CHAPTER

8r

Therapeutic

Communication isg

statement implies: "He kept staring at me, and I a message is verbalized can be as impoftarrt
began to wonder if I was dressed inappropriately or wbat is verbalized,.
had mustard on my face!"
Gazing at another's eyes arouses strong emoE ^^__ *-_.r-*_
tions. Thus, eye conta ct rarety tasrs longer than
COne CoNCEPT
3 seconds before one or both viewers experience
Therapeutic Communicatian

as

I
4

a powerful urge to glance away' Bteaking eye caregiver verbal and nonverlcal techniques that focus
contact lowers stress levels (Givens, 2010c).
,,, on the care receiver,s needS and advance the promo_
vocar cues, or
E :::""J,.[*3;t1,:;[T3i,*:ffi:]T",Hffi5]1""
Paralangaage is the gestural component of the # standing of behavioral motivation. lt is nonjudgmental,
spoken *ord. lt consisis of pitch, tone, and loud- ffi discourages defensiveness, and promotes trust.
ness of spoken messages; the rate of speaking;

paratansuase

expressively placed pauses; and emphasis assigned

il

to cr:lin words. rhese vocal cuel greatly ilnflu- ThefapeUtiC COmmgnicatign TeChniqUeS
ence the way individuals interpret verbal mes-

*i",tr"1'#;ou,f;";:*T::I"-f T:[:il:,1l:,:r::]J?#lJfJ','f ::,"1.1#;":i

Xffi
tense'
}{
p"T:-i*d

as being anxious or

therapeutically with clients. These are the "technivocal emphases can alter interpreta- cal piocedures" carried out by the nurse working
.. '"t"t.t""t
^S) tion
of the message. Three examples follow:
in fsychiatry and they should serye to enhance
. {X
1.
"I
felt
SURE
you
would
notice
development of a therapeutic nurse-client relationthe
change."
iF t
Interpreta.tion:
I
was
SURE
you
ship. Table 8-2 includes a list of rhese techniques,
would,
but
\ d
you
didn't.
a short explanation of their usefulness, and
S S
2.
"I
felt
sure YoU would notice the change.D examples of each'
A *
Interpreta.tion: I thought yOU would, even if
t N
nobodv else
NOntherapeuti' GOmmuni'ati'n
3. "I felt sure you would norice the CHANGE.,, TeChniqUeS
I \
fnturlrretation: Even if you didn,t notice
g
i
else, I thought you would notice the several approaches
\ g
are considered to be barriers
Tf^119
CHAI\IGE'
to open communication befween the nurse and
tl Sr' r;..'l l\ \' Verbal cues play a maior role in determining client. Hays and Larson (1,g6, identified a number
in human communication situations. How of these techniques, which are presented in
,t- Ua f,esRonses

did.

\d I

ts\

\r$
q$$l
Q't1',

Using silence

Gives the client the opportunity to

collect and organize thoughts, to
think through a point, or to consider
introducing a topic of greater concern than the one being discussed.

Accepting

Conveys an attitude of reception and

regard.

"Yes, I understand what you said."

Eye contact; nodding.

Giving recognition

Acknowledging and indicatlng awareness; better than complimenting,

which reflects the nurse's judgment.

"Hello, Mr. J. I notice that you made a

ceramic ashtray in OT."
"l see you made your bed."

Offering self

Making oneself available on an

unconditional basis, increasing
client's feelings of self-worth.

"l'll stay with you awhile."

S*u

;N
:"s
Fi$

"We can eat our lunch together."

"l'm interested in you."
Continued

Giving broad openings

Allows the client to take the initiative

in introducing the topic; emphasizes
the importance of the client's role in
the interaction.

"What would you like to talk about

today?"
"Tell me what you are thinking."

Offering general leads

Offers the client encouragement to

continue.

"Yes, I see." "Go on,"

"And after that?"

Placing the event in time

or sequence

Clarifies the relationship of events in

time so that the nurse and client can
view them in perspective.

"What seemed to lead up to . . .?"

"Was this before or after . . .?"
"When did this happen?"

Making observations

Verbalizing what is observed or perceived. This encourages the client to

recognize specific behaviors and
compare perceptions with the nurse.

"You seem tense."

"l notice you are pacing a lot."
"You seem uncomfortable when

Asking the client to verbalize what is

being perceived; often used with
clients experiencing hallucinations.

"Tell me what is happening now."

"Are you hearing the voices again?"
"What do the voices seem to be
saying?"

Asking the client to compare similarities and differences in ideas, experiences, or interpersonal relationships. This helps the client recognize life experiences that tend to
recur as well as those aspects of life

"Was this something like . . .?"

"How does this compare with the time

Restating

The main idea of what the client has

said is repeated. This lets the client
know whether or not an expressed
statement has been understood and
gives him or her the chance to continue, or to clarify if necessary.

Cl: "l can't study. My mind keeps

wandering."
Ns: "You have difficulty concentrating."
Cl: "l can't take that new job. What if I
can't do it?"
Ns: "You're afraid you will fail in this
new position."

Reflecting

Questions and feelings are referred

back to the client so that they may
be recognized and accepted, and
so that the client may recognize that
his or her point of view has value-a
good technique to use when the
client asks the nurse for advice.

Cl: "What do you think I should do

about my wife's drinking problem?"
Ns: "What do youthink you should do?"
Cl: "My sister won't help a bit toward
my mother's care. I have to do it all!"
Ns: "You feel angry when she doesn't
help."

Focusing

Taking notice of a single idea or even

a single word; works especially well
with a client who is moving rapidly
from one thought to another. This
technique is not therapeutic,
however, with the client who is very
anxious. Focusing should not be
pursued until the anxiety level has

"This point seems worth looking at

more closely. Perhaps you and I can
discuss it together."

Encouraging description

of perceptions

Encouraging comparison

subsided.

you..."

when . . .?"
"What was your response the last time
this situation occurred?"

CHAPTER

Exploring

Delving further into a subject, idea,

experience, or relationship; especially

helpfulwith clients who tend to

remain on a superficial level of communication. However, if the client
chooses not to disclose fufiher information, the nurse should refrain from
pushing or probing in an area that
obviously creates discomforl.
Seeking clarification
and validation

Presenting reality

Striving to explain that which is vague

or incomprehensible and searching
for mutual understanding. Clarifying
the meaning of what has been said
facilitates and increases understanding for both client and nurse.

8r

Therapeutic

Communication 15S

"Please explain that situation in more

detail."
"Tell me more about that particular

situation."

"l'm not sure that I understand. Would

you please explain?"
"Tell me if my understanding agrees
with yours."
"Do I understand correctly that you
said . . .?"

When the client has a misperception

of the environment, the nurse defines
reality or indicates his or her perception of the situation for the client.

"l understand that the voices seem

Expressing uncertainty as to the reality

of the client's perceptions; often
used with clients experiencing
delusional thinking.

"l find that hard to believe."

Verbalizing the implied

Putting into words what the client has

only implied or said indirectly; it can
also be used with the client who is
mute or is otherwise experiencing
impaired verbal communication. This
clarifies that which is implicitraiher
lhan explicit.

Cl: "lt's a waste of time to be here. I

can't talk to you or anyone."
Ns: "Are you feeling that no one
understands?"
Cl:(Mute)
Ns: "lt must have been very difficult
for you whgn your husband died in
the fire."

Attempting to translate
words into feelings

When feelings are expressed indirectly,

the nurse tries to "desymbolize"
what has been said and to find clues
to the underlying true feelings.

Cl: "l'm way out in the ocean."

Ns: "You must be feeling very lonely

When a client has a plan in mind for

dealing with what is considered to be
a stressful situation, it may serve to
prevent anger or anxiety from escalating to an unmanageable level.

"What could you do to let your anger

out harmlessly?"
"Next time this comes up, what
might you do to handle it more
appropriately?"

Voicing doubt

Formulating a plan of
action

Adapted frcn Hays, J. 5., & Larson, K. H. (1 963). Interacting with patients. New york: Macniilan.

real to you, but I do not hear any

voices."
"There is no one else in the room but
you and me."

"That seems rather doubtful to me."

"l understand that you believe this
to be true, but I see this situation
differently than you."

now."

raDre o-r. -L\urscs slruurq recugrlrzc arl(r errlllrllalc

the use of these patterns in their relationships with
clients. Avoiding these communication barriers will
maxtrnize the effectiveness of communication and
enhance the nurse-client relationship.

lLrt LrrE urlgrrl, allLt ur

Active Listening

SOLER:

established within the relationship that promotes

openness and honest expression.
Several nonverbal behaviors have been designated

as facilitative skills for attentive listening. Those

listed here can be identified by the acronym

S-Sit squarely facing the client. This

To listen actively is to be attentive to what the

client is saying, both verbally and nonverbally.
Attentive listening creates a climate in which the
client can communicate. With active listening the
nufse communicates acceptance and respect

gives the

message that the nurse is there to listen and is

interested in what the client has to say.

O-Observe an open posture. Posture is considered "open" when arms and legs remain
uncrossed. This suggests that the nurse is

lndicates to the client that there is no

cause for anxiety, thereby devaluing the
client's feelings; may discourage the
client from further expression of feelings if
he or she believes they will only be downplayed or ridiculed.

"l wouldn't worry about that if

Rejecting

Refusing to consider or showing contempt

for the client's ideas or behavior. This may
cause the client to disdontinue interaction
with the nurse for fear of further rejection.

"Let's not discuss . . ."

"l don't want to hear about . . ."
Better to say: "Let's look at that a
little closer."

Approving or disapproving

Sanctioning or denouncing the client's

ideas or behavior; implies that the nurse
has the right to pass judgment on whether
the client's ideas or behaviors are "good"
or "bad," and that the client is expected
to please the nurse. The nurse's acceptance of the client is then seen as conditional depending on the client's behavior.

"That's good. I'm glad that you . . ."

"That's bad. l'd rather you

lndicating accord with or opposition to the

client's ideas or opinions; implies that the
nurse has the right to pass judgment on
whether the client's ideas or opinions are
"right" or "wrong." Agreement prevents the
client from later modifying his or her point
of view without admitting error.
Disagreement implies inaccuracy, provoking the need for defensiveness on the part

"That's right. I agree."

"That's wrong. I disagree."
"l don't believe that."
Better to say: "Let's discuss what
you feel is unfair about the new
community rules."

Giving reassurance

Agreeing or disagreeing

were you."

"Everything will be all right."

Better to say: "We will work on
that together."

wouldn't . . ."
Better to sayr "Let's talk about
how your behavior invoked anger
in the other clients at dinner."

of the client.
Giving advice

Telling the client what to do or how to

behave implies that the nurse knows
what is best, and that the client is incapable of any self-direction. lt nurtures
the client in the dependent role by dis-

couraging independent thinking.

"l think you should . . ."

"Why don't you . . ."
Better to say: "What do you think
you should do?" or "What do you
think would be the best way to
solve this problem?"

CHAPTER

Probing

8r

Persistent questioning of the client; pushing for answers to issues the client does
not wish to discuss. This causes the
client to feel used and valued only for
what is shared with the nurse and
places the client on the defensive.

Therapeutic

Communication 157

"Tell me how your mother abused

you when you were a child."
"Tell me how you feel toward your
mother now that she is dead."
"Now tell me about . . ."
Better technique: The nurse should
be aware of the client's response
and discontinue the interaction at

the first sign of discomfort.

Defending

Attempting to protect someone or something from verbal attack. To defend what

the client has criticized is to imply that
he or she has no right to express ideas,
opinions, or feelings. Defending does
not change the client's feelings and may
cause the client to think the nurse is
taking sides against the client.

"No one here would lie to you."

"You have a very capable physician.
l'm sure he only has your best
interests in mind."

Better to say: "l will try to answer

your questions and clarify some
issues regarding your treatment.

Requesting an explanation

Asking the client to provide the reasons

for thoughts, feelings, behavior, and
events. Asking "why" a client did
something or feels a certain way can
be very intimidating, and implies that the
client must defend his or her behavior
or feelings.

"Why do you think that?"

"Why do you feel this way?"
"Why did you do that?"
Better to say! "Describe what
you were feeling just before that
happened."

lndicating the existence

of an external source
of power

Attributing the source of thoughts, feelings,

and behavior to others or to outside influences. This encourages the client to
project blame for his or her thoughts or
behaviors on others rather than accepting the responsibility personally.

"What makes you say that?"

"What made you do that?"

Belittling feelings

When the nurse misjudges the degree of

the client's discomfort, a lack of empathy
and understanding may be conveyed.
The nurse may tell the client to "perk up"
or "snap out of it." This causes the client
to feel insignificant or unimportant. When
one is experiencing discomfort, it is no
relief to hear that others are or have
been in similar situations.

Cl: "l have nothing to live for.

I wish lwere dead."
Ns: "Everybody gets down in the
dumps at times. I feel that way
myself sometimes."
Betterto say: "You must be very
upset. Tell me what you are feeling
right now."

Clich6s and trite expressions are meaningless in a nurse-client relationship.

When the nurse makes empty conversation, it encourages a like response from
the client.

"l'm fine, and how are you?"

expressed

Making stereotyped

comments

"What made you so angry last night?"

Better to say: "You became angry
when your brother insulted your
wife."

"Hang in there. lt's for your own

good."
"Keep your chin up."
Better to say: "The therapy must
be difficult for you at times. How
do you feel about your progress at
this point?"
Continued

158

UNIT

3r

Therapeutic Approaches in Psychiatric Nursing Care

Using denial

When the nurse denies that a problem

exists, he or she blocks discussion with
the client and avoids helping the client
identify and explore areas of difficulty.

Cl: "l'm nothing."

Ns: "Of course you're something.
Everybody is somebody.

Better to say: "You're feeling like no

one cares about you right now."

lnterpreting

With this technique the therapist seeks to

make conscious that which is unconscious, to tell the client the meaning of
his or her experience.

"What you really mean is . . ."

"Unconsciously you're saying . . ."

Better technique: The nurse must

leave interpretation of the client's
behavior to the psychiatrist. The
nurse has not been prepared to

perform this technique, and in

attempting to do so, may endanger
other nursing roles with the client.
lntroducing an unrelated

topic

Changing the subject causes the nurse to

take over the direction of the discussion.
This may occur in order to get to something that the nurse wants to discuss
with the client or to get away from a
topic that he or she would prefer not to

Cl: "l don't have anything to live for."

Ns: "Did you have visitors this

weekend?"
Better technique: The nurse must
remain open and free to hear the
client, to take in all that is being conveyed, both verbally and nonverbally.

discuss.
Adapted from Hays, J. 5., & Larson, K. H. 0963). lnteructing with patients. New York: Macmillan.

"open" to what the client has to say..With a

"closed" position, the nurse can convey a
somewhat defensive stance, possibly invoking
a similar response in the client.

L-Lean forward toward the client. This conveys

to the client that you are involved in the
interaction, interested in what is being said,
and making a sincere effort to be attentive.
E-Establish eye contact. Eye contact, intermittently directed, is another behavior that
conveys the nurse's involvement and willingness to listen to what the client has to
say. The absence of eye contact or the constant shifting of eye contact elsewhere in
the environment gives the message that the
nurse is not really interested in what is
being said.

R-Relax. V/hether sitting or standing during the

interaction, the nurse should communicate a
sense of being relaxed and comfortable with
the client. Restlessness and fidgetiness cofirmunicate a lack of interest and may convey a feeling of discomfort that is likely to be transferred
to the client.

Process Recordings
Process recordings are written reports of verbal
interactions with clients. They are verbatim (to the
extent that this is possible) accounts, written by the
nurse or student as a tool for improving interper-

sonal communication techniques. The process

recording can take many forms, but usually
includes the verbal and nonverbal communication
of both nurse and client. The exercise provides a
means for the nurse to analyze both the content

and the pattern of the interaction. The process

recording, which is not considered documentation,
is intended to be used as a learning tool for professional development. An example of one type of
process recording is presented inTable 8-4.