful technique when a client jumps from one topic to another.

Exploring Therapeutic Communication Technique

—delving further into a subject or an idea "Tell me more about that." "Would you describe it more fully?" "What kind of work?" When clients deal with topics superficially, exploring can help them examine the issue more fully. Any problem or concern can be better understood if explored in depth. If the client expresses an unwillingness to explore a subject, however, the nurse must respect his or her wishes.

Nontherapeutic Communication Techniques Challenging

—demanding proof from the client "But how can you be president of the United States?" "If you're dead, why is your heart beating?" Often, the nurse believes that if he or she can challenge the client to prove unrealistic ideas, the client will realize there is no "proof" and then will recognize reality. Actually, challenging causes the client to defend the delusions or misperceptions more strongly than before.

Nontherapeutic Communication Techniques Disapproving

—denouncing the client's behavior or ideas "That's bad." "I'd rather you wouldn't"...." Disapproval implies that the nurse has the right to pass judgment on the client's thoughts or actions. It further implies that the client is expected to please the nurse.

Reflecting Therapeutic Communication Technique

—directing client actions, thoughts, and feelings back to client Client: "Do you think I should tell the doctor"...?" Nurse: "Do you think you should?" Client: "My brother spends all my money and then has nerve to ask for more." Nurse: "This causes you to feel angry?" Reflection encourages the client to recognize and accept his or her own feelings. The nurse indicates that the client's point of view has value and that the client has the right to have opinions, make decisions, and think independently.

Voicing doubt Therapeutic Communication Technique

—expressing uncertainty about the reality of the client's perceptions "Isn't that unusual?" "Really?" "That's hard to believe." Another means of responding to distortions of reality is to express doubt. Such expression permits the client to become aware that others do not necessarily perceive events in the same way or draw the same conclusions. This does not mean the client will alter his or her point of view, but at least the nurse will encourage the client to reconsider or reevaluate what has happened. The nurse neither agreed nor disagreed; however, he or she has not let the misperceptions and distortions pass without comment.

General leads Therapeutic Communication Technique

—giving encouragement to continue "Go on." "And then?" "Tell me about it." General leads indicate that the nurse is listening and following what the client is saying without taking away the initiative for the interaction. They also encourage the client to continue if he or she is hesitant or uncomfortable about the topic.

Nontherapeutic Communication Techniques Agreeing

—indicating accord with the client "That's right." "I agree." Approval indicates the client is "right" rather than "wrong." This gives the client the impression that he or she is "right" because of agreement with the nurse. Opinions and conclusions should be exclusively the client's. When the nurse agrees with the client, there is no opportunity for the client to change his or her mind without being "wrong."

Accepting Therapeutic Communication Technique

—indicating reception "Yes." "I follow what you said." Nodding An accepting response indicates the nurse has heard and followed the train of thought. It does not indicate agreement but is nonjudgmental. Facial expression, tone of voice, and so forth also must convey acceptance or the words lose their meaning.

Nontherapeutic Communication Techniques Reassuring

—indicating there is no reason for anxiety or other feelings of discomfort "I wouldn't worry about that." "Everything will be all right." "You're coming along just fine." Attempts to dispel the client's anxiety by implying that there is not sufficient reason for concern completely devalue the client's feelings. Vague reassurances without accompanying facts are meaningless to the client.

Giving information Therapeutic Communication Technique

—making available the facts that the client needs My name is"...." "Visiting hours are"...." "My purpose in being here is"...." Informing the client of facts increases his or her knowledge about a topic or lets the client know what to expect. The nurse is functioning as a resource person. Giving information also builds trust with the client.

Offering self Therapeutic Communication Technique

—making oneself available "I'll sit with you awhile." "I'll stay here with you." "I'm interested in what you think." The nurse can offer his or her presence, interest, and desire to understand. It is important that this offer is unconditional; that is, the client does not have to respond verbally to get the nurse's attention.

Nontherapeutic Communication Techniques Belittling feelings expressed

—misjudging the degree of the client's discomfort Client: "I have nothing to live for"... I wish I was dead." Nurse: "Everybody gets down in the dumps," or "I've felt that way myself." When the nurse tries to equate the intense and overwhelming feelings the client has expressed to "everybody" or to the nurse's own feelings, the nurse implies that the discomfort is temporary, mild, self-limiting, or not very important. The client is focused on his or her own worries and feelings; hearing the problems or feelings of others is not helpful.

Presenting reality Therapeutic Communication Technique

—offering for consideration that which is real "I see no one else in the room." "That sound was a car backfiring." "Your mother is not here; I am a nurse." When it is obvious that the client is misinterpreting reality, the nurse can indicate what is real. The nurse does this by calmly and quietly expressing his or her perceptions or the facts, not by way of arguing with the client or belittling his or her experience. The intent is to indicate an alternative line of thought for the client to consider, not to "convince" the client that he or she is wrong.

Nontherapeutic Communication Techniques Making stereotyped comments

—offering meaningless clichés or trite comments "It's for your own good." "Keep your chin up." "Just have a positive attitude and you'll be better in no time." Social conversation contains many clichés and much meaningless chitchat. Such comments are of no value in the nurse-client relationship. Any automatic responses lack the nurse's consideration or thoughtfulness.

Suggesting collaboration Therapeutic Communication Technique

—offering to share, to strive, and to work with the client for his or her benefit "Perhaps you and I can discuss and discover the triggers for your anxiety." "Let's go to your room, and I'll help you find what you're looking for." The nurse seeks to offer a relationship in which the client can identify problems in living with others, grow emotionally, and improve the ability to form satisfactory relationships. The nurse offers to do things with, rather than for, the client.

Nontherapeutic Communication Techniques Disagreeing

—opposing the client's ideas "That's wrong." "I definitely disagree with"...." "I don't believe that." Disagreeing implies the client is "wrong." Consequently, the client feels defensive about his or her point of view or ideas.

Summarizing Therapeutic Communication Technique

—organizing and summing up that which has gone before "Have I got this straight?" "You've said that"...." "During the past hour, you and I have discussed"...." Summarization seeks to bring out the important points of the discussion and to increase the awareness and understanding of both participants. It omits the irrelevant and organizes the pertinent aspects of the interaction. It allows both client and nurse to depart with the same ideas and provides a sense of closure at the completion of each discussion.

Nontherapeutic Communication Techniques Probing

—persistent questioning of the client "Now tell me about this problem. You know I have to find out." "Tell me your psychiatric history." Probing tends to make the client feel used or invaded. Clients have the right not to talk about issues or concerns if they choose. Pushing and probing by the nurse will not encourage the client to talk.

Nontherapeutic Communication Techniques Using denial

—refusing to admit that a problem exists Client: "I'm nothing." Nurse: "Of course you're something—everybody's something." Client: "I'm dead." Nurse: "Don't be silly." The nurse denies the client's feelings or the seriousness of the situation by dismissing his or her comments without attempting to discover the feelings or meaning behind them.

Nontherapeutic Communication Techniques Rejecting

—refusing to consider or showing contempt for the client's ideas or behaviors "Let's not discuss"...." "I don't want to hear about"...." When the nurse rejects any topic, he or she closes it off from exploration. In turn, the client may feel personally rejected along with his or her ideas.

Restating Therapeutic Communication Technique

—repeating the main idea expressed Client: "I can't sleep. I stay awake all night." Nurse: "You have difficulty sleeping." Client: "I'm really mad, I'm really upset." Nurse: "You're really mad and upset." The nurse repeats what the client has said in approximately or nearly the same words the client has used. This restatement lets the client know that he or she communicated the idea effectively. This encourages the client to continue. Or if the client has been misunderstood, he or she can clarify his or her thoughts.

Nontherapeutic Communication Techniques Giving literal responses

—responding to a figurative comment as though it were a statement of fact Client: "They're looking in my head with a television camera." Nurse: "Try not to watch television" or "What channel?" Often, the client is at a loss to describe his or her feelings, so such comments are the best he or she can do. Usually, it is helpful for the nurse to focus on the client's feelings in response to such statements.

Consensual validation Therapeutic Communication Technique

—searching for mutual understanding, for accord in the meaning of the words "Tell me whether my understanding of it agrees with yours." "Are you using this word to convey that"...?" For verbal communication to be meaningful, it is essential that the words being used have the same meaning for both (all) participants. Sometimes, words, phrases, or slang terms have different meanings and can be easily misunderstood.

Seeking information Therapeutic Communication Technique

—seeking to make clear that which is not meaningful or that which is vague "I'm not sure that I follow." "Have I heard you correctly?" The nurse should seek clarification throughout interactions with clients. Doing so can help the nurse to avoid making assumptions that understanding has occurred when it has not. It helps the client to articulate thoughts, feelings, and ideas more clearly.

Translating into feelings Therapeutic Communication Technique

—seeking to verbalize client's feelings that he or she expresses only indirectly Client: "I'm dead." Nurse: "Are you suggesting that you feel lifeless?" Client: "I'm way out in the ocean." Nurse: "You seem to feel lonely or deserted." Often what the client says, when taken literally, seems meaningless or far removed from reality. To understand, the nurse must concentrate on what the client might be feeling to express himself or herself this way.

Nontherapeutic Communication Techniques Advising

—telling the client what to do "I think you should"...." "Why don't you"...." Giving advice implies that only the nurse knows what is best for the client.

Making observations Therapeutic Communication Technique

—verbalizing what the nurse perceives "You appear tense." "Are you uncomfortable when"...?" "I notice that you're biting your lip." Sometimes clients cannot verbalize or make themselves understood. Or the client

Verbalizing the implied Therapeutic Communication Technique

—voicing what the client has hinted at or suggested Client: "I can't talk to you or anyone. It's a waste of time." Nurse: "Do you feel that no one understands?" Putting into words what the client has implied or said indirectly tends to make the discussion less obscure. The nurse should be as direct as possible without being unfeelingly blunt or obtuse. The client may have difficulty communicating directly. The nurse should take care to express only what is fairly obvious; otherwise, the nurse may be jumping to conclusions or interpreting the client's communication.