Unit 2: Communication

&

psychiatric signs and symptoms

11/25/2019 By: Seada Bsc 1

 Objectives
• At the end of this chapter you will be able to
1. define what communication is and
differentiate its type
2 . List the Basic Elements of Communication

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 COMMUNICATION
• Is the process that people use to exchange information.
Types:
 Verbal: through the use of words
 consists of the words a person uses to speak to one or more
listeners
 Nonverbal :

 is the behavior that accompanies verbal content such as body

language, eye contact, facial expression, tone of voice, speed and

hesitations in speech and distance from the listeners.

 indicate the speaker’s thoughts, feelings, needs, and values that

he or she acts out mostly unconsciously

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 COMMUNICATION…
 Nonverbal communication includes all relayed
information that does not involve the spoken or written
word, including cues from all five senses.

 It has been estimated that about 7% of meaning is

transmitted by words,

 38% is transmitted by paralinguistic cues such as voice,

and 55% is transmitted by body cues.

 Nonverbal process represents a more accurate message

than does verbal content
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 Types of Nonverbal Behaviors
• Verbal cues: include all the nonverbal qualities of speech.
E.g. pitch; tone of voice; quality of voice; loudness or
intensity; rate and rhythm of talking; and unrelated nonverbal
sounds, such as laughing, groaning.

• Action cues (kinetics): are body movements,

Reflexes, posture, facial expression, gestures.
• Object cues: are the speaker's intentional and
unintentional use of all objects. Dress, furnishings,
and possessions
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 Types of Nonverbal Behaviors…

• Space: provides another clued to the nature of

the relationship between two people.

• Touch: involves both personal space and

action. Therapeutic touch or the nurse's laying
hands on or close to the body of an ill person
for the purpose of helping or healing.

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Basic Elements of
Communication
THERAPEUTIC COMMUNICATION:

• is an interpersonal interaction b/n the nurse

and the client

• All nurses need skills in therapeutic

communication to effectively apply the

nursing process and to meet standards of care

for their clients

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 THERAPEUTIC COMMUNICATION…
Therapeutic communication can help nurses to accomplish many goals:
• Establish a therapeutic nurse–client relationship.
• Identify the most important client concern (the client-centered
goal).
• Assess the client’s perception of the problem
• Facilitate the client’s expression of emotions.
• Teach the client and family necessary self-care skills.

• Recognize the client’s needs.

• Implement interventions designed to address the
client’s needs.
• Guide the client toward identifying a plan of action to a
satisfying and socially acceptable resolution.
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 Therapeutic Communication Techniques:
The SOLER position
• Egan (2010) identifies certain non-verbal skills summarized in the
acronym SOLER that can help the mental health nurse to create the
therapeutic space and tune in to what the client is saying.
These are:
• S: sitting facing the client squarely, at an angle
• O: adopting an open posture, arms and legs uncrossed
• L: leaning (at times) towards the person
• E: maintaining good eye contact, without staring
• R: relaxed posture.
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An open
stance

A closed
stance
1. Listening: is essential to understand the
patient. Therefore the first rule of a therapeutic
relationship is to listen to the patient.
• Real listening is difficult.
• It is an active, not a passive process.
2. Broad Openings: Broad openings, such as
"What are you thinking about?" "Can you tell
me more about that?" and "What shall we
discuss today?" encourage the patient to select
topics to discuss.

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 3.Restating: is the nurse's repeating of
the main thought the patient has
expressed.
4. Clarification: occurs when the
nurse attempts to put into words
vague ideas or thoughts that are
implicit or explicit in the patient's
talking. Such as "I'm not sure what
you mean. Are you saying that …?"
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5. Reflection of contents(Validation): lets the
patient know that the nurse has heard what was
said and understands the content.
It consists of repeating in fewer or different
words the essential ideas of the patient and
resembles paraphrasing.
Sometimes it helps to repeat a patient's
statement, emphasizing a key word.
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6. Focusing: helps the patient expand on a topic of
importance.
7. Sharing Perceptions: involves asking the patient to
verify the nurse's understanding of what the patient is
thinking or feeling.
• Perception checking is a way to explore incongruent or
double-blind communication. "You're smiling, but I
sense that you're really angry what happened."

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8. Theme Identification: are underlying issues or
problems experienced by the patient that emerge
repeatedly during the course of the nurse-patient
relationship.

• They can relate to feelings (depression or anxiety),

behavior (rebelling against authority or withdrawal),
experiences (being loved or hurt), or combinations of
all three.

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 9. Silence: Silence on the part of the nurse has
varying effects depending on how the patient
perceives it.
To a vocal patient, silence on the part of the nurse
may be welcome, as long as the patient knows the
nurse is listening.
• With a depressed or withdrawn patient, the nurse's
silence may convey support, understanding, and
acceptance.
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10. Humor: Humor is a basic part of the
personality and as a place within the
therapeutic relationship.

• As a part of interpersonal relationships, it is a

constructive coping behavior.

• By learning to express humor, a patient may be

able to learn to express other feelings.

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11. Informing: informing or information giving is
essential nursing technique in which the nurse
shares simple facts or information with the patient.
12. Suggesting: is the presentation of alternative
ideas, and is exploring alternative coping
mechanisms.
• The nurse's intent in using the suggesting technique
should be to provide feasible alternatives and allow
patients to explore their values in their unique life
situation.
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 Therapeutic impasses
• Therapeutic impasses are blocks in the progress of the
nurse-patient relationship.

• Impasses provoke intense feelings in both the nurse and

the patient, which may range from anxiety and
apprehension to frustration, love, or intense anger.

• Four specific therapeutic impasses and ways to overcome

them are discussed here: resistance, transference,
counter-transference, and boundary violations.

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 1. Resistance
• Resistance is the patient's reluctance or
avoidance of verbalizing or experiencing
troubling aspects of oneself.

• Resistance is often caused by the patient's

unwillingness to change when the need for
change is recognized.

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 2. Transference
• Transference is an unconscious response in which patients
experience feelings and attitudes toward the nurse that
were originally associated with other significant figures in
their life.
• Transference reduces self-awareness by allowing the
patient to maintain an inaccurate view of the world in
which all people are seen in similar terms.
• The first is the hostile transference. If the patient
internalizes anger and hostility, this resistance may be
expressed as depression and discouragement.
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 3. Counter transference
Counter transference is a therapeutic impasse created by the
nurse's specific emotional response to the qualities of
the patient.

Counter transference reactions are usually of the following

three types:

1. Reactions of intense love or caring

2. Reactions of intense disgust or hostility

3. Reactions of intense anxiety, often in response to

resistance by the patient.
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 4. Boundary violations
• Which occur when a nurse goes outside the
boundaries of the therapeutic relationship and
establishes a social, economic, or personal
relationship with a patient.

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 Possible boundary violations related to psychiatric nurses
The patient takes the nurse out to lunch or dinner.
The professional relationship turns into a social relationship.
The nurse attends a party at a patient's invitation.
The nurse regularly reveals personal information to the patient.
The patient introduces the nurse to family members, such as a son or daughter,
for the purpose of social relationship.
The nurse accepts free gifts from the patient's business.
The nurse agrees to meet the patient for treatment outside the usual setting
without therapeutic justification.
The nurse attends social functions that include the patient
The patient gives the nurse an expensive gift.
The nurse does business with or purchases services from the patient.
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 Communication and interviewing
skills

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.

Factors influencing the interview

• Interview setting (office, gen. hospital ward,
psych. Ward, emergency room, outpatient)
• Technical factors (telephone interruptions,
use of an interpreter, note taking, the
patient’s illness itself)
• Patients’ personality and character styles

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 .

Essentials of Interview skill

• Maintain good eye contact
• Adopt a relaxed posture and do not appear to be in a hurry
– show that you have the time to listen
– show your interest and attention
• Developing rapport: development of a constructive
therapeutic relationship
– Putting patients and interviewers at ease, show
compassion
• Facilitation : Leaning forward in the chair, and saying -yes,
and then …? Or Uh-huh,
• Gauge the timing of interjections

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 Basic interviewing skill

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 .

1-Identifying Nonverbal Behavior

e.g.
• A patient looks away while you are talking about
unpleasant issue
• or slumps in his chair, looks down, and mumbles
• The tone of the speech

Comment on his nonverbal behavior by saying, "I

noticed that when I asked you about this issue,
you began to show this behaviour-nonverbal"

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.

2-Open-ended vs. close-ended questions

• Open-ended questions encourage people to tell you
more about what they are thinking and feeling
Begin with broad, open-ended questioning,
• A close-ended, or directive, question is one that asks
for specific information and allows a patient few
options in answering –
too many close-ended questions can be restrictive

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 .

• Many levels of openness to questions

– "Tell me about your life?"
• (close ended: Are you married?, Do you have a
job?, etc. )
– "Tell me what happened last Saturday night?"
• ( close ended: Did you get quarreled with your
wife last Saturday night? )
– "Tell me about the role alcohol plays in your life?"
• ( close ended: "Tell me how many drinks you
take every night?")

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 Examples-
Close-ended Open-ended

1. Are you feeling better today? .

2. Are you planning to go to the
clinic next week?
3. Did the laboratory result make
you satisfied?
4. Are you scared to disclose your
HIV status to your wife?
5. Do you take your pills every
day?
6. Is living with HIV less difficult at
the present time?

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 Examples-
Close-ended
1. Are you feeling better today?
2. Are you planning to go to the
clinic next week?
3. Did the laboratory result make
you satisfied?
4. Are you scared to disclose your
HIV status to your wife?
5. Do you take your pills every
day?
6. Is living with HIV less difficult at
the present time?
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Open-ended
1. How do you feel today?
2. When did you plan to go to
clinic?
3. How did you feel about the
laboratory result?
4. What makes you feel disclosing
your HIV status to your wife?
5. How regular you take your pills?
6. What is it like to live with HIV at
the present time?
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 .

Write down examples of each of the following:

Closed-Ended Questions that someone might ask of a

patient who
Is struggling with medication adherence
Is concerned about forgetfulness
Is very sad and depressed

Open-Ended Questions for the same person

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 .

3. Reflective listening and empathic comment

• A statement that shows you understand another’s
meaning
• You generate a hypothesis of another person’s
meaning and then share it
• The interviewer derives this greater meaning from
– the context of what the client has said
– the words the client has used
– the client's nonverbal behavior.
• Focuses the client's attention on the thoughts or
feelings

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 .

Patient : I don’t know about my doctor. One time I

go to him and he’s as nice as he can be. The next
time he’s so rude I swear I won’t go back again.

Friend :
• Paraphrase: He seems to be very inconsistent.
• Empathic Response: You must feel uncomfortable
going to see him if you never know what to
expect.

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 .

Patient : I’m so glad I moved into the new town. Every

day there is something new to do. There are always
lots of things going on—I’m never bored.

Friend :
• Paraphrase: So there are a lot of activities to choose
from.
• Empathic Response: You seem to love living there.

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 Next class: Sign and Symptoms in
Psychiatry

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