Camile

C HAPTE R
6
Key Terms
• abstract messages • active listening • active observation • body language • ci
rcumstantiality • cliché • closed body positions • communication • concrete mess
ages • congruent message • content • context • contract • cues (overt and covert
) • culture • directive role • distance zones • eye contact • incongruent messag
e • intimate zone • metaphor • nondirective role • nonverbal communication • per
sonal zone • process • proverbs
Therapeutic Communication
Learning Objectives
After reading this chapter, you should be able to 1. 2. 3. Describe the goals of
therapeutic communication. Identify therapeutic and nontherapeutic verbal commu
nication skills. Discuss nonverbal communication skills such as facial expressio
n, body language, vocal cues, eye contact, and understanding of levels of meanin
g and context. Discuss boundaries in therapeutic communication with respect to d
istance and use of touch. Distinguish between concrete and abstract messages. Gi
ven a hypothetical situation, select an effective therapeutic response to the cl
ient.
4. 5. 6.
• proxemics • public zone • religion • social zone
• spirituality • therapeutic communication • verbal communication
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CHAPTER 6 • THERAPEUTIC COMMUNICATION
107
Communication is the process that people use to exchange information. Messages a
re simultaneously sent and received on two levels: verbally through the use of w
ords and nonverbally by behaviors that accompany the words (DeVito, 2004). Verba
l communication consists of the words a person uses to speak to one or more list
eners. Words represent the objects and concepts being discussed. Placement of wo
rds into phrases and sentences that are understandable to both speaker and liste
ner(s) gives an order and a meaning to these symbols. Content is verbal communic
ation, the literal words that a person speaks. Context is the environment in whi
ch communication occurs and can include the time and the physical, social, emoti
onal, and cultural environments. Context includes the circumstances or parts tha
t clarify the meaning of the content of the message (Greene & Burleson, 2003). I
t is discussed in more detail throughout this chapter. Nonverbal communication i
s the behavior that accompanies verbal content such as body language, eye contac
t, facial expression, tone of voice, speed and hesitations in speech, grunts and
groans, and distance from the listener(s). Nonverbal communication can indicate
the speaker’s thoughts, feelings, needs, and values that he or she acts out mos
tly unconsciously. Process denotes all nonverbal messages that the speaker uses
to give meaning and context to the message. The process component of communicati
on requires the listener(s) to observe the behaviors and sounds that accent the
words and to interpret the speaker’s nonverbal behaviors to assess whether they
agree or disagree with the verbal content. A congruent message is when content a
nd process agree. For example, a client says, “I know I haven’t been myself. I n
eed help.” She has a sad facial expression and a genuine and sincere voice tone.
The process validates the content as being true. But when the content and proce
ss disagree—when what the speaker says and what he or she does do not agree— the
speaker is giving an incongruent message. For example, if the client says, “I’m
here to get help,” but has a rigid posture, clenched fists, an agitated and fro
wning facial expression, and snarls the words through clenched teeth, the messag
e is incongruent. The process or observed behavior invalidates what the speaker
says (content). Nonverbal process represents a more accurate message than does v
erbal content. “I’m sorry I yelled and screamed at you” is readily believable wh
en the speaker has a slumped posture, a resigned voice tone, downcast eyes, and
a shameful facial expression, because the content and process are congruent. The
same sentence said in a loud voice and with raised eyebrows, a piercing gaze, a
n insulted facial expression, hands on hips, and outraged body language invalida
tes the words (incongruent message). The message conveyed is “I’m apologizing be
cause I think I have to. I’m not really sorry.”
WHAT IS THERAPEUTIC COMMUNICATION?
Therapeutic communication is an interpersonal interaction between the nurse and
client during which the nurse focuses on the client’s speci c needs to promote a
n effective exchange of information. Skilled use of therapeutic communication te
chniques helps the nurse understand and empathize with the client’s experience.
All nurses need skills in therapeutic communication to effectively apply the nur
sing process and to meet standards of care for their clients. Therapeutic commun
ication can help nurses to accomplish many goals: • Establish a therapeutic nurs
e–client relationship. • Identify the most important client concern at that mome
nt (the client-centered goal). • Assess the client’s perception of the problem a
s it unfolds. This includes detailed actions (behaviors and messages) of the peo
ple 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. • Impleme
nt interventions designed to address the client’s needs. • Guide the client towa
rd identifying a plan of action to a satisfying and socially acceptable resoluti
on. Establishing a therapeutic relationship is one of the most important respons
ibilities of the nurse when working with clients. Communication is the means by
which a therapeutic relationship is initiated, maintained, and terminated. The t
herapeutic relationship is discussed in depth in Chapter 5, including con dentia
lity, selfdisclosure, and therapeutic use of self. To have effective therapeutic
communication, the nurse also must consider privacy and respect of boundaries,
use of touch, and active listening and observation.
Privacy and Respecting Boundaries
Privacy is desirable but not always possible in therapeutic communication. An in
terview or conference room is optimal if the nurse believes this setting is not
too isolative for the interaction. The nurse also can talk with the client at th
e end of the hall or in a quiet corner of the day room or lobby, depending on th
e physical layout of the setting. The nurse needs to evaluate if interacting in
the client’s room is therapeutic. For example, if the client has dif culty maint
aining boundaries or has been making sexual comments, then the client’s room is
not the best setting. A more formal setting would be desirable. Proxemics is the
study of distance zones between people during communication. People feel more c
omfortable
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UNIT 2 • BUILDING THE NURSE-CLIENT RELATIONSHIP
Four types of touch: A, Functional–professional touch; B, Social–polite touch; C
, Friendship–warmth touch; D, Love–intimacy touch
with smaller distances when communicating with someone they know rather than wit
h strangers (DeVito, 2004). People from the United States, Canada, and many East
ern European nations generally observe four distance zones: • Intimate zone (0 t
o 18 inches between people): This amount of space is comfortable for parents wit
h young children, people who mutually desire personal contact, or people whisper
ing. Invasion of this intimate zone by anyone else is threatening and produces a
nxiety. • Personal zone (18 to 36 inches): This distance is comfortable between
family and friends who are talking. • Social zone (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 a
udience, small groups, and other informal functions (Hall, 1963). People from so
me cultures (e.g., Hispanic, Mediterranean, East Indian, Asian, Middle Eastern)
are more comfortable with less than 4 to 12 feet of space between them while tal
king. The nurse of European American or African American heritage may feel uncom
fortable if clients from these cultures stand close when talking. Conversely, cl
ients from these backgrounds may perceive the nurse as remote and indifferent (A
ndrews & Boyle, 2003).
Both the client and the nurse can feel threatened if one invades the other’s per
sonal or intimate zone, which can result in tension, irritability, dgeting, or
even ight. When the nurse must invade the intimate or personal zone, he or she
always should ask the client’s permission. For example, if a nurse performing an
assessment in a community setting needs to take the client’s blood pressure, he
or she should say, “Mr. Smith, to take your blood pressure I will wrap this cuf
f around your arm and listen with my stethoscope. Is this acceptable to you?” He
or she should ask permission in a yes/no format so the client’s response is cle
ar. This is one of the times when yes/no questions are appropriate. The therapeu
tic communication interaction is most comfortable when the nurse and client are
3 to 6 feet apart. If a client invades the nurse’s intimate space (0 to 18 inche
s), the nurse should set limits gradually, depending on how often the client has
invaded the nurse’s space and the safety of the situation.
Touch
As intimacy increases, the need for distance decreases. Knapp (1980) identi ed
ve types of touch: • Functional-professional touch is used in examinations or pr
ocedures such as when the nurse touches a client to assess skin turgor or a mass
euse performs a massage. • Social-polite touch is used in greeting, such as a ha
ndshake and the “air kisses” some women use to greet
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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 sho
ulder of a good friend, or the back slapping some men use to greet friends and r
elatives. • Love-intimacy touch involves tight hugs and kisses between lovers or
close relatives. • Sexual-arousal touch is used by lovers. Touching a client ca
n be comforting and supportive when it is welcome and permitted. The nurse shoul
d observe the client for cues that show if touch is desired or indicated. For ex
ample, holding the hand of a sobbing mother whose child is ill is appropriate an
d therapeutic. If the mother pulls her hand away, however, she signals to the nu
rse that she feels uncomfortable being touched. The nurse also can ask the clien
t about touching (e.g., “Would it help you to squeeze my hand?”). Although touch
can be comforting and therapeutic, it is an invasion of intimate and personal s
pace. Some clients with mental illness have dif culty understanding the concept
of personal boundaries or knowing when touch is or is not appropriate. Consequen
tly, most psychiatric inpatient, outpatient, and ambulatory care units have poli
cies against clients touching one another or staff. Unless they need to get clos
e to a client to perform some nursing care, staff members should serve as role m
odels and refrain from invading clients’ personal and intimate space. When a sta
ff member is going to touch a client while performing nursing care, he or she mu
st verbally prepare the client before starting the procedure. A client with para
noia may interpret being touched as a
threat and may attempt to protect himself or herself by striking the staff perso
n.
Active Listening and Observation
To receive the sender’s simultaneous messages, the nurse must use active listeni
ng and active observation. Active listening means refraining from other internal
mental activities and concentrating exclusively on what the client says. Active
observation means watching the speaker’s nonverbal actions as he or she communi
cates. Peplau (1952) used observation as the rst step in the therapeutic intera
ction. The nurse observes the client’s behavior and guides him or her in giving
detailed descriptions of that behavior. The nurse also documents these details.
To help the client develop insight into his or her interpersonal skills, the nur
se analyzes the information obtained, determines the underlying needs that relat
e to the behavior, and connects pieces of information (makes links between vario
us sections of the conversation). A common misconception by students learning th
e art of therapeutic communication is that they always must be ready with questi
ons the instant the client has nished speaking. Hence, they are constantly thin
king ahead regarding the next question rather than actively listening to what th
e client is saying. The result can be that the nurse does not understand the cli
ent’s concerns, and the conversation is vague, super cial, and frustrating to bo
th participants. When a super cial conversation occurs, the nurse may complain t
hat the client is not cooperating, is repeating things, or is not taking respons
ibility for getting better. Super ciality, however,
CLINICAL VIGNETTE: PERSONAL BOUNDARIES BETWEEN NURSE AND CLIENT
Saying he wanted to discuss his wife’s condition, a man accompanied the nurse do
wn the narrow hallway of his house but did not move away when they reached the p
arlor. He was 12 inches from the nurse. The nurse was uncomfortable with his clo
seness, but she did not perceive any physical threat from him. Because this was
the rst visit to this home, the nurse indicated two easy chairs and said, “Let’
s sit over here, Mr. Barrett” (offering collaboration). If sitting down were not
an option and Mr. Barrett moved in to compensate for the nurse’s backing up, th
e nurse could neutrally say, “I feel uncomfortable when anyone invades my person
al space, Mr. Barrett. Please back up at least 12 inches” (setting limits). In t
his message, the nurse has taken the blame instead of shaming the other person a
nd has gently given an order for a speci c distance between herself and Mr. Barr
ett. If Mr. Barrett were to move closer to the nurse again, the nurse would note
the behavior and ask the client about it—for example, “You have moved in again
very close to me, Mr. Barrett. What is that about?” (encouraging evaluation). Th
e use of an open-ended question provides an opportunity for the client to addres
s his behavior. He may have dif culty hearing the nurse, want to keep this discu
ssion con dential so his wife will not hear it, come from a culture in which 12
inches is an appropriate distance for a conversation, or be using his closeness
as a manipulative behavior (ensure attention, threat, or sexual invitation). Aft
er discussing Mr. Barrett’s response and understanding that he can hear adequate
ly, the nurse can add, “We can speak just ne from 2 or 3 feet apart, Mr. Barret
t. Otherwise, I will leave or we can continue this discussion in your wife’s roo
m” (setting limits). If Mr. Barrett again moves closer, the nurse will leave or
move to the wife’s room to continue the interview.
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can be the result of the nurse’s failure to listen to cues in the client’s respo
nses and repeatedly asking the same question. The nurse does not get details and
works from his or her assumptions rather than from the client’s true situation.
While listening to a client’s story, it is almost impossible for the nurse not
to make assumptions. A person’s life experiences, knowledge base, values, and pr
ejudices often color the interpretation of a message. In therapeutic communicati
on, the nurse must ask speci c questions to get the entire story from the client
’s perspective, to clarify assumptions, and to develop empathy with the client.
Empathy is the ability to place oneself into the experience of another for a mom
ent in time. Nurses develop empathy by gathering as much information about an is
sue as possible directly from the client to avoid interjecting their personal ex
periences and interpretations of the situation. The nurse asks as many questions
as needed to gain a clear understanding of the client’s perceptions of an event
or issue. Active listening and observation help the nurse to • Recognize the is
sue that is most important to the client at this time. • Know what further quest
ions to ask the client. • Use additional therapeutic communication techniques to
guide the client to describe his or her perceptions fully. • Understand the cli
ent’s perceptions of the issue instead of jumping to conclusions. • Interpret an
d respond to the message objectively.
terms how and here are vague. An anxious client might not be aware of where he o
r she is and reply, “Where am I?” or might interpret this as a question about ho
w he or she was conveyed to the hospital and respond, “The ambulance brought me.
” Clients who are anxious, from different cultures, cognitively impaired, or suf
fering from some mental disorders often function at a concrete level of comprehe
nsion and have dif culty answering abstract questions. The nurse must be sure th
at statements and questions are clear and concrete. The following are examples o
f abstract and concrete messages: Abstract (unclear): “Get the stuff from him.”
Concrete (clear): “John will be home today at 5 PM, and you can pick up your clo
thes at that time.” Abstract (unclear): “Your clinical performance has to improv
e.” Concrete (clear): “To administer medications tomorrow, you’ll have to be abl
e to calculate dosages correctly by the end of today’s class.”
Using Therapeutic Communication Techniques
The nurse can use many therapeutic communication techniques to interact with cli
ents. The choice of technique depends on the intent of the interaction and the c
lient’s ability to communicate verbally. Overall, the nurse selects techniques t
hat facilitate the interaction and enhance communication between client and nurs
e. Table 6.1 lists these techniques and gives examples. Techniques such as explo
ring, focusing, restating, and re ecting encourage the client to discuss his or
her feelings or concerns in more depth. In contrast, there are many nontherapeut
ic techniques that nurses should avoid (Table 6.2). These responses cut off comm
unication and make it more dif cult for the interaction to continue. Many of the
se responses are common in social interaction such as advising, agreeing, or rea
ssuring. Therefore, it takes practice for the nurse to avoid making these typica
l comments.
VERBAL COMMUNICATION SKILLS Using Concrete Messages
The nurse should use words that are as clear as possible when speaking to the cl
ient so that the client can understand the message. Anxious people lose cognitiv
e processing skills—the higher the anxiety, the less ability to process concepts
—so concrete messages are important for accurate information exchange. In a conc
rete message, the words are explicit and need no interpretation; the speaker use
s nouns instead of pronouns—for example, “What health symptoms caused you to com
e to the hospital today?” or “When was the last time you took your antidepressan
t medications?” Concrete questions are clear, direct, and easy to understand. Th
ey elicit more accurate responses and avoid the need to go back and rephrase unc
lear questions, which interrupts the ow of a therapeutic interaction. Abstract
messages, in contrast, are unclear patterns of words that often contain gures o
f speech that are dif cult to interpret. They require the listener to interpret
what the speaker is asking. For example, a nurse who wants to know why a client
was admitted to the unit asks, “How did you get here?” This is an abstract messa
ge: the
Interpreting Signals or Cues
To understand what a client means, the nurse watches and listens carefully for c
ues. Cues are verbal or nonverbal messages that signal key words or issues for t
he client. Finding cues is a function of active listening. Cues can be buried in
what a client says or can be acted out in the process of communication. Often,
cue words introduced by the client can help the nurse to know what to ask next o
r how to respond to the client. The nurse builds his or her responses on these c
ue words or concepts. Understanding this can relieve pressure on students who ar
e worried and anxious about what (text continues on page 116)
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Table 6.1
THERAPEUTIC COMMUNICATION TECHNIQUES
Therapeutic Communication Technique Accepting—indicating reception
Examples “Yes.” “I follow what you said.” Nodding
Rationale An accepting response indicates the nurse has heard and followed the t
rain of thought. It does not indicate agreement but is nonjudgmental. Facial exp
ression, tone of voice, and so forth also must convey acceptance or the words lo
se their meaning. Broad openings make explicit that the client has the lead in t
he interaction. For the client who is hesitant about talking, broad openings may
stimulate him or her to take the initiative. For verbal communication to be mea
ningful, it is essential that the words being used have the same meaning for bot
h (all) participants. Sometimes, words, phrases, or slang terms have different m
eanings and can be easily misunderstood. Comparing ideas, experiences, or relati
onships brings out many recurring themes. The client bene ts from making these c
omparisons because he or she might recall past coping strategies that were effec
tive or remember that he or she has survived a similar situation. To understand
the client, the nurse must see things from his or her perspective. Encouraging t
he client to describe ideas fully may relieve the tension the client is feeling,
and he or she might be less likely to take action on ideas that are harmful or
frightening. The nurse asks the client to consider people and events in light of
his or her own values. Doing so encourages the client to make his or her own ap
praisal rather than to accept the opinion of others. When clients deal with topi
cs super cially, exploring can help them examine the issue more fully. Any probl
em or concern can be better understood if explored in depth. If the client expre
sses an unwillingness to explore a subject, however, the nurse must respect his
or her wishes. The nurse encourages the client to concentrate his or her energie
s on a single point, which may prevent a multitude of factors or problems from o
verwhelming the client. It is also a useful technique when a client jumps from o
ne topic to another. It may be helpful for the client to plan in advance what he
or she might do in future similar situations. Making de nite plans increases th
e likelihood that the client will cope more effectively in similar situation. Ge
neral leads indicate that the nurse is listening and following what the client i
s saying without taking away the initiative for the interaction. They also encou
rage the client to continue if he or she is hesitant or uncomfortable about the
topic.
Table Continued
Broad openings—allowing the client to take the initiative in introducing the top
ic Consensual validation— searching for mutual understanding, for accord in the
meaning of the words Encouraging comparison— asking that similarities and differ
ences be noted
“Is there something you’d like to talk about?” “Where would you like to begin?”
“Tell me whether my understanding of it agrees with yours.” “Are you using this
word to convey that . . . ?” “Was it something like . . . ?” “Have you had simil
ar experiences?”
Encouraging description of perceptions—asking the client to verbalize what he or
she perceives Encouraging expression— asking the client to appraise the quality
of his or her experiences Exploring—delving further into a subject or idea
“Tell me when you feel anxious.” “What is happening?” “What does the voice seem
to be saying?” “What are your feelings in regard to . . . ?” “Does this contribu
te to your distress?” “Tell me more about that.” “Would you describe it more ful
ly?” “What kind of work?”
Focusing—concentrating on a single point
“This point seems worth looking at more closely.” “Of all the concerns you’ve me
ntioned, which is most troublesome?” “What could you do to let your anger out ha
rmlessly?” “Next time this comes up, what might you do to handle it?” “Go on.” “
And then?” “Tell me about it.”
Formulating a plan of action—asking the client to consider kinds of behavior lik
ely to be appropriate in future situations General leads—giving encouragement to
continue
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Table 6.1
THERAPEUTIC COMMUNICATION TECHNIQUES (Continued)
Therapeutic Communication Technique Giving information— making available the fac
ts that the client needs
Examples “My name is . . .” “Visiting hours are . . .” “My purpose in being here
is . . .”
Rationale Informing the client of facts increases his or her knowledge about a t
opic or lets the client know what to expect. The nurse is functioning as a resou
rce person. Giving information also builds trust with the client. Greeting the c
lient by name, indicating awareness of change, or noting efforts the client has
made all show that the nurse recognizes the client as a person, as an individual
. Such recognition does not carry the notion of value, that is, of being “good”
or “bad.” Sometimes clients cannot verbalize or make themselves understood. Or t
he client may not be ready to talk.
Giving recognition— acknowledging, indicating awareness
“Good morning, Mr. S. . . .” “You’ve nished your list of things to do.” “I noti
ce that you’ve combed your hair.” “You appear tense.” “Are you uncomfortable whe
n . . . ?” “I notice that you’re biting your lip.” “I’ll sit with you awhile.” “
I’ll stay here with you.” “I’m interested in what you think.” “What seemed to le
ad up to . . . ?” “Was this before or after . . . ?” “When did this happen?”
Making observations— verbalizing what the nurse perceives
Offering self—making oneself available
The nurse can offer his or her presence, interest, and desire to understand. It
is important that this offer is unconditional, that is, the client does not have
to respond verbally to get the nurse’s attention. Putting events in proper sequ
ence helps both the nurse and client to see them in perspective. The client may
gain insight into cause-and-effect behavior and consequences, or the client may
be able to see that perhaps some things are not related. The nurse may gain info
rmation about recurrent patterns or themes in the client’s behavior or relations
hips. When it is obvious that the client is misinterpreting reality, the nurse c
an indicate what is real. The nurse does this by calmly and quietly expressing t
he nurse’s perceptions or the facts, not by way of arguing with the client or be
littling his or her experience. The intent is to indicate an alternative line of
thought for the client to consider, not to “convince” the client that he or she
is wrong.
Placing event in time or sequence—clarifying the relationship of events in time
Presenting reality—offering for consideration that which is real
“I see no one else in the room.” “That sound was a car back ring.” “Your mother
is not here; I am a nurse.”
Re ecting—directing client actions, thoughts, and feelings back to client
Client: “Do you think I should tell Re ection encourages the client to recognize
and the doctor . . . ?” accept his or her own feelings. The nurse indicates Nur
se: “Do you think you should?” that the client’s point of view has value, and th
at Client: “My brother spends all my the client has the right to have opinions,
make money and then has nerve to ask decisions, and think independently. for mor
e.” Nurse: “This causes you to feel angry?” Client: “I can’t sleep. I stay awake
all night.” Nurse: “You have dif culty sleeping.” Client: “I’m really mad, I’m
really upset.” Nurse: “You’re really mad and upset.” The nurse repeats what the
client has said in approximately or nearly the same words the client has used. T
his restatement lets the client know that he or she communicated the idea effect
ively. This encourages the client to continue. Or if the client has been misunde
rstood, he or she can clarify his or her thoughts.
Restating—repeating the main idea expressed
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Table 6.1
THERAPEUTIC COMMUNICATION TECHNIQUES (Continued)
Therapeutic Communication Technique Seeking information— seeking to make clear t
hat which is not meaningful or that which is vague Silence—absence of verbal com
munication, which provides time for the client to put thoughts or feelings into
words, to regain composure, or to continue talking Suggesting collaboration— off
ering to share, to strive, to work with the client for his or her bene t Summari
zing—organizing and summing up that which has gone before
Examples “I’m not sure that I follow.” “Have I heard you correctly?”
Rationale The nurse should seek clari cation throughout interactions with client
s. Doing so can help the nurse to avoid making assumptions that understanding ha
s occurred when it has not. It helps the client to articulate thoughts, feelings
, and ideas more clearly. Silence often encourages the client to verbalize, prov
ided that it is interested and expectant. Silence gives the client time to organ
ize thoughts, direct the topic of interaction, or focus on issues that are most
important. Much nonverbal behavior takes place during silence, and the nurse nee
ds to be aware of the client and his or her own nonverbal behavior. The nurse se
eks to offer a relationship in which the client can identify problems in living
with others, grow emotionally, and improve the ability to form satisfactory rela
tionships. The nurse offers to do things with, rather than for, the client. Summ
arization seeks to bring out the important points of the discussion and to incre
ase the awareness and understanding of both participants. It omits the irrelevan
t and organizes the pertinent aspects of the interaction. It allows both client
and nurse to depart with the same ideas and provides a sense of closure at the c
ompletion of each discussion. Often what the client says, when taken literally,
seems meaningless or far removed from reality. To understand, the nurse must con
centrate on what the client might be feeling to express himself or herself this
way. Putting into words what the client has implied or said indirectly tends to
make the discussion less obscure. The nurse should be as direct as possible with
out being unfeelingly blunt or obtuse. The client may have dif culty communicati
ng directly. The nurse should take care to express only what is fairly obvious;
otherwise, the nurse may be jumping to conclusions or interpreting the client’s
communication. Another means of responding to distortions of reality is to expre
ss doubt. Such expression permits the client to become aware that others do not
necessarily perceive events in the same way or draw the same conclusions. This d
oes not mean the client will alter his or her point of view, but at least the nu
rse will encourage the client to reconsider or re-evaluate what has happened. Th
e nurse neither agreed nor disagreed; however, he or she has not let the misperc
eptions and distortions pass without comment.
Nurse says nothing but continues to maintain eye contact and conveys interest.
“Perhaps you and I can discuss and discover the triggers for your anxiety.” “Let
’s go to your room, and I’ll help you nd what your looking for.” “Have I got th
is straight?” “You’ve said that . . .” “During the past hour, you and I have dis
cussed . . .”
Translating into feelings— seeking to verbalize client’s feelings that he or she
expresses only indirectly
Client: “I’m dead.” Nurse: “Are you suggesting that you feel lifeless?” Client:
“I’m way out in the ocean.” Nurse: “You seem to feel lonely or deserted.” Client
: “I can’t talk to you or anyone. It’s a waste of time.” Nurse: “Do you feel tha
t no one understands?”
Verbalizing the implied— voicing what the client has hinted at or suggested
Voicing doubt—expressing uncertainty about the reality of the client’s perceptio
ns
“Isn’t that unusual?” “Really?” “That’s hard to believe.”
Adapted from Hays, J. S., & Larson, K. (1963). Interactions with patients. New Y
ork: Macmillan Press.
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Table 6.2
Techniques
NONTHERAPEUTIC COMMUNICATION TECHNIQUES
Examples “I think you should . . .” “Why don’t you . . .” “That’s right.” “I agr
ee.” Rationale Giving advice implies that only the nurse knows what is best for
the client. Approval indicates the client is “right” rather than “wrong.” This g
ives the client the impression that he or she is “right” because of agreement wi
th the nurse. Opinions and conclusions should be exclusively the client’s. When
the nurse agrees with the client, there is no opportunity for the client to chan
ge his or her mind without being “wrong.” When the nurse tries to equate the int
ense and overwhelming feelings the client has expressed to “everybody” or to the
nurse’s own feelings, the nurse implies that the discomfort is temporary, mild,
selflimiting, or not very important. The client is focused on his or her own wo
rries and feelings; hearing the problems or feelings of others is not helpful. O
ften the nurse believes that if he or she can challenge the client to prove unre
alistic ideas, the client will realize there is no “proof” and then will recogni
ze reality. Actually, challenging causes the client to defend the delusions or m
isperceptions more strongly than before. Defending what the client has criticize
d implies that he or she has no right to express impressions, opinions, or feeli
ngs. Telling the client that his or her criticism is unjust or unfounded does no
t change the client’s feelings but only serves to block further communication. D
isagreeing implies the client is “wrong.” Consequently, the client feels defensi
ve about his or her point of view or ideas. Disapproval implies that the nurse h
as the right to pass judgment on the client’s thoughts or actions. It further im
plies that the client is expected to please the nurse. Saying what the client th
inks or feels is “good” implies that the opposite is “bad.” Approval, then, tend
s to limit the client’s freedom to think, speak, or act in a certain way. This c
an lead to the client’s acting in a particular way just to please the nurse. Oft
en the client is at a loss to describe his or her feelings, so such comments are
the best he or she can do. Usually, it is helpful for the nurse to focus on the
client’s feelings in response to such statements. The nurse can ask, “What happ
ened?” or “What events led you to draw such a conclusion?” But to question, “Wha
t made you think that?” implies that the client was made or compelled to think i
n a certain way. Usually, the nurse does not intend to suggest that the source i
s external, but that is often what the client thinks.
Advising—telling the client what to do Agreeing—indicating accord with the clien
t
Belittling feelings expressed—misjudging the degree of the client’s discomfort
Client: “I have nothing to live for . . . I wish I was dead.” Nurse: “Everybody
gets down in the dumps,” or “I’ve felt that way myself.”
Challenging—demanding proof from the client
“But how can you be president of the United States?” “If you’re dead, why is you
r heart beating?”
Defending—attempting to protect someone or something from verbal attack?
“This hospital has a ne reputation.” “I’m sure your doctor has your best intere
sts in mind.”
Disagreeing—opposing the client’s ideas Disapproving—denouncing the client’s beh
avior or ideas Giving approval— sanctioning the client’s behavior or ideas
“That’s wrong.” “I de nitely disagree with . . .” “I don’t believe that.” “That’
s bad.” “I’d rather you wouldn’t . . .”
“That’s good.” “I’m glad that . . .”
Giving literal responses— responding to a gurative comment as though it were a
statement of fact Indicating the existence of an external source— attributing th
e source of thoughts, feelings, and behavior to others or to outside in uences
Client: “They’re looking in my head with a television camera.” Nurse: “Try not t
o watch television,” or “What channel?” “What makes you say that?” “What made yo
u do that?” “Who told you that you were a prophet?”
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Table 6.2
Techniques
NONTHERAPEUTIC COMMUNICATION TECHNIQUES (Continued)
Examples “What you really mean is . . .” “Unconsciously you’re saying . . .” Cli
ent: “I’d like to die.” Nurse: “Did you have visitors last evening?” Rationale T
he client’s thoughts and feelings are his or her own, not to be interpreted by t
he nurse or for hidden meaning. Only the client can identify or con rm the prese
nce of feelings. The nurse takes the initiative for the interaction away from th
e client. This usually happens because the nurse is uncomfortable, doesn’t know
how to respond, or has a topic he or she would rather discuss. Social conversati
on contains many clichés and much meaningless chitchat. Such comments are of no
value in the nurse–client relationship. Any automatic responses lack the nurse’s
consideration or thoughtfulness. Probing tends to make the client feel used or
invaded. Clients have the right not to talk about issues or concerns if they cho
ose. Pushing and probing by the nurse will not encourage the client to talk. Att
empts to dispel the client’s anxiety by implying that there is not suf cient rea
son for concern completely devalue the client’s feelings. Vague reassurances wit
hout accompanying facts are meaningless to the client. When the nurse rejects an
y topic, he or she closes it off from exploration. In turn, the client may feel
personally rejected along with his or her ideas. There is a difference between a
sking the client to describe what is occurring or has taken place and asking him
to explain why. Usually, a “why” question is intimidating. In addition, the cli
ent is unlikely to know “why” and may become defensive trying to explain himself
or herself. These types of questions force the client to try to recognize his o
r her problems. The client’s acknowledgement that he or she doesn’t know these t
hings may meet the nurse’s needs but is not helpful for the client. The nurse de
nies the client’s feelings or the seriousness of the situation by dismissing his
or her comments without attempting to discover the feelings or meaning behind t
hem.
Interpreting—asking to make conscious that which is unconscious; telling the cli
ent the meaning of his or her experience Introducing an unrelated topic—changing
the subject
Making stereotyped comments—offering meaningless clichés or trite comments Probi
ng—persistent questioning of the client
“It’s for your own good.” “Keep your chin up.” “Just have a positive attitude an
d you’ll be better in no time.” “Now tell me about this problem. You know I have
to nd out.” “Tell me your psychiatric history.”
Reassuring—indicating there is no reason for anxiety or other feelings of discom
fort Rejecting—refusing to consider or showing contempt for the client’s ideas o
r behaviors Requesting an explanation—asking the client to provide reasons for t
houghts, feelings, behaviors, events Testing—appraising the client’s degree of i
nsight
“I wouldn’t worry about that.” “Everything will be all right.” “You’re coming al
ong just ne.”
“Let’s not discuss . . .” “I don’t want to hear about . . .” “Why do you think t
hat?” “Why do you feel that way?”
“Do you know what kind of hospital this is?” “Do you still have the idea that .
. . ?” Client: “I’m nothing.” Nurse: “Of course you’re something—everybody’s som
ething.” Client: “I’m dead.” Nurse: “Don’t be silly.”
Using denial—refusing to admit that a problem exists
Adapted from Hays, J. S., & Larson, K. (1963). Interactions with patients. New Y
ork: Macmillan Press.
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question to ask next. The following example illustrates questions the nurse migh
t ask when responding to a client’s cue: Client: “I had a boyfriend when I was y
ounger.” Nurse: “You had a boyfriend?” (re ecting) “Tell me about you and your b
oyfriend.” (encouraging description) “How old were you when you had this boyfrie
nd?” (placing events in time or sequence) If a client has dif culty attending to
a conversation and drifts into a rambling discussion or a ight of ideas, the n
urse listens carefully for a theme, a topic around which the client composes his
or her words. Using the theme, the nurse can assess the nonverbal behaviors tha
t accompany the client’s words and build responses based on these cues. In the f
ollowing examples, the underlined words are themes and cues to help the nurse fo
rmulate further communication. Theme of sadness: Client: “Oh, hi, nurse.” (face
is sad; eyes look teary; voice is low, with little in ection) Nurse: “You seem s
ad today, Mrs. Venezia.” Client: “Yes, it is the anniversary of my husband’s dea
th.” Nurse: “How long ago did your husband die?” (Or the nurse can use the other
cue.) Nurse: “Tell me about your husband’s death, Mrs. Venezia.” Theme of loss
of control: Client: “I had a fender bender this morning. I’m okay. I lost my wal
let, and I have to go to the bank to cover a check I wrote last night. I can’t g
et in contact with my husband at work. I don’t know where to start.” Nurse: “I s
ense you feel out of control.” (translating into feelings) Clients may use many
word patterns to cue the listener to their intent. Overt cues are clear statemen
ts of intent, such as “I want to die.” The message is clear that the client is t
hinking of suicide or self-harm. Covert cues are vague or hidden messages that n
eed interpretation and exploration—for example, if a client says, “Nothing can h
elp me.” The nurse is unsure, but it sounds as if the client might be saying he
feels so hopeless and helpless that he plans to commit suicide. The nurse can ex
plore this covert cue to clarify the client’s intent and to protect the client.
Most suicidal people are ambivalent about whether to live or die and often admit
their plan when directly asked about it. When the nurse suspects self-harm or s
uicide, he or she uses a yes/no question to elicit a clear response. Theme of ho
pelessness and suicidal ideation: Client: “Life is hard. I want it to be done. T
here is no rest. Sleep, sleep is good . . . forever.”
Nurse: “I hear you saying things seem hopeless. I wonder if you are planning to
kill yourself.” (verbalizing the implied) Other word patterns that need further
clari cation for meaning include metaphors, proverbs, and clichés. When a client
uses these gures of speech, the nurse must follow up with questions to clarify
what the client is trying to say. A metaphor is a phrase that describes an obje
ct or situation by comparing it to something else familiar. Client: “My son’s be
droom looks like a bomb went off.” Nurse: “You’re saying your son is not very ne
at.” (verbalizing the implied) Client: “My mind is like mashed potatoes.” Nurse:
“I sense you nd it dif cult to put thoughts together.” (translating into feeli
ngs) Proverbs are old accepted sayings with generally accepted meanings. Client:
“People who live in glass houses shouldn’t throw stones.” Nurse: “Who do you be
lieve is criticizing you but actually has similar problems?” (encouraging descri
ption of perception) A cliché is an expression that has become trite and general
ly conveys a stereotype. For example, if a client says “she has more guts than b
rains,” the implication is that the speaker believes the woman to whom he or she
refers is not smart, acts before thinking, or has no common sense. The nurse ca
n clarify what the client means by saying, “Give me one example of how you see M
ary as having more guts than brains” (focusing).
NONVERBAL COMMUNICATION SKILLS
Nonverbal communication is behavior that a person exhibits while delivering verb
al content. It includes facial expression, eye contact, space, time, boundaries,
and body movements. Nonverbal communication is as important, if not more so, th
an verbal communication. It is estimated that one third of meaning is transmitte
d by words and two thirds is communicated nonverbally. The speaker may verbalize
what he or she believes the listener wants to hear, whereas nonverbal communica
tion conveys the speaker’s actual meaning. Nonverbal communication involves the
unconscious mind acting out emotions related to the verbal content, the situatio
n, the environment, and the relationship between the speaker and the listener. K
napp and Hall (2002) listed the ways in which nonverbal messages accompany verba
l messages: • Accent: using ashing eyes or hand movements • Complement: giving
quizzical looks, nodding
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• Contradict: rolling eyes to demonstrate that the meaning is the opposite of wh
at one is saying • Regulate: taking a deep breath to demonstrate readiness to sp
eak, using “and uh” to signal the wish to continue speaking • Repeat: using nonv
erbal behaviors to augment the verbal message such as shrugging after saying “Wh
o knows?” • Substitute: using culturally determined body movements that stand in
for words such as pumping the arm up and down with a closed st to indicate suc
cess
Facial Expression
The human face produces the most visible, complex, and sometimes confusing nonve
rbal messages. Facial movements connect with words to illustrate meaning; this c
onnection demonstrates the speaker’s internal dialogue (Greene & Burleson, 2003)
. Facial expressions can be categorized into expressive, impassive, and confusin
g: • An expressive face portrays the person’s moment-bymoment thoughts, feelings
, and needs. These expressions may be evident even when the person does not want
to reveal his or her emotions. • An impassive face is frozen into an emotionles
s deadpan expression similar to a mask. • A confusing facial expression is one t
hat is the opposite of what the person wants to convey. A person who is verbally
expressing sad or angry feelings while smiling is exhibiting a confusing facial
expression. Facial expressions often can affect the listener’s response. Strong
and emotional facial expressions can persuade the listener to believe the messa
ge. For example, by appearing perplexed and confused, a client could manipulate
the nurse into staying longer than scheduled. Facial expressions such as happy,
sad, embarrassed, or angry usually have the same meaning across cultures, but th
e nurse should identify the facial expression and ask the client to validate the
nurse’s interpretation of it—for instance, “You’re smiling, but I sense you are
very angry” (Sheldon, 2004). Frowns, smiles, puzzlement, relief, fear, surprise
, and anger are common facial communication signals. Looking away, not meeting t
he speaker’s eyes, and yawning indicate that the listener is disinterested, lyin
g, or bored. To ensure the accuracy of information, the nurse identi es the nonv
erbal communication and checks its congruency with the content (Sheldon, 2004).
An example is “Mr. Jones, you said everything is ne today, yet you frowned as y
ou spoke. I sense that everything is not really ne” (verbalizing the implied).
Closed body positions, such as crossed legs or arms folded across the chest, ind
icate that the interaction might threaten the listener who is defensive or not a
ccepting. A better, more accepting body position is to sit facing the client wit
h both feet on the oor, knees parallel, hands at the side of the body, and legs
uncrossed or crossed only at the ankle. This open posture demonstrates uncondit
ional positive regard, trust, care, and acceptance. The nurse indicates interest
in and acceptance of the client by facing and slightly leaning toward him or he
r while maintaining nonthreatening eye contact. Hand gestures add meaning to the
content. A slight lift of the hand from the arm of a chair can punctuate or str
engthen the meaning of words. Holding both hands with palms up while shrugging t
he shoulders often means “I don’t know.” Some people use many hand gestures to d
emonstrate or act out what they are saying, whereas others use very few gestures
. The positioning of the nurse and client in relation to each other is also impo
rtant. Sitting beside or across from the client can put the client at ease, wher
eas sitting behind a desk (creating a physical barrier) can increase the formali
ty of the setting and may decrease the client’s willingness to open up and commu
nicate freely. The nurse may wish to create a more formal setting with some clie
nts, however, such as those who have dif culty maintaining boundaries.
Body Language
Body language (gestures, postures, movements, and body positions) is a nonverbal
form of communication.
Closed body position
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or feeling (e.g., “Mr. Smith, you sound anxious. Is that how you’re feeling?”).
Eye Contact
The eyes have been called the mirror of the soul because they often re ect our e
motions. Messages that the eyes give include humor, interest, puzzlement, hatred
, happiness, sadness, horror, warning, and pleading. Eye contact, looking into t
he other person’s eyes during communication, is used to assess the other person
and the environment and to indicate whose turn it is to speak; it increases duri
ng listening but decreases while speaking (DeVito, 2004). Although maintaining g
ood eye contact is usually desirable, it is important that the nurse doesn’t “st
are” at the client.
Silence
Silence or long pauses in communication may indicate many different things. The
client may be depressed and struggling to nd the energy to talk. Sometimes paus
es indicate the client is thoughtfully considering the question before respondin
g. At times, the client may seem to be “lost in his or her own thoughts” and not
paying attention to the nurse. It is important to allow the client suf cient ti
me to respond, even if it seems like a long time. It may confuse the client if t
he nurse “jumps in” with another question or tries to restate the question diffe
rently. Also, in some cultures, verbal communication is slow with many pauses, a
nd the client may believe the nurse is impatient or disrespectful if he or she d
oes not wait for the client’s response.
Accepting body position
Vocal Cues
Vocal cues are nonverbal sound signals transmitted along with the content: voice
volume, tone, pitch, intensity, emphasis, speed, and pauses augment the sender’
s message. Volume, the loudness of the voice, can indicate anger, fear, happines
s, or deafness. Tone can indicate whether someone is relaxed, agitated, or bored
. Pitch varies from shrill and high to low and threatening. Intensity is the pow
er, severity, and strength behind the words, indicating the importance of the me
ssage. Emphasis refers to accents on words or phrases that highlight the subject
or give insight on the topic. Speed is number of words spoken per minute. Pause
s also contribute to the message, often adding emphasis or feeling. The high-pit
ched rapid delivery of a message often indicates anxiety. The use of extraneous
words with long tedious descriptions is called circumstantiality. Circumstantial
ity can indicate the client is confused about what is important or is a poor his
torian. Slow, hesitant responses can indicate that the person is depressed, conf
used and searching for the correct words, having dif culty nding the right word
s to describe an incident, or reminiscing. It is important for the nurse to vali
date these nonverbal indicators rather than to assume that he or she knows what
the client is thinking
UNDERSTANDING THE MEANING OF COMMUNICATION
Few messages in social and therapeutic communication have only one level of mean
ing; messages often contain more meaning than just the spoken words (DeVito, 200
4). The nurse must try to discover all the meaning in the client’s communication
. For example, the client with depression might say, “I’m so tired that I just c
an’t go on.” If the nurse considers only the literal meaning of the words, he or
she might assume the client is experiencing the fatigue that often accompanies
depression. However, statements such as the previous example often mean the clie
nt wishes to die. The nurse would need to further assess the client’s statement
to determine whether or not the client is suicidal. It is sometimes easier for c
lients to act out their emotions than to organize their thoughts and feelings in
to words to describe feelings and needs. For example, people who outwardly appea
r dominating and strong and often manipulate and criticize others in reality may
have low self-esteem and feel insecure. They do not verbalize
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their true feelings but act them out in behavior toward others. Insecurity and l
ow self-esteem often translate into jealousy and mistrust of others and attempts
to feel more important and strong by dominating or criticizing them.
UNDERSTANDING CONTEXT
Understanding the context of communication is extremely important in accurately
identifying the meaning of a message. Think of the difference in the meaning of
“I’m going to kill you!” when stated in two different contexts: anger during an
argument and when one friend discovers another is planning a surprise party for
him or her. Understanding the context of a situation gives the nurse more inform
ation and reduces the risk of assumptions. To clarify context, the nurse must ga
ther information from verbal and nonverbal sources and validate ndings with the
client. For example, if a client says, “I collapsed,” she may mean she fainted
or felt weak and had to sit down. Or she could mean she was tired and went to be
d. To clarify these terms and view them in the context of the action, the nurse
could say “What do you mean collapsed?” (seeking clari cation) or “Describe wher
e you were and what you were doing when you collapsed” (placing events in time a
nd sequence). Assessment of context focuses on who was there, what happened, whe
n it occurred, how the event progressed, and why the client believes it happened
as it did.
is not ignored or ridiculed because his or her beliefs and values differ from th
ose of the staff (Chant et al., 2002). As the therapeutic relationship develops,
the nurse must be aware of and respect the client’s religious and spiritual bel
iefs. Ignoring or being judgmental will quickly erode trust and could stall the
relationship. For example, a nurse working with a Native American client could
nd him looking up at the sky and talking to “Grandmother Moon.” If the nurse did
not realize that the client’s beliefs embody all things with spirit, including
the sun, moon, earth, and trees, the nurse might misinterpret the client’s actio
ns as inappropriate. Chapter 7 gives a more detailed discussion on spirituality.
CULTURAL CONSIDERATIONS
Culture is all the socially learned behaviors, values, beliefs, and customs tran
smitted down to each generation. The rules about the way in which to conduct com
munication vary because they arise from each culture’s speci c social relationsh
ip patterns (Sheldon, 2004). Each culture has its own rules governing verbal and
nonverbal communication. For example, in Western cultures, the handshake is a n
onverbal greeting used primarily by men often to size up or judge someone they j
ust met. For women, a polite “hello” is an accepted form of greeting. In some As
ian cultures, bowing is the accepted form of greeting and departing and a method
of designating social status. Because of these differences, cultural assessment
is necessary when establishing a therapeutic relationship. The nurse must asses
s the client’s emotional expression, beliefs, values, and behaviors; modes of em
otional expression; and views about mental health and illness. When caring for p
eople who do not speak English, the services of a quali ed translator who is ski
lled at obtaining accurate data are necessary. He or she should be able to trans
late technical words into another language while retaining the original intent o
f the message and not injecting his or her own biases. The nurse is responsible
for knowing how to contact a translator, regardless of whether the setting is in
patient, outpatient, or in the community. The nurse must understand the differen
ces in how various cultures communicate. It helps to see how a person from anoth
er culture acts toward and speaks with others. U.S. and many European cultures a
re individualistic; they value self-reliance and independence and they focus on
individual goals and achievements. Other cultures, such as Chinese and Korean, a
re collectivistic, valuing the group and observing obligations that enhance the
security of the group. Persons from these cultures are more private and guarded
when speaking to members outside the group and sometimes may even ignore outside
rs until they are formally introduced to the group. Cultural differences in gree
tings, personal
UNDERSTANDING SPIRITUALITY
Spirituality is a client’s belief about life, health, illness, death, and one’s
relationship to the universe. Spirituality differs from religion, which is an or
ganized system of beliefs about one or more all-powerful, all-knowing forces tha
t govern the universe and offer guidelines for living in harmony with the univer
se and others (Andrews & Boyle, 2003). Spiritual and religious beliefs usually a
re supported by others who share them and follow the same rules and rituals for
daily living. Spirituality and religion often provide comfort and hope to people
and can greatly affect a person’s health and health care practices. The nurse m
ust rst assess his or her own spiritual and religious beliefs. Religion and spi
rituality are highly subjective and can be vastly different among people. The nu
rse must remain objective and nonjudgmental regarding the client’s beliefs and m
ust not allow them to alter nursing care. The nurse must assess the client’s spi
ritual and religious needs and guard against imposing his or her own on the clie
nt. The nurse must ensure that the client
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space, eye contact, touch, and beliefs about health and illness are discussed in
-depth in Chapter 7.
THE THERAPEUTIC COMMUNICATION SESSION Goals
The nurse uses all the therapeutic communication techniques and skills previousl
y described to help achieve the following goals: • Establish rapport with the cl
ient by being empathetic, genuine, caring, and unconditionally accepting of the
client regardless of his or her behavior or beliefs. • Actively listen to the cl
ient to identify the issues of concern and to formulate a client-centered goal f
or the interaction. • Gain an in-depth understanding of the client’s perception
of the issue, and foster empathy in the nurse– client relationship. • Explore th
e client’s thoughts and feelings. • Facilitate the client’s expression of though
ts and feelings. • Guide the client to develop new skills in problemsolving. • P
romote the client’s evaluation of solutions.
After making the introduction and establishing the contract, the nurse can engag
e in small talk to break the ice and to help get acquainted with the client if t
hey have not met before. Then the nurse can use a broad opening question to guid
e the client toward identifying the major topic of concern. Broad opening questi
ons are helpful to begin the therapeutic communication session because they allo
w the client to focus on what he or she considers important. The following is a
good example of how to begin the therapeutic communication: Nurse: “Hello, Mrs.
Nagy. My name is Donna, and I am your nurse today and tomorrow from 7 AM to 3 PM
. What do you like to be called?” (introducing self, establishing limits of rela
tionship) Client: “Hi, Donna. You can call me Peggy.” Nurse: “The rain today has
been a welcome relief from the heat of the past few days.” Client: “Really? It’
s hard to tell what it’s doing outside. Still seems hot in here to me.” Nurse: “
It does get stuffy here sometimes. So tell me, how are you doing today?” (broad
opening)
Nondirective Role
Beginning Therapeutic Communication
Often the nurse can plan the time and setting for therapeutic communication, suc
h as having an in-depth, oneon-one interaction with an assigned client. The nurs
e has time to think about where to meet and what to say and will have a general
idea of the topic, such as nding out what the client sees as his or her major c
oncern or following up on interaction from a previous encounter. At times, howev
er, a client may approach the nurse saying, “Can I talk to you right now?” Or th
e nurse may see a client sitting alone, crying, and decide to approach the clien
t for an interaction. In these situations, the nurse may know that he or she wil
l be trying to nd out what is happening with the client at that moment in time.
When meeting the client for the rst time, introducing oneself and establishing
a contract for the relationship is an appropriate start for therapeutic communi
cation. The nurse can ask the client how he or she prefers to be addressed. A co
ntract for the relationship includes outlining the care the nurse will give, the
times the nurse will be with the client, and acceptance of these conditions by
the client. Nurse: “Hello, Mr. Kirk. My name is Joan, and I’ll be your nurse tod
ay. I’m here from 7 am to 3:30 pm. Right now I have a few minutes, and I see you
are dressed and ready for the day. I would like to spend some time talking with
you if this is convenient.” (giving recognition and introducing self, setting l
imits of contract)
When beginning therapeutic interaction with a client, it is often the client (no
t the nurse) who identi es the problem he or she wants to discuss. The nurse use
s active listening skills to identify the topic of concern. The client identi es
the goal, and information-gathering about this topic focuses on the client. The
nurse acts as a guide in this conversation. The therapeutic communication cente
rs on achieving the goal within the time limits of the conversation. The followi
ng are examples of client-centered goals: • Client will discuss her concerns abo
ut her 16-yearold daughter, who is having trouble in school. • Client will descr
ibe dif culty she has with side effects of her medication. • Client will share h
is distress about son’s drug abuse. • Client will identify the greatest concerns
he has about being a single parent. The nurse is assuming a nondirective role i
n this type of therapeutic communication, using broad openings and open-ended qu
estions to collect information and help the client to identify and discuss the t
opic of concern. The client does most of the talking. The nurse guides the clien
t through the interaction, facilitating the client’s expression of feelings and
identi cation of issues. The following is an example of the nurse’s nondirective
role: Client: “I’m so upset about my family.” Nurse: “You’re so upset?” (re ect
ing) Client: “Yes, I am. I can’t sleep. My appetite is poor. I just don’t know w
hat to do.” Nurse: “Go on.” (using a general lead)
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Client: “Well, my husband works long hours and is very tired when he gets home.
He barely sees the children before their bedtime.” Nurse: “I see.” (accepting) C
lient: “I’m busy trying to x dinner, trying to keep an eye on the children, but
I also want to talk to my husband.” Nurse: “How do you feel when all this is ha
ppening?” (encouraging expression) Client: “Like I’m torn in several directions
at once. Nothing seems to go right, and I can’t straighten everything out.” Nurs
e: “It sounds like you’re feeling overwhelmed.” (translating into feelings) Clie
nt: “Yes, I am. I can’t do everything at once all by myself. I think we have to
make some changes.” Nurse: “Perhaps you and I can discuss some potential changes
you’d like to make.” (suggesting collaboration) In some therapeutic interaction
s, the client wants only to talk to an interested listener and feel like he or s
he has been heard. Often just sharing a distressing event can allow the client t
o express thoughts and emotions that he or she has been holding back. It serves
as a way to lighten the emotional load and release feelings without a need to al
ter the situation. Other times, the client may need to reminisce and share pleas
ant memories of past events. Older adults often find great solace in reminiscing
about events in their lives such as what was happening in the world when they w
ere growing up, how they met and when they married their spouses, and so forth.
Reminiscence is discussed further in Chapter 21.
Directive Role
ci c mental illnesses and disorders are discussed as are speci c therapeutic com
munication interventions and examples of how to use the techniques effectively.
How to Phrase Questions
The manner in which the nurse phrases questions is important. Open-ended questio
ns elicit more descriptive information; yes/no questions yield just an answer. T
he nurse asks different types of questions based on the information the nurse wi
shes to obtain. The nurse uses active listening to build questions based on the
cues the client has given in his or her responses. In English, people frequently
substitute the word feel for the word think. Emotions differ from the cognitive
process of thinking, so using the appropriate term is important. For example, “
What do you feel about that test?” is a vague question that could elicit several
types of answers. A more speci c question is, “How well do you think you did on
the test?” The nurse should ask, “What did you think about . . . ?” when discus
sing cognitive issues and “How did you feel about . . . ?” when trying to elicit
the client’s emotions and feelings. Box 6.1 lists “feeling” words that are comm
only used to express or describe emotions. The following are examples of differe
nt responses that clients could give to questions using “think” and “feel”: Nurs
e: “What did you think about your daughter’s role in her automobile accident?” C
lient: “I believe she is just not a careful driver. She drives too fast.”
When the client is suicidal, experiencing a crisis, or is out of touch with real
ity, the nurse uses a directive role, asking direct yes/no questions and using p
roblemsolving to help the client develop new coping mechanisms to deal with pres
ent here-and-now issues. The following is an example of therapeutic communicatio
n using a more directive role: Nurse: “I see you sitting here in the corner of t
he room away from everyone else.” (making observation) Client: “Yeah, what’s the
point?” Nurse: “What’s the point of what?” (seeking clari cation) Client: “Of a
nything” Nurse: “You sound hopeless.” (verbalizing the implied) “Are you thinkin
g about suicide?” (seeking information) Client: “I have been thinking I’d be bet
ter off dead.” The nurse uses a very directive role in this example because the
client’s safety is at issue. As the nurse–client relationship progresses, the nu
rse uses therapeutic communication to implement many interventions in the client
’s plan of care. In Unit 4, spe-
Box 6.1
Afraid Alarmed Angry Anxious Ashamed Bewildered Calm Carefree Confused Depressed
Ecstatic Embarrassed Enraged Envious Excited Fearful Frustrated Guilty Happy Ho
peful
“FEELING” WORDS
Hopeless Horri ed Impatient Irritated Jealous Joyful Lonely Pleased Powerless Re
laxed Resentful Sad Scared Surprised Tense Terri ed Threatened Thrilled Uptight
122
Nurse: “How did you feel when you heard about your daughter’s automobile acciden
t?” Client: “Relieved that neither she nor anyone else was injured.” Using activ
e listening skills, asking many open-ended questions, and building on the client
’s responses help the nurse obtain a complete description of an issue or an even
t and understand the client’s experience. Some clients do not have the skill or
patience to describe how an event unfolded over time without assistance from the
nurse. Clients tend to recount the beginning and the end of a story, leaving ou
t crucial information about their own behavior. The nurse can help the client by
using techniques such as clari cation and placing an event in time or sequence.
Asking for Clari cation
that is increasing the client’s anxiety. The client is discussing a topic but se
ems to be focused elsewhere. Active listening and observing changes in the inten
sity of the nonverbal process help to give the nurse a sense of what is going on
. Many options can help the nurse to determine which topic is more important: 1.
Ask the client which issue is more important at this time. 2. Go with the new t
opic because the client has given nonverbal messages that this is the issue that
needs to be discussed. 3. Re ect the client’s behavior signaling there is a mor
e important issue to be discussed. 4. Mentally le the other topic away for late
r exploration. 5. Ignore the new topic, because it seems that the client is tryi
ng to avoid the original topic. The following example shows how the nurse can tr
y to identify which issue is most important to the client: Client: “I don’t know
whether it is better to tell or not tell my husband that I won’t be able to wor
k anymore. He gets so upset whenever he hears bad news. He has an ulcer, and bad
news seems to set off a new bout of ulcer bleeding and pain.” Nurse: “Which iss
ue is more dif cult for you to confront right now: your bad news or your husband
’s ulcer?” (encouraging expression)
Nurses often believe they always should be able to understand what the client is
saying. This is not always the case: The client’s thoughts and communications m
ay be unclear. The nurse never should assume that he or she understands; rather,
the nurse should ask for clari cation if there is doubt. Asking for clari catio
n to con rm the nurse’s understanding of what the client intends to convey is pa
ramount to accurate data collection (Summers, 2002). If the nurse needs more inf
ormation or clari cation on a previously discussed issue, he or she may need to
return to that issue. The nurse also may need to ask questions in some areas to
clarify information. The nurse then can use the therapeutic technique of consens
ual validation, or repeating his or her understanding of the event that the clie
nt just described to see if their perceptions agree. It is important to go back
and clarify rather than to work from assumptions. The following is an example of
clarifying and focusing techniques: Client: “I saw it coming. No one else had a
clue this would happen.” Nurse: “What was it that you saw coming?” (seeking inf
ormation) Client: “We were doing well, and then the oor dropped out from under
us. There was little anyone could do but hope for the best.” Nurse: “Help me und
erstand by describing what ‘doing well’ refers to.” (seeking information) “Who a
re the ‘we’ you refer to?” (focusing) “How did the oor drop out from under you?
” (encouraging description of perceptions) “What did you hope would happen when
you ‘hoped for the best’?” (seeking information)
Client’s Avoidance of the Anxiety-Producing Topic
Guiding the Client in Problem Solving and Empowering the Client to Change
Many therapeutic situations involve problem solving. The nurse is not expected t
o be an expert or to tell the client what to do to x his or her problem. Rather
, the nurse should help the client explore possibilities and nd solutions to hi
s or her problem. Often just helping the client to discuss and explore his or he
r perceptions of a problem stimulates potential solutions in the client’s mind (
Adkins, 2003).Thenurseshould introduce the concept of problem solving and offer
himself or herself in this process. Virginia Satir (1967) explained how importan
t the client’s participation is to nding effective and meaningful solutions to
problems. If someone else tells the client how to solve his or her problems and
does not allow the client to participate and develop problemsolving skills and p
aths for change, the client may fear growth and change. The nurse who gives advi
ce or directions about the way to x a problem does not allow the client to play
a role in the process and implies that the client is less than competent. This
process makes the client feel helpless and not in control and lowers selfesteem.
The client may even resist the directives in an attempt to regain a sense of co
ntrol. When a client is more involved in the problem-solving process, he or she
is more likely to follow through on the
Sometimes clients begin discussing a topic of minimal importance because it is l
ess threatening than the issue
123
solutions. The nurse who guides the client to solve his or her own problems help
s the client to develop new coping strategies, maintains or increases the client
’s self-esteem, and demonstrates the belief that the client is capable of change
. These goals encourage the client to expand his or her repertoire of skills and
to feel competent; feeling effective and in control is a comfortable state for
any client. Problem solving is frequently used in crisis intervention but is equ
ally effective for general use. The problemsolving process is used when the clie
nt has dif culty nding ways to solve the problem or when working with a group o
f people whose divergent viewpoints hinder nding solutions. It involves several
steps: 1. 2. 3. 4. 5. 6. Identify the problem. Brainstorm all possible solution
s. Select the best alternative. Implement the selected alternative. Evaluate the
situation. If dissatis ed with results, select another alternative and continue
the process.
again. Effective problem solving involves helping the client to resolve his or h
er own problems as independently as possible.
COMMUNITY-BASED CARE
As community care for people with physical and mental health problems continues
to expand, the nurse’s role expands as well. The nurse may become the major care
giver and resource person for increasingly high-risk clients treated in the home
and their families and may become more responsible for primary prevention in we
llness and health maintenance. Therapeutic communication techniques and skills a
re essential to successful management of clients in the community. Caring for ol
der adults in the family unit and in communities today is a major nursing concer
n and responsibility. It is important to assess the relationships of family memb
ers; identifying their areas of agreement and con ict can greatly affect the car
e of clients. To be responsive to the needs of these clients and their families
for support and caring, the nurse must communicate and relate to clients and est
ablish a therapeutic relationship. When practicing in the community, the nurse n
eeds self-awareness and knowledge about cultural differences. When the nurse ent
ers the home of a client, the nurse is the outsider and must learn to negotiate
the cultural context of each family by understanding their beliefs, customs, and
practices and not judging them according to his or her own cultural context. As
king the family for help in learning about their culture demonstrates the nurse’
s unconditional positive regard and genuineness. Families from other cultural ba
ckgrounds often respect nurses and health care professionals and are quite patie
nt and forgiving of the cultural mistakes that nurses might make as they learn d
ifferent customs and behaviors. Another reason the nurse needs to understand the
health care practices of various cultures is to make sure these practices do no
t hinder or alter the prescribed therapeutic regimens. Some cultural healing pra
ctices, remedies, and even dietary practices may alter the client’s immune syste
m and may enhance or interfere with prescribed medications. The nurse in communi
ty care is a member of the health care team and must learn to collaborate with t
he client and family as well as with other health care providers who are involve
d in the client’s care such as physicians, physical therapists, psychologists, a
nd home health aides. Working with several people at one time rather than just w
ith the client is the standard in community care. Self-awareness and sensitivity
to the beliefs, behaviors, and feelings of others are paramount to the successf
ul care of clients in the community setting.
Identifying the problem involves engaging the client in therapeutic communicatio
n. The client tells the nurse the problem and what he or she has tried to do to
solve it: Nurse: “I see you frowning. What is going on?” (making observation; br
oad opening) Client: “I’ve tried to get my husband more involved with the childr
en other than yelling at them when he comes in from work, but I’ve had little su
ccess.” Nurse: “What have you tried that has not worked?” (encouraging expressio
n) Client: “Before my surgery, I tried to involve him in their homework. My husb
and is a math whiz. Then I tried TV time together, but the kids like cartoons an
d he wants to watch stuff about history, natural science, or travel.” Nurse: “Ho
w have you involved your husband in this plan for him to get more involved with
the children?” (seeking information) Client: “Uh, I haven’t. I mean, he always s
ays he wants to spend more quality time with the kids, but he doesn’t. Do you me
an it would be better for him to decide how he wants to do this—I mean, spend qu
ality time with the kids?” Nurse: “That sounds like a place to start. Perhaps yo
u and you husband could discuss this issue when he comes to visit and decide wha
t would work for both of you.” (formulating a plan of action) It is important to
remember that the nurse is facilitating the client’s problem-solving abilities.
The nurse may not believe the client is choosing the best or most effective sol
ution, but it is essential that the nurse supports the client’s choice and assis
ts him or her to implement the chosen alternative. If the client makes a mistake
or the selected alternative isn’t successful, the nurse can support the client’
s efforts and assist the client to try
124
SELF-AWARENESS ISSUES
Therapeutic communication is the primary vehicle that nurses use to apply the nu
rsing process in mental health settings. The nurse’s skill in therapeutic commun
ication influences the effectiveness of many interventions. Therefore, the nurse
must evaluate and improve his or her communication skills on an ongoing basis.
When the nurse examines his or her personal beliefs, attitudes, and values as th
ey relate to communication, he or she is gaining awareness of the factors in uen
cing communication. Gaining awareness of how one communicates is the first step
toward improving communication. The nurse will experience many different emotion
al reactions to clients such as sadness, anger, frustration, and discomfort. The
nurse must re ect on these experiences to determine how emotional responses aff
ect both verbal and nonverbal communication. When working with clients from diff
erent cultural or ethnic backgrounds, the nurse needs to know or nd out what co
mmunication styles are comfortable for the client in terms of eye contact, touch
, proximity, and so forth. The nurse can then adapt his or her communication sty
le in ways that are bene cial to the nurse–client relationship.
Angry? Frustrated?” Use these self-assessment data to improve your communication
skills.
KEY POINTS
• Communication is the process people use to exchange information through verbal
and nonverbal messages. It is composed of both the literal words or content and
all the nonverbal messages (process), including body language, eye contact, fac
ial expression, tone of voice, rate of speech, context, and hesitations that acc
ompany the words. To communicate effectively, the nurse must be skilled in the a
nalysis of both content and process. • Therapeutic communication is an interpers
onal interaction between the nurse and client during which the nurse focuses on
the needs of the client to promote an effective exchange of information between
the nurse and client. • Goals of therapeutic communication include establishing
rapport, actively listening, gaining the client’s perspective, exploring client’
s thoughts and feelings, and guiding the client in problem solving. • The crucia
l components of therapeutic communication are con dentiality, privacy, respect f
or boundaries, self-disclosure, use of touch, and active listening and observati
on skills. • Proxemics is concerned with the distance zones between people when
they communicate: intimate, personal, social, and public. • Active listening inv
olves refraining from other internal mental activities and concentrating exclusi
vely on what the client is saying. • Verbal messages need to be clear and concre
te rather than vague and abstract. Abstract messages requiring the client to mak
e assumptions can be misleading and confusing. The nurse needs to clarify any ar
eas of confusion so that he or she does not make assumptions based on his or her
own experiences. • Nonverbal communication includes facial expressions, body la
nguage, eye contact, proxemics (environmental distance), touch, and vocal cues.
All are important in understanding the speaker’s message.
Points to Consider When Working on Therapeutic Communication Skills
• Remember that nonverbal communication is just as important as the words you sp
eak. Be mindful of your facial expression, body posture, and other nonverbal asp
ects of communication as you work with clients. • Ask colleagues for feedback ab
out your communication style. Ask them how they communicate with clients in dif
cult or uncomfortable situations. • Examine your communication by asking questio
ns such as “How do I relate to men? To women? To authority gures? To elderly pe
rsons? To people from cultures different from my own?” “What types of clients or
situations make me uncomfortable? Sad?
Internet Resources
RESOURCE • Resources for Listening and Communicating • Seven Keys to Listening •
Team Communication INTERNET ADDRESS http://www.allaboutcounseling.com http://ww
w.stresscure.com/relation/7keys.html http://www.yorkteam.com/teamc.htm
CHAPTER 6 • THERAPEUTIC COMMUNICATION REFERENCES
125
Critical T hinking Questions
1. Explain why the nurse’s attempt to solve the client’s problem is less effecti
ve than guiding the client to identify his or her own ways to resolve the issue.
2. The nurse is working with a client whose culture includes honoring one’s par
ents and being obedient, keeping “private” matters within the family only, and n
ot talking with strangers about family matters. Given this client’s belief syste
m, how will the nurse use therapeutic communication effectively?
• Understanding the context is important to the accuracy of the message. Assessm
ent of context focuses on the who, what, when, how, and why of an event. • Spiri
tuality and religion can greatly affect a client’s health and health care. These
beliefs vary widely and are highly subjective. The nurse must be careful not to
impose his or her beliefs on the client or to allow differences to erode trust.
• Cultural differences can greatly affect the therapeutic communication process
. • When guiding a client in the problem-solving process, it is important that t
he client (not the nurse) chooses and implements solutions. • Therapeutic commun
ication techniques and skills are essential to successful management of clients
in the community. • The greater the nurse’s understanding of his or her own feel
ings and responses, the better the nurse can communicate and understand others.
Visit http://connection.lww.com for further learning.
Adkins, E. (2003). The rst day of the rest of their lives. Journal of Psychosoc
ial Nursing and Mental Services, 41(7), 28–32. Andrews, M., & Boyle, J. (2003).
Transcultural concepts in nursing care (4th ed.). Philadelphia: Lippincott Willi
ams & Wilkins. Chant, S., Jenkinson, T., Randle, J., et al. (2002). Communicatio
n skills: Some problems in nursing education and practice. Journal of Clinical N
ursing, 11(1), 12–21. DeVito, J. A. (2004). The interpersonal communication hand
book (10th ed.). Boston: Pearson Education. Greene, J. O., & Burleson, B. R. (Ed
s.). (2003). Handbook of communication and social interaction skills. Mahwah, NJ
: Erlbaum Associates. Hall, E. (1963). Proxemics: The study of man’s spatial rel
ationships. In J. Gladstone (Ed.), Man’s image in medicine and anthropology (pp.
109– 120). Philadelphia: Mosby. Knapp, M., & Hall, J. (2002). Nonverbal behavio
r in human interaction (5th ed.). New York: Wadsworth. Knapp, M. L. (1980). Esse
ntials of nonverbal communication. New York: Holt, Rinehart & Winston. Peplau, H
. (1952). Interpersonal relations in nursing. New York: G. P. Putnam. Satir, V.
(1967). Conjoint family therapy: A guide to theory and technique (rev. ed.). Pal
o Alto, CA: Science and Behavior Books, Inc. Sheldon, L. K. (2004). Communicatio
n for nurses: Talking with patients. Thorofare, NJ: SLACK, Inc. Summers, L. C. (
2002). Mutual timing: An essential component of provider/patient communication.
Journal of the American Academy of Nurse Practitioners, 14(1), 19–25.
ADDITIONAL READINGS Castledine, G. (2002). Nurses’ bedside manner: Is it deterio
rating? British Journal of Nursing, 11(10), 723. Crouch, R. (2002). Communicatio
n is the key. Emergency Nurse, 10(3), 3–5. Dineen, K. (2002). Gift of presence.
Nursing 02, 32(6), 76. Fox, V. (2000). Empathy: The wonder quality of mental hea
lth treatment. Psychiatric Rehabilitation Journal, 23(3), 292–293. Kuehn, A. (20
02). Communication and the nursing shortage. American Nurse, 34(3), 6–7. Puentas
, W. J. (2000). Using social reminiscence to teach therapeutic communication ski
lls. Geriatric Nursing, 21(6), 315–318. Wallace, L. (2002). More than good manne
rs. Nursing 02, 33(7), 32.
Chapter Study Guide
MULTIPLE-CHOICE QUESTIONS
Select the best answer for each of the following questions. 1. Client: “I had an
accident.” Nurse: “Tell me about your accident.” This is an example of which th
erapeutic communication technique? A. Making observations B. Offering self C. Ge
neral lead D. Re ection 2. “Earlier today you said you were concerned that your
son was still upset with you. When I stopped by your room about an hour ago, you
and your son seemed relaxed and smiling as you spoke to each other. How did thi
ngs go between the two of you?” This is an example of which therapeutic communic
ation technique? A. Consensual validation B. Encouraging comparison C. Accepting
D. General lead 3. “Why do you always complain about the night nurse? She is a
nice woman and a ne nurse and has ve kids to support. You’re wrong when you sa
y she is noisy and uncaring.” This example re ects which nontherapeutic techniqu
e? A. Requesting an explanation B. Defending C. Disagreeing D. Advising 4. “How
does Jerry make you upset?” is a nontherapeutic communication technique because
it A. Gives a literal response B. Indicates an external source of the emotion C.
Interprets what the client is saying D. Is just another stereotyped comment 5.
Client: “I was so upset about my sister ignoring my pain when I broke my leg.” N
urse: “When are you going to your next diabetes education program?” This is a no
ntherapeutic response because the nurse has A. Used testing to evaluate the clie
nt’s insight B. Changed the topic C. Exhibited an egocentric focus D. Advised th
e client what to do 6. When the client says, “I met Joe at the dance last week,”
what is the best way for the nurse to ask the client to describe her relationsh
ip with Joe? A. “Joe who?” B. “Tell me about Joe.” C. “Tell me about you and Joe
.” D. “Joe, you mean that blond guy with the dark blue eyes?” 7. Which of the fo
llowing is a concrete message? A. “Help me put this pile of books on Marsha’s de
sk.” B. “Get this out of here.” C. “When is she coming home?” D. “They said it i
s too early to get in.”
Visit http://connection.lww.com for further learning.
126
CHAPTER 6 • STUDY GUIDE
127
SHORT-ANSWER QUESTIONS
De ne the following: 1. Culture
2. Proxemics
3. Incongruent message
4. Spirituality
5. Nonverbal communication
128
6. Cliché
7. Metaphor
8. Therapeutic use of self
In the following client statements, underline the cues (words, phrases, or issue
s) that should be followed up with therapeutic communication interventions. Then
write a therapeutic response. 1. “I feel good.”
2. “I can’t take it anymore.”
129
3. “I have two children, one from my wife and one from my girlfriend.”
4. “We were standing on the corner.”
5. “My son is never going to understand the way his wife is ruining them.”

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