Day 2
Therapeutic
Communication
Objective #14
• Discriminate between hearing and
listening
Becoming a better
listener
• Hearing
– Sensing sound
• Listening
– “A process that involves sensing,
interpreting, evaluating and reacting to
spoken messages.”
Stages of Listening
•
•
•
•
Sensation
Interpretation
Evaluation
Reaction
Active Listening
1. Attention
• Eye contact
• Control
distractions
• Focus
• Observe
Active Listening
1. Attention
2. Demonstrate
• Body language
Active Listening
1. Attention
2. Demonstrate
3. Feedback
• Paraphrase
• Reflect
• ?
Ask questions
• “The most important types of
question you will ask are…
–CLARIFYING QUESTIONS”
Active Listening
1. Attention
2. Demonstrate
3. Feedback
4. Defer judgment
• Don’t
interrupt
Objectivity
• “The process of remaining open…”
Active Listening
1. Attention
2. Demonstrate
3. Feedback
4. Defer judgment
5. Respond
Objective #15
• Relate how therapeutic
communication differs from social
communication
Style of Communication
Therapeutic
• Client
Social
• Family
• Friends
Focus
Therapeutic
Social
• Client
• Equal
Therapeutic
Social
• Planned
• Directed by nurse
• Spontaneity
Therapeutic
Social
• Confidentiality
• Mutual confidentiality
– Tx team
• Advocates
• Do NOT keep
secrets!
Therapeutic Communication
Client
Professional
• Discloses
information
• Emotional distance
– Objective
Objective #16
• Define and describe the importance
of each of the following:
– Readiness skills, Attending skills, Active
listening skills, Reflecting skills: content and
emotion
Readiness
• Establishing a therapeutic
relationship
• Choosing a quiet, safe setting
Attending Skills
• 90% Non-verbal
– “You are important to me!”
#1 Attending Skills
• Four Basic Components:
1. Eyes
2. Posture
3. Expressions
4. Prompts
Do
Attending Rules
Eye contact
DONT
• Make eye contact
• Be culturally aware
• Look at patient
frequently
• Stare
• Flutter
• Darting
Attending Skills
Posture
DO
DONT
• Relaxed
• Fidget
• ?Notes?
Prompts
• Encouraging prompts
– Non-verbal
– Verbal
Encouraging Leads
NON-VERBAL
•
•
•
•
•
•
•
Head nods
Um-hum’s
Hand movements
Smile
Smile/head nod
A half-head nod
Puzzled expression
Verbal
•
•
•
•
•
•
“good”
“yes”
“ok”
“wonderful”
“I see”
“go on”
Verbal following
• Silent listening 
• Repeat few words
Verbal following - Echoing
• Finding a word or few words
• toward the end of the senders
sentence/sentences
• that you can use to encourage more
clarification or discussion.
Verbal following - Echoing
• Patient: “about a week ago my wife
left me.”
• P.T. “Left you”? (slight questioning
tone)
Verbal following - Echoing
• Patient: “My girl friend is great
with my son. She has really been a
life-saver to both of us.”
• P.T. “Life-saver”?
• Think before you speak
• Take your time.
– “You are important to me. I
will be patient and consider
my response”.
• Silence is OK!
Reflective (mirroring) Statements
• “Empathic communication”
• Convey interest
• Build rapport
• Help person clarify information
• Help person express feelings
Reflective (mirroring) Statements
• Only mirror client
• Don’t add!!!!
Responding Skills
(action-oriented skills)
• “listen” for the feeling
• reflect the feeling
• feeling vocabulary
Reflective (mirroring) Statements
Feeling
Content
• “you’re
feeling….”
“… about
______”
Reflective (mirroring) Statements
Patient: (angrily) “why does everyone try to
bully me? I can’t make head or tails of
anything anymore”!
• P.T. “You’re angry about being confused”?
• P.T. “You are confused about being bullied
and angry about that”?
Reflective (mirroring) Statements
Depressed Patient: “I feel like just
sleeping or doing nothing but I can’t
sleep at night though. It’s ridiculous.
Maybe it’s because I worry too much”
• Feeling?
• Content?
A response using reflection of feeling and
content could be:
• Nurse: “You’re feeling really
lethargic, but you can’t sleep?”
• (condensed version)
Responding Skills
Example
• Child: “I went to my grandma’s and
she wasn’t home”.
• Nurse: “No one was home at
grandma’s. You were
disappointed.(?)”
Responding Skills
example
• Patient: “ I hate being in this
hospital”
• Nurse: “I know that you just
arrived, I’m wondering if you’re
scared and missing your family (?)”
Responding Skills
example
• Patient: ”I don’t want any students looking
in my chart”
• Nurse: “Could you be feeling embarrassed
about someone you don’t know looking in
your chart because you don’t know me?
Let’s have a conversation to remedy that (?)”
Paraphrasing (Reflection of Content)
• Use our own words
• Helps clarify inconsistencies
Intervention Skills:
• Intervention skills are as individualized as
there are patients and various mental
illnesses. Many interventions will be taught,
discussed, and practiced in 3rd semester!
Perception Checking
Responding Skills
Checking out perceptions
• Perception checking
–prevent misunderstanding
–Prevent conflict
–Goal
• Mutual understanding
3 parts
Perception checking
• Description
–Behavior
• Interpretation
–Provide two possible
• Clarification
–Request
Example
Perception Checking
• “When you stomped out of the room and slammed the
door…..”
– (Describe behavior)
• “I wasn’t sure whether you were mad at me….”
– (interpretation #1)
• “or just in a hurry”
– (interpretation #2)
• “What were you feeling”? Or “what was going on”?
– (request clarification)
Sample:
Perception Checking
•
•
•
•
Describe behavior
Interpretation #1
Interpretation #2
Request clarification
– Description
– When you walked out of the room
without saying “goodbye...”
– 2 possible interpretations
– “I didn’t know if you were mad at me”
– “or if you were in a hurry and forgot.”
• Request clarification
– “What was up?”
Objective #17
• Explain the concept of the
therapeutic self.
Use of Self
• 1o therapeutic
agent
Psychotherapeutic management
3 interventions
1. Therapeutic relationship
2. Psychopharmacology
3. Milieu Management
Therapeutic listening
Therapeutic Use of Self
• Objectivity
Therapeutic use of Self
• Empathy
–“ability to recognize & understand the
patient’s feelings and point of view
objectively”
Compare & Contrast
Empathy
• Accurately perceives
• Understand
• Objective
• Emotionally separate
Sympathy
• Shares feelings
• Shared experiences
• “Taking on other
problems”
• Emotionally involved
Course Objective #18
• Describe and give examples of each of the following
communication techniques and where they are
commonly used in the nursing process.
Giving Information
• Making available facts the patient
needs
• Skill
–Readiness
Examples
Giving information:
•
•
•
•
"My name is..."
"Visiting hours are..."
"My purpose in being here is..."
"I'm taking you to group. Here is
what you can expect today…”
Examples
Giving information:
• “I notice you’re looking at my name
badge, my name is ______ .. I’m a
Psychiatric Technician student”
• “I notice your stomach was growling,
can I show you the times for meals and
the menu”?
Giving information
• “Susie is getting an echocardiogram right now which
is a test that uses painless sound waves to create a
moving picture of her heart structures and valves
and should tell us what is causing her murmur”.
Giving recognition
• Acknowledging, indicating
awareness
Giving recognition
• Better than a compliment
• Skill
–Readiness
Examples
Giving recognition:
•
•
•
•
“Good morning Mr. Jones”
“You’ve tooled a leather wallet”
“I see that you’ve made your bed”
“I notice that you are out of your
bedroom today”
Showing acceptance
• Giving indication of reception
• Skill
–attending
Accepting
examples:
1.
2.
3.
4.
5.
6.
“Yes, I understand what you said.”
Making eye contact + nodding
“I follow what you said”
“Go on”?
“And then”?
“Tell me about it”
Offering Self
• Making one's self available
Offering self
Silence
Touch
Time
Offering self
•
•
•
•
I’ll sit with you awhile.”
“I’ll go with you to the cafeteria”
“I’ll stay awhile if you’d like.”
"I'm interested in your comfort."
Making Observations
• Verbalizing what is perceived
• Skill
–Reflecting
Making observations
•
•
•
•
•
“You seem tense.”
“You are trembling”
"I notice that you're biting your lips.“
“You seem deep in thought”
"You appear more comfortable with me
today,"
General Leads
• Encouragement to continue
• 1-2 words
General leads
•
•
•
•
•
“Go on.”
“And then…”
“You were saying”
“And after that...”
“Tell me more…”
Broad openings
• Allows the patient to take the
initiative in introducing the topic
• Empowerment
• Readiness Skill
Examples
Broad Openings
• "Is there something you'd like to
talk about?"
• "What are you thinking about?"
• "Where would you like to
begin?“
• “What’s on your mind?”
Asking broad questions
–Open-ended questions
• Cannot be answer with 1 or
2 words
Don’t close the question
• Tell me how your week has gone.
• Did you go to see that movie last
night?
Encouraging description of
perceptions
• Asking the patient to verbalize what
he perceives
• Helpful with
–Hallucination
Examples
Encouraging description
• “Tell me when you feel anxious."
• "What is happening?"
• "What does the voice seem to be
saying?"
Clarifying
• Seeking information to understand
Clarifying
Examples
• “Could you explain?
• I’m not sure I understand?
• The main point is?
Clarifying Questions
• Questions
– clarify misunderstanding
– continue conversation
– ‘reflection’ techniques
– Open-ended
• Avoid overanalyzing
• Helps patient become more aware of
their feelings
Clarifying
• Pt - “There is no point in asking for pain
medication”
• “Are you saying no one give you
medication when you have pain or do
you mean the medication doesn’t help
your pain?”
Validation examples:
1. “What would you say is the main point
of what you said”?
2. “Are you using this word to mean
_____”?
3. “Does my understanding of this agree
with yours”?
4. “Has the diarrhea stopped?”
Reflecting
• Directing back to the patient
questions, feelings, and ideas
• Helpful
–Patient asks for advice
Reflecting
examples:
• When the patient asks what he
should think or do or feel, the
nurse can ask….. “What do you
think”? Or “What are your
feelings”?
Reflecting
examples:
• Patient: “Do you think I should
tell my therapist”?
• Nurse: “Do you think you
should”?
Reflecting
• Pt – “My sister won’t help with our
mother’s care.”
• Nrs – “You feel angry. Have you
discussed this with her?”
• Nrs – “I sense that you feel angry”
Restating
• Paraphrasing
• Repeating the main idea
Restating
• Pt – “I couldn’t eat supper last
night.”
• Nrs – “You had difficulty
eating.”
Restating
• Pt – “I was awake most of the night.”
• Nrs – “You have trouble sleeping.”
Restating
• Patient: “I can’t study. My mind
keeps wandering.”
• Nurse: “You have difficulty
concentrating”?
Exploring
• Delving further into a subject or idea
Restating
• Patient: “I can’t take that new job.
What if I can’t do it”?
• Nurse: “You’re afraid you will fail
in this new position”?
Exploring
• Helpful
• with patients who remain on a
superficial level of communication
Exploring
• If the patient chooses not to delve
– Don’t push or probing
Exploring
• Expanding 
–clearly
–Insight
–solutions
Exploring examples:
1. “Please explain that situation in more detail”
2. “Tell me more about that particular
situation”
3. “Tell me more about that”
4. “Would you describe it more fully”?
5. “What kind of work”?
6. “What do you think your options are”?
Verbalizing the implied
• Voicing what the patient has
hinted at or suggested
Verbalizing the implied
• Patient: I can't talk to you or to
anyone. It's a waste of time.
• Nurse: Is it your feeling that no
one understands?
Verbalizing the implied
• Patient: My wife pushed me
around just like my mother and
sister did.
• Nurse: Is it your impression that
women are domineering?
Verbalizing the implied
• Makes less obscure
• Be direct
• Express only what is obvious
Verbalizing the Implied
• Helpful
–Mute
–Impaired verbal communication
Encouraging comparison
• Asking that similarities and
differences be noted
Examples
comparison:
• “Was this something like……”
• “Have you had similar experiences”
• “How does this compare to the time
when you……..”
• “Does this experience feel similar to
an experience that happened
before”?
Translate
words into feelings
• Decode
• Find clues to the underlying meaning
Translate
words into feelings
• Patient: “I’m way out in the ocean.”
• Nurse: “You must be feeling very
lonely now.”
Translate
words into feelings
• Patient: “I’m dead.”
• Nurse: “Are you suggesting that you feel
lifeless?” or “Is it that life seems without
meaning?”
Sequencing
• "What seemed to lead up to...?"
• "Was this before or after...?"
• "When did this happen?"
Sequencing
• Placing events in sequence of
time
• Clarifying
• Gives perspective
Stating reality
• Offering for consideration that which is
real.
Stating reality
• Patient: misperception
• Nurse: defines reality or
perception
Examples
Stating reality:
• “I understand that the voices are real to
you, but I do not hear what you are
hearing”
• “There is no one else in the room that you
and I are in”
• “That sound was a car backfiring”
• “You’re mother is not here. I am a nurse”
Voicing doubt
• Expressing uncertainty as to the
reality of the patient's perceptions.
Voicing Doubt
• CAREFUL!
–Delusional
• Benefits
–Awareness
Examples
Voicing Doubt
1.
2.
3.
4.
“I find that hard to imagine”
“That seems rather doubtful to me”
“Isn’t that unusual”?
“Really”?
Focusing
• Concentrating on a single point
• idea/word
• Helpful
– Patient moving rapidly from one thought to
another.
Focusing
examples:
• “I’d like to hear more about the
comment you made about your
roommate”
• “You had mentioned that you like
habit burger. What’s your favorite
burger there”?
Focusing
• "This point seems worth looking at
more closely.“
Silence
• Absence of verbal communication
Silence
1. Encourages
1. Talking
2. Focus
3. Discovery
2. Slows pace
3. Gives time
Silence is Golden
• Silence – uncomfortable
• "silent" (latin - sinere)
– “to let go"
• When we feel uncomfortable with
silence, we may be having difficulty
letting go of something.
Silence is Golden
• Multiple meaning
• Valuable tool
• “You’ve planted a window box.”
• “Good morning, Mrs. J.”
• “I’ve noticed you manicured your
nails.”
124
What is a common mistake students make when first
practicing therapeutic communication techniques?
A. Using too many techniques
B. Focusing on what the patient is saying
rather than on the techniques
C. Giving advice rather than encouraging
patients to problem solve
D. Or changing the subject before the patient
becomes anxious
125
Course OBJECTIVE #19
• Recognize and list non-therapeutic
interventions
ROAD BLOCKS
Blocks to Communication
ROAD BLOCKS
Red Flag Words
•
•
•
•
•
•
•
We
But
Should, Ought to
Why
Hard Work
Always/Never
Try
Belittling
• Dismissing, mocking, Minimizing
• Patient feels
– inferior
– Questions validity feelings
Belittling
• 3 yrs old says he is afraid of monsters.
• Mom - “You’re acting like a baby, there
are no monsters.”
Belittling
• Pt “I won’t leave here alive.”
• Nrs “That’s ridiculous. You shouldn’t
even think that way.”
Giving literal responses
• Pt: “They’re looking in my head
with a TV”.
• Nrs: “What channel?”
Giving literal responses
• Patient: “That doctor is a pain in the
neck.”
• Nurse: “Would you like your pain
medication?”
Challenging
• Demanding proof
Challenging
• “If you’re dead, why is your heart
beating?”
Disagreeing
• Opposing the patient’s ideas
Disagreeing
• Teenage girl “My boyfriend is
terrific”
• Mom – “I think he is a loser. You can
do better.”
Disagreeing
• Pt: “Why am I here? Nothing is
being done for me and I’m not
getting any better.”
• Nrs: “You’re getting better.”
Disagreeing
•
•
•
•
‘You should stop worrying like this.”
"That's wrong."
"I definitely disagree with..."
"I don't believe that."
ROAD BLOCKS
Disapproving
• Be non-judgmental
– piercings, tattoo’s, sexual
preference, pregnancy issues,
sexual misconduct etc.
• Word, tone & Body language
ROAD BLOCKS
Agreeing
• Statements that show you believe
the person is correct
ROAD BLOCKS
Examples
Disapproving
“Don’t you know how bad drugs are for
you”?
“How could you even think of killing
yourself when you have those 2
beautiful children that need you”
ROAD BLOCKS
Agreeing
• To neighbor “I’m thinking of divorcing my
husband.”
• “I’d get rid of him too.”
ROAD BLOCKS
Agreeing
• Pt – “I don’t think the doctor will send
me home tomorrow.”
• Nrs – “I am sure you are correct. I doubt
he will let you go home so soon.”
ROAD BLOCKS
Examples
Approving
“I’m so glad you’ve decided to
keep your baby”
“I’m excited for you that you’re
going back to church”
ROAD BLOCKS
Agreeing/Disagreeing
• Shuts door
• Places value judgment on behavior
• Nurse assumes responsibility
ROAD BLOCKS
Defending
• Justification
• Counter reply to a verbal attack
ROAD BLOCKS
Defending
• Teenage to day “I don’t get as much
of an allowance as Paul does.”
• Dad – “I’m doing the best I can.”
ROAD BLOCKS
Defending
• Pt – “I’ve had my call light on for 15
minutes.”
• Nrs – “I am doing the best I can. You are
not the only patient here.”
ROAD BLOCKS
Giving Authoritative Responses
• Nurse = superior
• Patient = intimidated & powerless.
ROAD BLOCKS
Authoritarian examples:
“I’m an educated nurse and know more than
you do about why you’re here”
“ Who do you think you’re talking to”?
ROAD BLOCKS
Stereotyped Responses
• Clichés
• Superficial
ROAD BLOCKS
Stereotyped Responses
• “I know what is happening to you.”
• “All 2 year olds are terrible.”
ROAD BLOCKS
Stereotyping
• Pt - “I am really worried about my
children. I came to the hospital so
quickly and didn’t get to see them.
They just wont understand. I wish I
could talk to them”
• Nurse: “I know exactly how you feel.”
ROAD BLOCKS
Stereotyping
•
•
•
•
“Keep your chin up”
“Men don’t cry”
“It’s for your own good”
“You’ll have the best doctor in town
with your insurance”
• “All clients with anxiety worry about
that”
ROAD BLOCKS
Giving false reassurance
• Without sincerity
• Sympathy
ROAD BLOCKS
Giving false reassurance
• “Don’t worry. Everything will be all
right. You will feel better soon.”
ROAD BLOCKS
Giving false reassurance
• Pt – “What will I do if this is malignant?”
• Nrs – “Don’t you worry. Everything will
work out just fine.”
ROAD BLOCKS
Giving advice
• Telling the patient what to do
ROAD BLOCKS
Giving advice
• What’s so bad about that?
–Judgmental
–Arrogant
–Pt. incapable
ROAD BLOCKS
Giving advice
• “If I were you…”
• “Why don’t you…”
ROAD BLOCKS
Giving Advice
• “What you should do is…
• “You know what would be the right
thing to do…
ROAD BLOCKS
Changing the subject
• Introducing a new topic
ROAD BLOCKS
Changing the subject
• Pt – “They are doing a biospy tomorrow.
I hope it isn’t cancer.”
• Nrs – “Are these pictures of your
children? They are such a nice looking
family.”
ROAD BLOCKS
Asking closed-ending questions
• Questions with one-word answers
ROAD BLOCKS
Asking closed-ending questions
• What’s so wrong with this?
ROAD BLOCKS
Asking
closed-ending questions
–“What time are you suppose to
come out of your room”?
ROAD BLOCKS
Asking
closed-ending questions
–Patient: “I’m upset that my
roommate got restrained”
–Nurse: “Are you suppose to be
talking about that”?
ROAD BLOCKS
Asking “why” questions
• Requesting an explanation?
• Puts them on the defensive
ROAD BLOCKS
Asking “why” questions
• “Why did you fall?”
ROAD BLOCKS
Probing
• Seeks information
beyond what is
necessary.
Course Objective #20
• Recognize communication deficits in
clients and teach appropriate social
skills.
Use feeling words
“I” messages  positive
• Honest
“You” messages  negative
• Guilt
• Blame
• Disrespect
Guidelines for giving constructive
feedback
•
•
•
•
Immediately
Private
Be specific
Explain the consequences
constructive feedback
• Avoid bringing up past
• Evaluate performance, not the
performer
• Use firsthand knowledge
• Agree on how to avoid it happening
again
Giving praise
•
•
•
•
•
Be honest
Attention
Unconditional
Areas of importance
Be specific