Therapeutic Communication
Lecture 5
Course Objective # 25
• List approaches and precautions to take with
the following patient experiencing:
• Potential for violence, Hallucinating,
Delusional, With conflicting values, With
incoherent speech, Manipulative, Crying,
That are sexually inappropriate,
Uncooperative or in denial,
Depressed/apathetic, Suspicious,
Hyperactive, Transference
Special Approaches/Precautions
• Brief encounters
Violent Behavior
•
•
•
•
Keep your distance
Do not touch without approval
Change the topic
Suggest a “Time Out”
Violent Behavior
• Sit by the door
– DO NOT BLOCK THE DOORWAY!
• Do not go into a room alone
• Leave temporarily
– Be aware of self-injury potential
• Call for assistance
Hallucinations
• False perceptions
(sensory)
• Does not have an
external stimuli
• Patients see, hear,
taste things that are
not really there
Illusions
• Has a real external
stimuli, but the patient
misinterprets the
stimuli
Delusions
• False beliefs
Hallucinations
• 1st
– Comment
– Assess the content
• Powerlessness
• Hatred
• Guilt
• Loneliness
Hallucinations
• Do not focus on the hallucination
– Activities &encounters
• “Do Not to act on commands”
• “Tell staff”
Bryan is a nurse assigned in a
psychiatric ward; he takes note that
the most common type of
hallucination is:
A. Visual
B. Olfactory
C. Auditory
D. Tactile
Delusions
• A fixed, false belief
• not consistent with the person’s
intelligence and culture
• unamenable to reason
Delusions
• 1st
– Clarify the meaning
– Rarely discussed
• Do not arguing
• Monitoring
Conflicting Values
• Nurses vs. patients
• Examine the effects of beliefs
• Perspective
Incoherent Speech
• Clarify
• Repeated questions  anxiety
• Frequent, brief support
Manipulation
• Means to gain attention, sympathy,
control & dependence
• 1st
– Address
– Limit-setting
– Help pts. to directly express their needs
Crying
• Allowed & encouraged
–Nrs – quite
• Stopped
–Offer opportunity to talk
Crying
• “you seem ready to cry.”
• “You still are upset about your brother’s
death?”
• “What are you think right now?”
• Offer a tissue
Sexual Innuendos or
Inappropriate Touch
• Correct
• Discuss
• If continue
– Limit-setting
– Reassignments
Lack of Cooperation/Denial
• ID the cause
–Disturbances in thought process
–Lack of insight
–Disagreement
–Fear
Lack of Cooperation/Denial
• Discussed directly
• Trust
• Patience
Depressed Affect/Apathy
• Acknowledge feelings but discourage
rumination
• Encourage
– personal care
• Postpone major decisions
Depressed Affect/Apathy
• Patience
• Frequent contact
• Empathy
Suspiciousness
• Underlying
– Fear
• Communicate
– Clearly & simple
– Avoid arguments
– Rational
• Encourage participation
– Do not force
Hyperactivity
•
•
•
•
Decrease stimulation
Physical activity
Remain calm
PRN meds?
Terry with mania is skipping up and down
the hallway practically running into other
clients. Which of the following activities
would the nurse in charge expect to
include in Terry’s plan of care?
A. Watching TV
B. Cleaning dayroom tables
C. Leading group activity
D. Reading a book
CLIENT SHIFTS THE FOCUS OF THE
INTERVIER TO THE NURSE AND
OFF OF THEMSELVES:
• Client: “Do you have any children? Are
you married?”
• Nurse: “This time is for you.”
• Nurse: “Do you have any children?”
Client tries to get the nurse to take
care of them.
• Client: “Could you tell my doctor…”
• Nurse: “I’ll leave a message with the
clerk that you want to see him.”
• “You know best what you want to say to
him. I’ll be interested in what he has to
say.”
Object #11
• Compare and contrast the
different theories of
communication
Psychoanalytical Theory
• Father:
–Sigmund Freud
• 3 part theory
1. Levels of awareness
2. Components of the
personality/mind
3. Psychosexual stages
Freud’s levels of awareness
• Conscious
• Sub-conscious
• Unconscious
Level of awareness: Conscious
• Immediate awareness
–Reality
–logic
Level of awareness: Subconscious
• AKA: Preconscious
• Stores memories,
thoughts, feelings
• recalled with little
effort
Level of awareness: Unconscious
• “Closed” to awareness
• Painful memories 
–Stress
Psychoanalytical Theory
• Father:
–Sigmund Freud
• 3 part theory
1. Levels of awareness
2. Components of the
personality/mind
3. Psychosexual stages
3 Components of the mind
• Id
• Ego
• Superego
Component of the Mind:
• Primitive urges
–Pleasure
–Libido
–Immediate
Id
Component of the Mind: SuperEgo
• Judges, controls, punishes
–Right from wrong
–Conscience
Component of the Mind: SuperEgo
• Judges, controls, punishes
–Right from wrong
–Conscience
Component of the Mind: SuperEgo
• Judges, controls, punishes
–Right from wrong
–Conscience
Component of the Mind: SuperEgo
• Judges, controls, punishes
–Right from wrong
–Conscience
Component of the Mind: Ego
• Executive
• Compromise
• “Well, maybe later”
Defense Mechanisms
• AKA: Mental mechanisms
–Coping Mechanisms
• Protect the EGO
–Adaptive
–Maladaptive
Defense Mechanism:
Suppression
• Putting it out of
your awareness
Defense Mechanism: Denial
• AKA: Repression
• Unable to
recognize the event
Defense Mechanism: Rationalization
• Justify or excuse
undesirable
action or
feelings
Defense Mechanism: Identification
• Take on the
personality traits
of another
Defense Mechanism: Sublimation
• Redirect impulses
into acceptable
outlets
Defense Mechanism: Regression
• Conflict 
• return to an
earlier stage
Defense Mechanism: Displacement
• Transfer emotions
from person to
object
Defense Mechanism: Projection
• “Blaming mechanism”
• Rejects unacceptable
thoughts or feelings
and attribute them to
another person
Defense Mechanism: Compensation
• Make up for
deficiencies in
one area by
excelling in
another are
Defense Mechanism: Undoing
• Attempt to
make-up for
something
unacceptable
Defense Mechanism: Reaction formation
• Overcompensation
• Unacceptable feelings or thoughts are
replaced with opposite feelings or thoughts
Defense Mechanism: Conversion
• Unconscious anxiety converts into
physical symptoms (no organic basis)
Defense Mechanism:
Acting Out
• Extreme behavior in order to
express thoughts or feelings
Psychoanalytical Theory
• Father:
–Sigmund Freud
• 3 part theory
1. Levels of awareness
2. Components of the
personality/mind
3. Psychosexual stages
Freud’s 5 Stages of
Psychosexual Development
1. Oral
2. Anal
3. Phallic
4. Latency
5. Genital
• Conflict 
• Resolve 
• Next stage
Oral Stage
• Age
– Birth – 18 months
• Erogenous area
– Mouth
• Developmental task
– Weaning
– See self as separate
from environment
Oral Stage
• Fixation
– Dependency
– Aggression
– Seek oral stimulation
Anal Stage
• Age:
– 18 months – 3 years
• Erogenous area:
– Anus
• Developmental task:
– Learning independence and control
– Toilet training
Anal Stage
• Fixation:
–Anal-expulsive
• Messy, wasteful,
destructive
–Anal-retentive
• Stringent,
orderly, rigid
Phallic Stage
• Age
–3 – 6 years
• Erogenous area
–Genital organs
• Developmental task
–ID with parent of the same
gender
Phallic Stage
• Oedipus complex
– Boys sexual attraction to mom
• Electra complex
– Girl attracted to dad
Latency stage
• Age
– 6-12 years
• Erogenous area
– Dormant
• Developmental task
– Peer relationships
Genital Stage
• Age
– 13-20 years
• Erogenous area
– Genital
– Puberty
• Developmental task
– Relationships with opposite sex
– Balance
Psychoanalytical Theory
• Father:
– Sigmund Freud
• 3 part theory
1. Levels of awareness
2. Components of the
personality/mind
3. Psychosexual stages
Summary: Freud
• Personality determined by childhood events
• Psychosexual stages
– Incomplete stage 
– Fixation 
– Adult personality
Psychosocial Theory
• Erik Erikson
• 8 stages span lifespan
• Tasks have to be
accomplished 
– h Independence
– h Self-esteem
Erikson’s Psychosocial Theory
Trust Vs. Mistrust
• Age
– Birth – 18 mo.
– Infancy
• Major developmental Task
– Develop trust with mothering
figure and generalize it to others
• Major Question:
– "Can I trust the people around
me?“
• Basic Virtue:
– Hope
• Important Event:
– Feeding
Erikson’s Psychosocial Theory
Autonomy Vs. Shame & Doubt
• Age
– 18 mo – 3 yrs
– Early Childhood
• Major developmental Task
– Gain some control &
independence within the
environment
• Major Question:
– "Can I do things myself or am I
reliant on the help of others?"
• Basic Virtue:
– Will
• Important Event:
– Toilet Training
Erikson’s Psychosocial Theory
Initiative Vs. Guilt
• Age
– 3-6 yrs
– Late childhood
• Major developmental Task
– Develop sense of purpose &
the ability to initiate and direct
own activities
• Major Question:
– “Am I good or bad?”
• Basic Virtue: Purpose
• Important Event:
– Exploration, Play
Erikson’s Psychosocial Theory
Industry Vs. Inferiority
• Age
– 6 – 12 yrs
– School age
• Major developmental Task
– Develop self-confidence by
learning, competing etc.
• Major Question:
– "How can I be good?“
• Basic Virtue:
– Competence
• Important Event:
– School
Erikson’s Psychosocial Theory
Identity Vs. Role Confusion
• Age
– 12 – 20 yrs
– Adolescence
• Major developmental Task
– Integrate tasks mastered &
secure sense of self
• Major Question:
– "Who am I?“
• Basic Virtue:
– Fidelity
• Important Event:
– Social Relationships
Erikson’s Psychosocial Theory
Intimacy Vs. Isolation
• Age
– 20 – 30
– Young adulthood
• Major developmental Task
– Form intense lasting
relationship
• Major Question:
– "Will I be loved or will I be
alone?“
• Basic Virtue:
– Love
• Important Event:
– Romantic Relationships
Erikson’s Psychosocial Theory
Generativity Vs. Stagnation
• Age
– 30 – 65 yrs
– Adulthood
• Major developmental Task
– Achieve life goals and also
considering the welfare of future
generations
• Major Question:
– "How can I contribute to the
world?“
• Basic Virtue:
– Care
• Important Event:
– Parenthood & Work
Erikson’s Psychosocial Theory
Ego Integrity Vs. Despair
• Age
– 65 yrs – death
– Old age
• Major developmental Task
– To review one’s life and derive
meaning
• Major Question:
– "Did I live a meaningful life?“
• Basic Virtue:
– Wisdom
• Important Event:
– Reflecting back on life
Cognitive Theory
• Jean Piaget
• Intellect & develop
thought processes
Piaget’s Stages of Cognitive Development
SENSORIMOTOR
• Age
– Birth – 2 yrs
• Major developmental Task
–
–
–
–
Mobility
Sense of self
Object permanence
Form mental images
Piaget’s Stages of Cognitive Development
Preoperational
• Age
– 2 – 6 yrs
• Major developmental Task
– Express self with language
– Understanding gestures
– Object permanence
Piaget’s Stages of Cognitive Development
Concrete operational
• Age
– 6 - 12 yrs
• Major developmental Task
–
–
–
–
–
Logical thinking
Reversibility & spatiality
Differentiate and classify
Socializing
Apply rules
Piaget’s Stages of Cognitive Development
Formal operational
• Age
– 12 – 16 yrs
• Major developmental Task
–
–
–
–
Abstract thinking
Testing hypotheses
Logical thinking
Cogitative maturity
Physiological Needs
• O2
• Food
• Water
Safety Needs
• Feeling free from
danger and risk
• Secure in one’s own
environment
Belonging
• Feeling worthy of
affection and social
support
Self-Esteem
• Feeling competent
• Strong self-worth
Self-Actualization
• Meeting one’s full
potential
Theory of Moral Development
• Lawrence Kohlberg
• Develop moral
reasoning as you gain
ability to think logically
• 3 levels of moral
development
• 6 stages of acquired
moral reasoning
Kohlberg Dilemma
• In Europe, a woman was near death from a special kind of
cancer. There was one drug that the doctors thought might
save her. It was a form of radium that a druggist in the same
town had recently discovered. The drug was expensive to
make, but the druggist was charging ten times what the drug
cost him to make. He paid $200 for the radium and charged
$2,000 for a small dose of the drug. The sick woman's
husband, Heinz, went to everyone he knew to borrow the
money, but he could only get together about $1,000 which is
half of what it cost. He told the druggist that his wife was
dying and asked him to sell it cheaper or let him pay later. But
the druggist said: "No, I discovered the drug and I'm going to
make money from it." So Heinz got desperate and broke into
the man's store to steal the drug-for his wife. Should the
husband have done that?
Level: Preconventional
• Age 4-10 yrs
• Stage
1. Punishment &
obedience oriented
2. Instrumental relativist
oriented
• Behavior motivated by
fear of punishment
• Behavior motivated by
egocentrism and
concern for self
Level: Conventional
• Age: 10-13 yrs
• Stage
3. Interpersonal
concordance
orientation
4. Law and order
orientation
• Behavior motivated by
expectations of others,
strong desire for
approval & acceptance
• Behavior motivated by
respect for authority
Level: Postconventional
• Age: adolescence up
• Stages
5. Social contract legalistic
orientation
6. Universal ethical
principle orientation
• Behavior motivated by
respect for laws and
moral principles
• Behavior motivated by
internalized principles
of honor