Therapeutic communication

1. Mrs . Sujata umbarkar

2. THERAPEUTIC COMUNICATION
Therapeutic communication is the interpersonal
interaction between the nurse and the patient
during which the nurse focuses on the patients
specific needs to promote an effective exchange of
information

3. GOALS OF THERAPEUTICNURSE – PATIENT
INTERACTION
• Self realization, self acceptance & an increase genuine self
respect.
• A clear sense of personal identity
• An improved level of personal integration.
• An ability to form intimate, inter-dependent, interpersonal
relationship with a capacity to give & receive love.
• Improved functioning & increase ability to satisfy needs &
achieve realistic personal goals.
• Identify the most important patient’s needs.
• Assess the perception of the patients problem
• Implement the interventions designed to address the
patient’s needs.

4. TYPES OF THERAPEUTIC COMMUNICATION
1) VERBAL COMMUNICATION
 It occurs through the medium of words, spoken or
written.
 The advantage of verbal communication is that it can
convey factual information accurately & effectively.
 But it is less effective means of communicating
feelings. Another limitation of verbal communication
is that word can change meaning with different
cultural groups.

5. 2) NON VERBAL COMMUNICATION
• Includes everything that does not involve the
spoken or the written word. It involves all the
five senses. These are five types of nonverbal
behavior.
Vocal cues
Action cues
Object cues
Space cues
Touch cues
Cont.

6. LEVELS OF COMMUNICATION
A] Intrapersonal communication
B] Interpersonal communication
C] Transpersonal communication
D] Small group communication
E] Public communication
F] Organizational communication
Vertical Communication
Horizontal communication
Diagonal Communication

7. PRINCIPLES OF THERAPEUTIC
COMMUNICATION
• The patient should be the primary focus of the
interaction.
• Professional attitudes set the tone of the
therapeutic relationship.
• Use self disclosure cautiously & only when it has
a therapeutic purpose.
• Avoid social relationship with patients.
• Maintain patient confidentiality.
• Assess the patient’s intellectual competence to
determine the level of understanding.

8. Cont.
• Implement the interventions from the
theoretic base.
• Maintain a non judgmental attitude. Avoid
making judgments about patients behavior.
• Avoid giving advice.
• Guide the patient to interpret his/ her
experiences rationally.

9. SKILLS FOR EFFECTIVE COMMUNICATION
• Maintain good eye to eye contact.
• Maintain good body postures & expressions
• Use of silence is essential
• Listen well & give time for answering
• Create interest during communication process
• Participate actively in communication
• Reduce the barriers

10. • Sender
• The receiver
• Message
• Feedback
• Context
COMPONENTS OF COMMUNICATION

11. MODELS ON COMMUNICATION
• Standardize model of communication
• Simplified model of communication
• Shannon’s Model of Communication
• Transactional model of communication
• An Intermediary model on communication
• An Interactive model of communication
• The ecological model of communication

12. SENDER RECEIVER
Environment
MEESSAGE
TRANSACTIONAL MODEL OF COMMUNICATION
TRANSACTIONAL MODEL OF
COMMUNICATION

13. Cont.
“It reflects the analysis of the study of
transactions taking place between two
peoples.”
This approach to personality was developed
by Eric Bern (1964), a psychiatrist who made
transactional analysis a popular theory in his
classic book “GAMES Peoples Play; the
psychology of human relationships.

14. Transaction can be…..
a) Complementary
Transaction: The
arrows in ego state
diagram are
parallel & the
communication
flows smoothly.
Parent
Adult
Child
PATIENT NURSE
Parent
Adult
Child

15. Cont.
b) Cross Transaction:
In this the
communication is less
effective & mostly
breaks down. Parent
Adult
Child
PATIENT NURSE
Parent
Adult
Child

16. c) Ulterior Transaction: It
takes place at two
levels, The social level
& psychological level.
This transaction tends
to be destructive
because the
communication
conceals their true
motivation.
Cont.
Parent
Adult
Child
PATIENT NURSE
Parent
Adult
Child
Social Level

17. PHASES OF THERAPEUTIC
COMMUNICATION
1. Orientation phase
2. Identification phase
3. Working Phase
4. Maintenance phase
5. Termination Phase

18. TECHNIQUES OF THERAPEUTIC
COMMUNICATION
1} LISTENING
• It is the active process of receiving information.
Listening is the sign of respect for the person who
is talking & is powerful reinforce of relationships.
• Example: Responses on the part of the nurse
such as maintaining eye to eye contact, nodding,
gesturing & other forms of receptive non verbal
communication convey to the patient that he is
being listened to & understand.
• Therapeutic Value: Indicates acceptance by the
nurse & the values of patient’s initiative.

19. 2} BROAD OPENING
• These encourage the patient to select the
topic for discussion, & indicate that the nurse
is there listening to him & follow him.
• Example: “What are you thinking about?”
“What shall we discuss today?”
“Can you tell me more about that?”
• Therapeutic Value: Indicates acceptance by
the nurse & the value of patient initiative.

20. 3} RESTATING
• The nurse repeats to the patient the main thought he
has expresses. It indicates that the nurse is listening. It
also brings attention to something important.
• Example:
“You said that your mother left you when
you were five years old.”
“You said that you were hurt at left hand
during a fight with your father.”
• Therapeutic Value: Indicates that the nurse is listening
& validates, reinforces or call attention to something
important that has been said.

21. 4} CLARIFICATION
• The patient’s verbalization, especially when he is
disturbed or feeling deeply is not always clear.
The nurses need to provide correlation between
the patient’s feelings & actions.
• Example: “I am not sure what you mean?” could
you tell me ones again?”
• Therapeutic Value: It helps to clarify feelings,
ideas & perceptions of the patient & provides an
explicit correlation between hem & the patient’s
actions.

22. 5} REFLECTION
• This means directing back to the patients ideas, feelings,
questions & content. Reflection of the content is also called as
validation. Reflection of feelings consists of responses to the
patient’s feelings about the content. Reflection of the content
is for the patient to know that we have heard & that we have
understood the content.
• Example: “You are feeling tensed & anxious and it is related to
the conversation that you had with your husband last night.”
• Therapeutic Value: Validates the nurses understanding of
what the patient is saying & signifies empathy, interest &
respect for the patient.

23. 6} HUMOR
• This is the discharge of the energy through he
comic enjoyment of the imperfection. It is a
socially acceptable form of a sublimation. Humor
resolves paradoxes, tempers, aggressions &
reveals new options to the patients.
• Example: Joking allows the nurse & the patient to
retain their uneasy security in their unchanging
individual existences.
• Therapeutic Value: Can promote insight by
making repressed material conscious paradoxes,
tempering aggression & revealing new options, &
is a socially acceptable form of sublimation.

24. 7} INFORMING
• This is a skill of giving information. The nurse
shares simple facts with the patient.
• Example: “I think you need to know more
about your medication”
• Therapeutic Value: Helpful in health teaching
or patient education about relevant aspects of
patients well being & safe care.

25. 8} FOCUSING
• It means expanding the discussion on a topic
of importance. It helps the patient to become
more specific move from vagueness to clarity
& focus on reality.
• Example: “I think we should talk more about
your relationship with your father”
• Therapeutic Value: Allows the patient to issue
the central issues & keeps the communication
process goal directed.

26. 9} SHARING PERCEPTIONS
• These are the techniques of asking the patient
to verify the nurse understands what he is
thinking or feeling.
• Example: “You are smiling, but I sense that
you are really very angry with me.”
• Therapeutic Value: Conveys the nurses
understanding to the patient & has the
potential for the clearing up confusing
communication.

27. 10} THEME IDENTIFICATION
• This involves identifying the underline issues or
problems experienced by the patient that emerged
repeatedly during the course of the nurse patient
interaction. Ones we identify the basic themes, it
becomes easy to decide which of the patients feelings
& thoughts to respond to & peruse.
• Example: “I noticed that you said, you had been hurt
or rejected by the man. Do you thibk this is an
underlying issue?”
• Therapeutic Value: It allows the nurse to promote the
patient’s exploration & understanding of important
problems.

28. 11} SILENCE
• This is the lack of the verbal communication
for the therapeutic reason.
• Example: Sitting with the patient & non-
verbally communicating with the patient.
• Therapeutic Value: Allows the patient time to
think & gain insight & slow the pace f
interaction & encourage the patient to initiate
the conversation while enjoying the nurse’s
support understanding & acceptance.

29. 12} SUGGESTING
• This is presentation of alternative ideas
related to problem solving.
• Example: “Have you thought about
responding to your boss in a different way
when he raises that issue with you?”
• Therapeutic Value: Increases the patients
perceived notions or choices.

30. BARRIERS TO THERAPEUTIC
COMMUNICATION
• Rejecting responses
• Failure to listen
• Reassurance
• Probing
• Stereotyping the patient response
• Changing Topics
• Challenging the patient
• Advising
• Belittling the patient
• Using Denial

31. 1) Personal Barriers
– Age & Sex
– Language
– Mental state
– Personality Complexes
– Bias & Prejudice
– Impatience
– Inhibition Attitude
– Hospitalization
– Cultural factors

32. 2) Physical Impediments
3) Psychological Factors
4) Mechanical Factors
5) Educational Differences
6) Socio-economical Factors
7) Ambiguity of Words/Phrases
8) Presentation of information

33. 9) Noises
There are many examples of noise:
• Environmental Noise
• Physiological-Impairment Noise
• Semantic Noise
• Syntactical Noise
• Organizational Noise
• Psychological Noise

34. THERAPUTIC IMPASSES
1. Resistance
2. Transference
3. Counter Transference
4. Gift giving
5. Boundary Violations

35. Forms of resistance displayed by the
patient
• Suppression & repression
• Intensifications of symptoms
• Self devaluation & hopeless attitude towards the
future
• Forced flight into health where there is sudden but
short leaved recovery by the patient.
• Intellectual inhibitions – Forgetfulness, late for session,
silent or sleepy
• Superficial talk
• Irrational behaviors
• Refuses to assume responsibilities

36. Types of Transference
• Hostile transference: If the patient internalizes his
anger & hostility he may express his resistance as
depression & discouragement. He may ask to
termination the relationship on the grounds that he
has no chance of getting well. If the patient
externalizes his hostility, he may become critical,
defiant & irritable. He may doubt about he nurses
training, experience or personal adjustment.
• Dependent reaction transference: This are
characterized by patients who are submissive,
subordinate & integrating & regard the nurse as a
“Godlike” figure. The patient overvalues the nurses
characteristics & qualities.

37. Interventions for resistance &
transference
• Nurse must be prepared to be exposed to powerful
negative or positive emotional feeling coming from the
patient.
• Make therapeutic contracts, develop a mutually
acceptable goals or plans of action, defing the goals,
purposes & roles of nurse & patient in relationship.
• Listen to patients analysis of resistance & transference.
Use clarification & reflection of feelings.
• Explore the possible reasons for the resistance & work
through the transference reaction with the patient.

38. Forms of counter transference
displayed by the nurse
• Inability to emphasize with the patient on certain problem
areas.
• Depressed feeling during or after the session.
• Drowsiness during the sessions
• Feeling of anger
• Arguing with the patient or a tendency to push the patient
before he is ready.
• Involvement with the patient on a personal or a social level.
• Dreaming about the patient
• Sexual or aggressive fantasies towards the patient.
• Recurrent anxiety, unease or guilt feeling about the
patients.

39. Interventions to Counter
Transference:
• Experience of working with psychiatric patients.
• Constantly looking out for counter transference.
• Utilize counter transference for therapeutic purpose
• Apply self examination through out the course of
relationship.
• Pursue to find out the course of relationship
• Have individual or group supervision
• Weekly clinical seminars, peer consultation &
professional meetings can also offer emotional
support.

40. Gift giving
• Receiving a gift from the patients make the
nurse to inhibit independent decision making
& create a feeling of anxiety or guilt. Gift is
something of value is voluntarily offered to
another person, usually to convey gratitude.

41. Boundary Violations
• Receive the feedback that her behavior is
intrusive with the patient or their families
• Had difficulty in setting limits
• Relates to a patient like a friend
• Has sexual feelings towards patients
• Feels that he/she is the only one who
understands the patient
• Feels that other staff is too critical to the patient.
• Believes that other staff members are jealous of
his/ her relationship with the patient

42. FUNCTION OF THERAPEUTIC
COMMUNCIATION
• Allows the patient to express his thoughts & feelings &
relate this to observed & reported actions.
• Clarifies the areas of conflict & anxiety.
• Identifies & maximizes the patient’s ego strengths &
encourages socialization & family relatedness.
• Corrects the communication problems
• Modifies maladaptive behavior pattern
• Encourage the patient to test new patterns of
behaviors & new coping mechanism.
• Encourages forming a good nurse patient relationship.

43. PROBLEMS OF COMMUNICATION
• Aphasia
• Dysarthria
• Expressive language disorder
• Dysnomia
• Stuttering
• Cluttering
• Lisp
• Other Communication Disorder:
– Esophageal Voice
– Specific language disorder
– Late language Emergency
– Voice disorder
– Social communication disorder.

44. TOUCH THERAPY
• ZONES OF TOUCH
– Social Zone: Primitive not needed, (hands, arms,
shoulders, back)
– Consent Zone: Permission needed (Mouth, wrist,
feet)
– Vulnerable Zone: Special care needed (Face, neck,
front of body)
– Intimate zone: Great sensitivity needed (genital,
rectum)

45. TYPES OF TOUCH IN PSYCHOTHERAPY
• Ritualistic or socially accepted gestures
• Conversational marker
• Consoling or reassuring
• Playfull touch
• Grounding or reorienting
• Task oriented
• Corrective experience
• Instructional or modeling
• Celebratory or congratulatory
• Experimental
• Referential
• Inadvertent
• Self defense
• Therapeutic intervention – A body therapy medical technique
• Inappropriate, unethical & mostly illegal forms of touch include sexual,
hostile – violent & punishing touch.

46. THERAPEUTIC TOUCH
• It was created by a nurse &
theosophist, Dolores Krieger,
PhD, RN in early 1970’s.
• “It is a type of energy medicine
whereby the therapist moves
his hands over the patient’s
body (energy field) allegedly
directing the flow of chi or
prana so that patient can heal.”

47. TOUCHTHERAPY
• It is the gentle energy based therapy that emphasizes heart
centered care & compassionate healing intension. This
technique uses gentle, non invasive touch to influence &
restore harmony, energy & balance to mind, body & spirit. By
performing touch therapy the body’s energy level becomes
smooth & balanced.
Indications
• Back & neck pain, Bone fractures, Fibromyalgia, anxiety,
depression, headaches, cancers, arthritis.
Benefits of touch therapy
• Stress reduction, Lowers anxiety level, decrease need for pain
medication, treatment of pain & sickness, enhancement of
immune system, benefits to joints, muscles & nervous system,
faster recovery from surgery & chemotherapy, better blood
circulation, peace to the dying peoples.

48. PROBLEMS OF COMMUNICATION
• Aphasia
• Dysarthria
• Expressive language disorder
• Other communication disorder:
• Late language emergency
• Specific language
disorder
• Social communication
disorder
• Speech sound disorder
• Voice disorder
• Dysnomia
• Stuttering
• Cluttering
• Lisp
• Esophageal voice

49. THANK YOU!!!!