THERAPEUTIC COMMUNICATION TECHNIQUES

y y y y y y y y y y y y y y y y y y y y

Using silence - allows client to take control of the discussion, if he or she so desires Accepting - conveys positive regard Giving recognition - acknowledging, indicating awareness Offering self - making oneself available Giving broad openings - allows client to select the topic Offering general leads - encourages client to continue Placing the event in time or sequence - clarifies the relationship of events in time Making observations - verbalizing what is observed or perceived Encouraging description of perceptions - asking client to verbalize what is being perceived Encouraging comparison - asking client to compare similarities and differences in ideas, experiences, or interpersonal relationships Restating - lets client know whether an expressed statement has or has not been understood Reflecting - directs questions or feelings back to client so that they may be recognized and accepted Focusing - taking notice of a single idea or even a single word Exploring - delving further into a subject, idea, experience, or relationship Seeking clarification and validation - striving to explain what is vague and searching for mutual understanding Presenting reality - clarifying misconceptions that client may be expressing Voicing doubt - expressing uncertainty as to the reality of clients perception Verbalizing the implied - putting into words what client has only implied Attempting to translate words into feelings - putting into words the feelings the client has expressed only indirectly Formulating plan of action - striving to prevent anger or anxiety escalating to unmanageable level when stressor recurs

Psychotherapy

1. Gestalt therapy is an existential/experiential form of psychotherapy that emphasizes personal responsibility, and that focuses upon the individual's experience in the present moment, the therapist-client relationship, the environmental and social contexts of a person's life, and the self-regulating adjustments people make as a result of their overall situation. Gestalt therapy focuses on process (what is actually happening) as well as on content (what is being talked about). The emphasis is on what is being done, thought, and felt at the present moment (the phenomenality of both client and therapist), rather than on what was, might be, could be, or should have been. Gestalt therapy is a method of awareness practice (also called "mindfulness" in other clinical domains), by which perceiving, feeling, and acting are understood to be conducive to interpreting, explaining, and conceptualizing (the hermeneutics of experience).This distinction between direct experience versus indirect or secondary interpretation is developed in the process of therapy. The client learns to become aware of what he or she is doing and that triggers the ability to risk a shift or change. The objective of Gestalt therapy is to enable the client to become more fully and creatively alive and to become free from the blocks and unfinished business that may diminish satisfaction, fulfillment, and growth, and to experiment with new ways of being. For this reason Gestalt therapy falls within the category of humanistic psychotherapies. Because Gestalt therapy includes perception and the meaning-making processes by which experience forms, it can also be considered a cognitive approach. Because Gestalt therapy relies on the contact between therapist and client, and because a relationship can be considered to be contact over time, Gestalt therapy can be considered a relational or interpersonal approach. Because Gestalt therapy appreciates the larger picture which is the complex situation involving multiple influences in a complex situation, it can be considered a multisystemic approach. Because the processes of Gestalt therapy are experimental, involving action, Gestalt therapy can be considered both a paradoxical and an experiential/experimental approach.

2. Cognitive therapy (CBT) is a psychotherapeutic approach: a talking therapy. CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goaloriented, systematic procedure in the present. The title is used in diverse ways to designate behavior therapy,cognitive therapy, and to refer to therapy based upon a combination of basic behavioral and cognitive research. There is empirical evidence that CBT is effective for the treatment of a variety of problems, including mood, anxiety, personality, eating, substance abuse, and psychotic disorders.Treatment is often manualized, with specific technique-driven brief, direct, and time-limited treatments for specific psychological disorders. CBT is used in individual therapy as well as group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are more cognitive oriented (e.g. cognitive restructuring), while others are more behaviorally oriented (in vivo exposure therapy). Other interventions combine both (e.g. imaginal exposure therapy) CBT was primarily developed through a merging of behavior therapy with cognitive therapy. While rooted in rather different theories, these two traditions found common ground in focusing on the "here and now", and on alleviating symptoms.Many CBT treatment programs for specific disorders have been evaluated for efficacy; the health-care trend of evidence-based treatment, where specific treatments for symptom-based diagnoses are recommended, has favored CBT over other approaches such as psychodynamic treatments. CBT is the treatment of choice for a number of mental health difficulties, including post-traumatic stress disorder, OCD, bulimia nervosa, andclinical depression. 3. Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group. The term can legitimately refer to any form of psychotherapy when delivered in a group format, including Cognitive behavioural therapy or Interpersonal therapy, but it is usually applied to psychodynamic group therapy where the group context and group process is explicitly utilised as a mechanism of change by developing, exploring and examining interpersonal relationships within the group. The broader concept of group therapy can be taken to include any helping process that takes place in a group, including support groups, skills training

groups (such as anger management, mindfulness, relaxation training or social skills training), and psycho-education groups. The differences between psychodynamic groups, activity groups, support groups, problem-solving and psycoeducational groups are discussed by Montgomery (2002).Other, more specialised forms of group therapy would include non-verbal expressive therapies such as dance therapy,music therapy.

4. Behaviour therapy (behaviour modification) is an approach to psychotherapy based on learning theory which aims to treat psychopathology through techniques designed to reinforce desired and eliminate undesired behaviours. It is focused on helping an individual understand how changing their behavior can lead to changes in how they are feeling. The goal of behavior therapy is usually focused on increasing the persons engagement in positive or socially reinforcing activities. Behavior therapy is a structured approach that carefully measures what the person is doing and then seeks to increase chances for positive experience. Common techniques include:
y Self-Monitoring This is the first stage of treatment. The person is asked to keep a detailed log of all of their activities during the day. By examining the list at the next session, the therapist can see exactly what the person is doing. Schedule of Weekly Activities This is where the patient and therapist work together to develop new activities that will provide the patient with chances for positive experience. Role Playing This is used to help the person develop new skills and anticipate issues that may come up in social interactions. Behavior Modification In this technique the patient will receive a reward for engaging in positive behavior.

y y

5. Milieu Therapy is the concept developed from a desire to counteract the negative, regressive effects of institutionalization: reduced ability to think and act independently, an adoption of institutional values and attitudes, and loss of commitments in the outside world.
Several strategies have been developed to counter these negative effects. They include
y y

Distribution of power Open communication

y y y y

Structured interactions Work- related activities. Community and family involvement in the treatment process Adaptation of the environment to meet developmental needs.

Distribution of power
y

The milieu therapy approach involves flattening the control hierarchy so all participants have a voice in decision making. This process may include the whole population of the treatment unit, or a governing council may take the final decisions based on input from various smaller groups of clients and staff members. The ultimate goal of any treatment program is client autonomy. This may be achieved through a stepwise progression through a number of treatment programs or by gradually increasing independence within a given program. Consciously incorporating a plan for increasing independence is a means to achieve client autonomy.

Open communication: y

Although the importance of open communication has been widely recognized in literature, it is still not a reality in many settings. One reason for this may be the insecurity of persons in the authority. Open communication requires risk taking. Questioning and criticism may be threatening, where as there is little to risk if no feedback is allowed. Cultural norms, personal defenses and established communication patterns may blockthe communications. In the therapeutic milieu, treatment decisions are often made by the clients themselves, who therefore need information to make effective decision. It is not necessary to communicate personal information but clients and staff need to be aware of individual treatment goals to ensure everyone is working towards the same goal. In this atmosphere, exclusive confidentiality is replaced by mutual trust, honesty and open communication.

Structured interactions
y

K.A Menninger pioneered the concept of structured interaction patterns in the form of attitude therapy. An advantage of the structured interaction approach is that all staff members approach

the client in a consistent manner, acknowledging specific diagnostic areas, thereby shortening treatment time. The difficulty with this approach is that once a diagnosis is made and an attitude prescribed there is little flexibility in the interaction pattern. Day- to day fluctuations in the clients condition may not be accounted for, and some staff members sometimes seem stilted in their response to clients.

Work related activities: y

The focus of these activities is on benefits to the client rather than to the agency. Work under realistic circumstances and for appropriate rewards is probably the best central activity for all clients. Several factors contribute to effective work therapy programs. First, clients need to choose the type of work they wish to perform Second, work activities should be geared toward developing skills that will be useful in actual job situations. The current trend is to place clients on the job and provide funds for staff support in the work environment. Third, a variety of activities provides the opportunity to test different areas for future job interests.

y y

Community and family involvement:

y

As a result of more effective medications and humane treatment philosophies, community mental health centers emerged. Hospitalization is considered desirable only for acute illnesses. For easy accessibility, mental health centers are placed conveniently within a neighborhood. According to milieu therapy approach, clients are kept in their usual environment, for example, a day treatment center or halfway house, and continue most of their routineactivities while receiving treatment. If one family member is hospitalized, an attempt is made to continue family involvement. This is an effective way to improve family interaction and minimize the isolation resulting from hospitalizing one family member.

Adaptation of the environment to meet the developmental needs:

y

To develop his full potential an individual must have an environment adapted to his current needs. Adapting the

environment to meet these multiple needs is challenging due to the extension of milieu therapy to all age groups and the inclusion of family members with individuals of varying ages within the treatment milieu. Clients who are regressed or who are overwhelmed need more structure and support; other clients benefit from a program that promotes autonomy and responsibility. A program that provides stepwise increase in responsibility would be an effective solution.

Progressive levels of responsibility according to clients self care capacity: Level I: Displays a destructive behavior to self, others, or the environment.
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Disoriented to time, place and person. Unable to function in group therapy. Exhibits poor personal hygiene.

Level II: Does not display destructive behavior.

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Knows the current time, date and place. Attends at least one therapeutic group daily. Attempts to maintain good personal hygiene

Level III: Attends All Therapeutic Activities.

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Participates actively in the Community Meetings and serves on at least one client committee. Develops a self-directed behavior plans to change or resolve a personal problem. Knows the names of all medications and the times they are to be taken. Participates in a family session.

Level IV: Takes an active role in assisting other clients to gain level changes.
y y

Demonstrates willingness to serve as an officer on the client committee. Assumes a leadership role in the community, acts as a positive role model, and ensures that other clients are prompt in their attendance of regularly scheduled activities and group meetings.

Initiates discussions with the mental health team concerning discharge planning.

One approach to differing levels of responsibilities is to divide the clients into small groups according to their developmental needs. More regressed clients focus on physical and safety needs, and more advanced individuals concentrate on social, esteem and selfactualizing needs. Individuals progress to more advanced levels as their needs indicate.
Goals of milieu therapy:

1. Manipulate the environment so that all aspects of clients hospital experience are considered therapeutic. 2. Client is expected to learn adaptive coping, interaction and relationship skills that can be generalized to other aspects of his or her life. 3. Achieving client autonomy
Principles of milieu therapy
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To promote a fundamental respect for individuals (both clients and staff). To use opportunities for communication between client and staff for maximum therapeutic benefit. To encourage clients to act at a level equal to their ability and to enhance their self esteem( autonomy is reinforced) To promote socialization. To provide opportunities for clients to be part of unit management. Individuals are held responsible for own actions. Peer pressure is utilized to reinforce rules and regulations. Team approach is used. Group discussions and temporary seclusions are favoured approaches for acting out behaviour. The nurses function is to act in ways that consistently promote these goals. 6. Psychosexual therapy known as PST, is treatment by a qualified practitioner which addresses a sexual dysfunction or emotional block within a relationship. PST has a proven success rate and takes referrals from GPs and counsellors to look at physiological and psychological problems which are causing distress. Any physical cause such as medication, alcohol, stress or illness will also be considered. PST is a behavioural

programme which openly explores and discusses the sexual problem and looks at emotional blocks for the couple. The main dysfunctions for men:
y y y

Erectile failure: the inability to maintain an erection sufficiently to allow penetration. Premature Ejaculation: this is the inability to control the timing so ejaculation occurs too soon. Retarded Ejaculation: An inability to ejaculate at all or intercourse taking too long before ejaculation takes place.

The main dysfunctions for women:

y y y

Vaginismus: involuntary spasm of the muscles around the vagina, which make sexual intercourse impossible. Dyspareunia: Penetration is painful. Orgasmic Dysfunction: an inability to experience an orgasm.

There are five distinctive stages of arousal which are a combination of the emotional and physical communication between the couple. The timing and the meaning can be quite different for each partner. For example where anger and resentment are major issues within a relationship the excitement phase may be problem-free but the resolution stage may be disappointing. Such a couple may rely on pornography or arousing jealousy in the other.
y y y y y

Desire Excitement Plateau Orgasm Resolution

Intensive therapy, using a behavioural approach, should only be attempted by a suitably qualified therapist. Inappropriate sex therapy can reinforce problems in a relationship rather than help the situation. Dealing with physiological or emotional difficulties must be sensitively and skilfully managed.

7. Psychosocial Therapy