Therapeutic Technique

1. Offering Self
• making self-available and showing interest and concern.
• “I will walk with you”
2. Active listening
• paying close attention to what the patient is saying by observing both verbal and non-verbal cues.
• Maintaining eye contact and making verbal remarks to clarify and encourage further communication.
3. Exploring
• “Tell me more about your son”
4. Giving broad openings
• What do you want to talk about today?
5. Silence
• Planned absence of verbal remarks to allow patient and nurse to think over what is being discussed and to say more.
6. Stating the observed
• verbalizing what is observed in the patient to, for validation and to encourage discussion
• “You sound angry”
7. Encouraging comparisons
• • asking to describe similarities and differences among feelings, behaviors, and events.
• • “Can you tell me what makes you more comfortable, working by yourself or working as a member of a team?”
8. Identifying themes
• asking to identify recurring thoughts, feelings, and behaviors.
• “When do you always feel the need to check the locks and doors?”
9. Summarizing
• reviewing the main points of discussions and making appropriate conclusions.
• “During this meeting, we discussed about what you will do when you feel the urge to hurt your self again and this include…”
10. Placing the event in time or sequence
• asking for relationship among events.
• “When do you begin to experience this ticks? Before or after you entered grade school?”
11. Voicing doubt
• voicing uncertainty about the reality of patient’s statements, perceptions and conclusions.
• “I find it hard to believe…”
12. Encouraging descriptions of perceptions
• asking the patients to describe feelings, perceptions and views of their situations.
• “What are these voices telling you to do?”
13. Presenting reality or confronting
• stating what is real and what is not without arguing with the patient.
• “I know you hear these voices but I do not hear them”.
• “I am Lhynnelli, your nurse, and this is a hospital and not a beach resort.
14. Seeking clarification
• asking patient to restate, elaborate, or give examples of ideas or feelings to seek clarification of what is unclear.
• “I am not familiar with your work, can you describe it further for me”.
• “I don’t think I understand what you are saying”.
15. Verbalizing the implied
• rephrasing patient’s words to highlight an underlying message to clarify statements.
• Patient: I wont be bothering you anymore soon.
• Nurse: Are you thinking of killing yourself?
16. Reflecting
• throwing back the patient’s statement in a form of question helps the patient identify feelings.
• Patient: I think I should leave now.
• Nurse: Do you think you should leave now?
17. Restating
• repeating the exact words of patients to remind them of what they said and to let them know they are heard.
• Patient: I can’t sleep. I stay awake all night.
• Nurse: You can’t sleep at night?
18. General leads
• using neutral expressions to encourage patients to continue talking.
• “Go on…”
• “You were saying…”
19. Asking question
 • using open-ended questions to achieve relevance and depth in discussion.
• “How did you feel when the doctor told you that you are ready for discharge soon?”
20. Empathy
• recognizing and acknowledging patient’s feelings.
• “It’s hard to begin to live alone when you have been married for more than thirty years”.
21. Focusing
• pursuing a topic until its meaning or importance is clear.
• “Let us talk more about your best friend in college”
• “You were saying…”
22. Interpreting
• providing a view of the meaning or importance of something.
• Patient: I always take this towel wherever I go.
• Nurse: That towel must always be with you.
23. Encouraging evaluation
• asking for patients views of the meaning or importance of something.
• “What do you think led the court to commit you here?”
• “Can you tell me the reasons you don’t want to be discharged?
24. Suggesting collaboration
• offering to help patients solve problems.
• “Perhaps you can discuss this with your children so they will know how you feel and what you want”.
25. Encouraging goal setting
• asking patient to decide on the type of change needed.
• “What do you think about the things you have to change in your self?”
26. Encouraging formulation of a plan of action
• probing for step by step actions that will be needed.
• “If you decide to leave home when your husband beat you again what will you do next?”
27. Encouraging decisions
• asking patients to make a choice among options.
• “Given all these choices, what would you prefer to do.
28. Encouraging consideration of options
• asking patients to consider the pros and cons of possible options.
• “Have you thought of the possible effects of your decision to you and your family?”
29. Giving information
• providing information that will help patients make better choices.
• “Nobody deserves to be beaten and there are people who can help and places to go when you do not feel safe at home
anymore”.
30. Limit setting
• discouraging nonproductive feelings and behaviors, and encouraging productive ones.
• “Please stop now. If you don’t, I will ask you to leave the group and go to your room.
31. Supportive confrontation
• acknowledging the difficulty in changing, but pushing for action.
• “I understand. You feel rejected when your children sent you here but if you look at this way…”
32. Role playing
• practicing behaviors for specific situations, both the nurse and patient play particular role.
• “I’ll play your mother, tell me exactly what would you say when we meet on Sunday”.
33. Rehearsing
• asking the patient for a verbal description of what will be said or done in a particular situation.
• “Supposing you meet these people again, how would you respond to them when they ask you to join them for a drink?”.
34. Feedback
• pointing out specific behaviors and giving impressions of reactions.
• “I see you combed your hair today”.
35. Encouraging evaluation
• asking patients to evaluate their actions and their outcomes.
• “What did you feel after participating in the group therapy?”.
36. Reinforcement
• giving feedback on positive behaviors.
• “Everyone was able to give their options when we talked one by one and each of waited patiently for our turn to speak”.
Avoid pitfalls:
1. Giving advise
 2. Talking about your self
3. Telling client is wrong
4. Entering into hallucinations and delusions of client
5. False reassurance
6. Cliché
7. Giving approval
8. Asking WHY?
9. Changing subject
10. Defending doctors and other health team members.
Non-therapeutic Technique
1. Overloading
• talking rapidly, changing subjects too often, and asking for more information than can be absorbed at one time.
• “What’s your name? I see you like sports. Where do you live?”
2. Value Judgments
• giving one’s own opinion, evaluating, moralizing or implying one’s values by using words such as “nice”, “bad”, “right”,
“wrong”, “should” and “ought”.
• “You shouldn’t do that, its wrong”.
3. Incongruence
• sending verbal and non-verbal messages that contradict one another.
• The nurse tells the patient “I’d like to spend time with you” and then walks away.
4. Underloading
• remaining silent and unresponsive, not picking up cues, and failing to give feedback.
• The patient ask the nurse, simply walks away.
5. False reassurance/ agreement
• Using cliché to reassure client.
• “It’s going to be alright”.
6. Invalidation
• Ignoring or denying another’s presence, thought’s or feelings.
• Client: How are you?
• Nurse responds: I can’t talk now. I’m too busy.
7. Focusing on self
• responding in a way that focuses attention to the nurse instead of the client.
• “This sunshine is good for my roses. I have beautiful rose garden”.
8. Changing the subject
• introducing new topic
• inappropriately, a pattern that may indicate anxiety.
• The client is crying, when the nurse asks “How many children do you have?”
9. Giving advice
• telling the client what to do, giving opinions or making decisions for the client, implies client cannot handle his or her own life
decisions and that the nurse is accepting responsibility.
• “If I were you… Or it would be better if you do it this way…”
10. Internal validation
• making an assumption about the meaning of someone else’s behavior that is not validated by the other person (jumping into
conclusion).
• The nurse sees a suicidal clients smiling and tells another nurse the patient is in good mood.
Other ineffective behaviors and responses:
1. Defending – Your doctor is very good.
2. Requesting an explanation – Why did you do that?
3. Reflecting – You are not suppose to talk like that!
4. Literal responses – If you feel empty then you should eat more.
5. Looking too busy.
6. Appearing uncomfortable in silence.
7. Being opinionated.
8. Avoiding sensitive topics
9. Arguing and telling the client is wrong
10. Having a closed posture-crossing arms on chest
11. Making false promises – I’ll make sure to call you when you get home.
12. Ignoring the patient – I can’t talk to you right now
13. Making sarcastic remarks
14. Laughing nervously
15. Showing disapproval – You should not do those things.
Mental Status Examination
Definition
A mental status examination (MSE) is an assessment of a patient's level of cognitive (knowledge-related) ability, appearance, emotional
mood, and speech and thought patterns at the time of evaluation. It is one part of a full neurologic (nervous system) examination and
includes the examiner's observations about the patient's attitude and cooperativeness as well as the patient's answers to specific
questions. The most commonly used test of cognitive functioning per se is the so-called Folstein Mini-Mental Status Examination
(MMSE), developed in 1975.

Purpose
The purpose of a mental status examination is to assess the presence and extent of a person's mental impairment. The cognitive functions
that are measured during the MSE include the person's sense of time, place, and personal identity; memory; speech; general intellectual
level; mathematical ability; insight or judgment; and reasoning or problem-solving ability. Complete MSEs are most commonly given to
elderly people and to other patients being evaluated for dementia (including AIDS-related dementia). Dementia is an overall decline in a
person's intellectual function—including difficulties with language, simple calculations, planning or decision-making, and motor
(muscular movement) skills as well as loss of memory. The MSE is an important part of the differential diagnosis of dementia and other
psychiatric symptoms or disorders. The MSE results may suggest specific areas for further testing or specific types of required tests. A
mental status examination can also be given repeatedly to monitor or document changes in a patient's condition.
Precautions
The MSE cannot be given to a patient who cannot pay attention to the examiner, for example as a result of being in a coma or
unconscious; or is completely unable to speak (aphasic); or is not fluent in the language of the examiner.
Description
The MMSE of Folstein evaluates five areas of mental status, namely, orientation, registration, attention and calculation, recall and
language. A complete MSE is more comprehensive and evaluates the following ten areas of functioning:
• Appearance. The examiner notes the person's age, race, sex, civil status, and overall appearance. These features are significant
because poor personal hygiene or grooming may reflect a loss of interest in self-care or physical inability to bathe or dress
oneself.
• Movement and behavior. The examiner observes the person's gait (manner of walking), posture, coordination, eye contact,
facial expressions, and similar behaviors. Problems with walking or coordination may reflect a disorder of the central nervous
system.
• Affect. Affect refers to a person's outwardly observable emotional reactions. It may include either a lack of emotional response
to an event or an overreaction.
• Mood. Mood refers to the underlying emotional "atmosphere" or tone of the person's answers.
• Speech. The examiner evaluates the volume of the person's voice, the rate or speed of speech, the length of answers to
questions, the appropriateness and clarity of the answers, and similar characteristics.
• Thought content. The examiner assesses what the patient is saying for indications of hallucinations, delusions, obsessions,
symptoms of dissociation, or thoughts of suicide. Dissociation refers to the splitting-off of certain memories or mental
processes from conscious awareness. Dissociative symptoms include feelings of unreality, depersonalization, and confusion
about one's identity.
• Thought process. Thought process refers to the logical connections between thoughts and their relevance to the main thread of
conversation. Irrelevant detail, repeated words and phrases, interrupted thinking (thought blocking), and loose, illogical
connections between thoughts, may be signs of a thought disorder.
• Cognition. Cognition refers to the act or condition of knowing. The evaluation assesses the person's orientation (ability to locate
himself or herself) with regard to time, place, and personal identity; long- and short-term memory; ability to perform simple
arithmetic (counting backward by threes or sevens); general intellectual level or fund of knowledge (identifying the last five
Presidents, or similar questions); ability to think abstractly (explaining a proverb); ability to name specified objects and read or
write complete sentences; ability to understand and perform a task (showing the examiner how to comb one's hair or throw a
ball); ability to draw a simple map or copy a design or geometrical figure; ability to distinguish between right and left.
• Judgment. The examiner asks the person what he or she would do about a commonsense problem, such as running out of a
prescription medication.
• Insight. Insight refers to a person's ability to recognize a problem and understand its nature and severity.
The length of time required for a mental status examination depends on the patient's condition. It may take as little as five minutes to
examine a healthy person. Patients with speech problems or intellectual impairments, dementia, or other organic brain disorders may
require fifteen or twenty minutes. The examiner may choose to spend more time on certain portions of the MSE and less time on others,
depending on the patient's condition and answers.
Preparation
Preparation for a mental status examination includes a careful medical and psychiatric history of the patient. The history helps the
examiner to interpret the patient's appearance and answers with greater accuracy, because some physical illnesses may produce
psychiatric symptoms or require medications that influence the patient's mood or attentiveness. The psychiatric history should include a
family history as well as the patient's personal history of development, behavior patterns, and previous treatment for mental disorders (if
any). Symptoms of dissociation, for example, often point to a history of childhood abuse, rape, or other severe emotional traumas in
adult life. The examiner should also include information about the patient's occupation, level of education, marital status, and right- or
left-handedness. Information about occupation and education helps in evaluating the patient's use of language, extent of memory loss,
reasoning ability, and similar functions. Handedness is important in determining which half of the patient's brain is involved in writing,
picking up a pencil, or other similar tasks that he or she may be asked to perform during the examination.
Aftercare
Depending on the examiner's specific observations, the patient may be given additional tests for follow-up. These tests might include
blood or urine samples to test for drug or alcohol abuse, anemia, diabetes, disorders of the liver or kidneys, vitamin or thyroid
deficiencies, medication side effects, or syphilis and AIDS. Brain imaging (CT, MRI, or PET scans) may be used to look for signs of
seizures, strokes, head trauma, brain tumors, or other evidence of damage to specific parts of the brain. A spinal tap may be performed if
the doctor thinks the patient may have an infection of the central nervous system.
Normal results
Normal results for a mental status examination depend to some extent on the patient's history, level of education, and recent life events.
For example, a depressed mood is appropriate in the context of a recent death or other sad event in the patient's family but inappropriate
in the context of a recent pay raise. Speech patterns are often influenced by racial or ethnic background as well as by occupation or
schooling. In general, however, the absence of obvious delusions, hallucinations, or thought disorders together with the presence of
insight, good judgment, and socially appropriate appearance and behavior are considered normal results. A normal numerical score for
the MMSE is between 28 and 30.
Abnormal results
Abnormal results for a mental status examination include:
• Any evidence of organic brain damage.
• Evidence of thought disorders.
• A mood or affect that is clearly inappropriate to its context.
• Thoughts of suicide.
• Disturbed speech patterns.
• Dissociative symptoms.
• Delusions or hallucinations.
A score below 27 on the MMSE usually indicates an organic brain disorder.
Key terms
Aphasia — The loss of the ability to speak, or to understand written or spoken language. A person who cannot speak or understand
language is said to be aphasic.
Cognition — The act or process of knowing or perceiving.
Coma — A state of prolonged unconsciousness in which a person cannot respond to spoken commands or mildly painful physical
stimuli.
Delusion — A belief that is resistant to reason or contrary to actual fact. Common delusions include delusions of persecution, delusions
about one's importance (sometimes called delusions of grandeur), or delusions of being controlled by others.
Dementia — A decline in a person's level of intellectual functioning. Dementia includes memory loss as well as difficulties with
language, simple calculations, planning or decision-making, and motor (muscular movement) skills.
Dissociation — The splitting off of certain mental processes from conscious awareness. Specific symptoms of dissociation include
feelings of unreality, depersonalization, and confusion about one's identity.
Hallucination — A sensory experience, usually involving either sight or hearing, of something that does not exist outside the mind.
Illusion — A false visual perception of an object that others perceive correctly. A common example is the number of sightings of
"UFOs" that turn out to be airplanes or weather balloons.
Obsession — Domination of thoughts or feelings by a persistent idea, desire, or image.
Organic brain disorder — An organic brain disorder refers to impaired brain function due to damage or deterioration of brain tissue.