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Mental Health Nursing II NURS 2310 Unit 3 Therapeutic Communication

Objective 1

Defining therapeutic milieu

The therapeutic milieu is a scientific structuring of the environment in order to effect behavioral changes and to improve the psychological health and functioning of the individual. Within this structured environment, the client is expected to learn adaptive coping, interaction, and relationship skills that can be generalized to other aspects of his or her life.

Objective 2

Analyzing the nurse’s role in maintaining the therapeutic milieu in an inpatient psychiatric/mental health setting

The nurse maintains the therapeutic milieu in the inpatient setting by: 

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Encouraging health promotion Providing therapeutic interaction Allowing clients to participate in governing the unit Expecting the client to take responsibility for his or her own behavior Utilizing peer pressure or peer support as a tool to bring about acceptable group norms Dealing with inappropriate behaviors as they occur Avoiding restrictions and punishments

Objective 3

Reviewing the components of nurse-client relationship development and therapeutic communication

Therapeutic use of self: 

Ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions

Therapeutic communication: Consists of verbal and nonverbal techniques that focus on the client’s needs and advance the promotion of healing and change  Encourages the exploration of feelings and fosters understanding of behavioral motivation  Promotes trust, discourages defensiveness, and is nonjudgmental 

Active listening: Being attentive to what the client is saying both verbally and nonverbally  Facilitative skills include – – facing the client squarely – observing an open posture – leaning toward the client – establishing eye contact – maintaining a relaxed demeanor 

Feedback: 

Communication method that helps the client consider a modification of behavior

Therapeutic relationship: Interaction between two people in which input from both participants contributes to a climate of healing, growth promotion, and/or illness prevention  Goal-oriented – goal of the relationship determined jointly by nurse and client – goal is most often directed at learning and growth promotion in an effort to bring about some type of change in the client’s life – may be based on a problem-solving model 

Conditions essential to the development of a therapeutic relationship include:  Rapport – special feelings on the part of both the client and nurse based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude – establishing rapport may be accomplished by discussing non-health-related topics 

Genuineness – the ability to be open, honest, and “real” in interactions

Developing therapeutic relationships (cont’d)  Trust

– confidence in another person’s presence, reliability, integrity, veracity, and sincere desire to provide assistance when requested  providing a blanket when the client is cold  providing food when the client is hungry  keeping promises  being consistent  ensuring confidentiality

Developing therapeutic relationships (cont’d)  Respect – unconditional positive regard  calling the client by name  spending time with the client  allowing sufficient time to answer the client’s questions or concerns  always being open and honest  striving to understand the motivation behind the client’s behavior

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Empathy – process in which one is able to see beyond outward behavior and accurately sense another’s inner experience

Objective 4 Exploring the phases of the therapeutic relationship

Phases of the therapeutic relationship: 

Preinteraction phase – Preparation for the first encounter with the client

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Orientation (Introductory) phase – The nurse and client become acquainted

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Working phase – Accomplishment of the therapeutic work of the relationship

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Termination phase – Bringing a therapeutic conclusion to the relationship

Boundary issues within a professional relationship may include:  Transference – When the client unconsciously attributes to the nurse feelings and behavioral dispositions formed toward a person from his or her past 

Countertransference – The nurse’s behavioral and emotional response to the client which may be related to unresolved feelings toward significant others from the nurse’s past, or may be generated in response to transference feelings on the part of the client

Boundary issues (cont’d) 

Self-disclosure – May be appropriate when the information to be shared is judged to be therapeutically beneficial to the client – Never used for the purpose of meeting the nurse’s own needs

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Gift-giving – Professional judgment – Institutional policy – Never financial  suggest a donation elsewhere

Boundary issues (cont’d) 

Touch – Caring touch with no associated physical need can be therapeutically appropriate – Beware of situations in which touch may be misinterpreted, culturally unacceptable, or dangerous  paranoid patient  psychotic client

Warning signs that may indicate a potential breech in professional boundaries in the nurse-client relationship include:  Favoring one client’s care over another’s  Swapping assignments with another nurse to care for a particular client  Giving special attention or treatment to one client over others  Spending free time with one particular client  Sharing personal information or work concerns with a client  Continuing contact/communication with a client after discharge

Objective 5 Correlating appropriate modes of therapeutic communication with specific psychiatric behaviors

Modes of therapeutic communication: 

Using silence

– gives the client the opportunity to collect and organize thoughts

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Accepting

– conveys an attitude of reception and regard

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Giving recognition – acknowledging

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Offering general leads

– offers the client encouragement to continue

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Making observations

– verbalizing what is observed or perceived

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Restating

– repeating the main idea of what the client has said

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Encouraging description of perceptions

– asking the client to verbalize what is being perceived

Therapeutic communication (cont’d) 

Reflecting

– referring questions and feelings back to the client so that they may be recognized and accepted

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Focusing

– taking notice of a single idea or a single word – works well with the client who is moving rapidly from one thought to another – not to be used with a client who is anxious

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Presenting reality

– when a client has a misperception of the environment, the nurse defines reality

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Voicing doubt

– expressing uncertainty as to the reality of percpetions

Objective 6 Exploring the concept of therapeutic community

The therapeutic community holds that everything that happens to the client or within the client’s environment is considered to be part of the treatment program.

Community factors, such as social interactions, the physical structure of the treatment setting, and schedule of activities may generate negative responses which are used as examples to help the client learn how to manage stress more adaptively in real-life situations.

Conditions that promote the therapeutic community include:  The fulfillment of basic physiological needs  The conduciveness of the physical facilities to achievement of the goals of therapy  The existence of a democratic form of self-governance  The assignment of responsibilities based on each client’s capabilities  The scheduling of a structured program of social and work-related activities  The inclusion of community and family with regards to discharge planning

Objective 7

Examining the use of groups as a therapeutic tool

Group: Collection of individuals whose association is founded on shared commonalities of interest, values, norms, or purpose  Membership is generally 

– by chance (born into the group) – by choice (voluntary affiliation) – by circumstance (the result of life-cycle events over which an individual may or may not have control)

Group Therapy = a form of psychosocial treatment in which a number of clients meet together with a therapist for purposes of sharing, gaining personal insight, and improving interpersonal coping strategies.

Use of a group as a therapeutic tool:           

Instillation of hope Universality Imparting of information Altruism Corrective recapitulation of the primary family group Development of socializing techniques Imitative behavior Interpersonal learning Group cohesiveness Catharsis Existential factors

Objective 8

Identifying group types, roles, functions, development and stages

Functions of a group:    

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Socialization Support Task completion Camaraderie Informational Normative – enforcement of established norms

Empowerment  Governance 

– rules committees

Types of groups: 

Task Groups – accomplishing a specific outcome or task – focus on problem-solving and decision-making

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Teaching Groups – exist to convey knowledge and information to a number of individuals

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Supportive/Therapeutic Groups – concerned with preventing future upsets by teaching effective ways of dealing with emotional distress

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Self-Help Groups – allow clients to talk about their fears and relieve feelings of isolation while receiving comfort and advise from others undergoing similar experiences

Member roles within groups: Task Roles Maintenance Roles  Coordinator  Compromiser  Evaluator  Encourager  Elaborator  Follower  Energizer  Gatekeeper  Initiator  Harmonizer  Orienter Individual Roles  Aggressor  Monopolizer  Blocker  Recognition Seeker  Dominator  Seducer  Mute/Silent member

Phases of group development: Phase I Initial or Orientation Phase Group activities – leader and members work together to establish the rules that will govern the group Leader expectations – leader expected to orient members to specific group processes, encourage members to participate without disclosing too much too soon, promote an environment of trust, and ensure group rules don’t interfere with goal fulfillment Member behaviors – members have not yet established trust; fear of not being accepted by the group

Phases of group development (cont’d) Phase II Middle or Working Phase Group activities – productive work toward completion of the task is undertaken; problemsolving and decision-making occur Leader expectations – role diminishes and becomes one of facilitator Member behaviors – trust established among members; members turn to each other more often, and less so to the leader; members accept criticism from others and use it constructively to create change

Phases of group development (cont’d) Phase III Final or Termination Phase Group activities – termination process discussed in depth for several meetings before the final session Leader expectations – the leader encourages group members to reminisce about what has occurred, review the goals, and discuss actual outcomes Member behaviors – grief response may be evident; may lead to discussion of previous losses; successful termination of the group may help members develop the skills needed when losses occur in other dimensions of their lives.