Communication is the process that people use to exchange information.

Messages are simultaneously sent and

received on two levels: verbally through the use of words and nonverbally by behaviors that accompany the
words (Balzer Riley, 2000).
 Therapeutic communication is an interpersonal interaction between the nurse and client during which the
nurse focuses on the client’s specific needs to promote an effective exchange of information.
 Therapeutic communication can help nurses to accomplish many goals:
• Establish a therapeutic nurse–client relationship.
• Identify the most important client concern at that moment (the client-centered goal).
• Assess the client’s perception of the problem as it unfolded. This includes detailed actions (behaviors and
messages) of the people involved and the client’s thoughts and feelings about the situation, others, and
self.
• 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.

THERACOM 1
 Types of Communication
Verbal Communication
 An individual uses verbal communication to convey content such as ideas, thoughts, or concepts to one or
more listeners.
Nonverbal Communication
 Nonverbal communication is said to reflect a more accurate description of one’s true feelings because
people have less control over nonverbal reactions
Vocal Cues.
 Pausing or hesitating while conversing, talking in a tense or flat tone, or speaking tremulously
is vocal cues that can agree with or contradict a client’s verbal message.
 Speaking softly may indicate a concern for another, whereas speaking loudly may be the
result of feelings of anger or hostility.
Gestures, Position or Posture.
 Pointing, finger tapping, winking, hand clapping, eyebrow raising, palm rubbing, hand
wringing, and beard stroking are examples of nonverbal gestures that communicate various
thoughts and feelings.
 They may betray feelings of insecurity, anxiety, apprehension, power, enthusiasm, eagerness,
or genuine interest.
 The position one assumes can designate authority, cowardice, boredom, or indifference.
 Clusters of Gestures, Position or Posture.

THERACOM 2
Physical Appearance.
 People who are depressed may pay little attention to their appearance.
 They may appear unkempt and unconsciously don dark-colored clothing, reflecting their
depressed feelings.
 Persons who are confused or disoriented may forget to put on items of clothing, put them on
inside out, or dress inappropriately.
 Weight gain or weight loss also may be a form of nonverbal communication.
 People who exhibit either may be experiencing a low self-concept or feelings of anxiety,
depression, or loneliness.
 The client with mania may dress in brightly colored clothes with several items of jewelry and
excessive make-up.
 People with a positive self-concept may communicate such a feeling by appearing neat, clean,
and well dressed.
Privacy and Respecting Boundaries: Distance or Spatial Territory. Adult, middle-class Americans commonly
use four zones of distance awareness
 Proxemics is the study of distance zones between people during communication. People
feel more comfortable with smaller distances when communicating with someone they know
rather than with strangers (Northouse & Northouse, 1998).
 • Intimate zone (0 to 18 inches between people): This amount of space 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 or 48 inches): This distance is comfortable between family and
friends who are talking.
 • Social zone (1 or 4 to 12 feet): This distance is acceptable for communication in social,
work, and business settings.
 • Public zone (12 to 25 feet): This is an acceptable distance between a speaker and an
audience, small groups, and other informal functions (Hall, 1963).

THERACOM 3
THERACOM 4
Touch
 As intimacy increases, the need for distance decreases.
 Knapp (1980) identified five types of touch:
• Functional-professional touch is used in examinations or procedures such as when the
nurse touches a client to assess skin turgor or a masseuse performs a massage.
• Social-polite touch is used in greeting, such as a handshake and the “air kisses” some
women use to greet acquaintances, or when a gentle hand guides someone in the correct
direction.
• Friendship-warmth touch involves a hug in greeting, an arm thrown around the
shoulder of a good friend, or the back slapping some men use to greet friends and
relatives.
• Love-intimacy touch involves tight hugs and kisses between lovers or close relatives.
• Sexual-arousal touch is used by lovers.
 The nurse should exercise caution when touching people. For example:
 Hand shaking, hugging, holding hands, and kissing typically denote positive feelings for
another person.
 The client with depression or who is grieving may respond to touch as a gesture of concern,
whereas the client who is sexually promiscuous may consider touching an invitation to sexual
advances.
 A child suffering from abuse may recoil from the nurse’s attempt to comfort, whereas a
person who is dying may be comforted by the presence of a nurse sitting by the bedside
silently holding his or her hand.
 Touch for paranoid schizophrenics may be very invasive.
Facial Expression.
 A blank stare, startled expression, sneer, grimace, and broad smile are examples of facial
expressions denoting one’s innermost feelings.
 The client with depression seldom smiles.
 Clients experiencing dementia often present with apprehensive expressions because of
confusion and disorientation.
 Clients experiencing pain may grimace if they do not receive pain medication or other
interventions to reduce their pain.
Eye Contact
 It promotes the union and interaction of individuals, which is a direct and pure reciprocity.
 We avoid visual contact depending on whether or not we desire this union.
 Eye contact of extended duration can also be used to indicate aggressiveness or create anxiety
to others.
Silence

Guidelines for Establishing Broader Comfort Zones for Effective Therapeutic Communication
• Know yourself
• Be honest with your feelings
• Be secure in your ability to relate to people
• Be sensitive to the needs of others
• Be consistent
• Recognize symptoms of anxiety
• Watch your nonverbal reactions
• Use words carefully
• Recognize differences
• Recognize and evaluate your own actions and responses

THERACOM 5
 Ineffective Therapeutic Communication
• Failure to listen
• Conflicting verbal and nonverbal messages
• A judgmental attitude
• Misunderstanding because of multiple meanings words
• False reassurance
• Giving of advice
• Disagreement with or criticism of a person who is seeking support
• The inability to receive information because of a preoccupied or impaired thought process
• Changing of the subject if one becomes uncomfortable with the topic being discussed

Boundaries of Therapeutic Relationships

1. The foundation of a nurse–client therapeutic relationship is based on trust and respect for the dignity and
worth of the client.
2. Professional boundaries are limits that protect the space between the professional nurse’s power and the
client’s vulnerability in a therapeutic relationship (Peterson, 1992).
3. The nurse is responsible for:
a. maintaining professional boundaries;
b. to act as a client advocate;
c. and to intervene, when appropriate, to prevent or stop boundary violations

The six subroles of the psychiatric nurse during a therapeutic relationship are as follows:
1. • Nurse–teacher
2. • Mother surrogate
3. • Technical nurse
4. • Nurse–manager
5. • Socializing agent
6. • Counselor or nurse–therapist

Phases of a Therapeutic Nurse-Patient Relationship

Preorientation Phase
1. 5 seconds to several weeks
2. Assess patient unresolved problems
3. Patient may not be actively involved at this point
4. Self-awareness of the nurse

Initiating or Orientation (Introductory/Getting-To-Know-You) Phase

Therapeutic tasks accomplished by the psychiatric– mental health nurse during the initiating phase include:
1. Building trust and rapport by demonstrating acceptance
2. Establishing a therapeutic environment, including privacy
3. Establishing a mode of communication acceptable to both client and nurse
4. Initiating a therapeutic contract by establishing a time, place, and duration for each meeting, as well as the
length of time the relationship will be in effect
5. Assessing the client’s strengths and weaknesses
6. Sets the tone of the relationship
7. Introductions are made, Setting limits and Roles are defined
8. Conversation are focused on data assessment
9. Be aware that patient may be resistant, test true intent or deny problem
Working Phase
During the working phase, the client focuses on unpleasant, painful aspects of life while the nurse provides support.
Therapeutic tasks accomplished by the psychiatric–mental health nurse during the working phase include:
1. Exploring client’s perception of reality and evaluates problems
2. Helping client develop positive coping behaviors
3. Identifying available support systems

THERACOM 6
 4. Promoting a positive self-concept
5. Encouraging verbalization of feelings
6. Developing a plan of action with realistic goals together with the patient
7. Implementing the plan of action
8. Evaluating the results of the plan of action
9. Promoting client independence
10. Nurse may take the role as a counselor and facilitator
11. Patient actively participate
12. Patient are free to examine problems and try to gain insight or find solution

Terminating Phase
Mutually accepted goals resulting in the termination of a therapeutic relationship include the client’s ability to:
1. Provide self-care and maintain his or her environment
2. Demonstrate independence and work interdependently with others
3. Recognize signs of increased stress or anxiety
4. Cope positively when experiencing feelings of anxiety, anger, or hostility
5. Demonstrate emotional stability
6. Nurse reviews and summarizes the patient’s progress
7. Together the nurse and patient determine if goals have been met
8. Nurse formally ends the relationship, being sure to acknowledge patient’s feelings about termination
9. Be aware patient may feel hurt or angry at the nurse’s abandonment

Things to Remember when Communicating

S - Slowly approach and wait for acknowledgement
- Sit facing the client or, if client is uncomfortable, sit parallel and
lower than the client
- Setting should be quite and free from disturbance
- Speak slowly and clearly
- Self-disclosure to help establish rapport
- use Silence as a therapeutic technique
- Sufficient time should be given
- Seek validation to ensure and confirm that you and the patient
are talking the same thing
- use personal Space at comfortable distance
O - Open gesture
F - Forward lean, don’t back away if the client gets near, mirror the
clients posture and gestures appropriately
- Feedback should focus on the behavior and not on the person
1. Specific
2. Can be realistically modified
3. Provide information rather than advise
4. ASAP
- Focus on a single idea
T - Touch when acceptable

E - Explain to the patients that they can ask questions

- appropriate Eye contact, if uncomfortable, direct your eyes to
what the client is looking at
N - Never forget to respect
- Nonverbal communication are culturally significant
- Never forget to listen
Strategies for THERACOM
Elimination:

THERACOM 7
  Authoritarian answers
o Imposing
o Pressuring
o Advising
 Why? questions
 Let us explore questions, Interrogation
 Do not worry questions, False reassurance
 Nurse-focused
o Casting judgments
o Probing
o Minimizing
o Rushing
o Taking sides
 Close-ended questions
Decide using the following elements:
 Give correct information, Presentation of reality
 Be empathetic, Reflect the patient’s feelings, Verbalization of the patient’s feelings
Reducing Communication Barriers
 Language Difficulties or Differences
1. use words appropriate for the P’s educational level
2. avoid medical terms that is unlikely to understand
3. be aware of words that have more than one meaning
4. obtain an interpreter if speaks another language or dialect
5. be aware that 3rd person presence may make the P less willing to share feelings
 Impaired Hearing
1. check if P wears hearing aid or can lip read
2. face P, speak clearly and slowly using common words
3. keep question short, simple and direct
4. if severe hearing impairment, do it in written if P can do or understand written language or may need to
collect information from the family
5. for elderly, speak low-pitched tone
 Inappropriate Responses
o avoid appearing to discount the P’s feelings, as by changing subject abruptly – P way get the
impression that the N is disinterested, anxious, or annoyed or that you are judging
 Thought Disorder
1. if thought is incoherent or irrelevant, P may be unable to interpret messages correctly, focus on
interview or provide correct responses
2. when assessing P, ask simple questions about concrete topics and clarify responses
3. Encourage P to express clearly
 Paranoid Thinking
1. approach in non-threatening way
2. avoid touch – misinterpreted as harm
3. keep in mind that paranoid P may mean the things they say
 Hallucinations
1. hallucinating P can not hear or respond appropriately
2. show concern but do not reinforce hallucinatory perception
3. be specific as possible when giving commands
 Delusions
1. deluded P defends irrational beliefs or ideas despite factual evidence to the contrary
2. some delusions may be so bizarre that you will recognize them immediately / others may be hard to
identify
3. Do not condemn or agree with delusions and do not dismiss a statement because you think it is
delusional – instead, gently, emphasize reality without arguing
 Delirium
1. Experience disorientation, hallucinations and confusion
2. Misinterpretation and inappropriate responses commonly result
3. Talk to P directly, ask simple questions and offer frequent reassurance
 Dementia
1. irreversible deterioration of mental capacity
2. may experience changes in memory and thought patterns
3. language may become distorted or slurred
4. when interviewing, minimize distractions
5. use simple concise language
6. avoid statement that could be easily misinterpreted
NONTHERAPEUTIC COMMUNICATION TECHNIQUES
Multidisciplinary Treatment Team