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Therapeutic Communication<br /><ul><li>focus on client needs
client chooses subject
therapeutic assistance
if they need help for example coping give them examples of coping mechanisms such as deep breathing
active listening by clinician
active listening includes giving good eye contact, repeating what they say so they know you are listening, etc
healthy boundaries maintained
don’t want to go into their room talking about things you shouldn’t etc.  don’t want to be best friend, give phone number,...
time limited
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Psych 1


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1/12/10 Lecture Notes

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Psych 1

  1. 1. Therapeutic Communication<br /><ul><li>focus on client needs
  2. 2. client chooses subject
  3. 3. therapeutic assistance
  4. 4. if they need help for example coping give them examples of coping mechanisms such as deep breathing
  5. 5. active listening by clinician
  6. 6. active listening includes giving good eye contact, repeating what they say so they know you are listening, etc
  7. 7. healthy boundaries maintained
  8. 8. don’t want to go into their room talking about things you shouldn’t etc. don’t want to be best friend, give phone number, or give out personal info. Etc
  9. 9. time limited
  10. 10. we have 5-15min to spend with you, what would you like to talk about?
  11. 11. Occurs at certain time
  12. 12. You are there for a specific shift</li></ul>Social Communication<br /><ul><li>Meets everyones needs
  13. 13. Sort of a peer peer relationship
  14. 14. Topics are at random
  15. 15. Each person can come up w/ a topic whereas in therapeutic communication the client comes up with a topic
  16. 16. Give and receive friendship
  17. 17. Opinions and advice given
  18. 18. Blurred boundaries
  19. 19. Subjectively involved</li></ul>** Know therapeutic vs social communication!!!<br />Space and Territory<br /><ul><li>4 spatial zones
  20. 20. Intimate – 18inches
  21. 21. Personal – 18inches-4feet, 3feet when sitting down (important b/c this is where most therapeutic communication will be taking place)
  22. 22. Social – 4-12feet
  23. 23. Public – 12-25feet
  24. 24. Important to know that these spatial zones are based on ppls perceptions too – someone w/ bipolar or schitzophrenia may not see these boundaries and you have to remind them that you aren’t part of their personal space</li></ul>Goals of a Nurse Client Relationship<br /><ul><li>Establish boundaries
  25. 25. How to establish boundaries w/ mentally ill pt: Say Hi my name is --- I will be your student nurse today – this sets relationship
  26. 26. Accept client’s uniqueness
  27. 27. Ppl don’t want to be treated all as the same person!
  28. 28. Be honest and direct
  29. 29. if you aren’t honest with them they will not trust you
  30. 30. Focus on therapeutic communication (see above for bulleted list)
  31. 31. Active listener
  32. 32. Facilitate expression
  33. 33. Allow them to express themselves – ask them open ended questions
  34. 34. Corrective, emotional experience
  35. 35. Set limits. Tell them what is allowed and what is not allowed.</li></ul>Nurse-Client Relationship<br /><ul><li>Establish Rapport
  36. 36. Fostering trust, starting a bond
  37. 37. Trust
  38. 38. Say what you mean, mean what you say
  39. 39. Congruence
  40. 40. Consistent
  41. 41. With boundaries, truth, relationship, facial expressions
  42. 42. Honesty
  43. 43. Uniqueness
  44. 44. Confidentiality
  45. 45. Especially important in psych
  46. 46. Blind trust
  47. 47. We expect them to trust us b/c we are in med profession. Some do but some have difficulties b/c of past relationships
  48. 48. Respect
  49. 49. Respect pts rights; don’t talk down to them; actively listen;
  50. 50. Genuineness
  51. 51. Be real
  52. 52. Not fake/phony
  53. 53. Congruent
  54. 54. Empathy Vs. Sympathy
  55. 55. Empathy is when you can see things f/ the clients perspective and understand the clients feelings
  56. 56. Sympathy is when you share that same feeling that the client is feeling
  57. 57. EXAMPLE: I can empathize w/ someone who has been on drugs who has had relapses but I can’t sympathize with them b/c I haven’t been there before.
  58. 58. Objectivity vs Subjectivity</li></ul>Role of Psychiatric Mental Health Nurse<br /><ul><li>Mental Health nursing focuses on helping people cope with present and potential problems
  59. 59. GENERALIST – nurse who goes into nursing and decides to become psych nurse – other than nursing degree there is no special degree they have to have other than taking state boards
  60. 60. ADVANCED PRACTICE – Nurse practitioners and clinical nurse specialists – there is an advanced degree which is at least a masters degree in nursing – can also write scripts if they have prescriptive authority</li></ul>Therapeutic Relationships<br /><ul><li>Pre-interaction phase (PHASE 1)
  61. 61. Where you obtain pt information, where you examine your own fears, feelings, and anxieties (when you 1st meet your pt)
  62. 62. Orientation phase (PHASE 2)
  63. 63. Where you establish trust and rapport, you also establish a contract for intervention like what are we going to do today, assess and formulate a nursing diagnosis here and establish goals, this phase is more nursing centered
  64. 64. Working phase (PHASE 3)
  65. 65. Action taking place here; The pt becomes actively involved in meeting goals (pt is doing most of the talking while nurse listens);
  66. 66. Use problems solving model
  67. 67. Termination (PHASE 4)
  68. 68. When goals have been achieved; give them plan for continued assistance (follow up apts etc); where feelings regarding termination are explored </li></ul>2 Phases pt might be resistant – Working phase and termination phase<br />Discharge planning begins at patient admission<br />Termination begins during orientation – have you at least start putting in follow up plans for them to follow up<br />Problem Solving Model (part of working phase!!)<br /><ul><li>Identify the problem
  69. 69. Patient needs to identify problem because pt is doing most of the talking
  70. 70. Discussion of desired changes
  71. 71. Have problem which changes do you want to make to that problem?
  72. 72. Identify realistic changes
  73. 73. What can’t be changed, adapt to
  74. 74. Ex: if living arrangements can’t be changed maybe you can adjust
  75. 75. Give Alternatives for changes
  76. 76. Ex: for a smoker who now can’t smoke in hospital maybe will chew on a straw etc
  77. 77. Give Benefits vs. consequences of each alternative (PROS VS CONS)
  78. 78. Assist with alternative selection
  79. 79. Sometimes they have all these alternatives and they don’t know where to begin
  80. 80. Encourage implementation of change (encourage their efforts in trying even if they weren’t successful)
  81. 81. Provide positive feedback
  82. 82. Assist in evaluating the outcomes and modify if necessary
  83. 83. How do they feel things went?</li></ul>Terms to Know<br /><ul><li>Transference: client transfers feelings onto the clinician (ex: you remind them of someone they don’t like so now they don’t like you)
  84. 84. Counter transference: When you transfer feelings onto the client
  85. 85. Resistance: Inability of the client to accept change (may see in working or termination phase) </li></ul>Therapeutic Milieu<br /><ul><li>Milieu: surroundings or environment and how do these promote therapeutic relationships
  86. 86. Rehabilitation uses the whole environment (the rooms, decorations, etc.)
  87. 87. Adaptive coping skills – such as learning your triggers such as anger, etc.
  88. 88. Interaction / relationship skills – teach them to talk to other people (they will be modeling you)
  89. 89. Multidisciplinary Therapies – different therapies
  90. 90. Occupational therapy
  91. 91. Recreation / Art / Music
  92. 92. Group therapy
  93. 93. Family therapy
  94. 94. Home-Life
  95. 95. Community Meetings – chance for pt to air grievances and a time for us to reinforce behaviors
  96. 96. Psychodrama – acting out behaviors; modeling a behavior through role play
  97. 97. Characteristics of therapeutic milieu
  98. 98. 24-hr environment – nurses are there 24hrs a day for the pt so nurses have a lot of say what goes on
  99. 99. Individualized treatment plan – EVERY pt has to have an individualized treatment plan
  100. 100. Self-governing / responsibility (for example: community meetings, wash own clothes, wear their own clothes
  101. 101. Structured activities – group is at a certain time, breakfast at certain time
  102. 102. Link with family – family group
  103. 103. Community involvement
  104. 104. Health team cooperation
  105. 105. Methodology/Rules of Therapeutic Milieu
  106. 106. Purposeful and planned
  107. 107. Behavior testing
  108. 108. Limit setting – set limits by while group is going on no phone calls, snack time at certain time, no smoke breaks, etc.
  109. 109. Participation in groups is expected
  110. 110. Respect / dignity – teaches them to respect the dignity of peers (can’t threaten other people)
  111. 111. Teaches them Acceptance / optimism
  112. 112. Pro communication
  113. 113. Effective management of milieu
  114. 114. Safety – freedom from danger or harm
  115. 115. Structure
  116. 116. Norms – expectations; rules that have been agreed upon; socially acceptable (ex: violence will not be tolerated)
  117. 117. Limit setting – related to the norms – the consequence! If you do this, this will happen.
  118. 118. Provide a Balance – as people get better want to give more freedoms
  119. 119. Environmental Modification – (ex: Noise level)
  120. 120. Team Members
  121. 121. Psychiatrist – a medical doctor who can prescribe medications and can provide therapy – in an inpatient facility there are too many pts so they often just prescribe
  122. 122. Psychologist – usually have a degree in psychology and may be called doctor; can provide therapy and conduct research; also administer and interpret psych testing (KNOW DIF BTWN PSYCHIATRIST AND PSYCHOLOGIST)
  123. 123. Social worker – master of science and social work; can be a therapist on unit providing group therapy and mobilize community support systems; can get a liaison to work with them to follow up with pt
  124. 124. Clinical nurse specialist / Nurse Practitioner- can provide therapy and prescribe meds in collaboration with physician (masters in nursing)
  125. 125. Staff Nurses – Any nurse (BSN, RN, LPN) These nurses assess the patient and look for side effects of medications; provide medication teaching; and structure meaningful activities
  126. 126. MHT – Mental Health Technician and Psych Tech – tend to do a lot of aide work but also do charting and groups
  127. 127. OT – Occupational Therapist – Help pts with ADL’s sometimes arts and crafts (distract and accomplishment);
  128. 128. RT – Recreational Therapist – Provides diversional activities use crafts games and hobbies to teach the balance between work and play
  129. 129. Music Therapist – music can play a role in your mood
  130. 130. Art Therapist – Explore moods through a project that they are doing and it can uncover repressed memories
  131. 131. Psychodramatist – person who role plays
  132. 132. Dietician – certain foods can alter moods such as sugar, caffeine, etc. Some medications they are on can cause massive weight gain and they need dietician. With weight gain can cause insulin resistance or diabetes. Pt can be bulimic or anorexic.
  133. 133. Chaplain – Spiritual needs
  134. 134. Client – determine the outcome of therapy; they are the only ones that can determine outcome therefore they are THE MOST IMPORTANT TEAM MEMBER
  135. 135. Case Manager – coordinate access to care – take them to dr. apt, shopping, etc. GOAL of the case manager is to keep the patient in the community and out of the hospital
  136. 136. Pharmacist – can give information on meds; can give meds (that dr prescribes); let pt know about pt assistance programs b/c meds cost a lot</li></ul>Community Mental Health<br />Test question on prevention types<br /><ul><li>Primary prevention – prevents something from occurring (health promotion; bereavement groups; screening for schools)
  137. 137. Secondary prevention – occurs after a diagnosis has been made; want to limit the patients illness as much as possible (crisis hotline; medications)
  138. 138. Tertiary prevention – usually long term (rehab) (home health)
  139. 139. GOAL of community mental health
  140. 140. Keep optimal level of mental health for community
  141. 141. Must look at client wholistically (emotional, physical, spiritual, whole being)
  142. 142. Need for services are increasing
  143. 143. Major reason people relapse is because of medication noncompliance</li></ul>Communication Types<br /><ul><li>Verbal – anything written or said
  144. 144. Nonverbal – how something is said can be nonverbal; expressions
  145. 145. Kinesic – movement</li></ul>Nonverbal Communication<br /><ul><li>High % of our communication is nonverbalexamples: tone of voice, raise eyebrows, hand movements, facial expression
  146. 146. Can:
  147. 147. Contradict/complement verbal communication
  148. 148. Emphasize emotions
  149. 149. Control the environment
  150. 150. Be communication of choice for some people
  151. 151. Important thing about nonverbals are that they provide information but have to validated</li></ul>What Makes Nonverbals<br /><ul><li>Body movement
  152. 152. Facial expressions
  153. 153. Eye contact
  154. 154. Dress and physical appearance
  155. 155. Touch – therapeutic touch is important; you should not touch anyone unless they seem receptive to it, not even a tap on the shoulder because you don’t know who has been abused; and it may be against someone’s religion
  156. 156. Types of Touch
  157. 157. Functional touch – a professional touch – business like and impersonal (tailor, dressmaker, etc)
  158. 158. Social or polite touch – impersonal but affirming touch (shaking hands)
  159. 159. Friendship or warm touch – indicates a strong liking; (hand on shoulder)
  160. 160. Love and Intimacy touch – conveys a mutual attraction (strong and lasting embrace)
  161. 161. Sexual arousal – expresses physical attraction and involves sexual parts
  162. 162. Vocal cues – pitch, tone, loudness, rate of speech</li></ul>Conditions Affecting Communication<br /><ul><li>Values / attitudes / beliefs / past experiences
  163. 163. Culture / religion
  164. 164. Social status
  165. 165. Gender
  166. 166. Age / Developmental Level
  167. 167. Environment </li></ul>Therapeutic Technique<br /><ul><li>Therapeutic use of self
  168. 168. Self awareness (likes, dislikes, who am I? etc)
  169. 169. Self understanding (understand my own boundaries and abilities)
  170. 170. Philosophical beliefs (belief about life and death, do I believe there is anything after death? Is life valuable?)
  171. 171. Life
  172. 172. Death
  173. 173. Overall human condition (do I believe some people are just meant to be depressed?)
  174. 174. Attending behavior
  175. 175. SOLER
  176. 176. S – sit squarely facing the patient
  177. 177. O – open posture
  178. 178. L – lean in towards patient
  179. 179. E – eye contact
  180. 180. R – relax
  181. 181. Verbal – want to say some of the same things they’ve said (pt: I feel depressed you: you feel depressed?)
  182. 182. Don’t ask why questions to a psychiatric patient because sometimes they don’t know why and you are asking for a rationale that they may not be rationale about (instead of why are you sad; what makes you sad)
  183. 183. Positive regard – respecting the pt for who they are and their own uniqueness
  184. 184. Favorable Environment
  185. 185. You and pt in comfortable stance
  186. 186. Fair Eye contact (fair, appropriate, glaring to describe eye contact not good or poor or adequate)
  187. 187. Eye level
  188. 188. Client’s lead – therapeutic communication
  189. 189. Nodding / smiling – appropriately – make sure they know you are hearing what they are saying and whether you agree with them or not</li></ul>Supportive Therapeutic Groups<br /><ul><li>What group is about: Group content
  190. 190. Seating arrangement – want to have a seating arrangement that promotes therapeutic interaction and want all to be seen appropriate – usually circular fashion
  191. 191. Selective interacting – if it isn’t part of group process stop it
  192. 192. Notice nonverbal communication
  193. 193. Cohesiveness of the group – the togetherness of the group
  194. 194. Underlying tension – be aware of any
  195. 195. Yalom’s Factors
  196. 196. Group roles
  197. 197. Leader
  198. 198. Facilitator
  199. 199. Dictator
  200. 200. clown
  201. 201. Etc.</li></ul>Yalom’s 11 Curative Factors (only occur in a group) – a process of learning comes from groups<br /><ul><li>Installation of hope – seeing that other people have the same illness and you gaining hope as a result
  202. 202. Universality – seeing that you aren’t the only one with the same problem
  203. 203. Imparting information – when you get information or give information to each other
  204. 204. Altruism – Self growth by helping other people
  205. 205. Corrective Recapitulation of Family group – role playing the family roles
  206. 206. Development of socializing techniques –
  207. 207. Imitative behavior – role model to one another
  208. 208. Interpersonal learning – The benefit of interacting with others
  209. 209. Group cohesiveness – togetherness – sense of belonging
  210. 210. Catharsis – when they let all their feelings out – can be positive or negative (laughter, crying)
  211. 211. Existential factors – When you look at the purpose and existence of life </li></ul>Other group information<br /><ul><li>Should not be part of the group:
  212. 212. Someone who is actively psychotic (will be responding to voices in their head which will be impeding group improvement)
  213. 213. Antisocial personality disorder (don’t care about anyone else’s rights, rules, laws, etc)
  214. 214. In alcohol/drug withdrawal – will be physically ill and can’t concentrate
  215. 215. Under influence of drugs / alcohol – no information will be retained
  216. 216. All groups are reality based – here and now
  217. 217. Physical conditions that influence group process
  218. 218. Seating arrangement – circle
  219. 219. Size: ideally 7-10 clients in a group
  220. 220. Membership (close to same age and same gender)
  221. 221. Open vs. closed group (close group – we can’t add anymore to this class; open – can come and go at will)</li></ul>Application of Nursing Process<br /><ul><li>Plan (care plan)
  222. 222. Implementation
  223. 223. Health teaching
  224. 224. Community referrals
  225. 225. Evaluation
  226. 226. Goals: what you and the client want a client to achieve
  227. 227. Outcome criteria: an indication that the client is achieving the goalEx: Pt wants to be alcohol free (goal); Pt is attending AA meeting (outcome criteria) </li></ul>25 questions – multiple choice TEST NEXT WEEK<br />