CHAPTER 6: THERAPEUTIC COMMUNICATION
accomplish many goals: most comfortable when the nurse and client are 3 to 6
COMMUNICATION is the process that people use to
exchange information. messages are simultaneously sent
and received on two levels
VERBAL COMMUNICATION consists of the words a
person uses to speak to one or more listeners
CONTEXT is the environment in which communication
occurs and can include the time and the physical, social,
emotional, and cultural environments
-situation or circumstances that clarify the meaning
of the content of the message.
NONVERBAL COMMUNICATION is 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 listeners.
-can indicate the speakers thoughts, feelings,
needs, and values that he or she acts out mostly
unconsciously.
PROCESS denotes all nonverbal messages that the
speaker uses to give meaning and context to the message.
-requires the listeners to observe the behaviors
and sounds that accent the words and to interpret the
speakers nonverbal behaviors to assess whether they
agree or disagree with the verbal content
CONGRUENT MESSAGE-conveyed when content and
process agree
- process validates the content as being true
INCONGRUENT MESSAGE -when the content and
process disagreewhen what the speaker says and what
he or she does do not agree
THERAPEUTIC COMMUNICATION is an interpersonal
interaction between the nurse and the client during which
the nurse focuses on the clients specific needs to promote
an effective exchange of information.
Therapeutic communication can help nurses to
Establish a therapeutic nurseclient relationship.
Identify the most important client concern at that moment
(the client-centered goal).
Assess the clients perception of the problem as it
unfolds.
Facilitate the clients expression of emotions.
Teach the client and family necessary self-care skills.
Recognize the clients needs.
Implement interventions designed to address the clients
needs.
Guide the client toward identifying a plan of action
PROXEMICS is the study of distance zones between
people during communication
four distance zones:
Intimate zone (0 to 18 inches)
-is 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.
Personal zone (18 to 36 inches):
-comfortable between family and friends who are
talking.
Social zone (4 to 12 feet):
-acceptable for communication in social, work, and
business settings.
Public zone (12 to 25 feet):
-acceptable distance between a speaker and an
audience, small groups, and other informal functions
**The therapeutic communication interaction is
feet apart.**
TOUCH
Functional-professional touch is used in examinations
or procedures
Social-polite touch is used in greeting, such as a
handshake and the air kisses
Friendship-warmth touch involves a hug in greeting, an
arm thrown around the shoulder of a good friend, or the
backslapping
Love-intimacy touch involves tight hugs and kisses
between lovers or close relatives.
Sexual-arousal touch is used by lovers.
ACTIVE LISTENING means refraining from other internal
mental activities and concentrating exclusively on what the
client says.
ACTIVE OBSERVATION means watching the speakers
nonverbal actions as he or she communicates.
NONVERBAL COMMUNICATION is the behavior a person
exhibits while delivering verbal content.
-It includes facial expression, eye contact, space,
time, boundaries, and body movements.
-It is estimated that one third of meaning is
transmitted by words and two thirds is communicated
nonverbally
Knapp and Hall (2009) listed the ways in which
nonverbal messages accompany verbal messages:
Accent: using flashing eyes or hand movements
Complement: giving quizzical looks, nodding
Contradict: rolling eyes to demonstrate that the meaning
is the opposite of what one is saying
 Regulate: taking a deep breath to demonstrate SPIRITUALITY is a clients belief about life, health, illness,
readiness to speak, using and uh to signal the wish to death, and ones relationship to the universe
continue speaking
ASSERTIVE COMMUNICATION is the ability to express
Repeat: using nonverbal behaviors to augment the verbal positive and negative ideas and feelings in an open,
message, such as shrugging after saying Who knows? honest, and direct way
Substitute: using culturally determined body movements It recognizes the rights of both parties, and is
that stand in for words, such as pumping the arm up and useful in a variety of situations, such as resolving conflicts,
down with a closed fist to indicate success solving problems, and expressing feelings or thoughts that
are difficult for some people to express.
FACIAL EXPRESSION produces the most visible,
complex, and sometimes confusing nonverbal messages.
Facial expressions can be categorized into expressive,
impassive, and confusing:
expressive face portrays the persons moment-by
moment thoughts, feelings, and needs. These expressions
may be evident even when the person does not want to
reveal his or her emotions.
An impassive face is frozen into an emotionless
deadpan expression similar to a mask.
A confusing facial expression is one that is the
opposite of what the person wants to convey. A person who
is verbally expressing sad or angry feelings while smiling is
exhibiting a confusing facial expression.
VOCAL CUES are nonverbal sound signals transmitted
along with the content: voice volume, tone, pitch, intensity,
emphasis, speed, and pauses augment the senders
message.
EYE CONTACT the mirror of the soul because they often
reflect our emotions. Messages that the eyes give include
humor, interest, puzzlement, hatred, happiness, sadness,
horror, warning, and pleading.
- is used to assess the other person and the
environment and to indicate whose turn it is to speak; it
increases during listening but decreases while speaking
SILENCE OR LONG PAUSES in communication may
indicate many different things
 CHAPTER 7: CLIENTS RESPONSE TO ILLNESS
Self-efficacy-is a belief that personal abilities and efforts
affect the events in our lives
-People with high self-efficacy set personal goals,
are self-motivated, cope effectively with stress, and request
support from others when needed.
- People with low self-efficacy have low
aspirations, experience much self-doubt, and may be
plagued by anxiety and depression
Four main ways to do so follow:
Experience of success or mastery in overcoming
obstacles
Social modeling (observing successful people instills the
idea that one can also succeed)
Social persuasion (persuading people to believe in
themselves)
Reducing stress, building physical strength, and learning
how to interpret physical sensations positively (e.g.,
viewing fatigue as a sign that one has accomplished
something rather than as a lack of stamina).
Hardiness-is the ability to resist illness when under stress.
three components:
1. Commitment: active involvement in life activities
2. Control: ability to make appropriate decisions in life
activities
3. Challenge: ability to perceive change as beneficial
rather than just stressful.
Resilience -having healthy responses to stressful
circumstances or risky situations.
Resourcefulness-involves using problem-solving abilities
and believing that one can cope with adverse or novel
situations
Spirituality involves the essence of a persons being and
his or her beliefs about the meaning of life and the purpose
for living.
Sense of belonging is the feeling of connectedness with 2. Factors in Cultural Assessment
or involvement in a social system or environment of which
a person feels an integral part six cultural phenomena:
communication, physical distance or space, social
Value refers to feeling needed and accepted.
organization, time orientation, environmental control, and
Fit refers to feeling that one meshes or fits in with the biologic variations
system or environment. 3. Socioeconomic Status and Social Class
-This means that when a person belongs to a
system or group, he or she feels valued and worthwhile Socioeconomic status refers to ones income, education,
within that support system. and occupation. It strongly influences a persons health,
including whether or not the person has insurance and
Social networks are groups of people whom one knows adequate access to health care or can afford prescribed
and with whom one feels connected
treatment.
Social support is emotional sustenance that comes from 4. Cultural Patterns and Differences
friends, family members, and even health-care providers
who help a person when a problem arises. It is different
from social contact, which does not always provide
emotional support.
Family Support can be a key factor in the recovery of
clients with psychiatric illnesses
CULTURAL FACTORS
Culturally competent nursing care means being sensitive to
issues related to culture, race, gender, sexual orientation,
social class, economic situation, and other factors.
1. Beliefs About Causes of Illness
Culture has the most influence on a persons health beliefs
and practices. It has been shown to influence ones
concept of disease and illness
Unnatural or personal beliefs attribute the cause of
illness to the active, purposeful intervention of an outside
agent, spirit, or supernatural force or deity. The natural
view is rooted in a belief that natural conditions or forces,
such as cold, heat, wind, or dampness, are responsible for
the illness
 CHAPTER 8: ASSESSMENT
ASSESSMENT IS THE FIRST STEP of the nursing
process and involves the collection, organization, and
analysis of information about the clients health
The purpose of the psychosocial assessment is to
construct a picture of the clients current emotional state,
mental capacity, and behavioral function
FACTORS INFLUENCING ASSESSMENT
1. Client Participation/Feedback
A thorough and complete psychosocial assessment
requires active client participation. If the client is unable or
unwilling to participate, some areas of the assessment will
be incomplete or vague
2. Clients Health Status
If the client is anxious, tired, or in pain, the nurse may have
difficulty eliciting the clients full participation in the
assessment
3. Clients Previous Experiences/ Misconceptions
About Health Care
The clients perception of his or her circumstances can
elicit emotions that interfere with obtaining an accurate
psychosocial assessment
4. Clients Ability to Understand
determine the clients ability to hear, read, and understand
the language being used in the assessment.
5. Nurses Attitude and Approach
If the client perceives the nurses questions to be short and
curt or feels rushed or pressured to complete the
assessment, he or she may provide only superficial
information or omit discussing problems in some areas
altogether. The client also may refrain from providing
sensitive information if he or she perceives the nurse as
nonaccepting, defensive, or judgmental.
CONTENT OF THE ASSESSMENT
History
Background assessments include the clients history, age
and developmental stage, cultural and spiritual beliefs, and
beliefs about health and illness.
General appearance and motor behavior
Automatisms: repeated purposeless behaviors often
indicative of anxiety, such as drumming fingers,
twisting locks of hair, or tapping the foot
Psychomotor retardation: overall slowed
movements
Waxy flexibility: maintenance of posture or position
over time even when it is awkward or uncomfortable
Mood and affect
Mood refers to the clients pervasive and enduring
emotional state.
Affect is the outward expression of the clients
emotional state.
Blunted affect: showing little or a slow-to-respond
facial expression
Broad affect: displaying a full range of emotional
expressions
Flat affect: showing no facial expression
Inappropriate affect: displaying a facial expression
that is incongruent with mood or situation; often silly or
giddy regardless of circumstances
Restricted affect: displaying one type of expression,
usually serious or somber.
labile (rapidly changing)- exhibits unpredictable and
rapid mood swings from depressed and crying to
euphoria with no apparent stimuli, the mood
Thought process and content
Thought process refers to how the client thinks. The
nurse can infer a clients thought process from speech and
speech patterns.
Thought content is what the client actually says
Circumstantial thinking: a client eventually answers a
question but only after giving excessive unnecessary detail
Delusion: a fixed false belief not based in reality
Flight of ideas: excessive amount and rate of speech
composed of fragmented or unrelated ideas
Ideas of reference: clients inaccurate interpretation that
general events are personally directed to him or her, such
as hearing a speech on the news and believing the
message had personal meaning
Loose associations: disorganized thinking that jumps
from one idea to another with little or no evident relation
between the thoughts
Tangential thinking: wandering off the topic and never
providing the information requested
Thought blocking: stopping abruptly in the middle of a
sentence or train of thought; sometimes unable to continue
the idea
Thought broadcasting: a delusional belief that others
can hear or know what the client is thinking
Thought insertion: a delusional belief that others are
putting ideas or thoughts into the clients headthat is, the
ideas are not those of the client
Thought withdrawal: a delusional belief that others are
taking the clients thoughts away and the client is
powerless to stop it
 Word salad: flow of unconnected words that convey no
meaning to the listener.
Sensorium and intellectual processes
a. Orientation refers to the clients recognition of
person, place, and time
-The order of person, place, and time is significant.
-a person is disoriented, he or she first loses track
of time, then place, and finally person.
- Orientation returns in the reverse order: first, the
person knows who he or she is, then realizes
place, and finally time
b. Memory- assesses memory, both recent and
remote, by asking questions with verifiable
answers
c. Ability to Concentrate
Judgment and insight
is to make associations or interpretations about a situation
or comment
Judgment and Insight
Judgment refers to the ability to interpret ones
environment and situation correctly and to adapt ones
behavior and decisions accordingly
Insight is the ability to understand the true nature
of ones situation and accept some personal responsibility
for that situation
Self-concept
Self-concept is the way one views oneself in terms
of personal worth and dignity
ask the client to describe himself or herself and
what characteristics he or she likes and what he or she
would change.
Roles and relationships

Sensory-Perceptual Alterations
Some clients experience hallucinations (false sensory
perceptions or perceptual experiences that do not really
exist).

Hallucinations can involve the five senses and bodily

sensations. Physiologic and self-care concerns

Auditory hallucinations (hearing voices) are the most

common;

visual hallucinations (seeing things that dont really exist)

are the second most common.
 CHAPTER 9: LEGAL AND ETHICAL ISSUES
Box 9.1 HIGHLIGHTS OF PATIENTS BILL
OF RIGHTS
To be informed about benefits, qualifications
of all providers, available treatment options,
and appeals and grievance procedures
Confidentiality
Choice of providers
Treatment determined by professionals, not
third-party payers
Parity
Nondiscrimination
All benefits within scope of benefit plan
Treatment that affords greatest protection
and benefit
Fair and valid treatment review processes
Treating professionals and payers held
accountable for any injury caused by gross
incompetence, negligence, or clinically
unjustified decisions.
Involuntary hospitalization
-they are willing to seek treatment and agree to be
hospitalized
Release from the Hospital
- Clients admitted to the hospital voluntarily have
the right to leave, provided they do not represent a danger
to themselves or others.
Mandatory outpatient treatment (MOT)( also called
conditional release or outpatient commitment)
-is the requirement that clients continue to
participate in treatment on an involuntary basis after their
release from the hospital into the community.
-This may involve taking prescribed medication,
keeping appointments with healthcare providers for follow-
up, and attending specific treatment programs or groups
- Court-ordered outpatient treatment is most
common among persons with severe and persistent metal
illness who have had frequent and multiple contacts with
mental health, social welfare, and criminal justice agencies
Conservatorship
the court appoints a person to act as a legal
guardian who assumes many responsibilities for the
person, such as giving informed consent, writing checks,
and entering contracts.
The client with a guardian loses the right to enter
into legal contracts or agreements that require a signature
Least Restrictive Environment
It means that a client does not have to be hospitalized if he
or she can be treated in an outpatient setting or in a group
home. It also means that the client must be free of restraint
or seclusion unless it is necessary.
Restraint is the direct application of physical force to a
person, without his or her permission, to restrict his or her
freedom of movement
2 types of restrain:
Human restraint occurs when staff members physically
control the client and move him or her to a seclusion room.
Mechanical restraints are devices, usually ankle and wrist
restraints, fastened to the bed frame to curtail the clients
physical aggression, such as hitting, kicking, and hair
pulling.
Seclusion is the involuntary confinement of a person in a
specially constructed, locked room equipped with a security
window or camera for direct visual monitoring
Any sharp or potentially dangerous objects, such as pens,
glasses, belts, and matches, are removed from the client
as a safety precaution
Short-term use of restraint or seclusion is permitted only
when the client is imminently aggressive and dangerous to
himself or herself or to others, and all other means of
calming the client have been unsuccessful
Confidentiality
regulated by the federal government through the Health
Insurance Portability and Accountability Act (HIPAA) of
1996. The law guarantees the privacy and protection of
health information and outlines penalties for violations.
Duty to Warn Third Parties
mental health clinicians have a duty to warn identifiable
third parties of threats made by clients, even if these
threats were discussed during therapy sessions otherwise
protected by privilege. Based on the Tarasoff decision,
many states have enacted laws regarding warning a third
party of threats or danger.
Insanity Defense
MNaghten Rule- a person accused of a crime is not guilty
because that person cannot control his or her actions or
cannot understand the wrongfulness of the act is known as
the
Nursing Liability
Nurses are expected to meet standards of care, meaning
the care they provide to clients meets set expectations and
is what any nurse in a similar situation would do.
Torts
- a wrongful act that results in injury, loss, or
damage. Torts may be either unintentional or intentional
Negligence is an unintentional tort that involves causing
harm by failing to do what a reasonable and prudent
person would do in similar circumstances.
Malpractice is a type of negligence that refers specifically
to professionals such as nurses and physicians
For a malpractice suit to be successful, that is, for the
nurse, physician, or hospital or agency to beliable, the
client or family needs to prove the following four
elements:
1. Duty: A legally recognized relationship (i.e., physician to
client, nurse to client) existed.
2. Breach of duty: The nurse (or physician) failed to
conform to standards of care.
3. Injury or damage: The client suffered some type of loss,
damage, or injury.
4. Causation: The breach of duty was the direct cause of
the loss, damage, or injury.
Intentional Torts- result in harm to the client. Examples
include assault, battery, and false imprisonment.
Assault involves any action that causes a person to fear
being touched in a way that is offensive, insulting, or
physically injurious without consent or authority
Battery involves harmful or unwarranted contact with a
client; actual harm or injury may or may not have occurred
False imprisonment is defined as the unjustifiable
detention of a client such as the inappropriate use of
restraint or seclusion.
Proving liability for an intentional tort involves three
elements
1. The act was willful and voluntary on the part of the
defendant (nurse).
2. The nurse intended to bring about consequences
or injury to the person (client).
3. The act was a substantial factor in causing injury
or consequences.
Prevention of Liability Nurses can minimize the risk for
lawsuits through safe, competent nursing care and
descriptive, accurate documentation.
ETHICAL ISSUES
Ethics is a branch of philosophy that deals with values of
human conduct related to the rightness or wrongness of
actions and to the goodness and badness of the motives
and ends of such actions
Utilitarianism s a theory that bases decisions on the
greatest good for the greatest number.
Deontology is a theory that says decisions should be
based on whether or not an action is morally right with no
regard for the result or consequences (autonomy,
beneficence, nonmaleficence, justice, veracity, and fidelity.)
Autonomy refers to the persons right to self-determination
and independence.
Beneficence refers to ones duty to benefit or to promote
good for others.
Nonmaleficence is the requirement to do no harm to
others either intentionally or unintentionally.
Justice refers to fairness; that is, treating all people fairly
and equally without regard for social or economic status,
race, sex, marital status, religion, ethnicity, or cultural
beliefs.
Veracity is the duty to be honest or truthful.
Fidelity refers to the obligation to honor commitments and
contracts.
Ethical Dilemmas in Mental Health
Ethical dilemma is a situation in which ethical principles
conflict or when there is no one clear course of action in a
given situation

CHAPTER 5 THERAPEUTIC RELATIONSHIP
Trust- The nurseclient relationship requires trust. Trust
builds when the client is confident in the nurse and when
the nurses presence conveys integrity and reliability.
Congruence occurs when words and actions match. For
example, the nurse says to the client, I have to leave now
to go to a clinical conference, but I will be back at 2 PM,
and indeed returns at 2 PM to see the client. The nurse
needs to exhibit congruent behaviors to build trust with the
client.
TRUSTING BEHAVIORS
Caring Openness Objectivity Respect Interest
Understanding Consistency Treating the client as a
human being Suggesting without telling Approachability
Listening Keeping promises Honest
Genuine Interest- When the nurse is comfortable with
himself or herself, aware of his or her strengths and
limitations, and clearly focused, the client perceives a
genuine person showing genuine interest
Empathy- the ability of the nurse to perceive the meanings
and feelings of the client and to communicate that
understanding to the client
Acceptance- The nurse who does not become upset or
respond negatively to a clients outbursts, anger, or acting
out conveys acceptance to the client
Positive Regard- The nurse who appreciates the client as a
unique worthwhile human being can respect the client
regardless of his or her behavior, background, or lifestyle.
This unconditional nonjudgmental attitude is known as
positive regard and implies respect
Self-Awareness and Therapeutic Use of Self