Running Head: CRITIQUE AND ANALYSIS OF INTERPERSONAL SKILLS

Critique and Analysis of Interpersonal Skills Dermot Connolly Stenberg College

CRITIQUE AND ANALYSIS OF INTERPERSONAL SKILLS Abstract One of the key roles of a psychiatric nurse is the development of an interpersonal relationship with their patients. The purpose of this paper was for each student to assess their own interpersonal skills through the use of micro skills such as empathy, active listening and attending. This assessment took place through a ten minute recorded interaction with a fellow classmate where the analysis of that interaction was completed through the use of a therapeutic relationship analysis transcription grid. The assessment allowed for the critical reflection of the micro skills used and highlighted areas of strengths such as empathic listening as well as areas for improvement such as effective use of silence and attending. Keywords: Empathy, interpersonal relationships, attending, active listening.

CRITIQUE AND ANALYSIS OF INTERPERSONAL SKILLS Critique and Analysis of Interpersonal Skills In his attempt to describe counseling, Burnard makes the point that in effect we are all

counsellors Burnard, P. (2005) p1. We all know of someone who has suffered a traumatic event in their lives and there may have being times when we have reached out to someone to offer support and advice when the occasion seems appropriate. This in effect is counseling and its use and application can have a profound effect on those that use it. The analysis of a students own interpersonal and counselling skills allows for the student to critically reflect on their own abilities as a counselor. It allows the student to practice the development of effective interpersonal relationships with their clients. In the example presented in this paper the client came to counselling describing a traumatic event from her past. The event centered on the suicide of her then boyfriend in 2002 and the impact this suicide had on her life. The interaction between the student and the client was recorded in taped conversation with the clients written consent. This assessment calls for a ten minutes interaction to be recorded and submitted for analysis. While the interaction was nineteen minutes in length, only the first ten minutes are submitted here for analysis. The purpose of this paper is to share the analysis and reflection of the student counselor during this ten minute interaction with the client. It is a personal critique and a look into the techniques used and missed during this interaction. Analysis During the course of the interaction with the client the use and misuse of some key couselling skills were identified. The first of these skills was active listening and its relationship with attending with the client. Active listening has a profound effect on the development of a

CRITIQUE AND ANALYSIS OF INTERPERSONAL SKILLS therapeutic relationship with the client. Used correctly, the client feels that their story has being heard and properly understood. Attending with the client involves focusing on what the client is trying to communicate and being aware of what is being said. During this assessment some of the effective uses of active listening were demonstrated through the use of silence, body language and words that demonstrate to the client that she was understood. In one example the client spoke of her husbands reaction to the news of her ex-boyfriends suicide. The client felt that the news was difficult for her husband and he attempted to hide it from her in an attempt to be supportive. Through the simple use of words like Mmm accompanied with eye contact, a nodding head and the correct facial expression, the client was shown that she had been actively

listened to. In other instances, the use of silence had a similar effect. In these instances, the use of silence coupled again with the appropriate non verbal communication, allows the client to understand that she was being listened to and allowed her to continue with her story. The subject of attending demonstrated an excellent example of a skill that was missed. During the interaction, the client discusses one of the sources of her strength. Instead of acknowledging those strengths, the interaction is switched to a completely different topic where the assumption is made that the suicide had an effect on the clients ability to form relationships. This assumption was unfounded and demonstrated what Burnard calls a zone three in terms of attending. In a zone three, the counsellor is formulating theories and interpretations about the client instead of listening to them. The implementation of John Herons six category intervention analysis has being very influential in the development of couselling skills and relations since 1975. Sloan & Watson (2001). Heron developed his interventions and sub divided them into authoritative (prescriptive, informative and confronting) and facilitative (cathartic, catalytic and supportive). (Reference

CRITIQUE AND ANALYSIS OF INTERPERSONAL SKILLS Counseling and psychotherapy). The use of these interventions played an important role in the analysis of the student assessment. The use and misuse of both the catalytic and supportive

interventions are evident throughout the recorded interaction. An example of the effective use of catalytic intervention is evident when the client discusses her difficulty in seeing young people with so much to live for attempting suicide. The client is encouraged to explore these feelings of difficulty more through the use of a question that asks her who she turns to in such difficult times. Her response draws the client into a discussion about the use of her husband as a source of strength. There are also some examples where the misuse of Herons interventions is evident. An example of this is when the client asks herself and the counsellor about the importance of being able to pull herself together and deal with the situation with which she is facing. The response is one of silence when a more appropriate response would have being a supportive intervention which would have made the client feel that she was correct. Instead, the silence left the impression that the counsellor may not have agreed with the client, potentially leaving the client with the feeling that she was being judged and misunderstood. The interaction also demonstrated one example of prescriptive intervention as a continuation of the clients frustration with young peoples attempts at suicide and her struggles to understand it. The counsellor attempts to recommend a particular course of action by reaching out to these people but this interaction runs the risk of being misinterpreted as being moralistic by the client. The use of silence is also an important aspect of any therapeutic relationship and there are a few occasions during the course of this interaction where silence was used with varying degrees of success. It is important for the counsellor to understand and recognize when a client is using silence as a tool to allow for reflection of their thoughts and when it is necessary for the counsellor to break the silence and interact with the client. Burnard, P. (2005). One such example

CRITIQUE AND ANALYSIS OF INTERPERSONAL SKILLS of the misuse of silence is at the start of the interaction where the client introduces the topic

under discussion only for the silence to be broken by an awkward OK erm from the counsellor. The client would have benefited greatly if the silence was allowed to continue where the client could begin to recall her story. Effective use of silence is evident when the client describes her anger after finding her boyfriends body in the truck. The brief silence that follows is designed to be a supportive interaction to allow the client to continue with her story. It also lets the client see that the counsellor has actively listened to her anger. Other important interactions are evident in the recorded interaction such as the use of empathy and open ended questions. Tschudin (1989) (as cited by Cassedy & Cutcliffe 1998), described empathy as one person helping another person out of a ditch. Using this analogy, the person has one foot in the ditch and one foot on the bank. The world of the individual in distress is represented by the foot in the ditch while the world of the other individual is represented by the foot on the bank. In this assessment, the use of empathy is demonstrated when the client discusses her decision to tell her husband about her ex boyfriends suicide. Empathy is effectively displayed through the counsellors recognition of the criticality of that decision. The empathy is recognized by the client through her response of definitely, which allows her to continue her story. As the clients story continues, the interaction moves on to discuss her husbands reaction to the death of her ex-boyfriend. During this discussion the client is asked if her husbands positive reaction helped the client come to terms with the suicide. This is a deliberate open ended question designed to give the client the opportunity to explore the topic in greater detail, which she does.

CRITIQUE AND ANALYSIS OF INTERPERSONAL SKILLS Reflection

The use of practical interactions between students to help demonstrate the effective use of couselling techniques in client / patient interactions can be very effective. Throughout this course many such techniques used in the treatment and assessment of patients are discussed and analyzed. The practical application of these techniques act as a valuable insight into the skills learned and the skills missed by a student during the course of developing an interpersonal relationship with a client. From the interaction presented in this assessment several of these key skills were recognized. The first of these was the use and misuse of silence. It can be difficult to know when to correctly use silence and even more difficult to determine when to break a silence and when to let it continue. It could also be argued that the introduction of one of Herons interventions could be used as an effective alternative to silence. This exercise also highlighted the importance of recognizing silence in clinical practice. The effective use of silence can allow the client time to reflect on their responses while also allowing them time to continue their story. The importance of active listening and attending was also highlighted as an important outcome from this assignment. There were several occasions where the client discussed her emotions and frustrations with the events that surrounded the death of her ex-boyfriend. The counselling reactions to these emotions play a key role in how the client interprets the level of understand being demonstrated. Simple verbal affirmations and tone of voice can help the client understand that they have being actively listened to. Non verbal communication is equally as important. Proper use of facial expressions and body position demonstrates to the client that they have been understood. This assessment also highlighted the misuse of attending on behalf of the counsellor. There were instances when the counsellors attention was not always focused on the client. There were instances when the counsellor was thinking ahead to the next question instead

CRITIQUE AND ANALYSIS OF INTERPERSONAL SKILLS of focusing on the responses from the client. This is an important area where improvement is

needed through recognition of these instances where the counsellor has lost focus. In the clinical setting, if the nurse is not focused on the client, it can lead to instances where assumptions are made about the client and their story without having those assumptions confirmed. The location of any therapeutic interaction is of the utmost importance. Poor choice of location can make it difficult for some key elements of the therapeutic relationship to be developed such as active listening and attending. For the purpose of this exercise, the location for this assessment was a quiet comfortable room with no distractions. This allowed both the client and the counsellor to feel comfortable during the interaction. There were a few occasions when the client sat back into a more comfortable position as she reflected on a particular event and other occasions where she sat forward to describe an event that was difficult for her. When interacting with patients in a clinical setting, it will be important to select a location that is comfortable for both the client and the nurse. Scheduling all interactions with the client ahead of time in the same location would also be beneficial as the client is made aware of the interaction in advance and in a location they can become familiar with. There are a broad range of skills available to the counsellor to aid in the development of an effective interpersonal relationship. Used correctly these skills can help the client tell their story in a manner that allows them to develop a greater understanding of their problem and enable them play an active role in its resolution. The application of these skills are best developed through practical exercises like the one used in this assessment. Through one to one interactions with fellow classmates, students are given the opportunity to reflect on the theory of psychiatric nursing and its application in a clinical environment. Practical exercises such as these allows for the critical reflection of the students own strengths and weaknesses. The development

CRITIQUE AND ANALYSIS OF INTERPERSONAL SKILLS and use of such tools as the therapeutic analysis grid enables the student to breakdown the interaction into point form highlighting at a glance the skills recognized and missed during the

exercise. In the example presented in this exercise, student strengths such as empathetic listening were recognized along with weaknesses such as the effective use of silence and attending.

CRITIQUE AND ANALYSIS OF INTERPERSONAL SKILLS References

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Burnard, P. (2005). Counselling Skills for Health Professionals (4th edition). Nelson Thornes Ltd. Cassedy, P. & Cutcliffe, J., (1998). Empathy, students and the problems of genuineness. Mental Health Practice. (1) 9. 28-33. Counseling and psychotherapy. (n.d.). Retrieved from: http://stenbergcollege.mrooms3.net/file.php/321/psyn_103_session_7_rf1a-e.pdf Sloan, G., & Watson, H. (2001). John Herons six-category intervention analysis: towards understanding interpersonal relations and progressing the delivery of clinical supervision for mental health nursing in the United Kingdom. Journal of Advanced Nursing, 36(2), 206-14. doi:10.1046/j.1365-2648.2001.01961.x

CRITIQUE AND ANALYSIS OF INTERPERSONAL SKILLS Appendix 1 Ten Minute Recording of the Interaction between Client and Student.

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http://dl.dropbox.com/u/85067716/Dermot.mp3

Appendix 2 Therapeutic Relationship Analysis Transcription Grid Client response We can talk about the suicide of my boyfriend Ian who died in March 2002 After the client describes finding her boyfriend dead in the truck for a very long time she said she was mad and she describes yelling at him and uses the term never being so mad in my life Client describes how she found the body Student response OK erm Skill used Skill missed Better phrase Silence Client would have felt more at ease if silence was used to allow her to continue her story This must have being a shock for you; do you think this was the source of your anger?

Silence

Active Listening and supportive intervention to allow the client continue her story

Catalytic intervention

The clients story is summarized and state to the client that the experience must have being very difficult for the client. Where do you think you found the strength Silence

Client acknowledges her own strength Client states I have to pull myself together and deal with this situation

Use of an assessment summary to highlight to the client that her story was being actively listened to. This is confirmed by the clients response very difficult Catalytic intervention

Supportive intervention Supportive intervention

You certainly demonstrated a lot of strength. Umm, indicates that the clients question was listened to and understood.

CRITIQUE AND ANALYSIS OF INTERPERSONAL SKILLS right? Client states you find your strength out of necessity

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Do you feel it affected your ability to form relationships?

Active listening and supportive intervention

I blamed myself, like how can somebody kill themselves As silly as that sounds, you defiantly go through those emotions

Silence

Active listening and empathic listening Open question to allow the client to continue with her story. This developed her exploration into her interpretations of peoples reactions to the suicide Empathetic listening to show the client that they are being understood. Use of an assessment summary to highlight to the client that her story was being actively listened to. Acknowledgment is also given to the clients strength. This is confirmed

Client would have benefited by having her strengths acknowledged and being supportive of those strengths. Instead the subject was changed as the question reflected that the counselor was not attending the client. The question reflected attention that was focused on fantasy. You felt somehow responsible for his death.

Why do you think that is?

Id go to the grocery store or Walmart and people would be whispering behind my back

Uhum

This portion of the clients story is summarized. Acknowledgmen t is given to the clients anger, to her strength in dealing with the paramedics and awareness of other peoples

CRITIQUE AND ANALYSIS OF INTERPERSONAL SKILLS response to the suicide. by the clients exploration into her anger at the paramedic over the phone. Active listening and understanding Prescriptive intervention but may have being expressed in a manner that was moralistic

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Im fine now, its part of my life story. The client discusses the young people she sees that have attempted suicide and her anger at them as she feels they have so much to live for. But it does break my heart when I see them come in

Right Have you ever felt the need to reach out and help these people who have attempted suicide? When it does break your heart and if you feel overwhelmed, who do you turn to?

Did this make you want to help in any way?

Catalytic intervention Which encouraged the client to talk about her husband as a source of strength.

The interaction assumed that the client felt overwhelmed when this was never stated. A better phrase would have being I can sense it is very difficult for you to see these young people, how do you channel that difficulty?

When we became serious, that was a big, do I or dont I tell him that my last boyfriend died.

That sounds like that was a critical decision for your relationship

The client discusses her husbands reaction to the news that her

Do you think that your husbands reaction to your boyfriends

Empathy and acknowledgement that the client has being heard and understood. This is confirmed by the clients definitely response which allowed the client to continue her story. Open question to prompt exploration.

CRITIQUE AND ANALYSIS OF INTERPERSONAL SKILLS boyfriend committed suicide. I think he struggled with it but put on a strong face for me because he knew that I really struggled having to tell him suicide helped you come to terms with it? Mmm

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Empathic listening to show the client that they have being understood.

Appendix 3 Consent Form