Therapeutic communication is an essential interpersonal interaction between nurses and patients, focusing on meeting patient needs and promoting effective information exchange. The nurse employs various techniques, such as listening, restating, and clarifying, to facilitate the patient's expression of emotions, assess perceptions, and support problem-solving. The therapeutic nurse-patient relationship is characterized by empathy, warmth, and genuineness, structured through distinctly defined phases, aimed at enhancing patient growth and independence.

1. THERAPEUTIC
COMMUNICATION
AND NURSE-
PATIENT
RELATIONSHIP

2. Communication refers to the giving and
receiving of information. Communication is the
means by which people influence the behaviour
of another, leading to the successful outcome of
nursing intervention.
COMMUNICATION

3. THERAPEUTIC COMMUNICATION
● Therapeutic communication is an
interpersonal interaction between the
nurse and the patient during which the
nurse focuses on the patient's specific
needs to promote an effective exchange of
information.

4. GOALS
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 Establish a therapeutic nurse-patient relationship
 Identify the most important patient's needs
 Assess the patient's perception of the problem
 Facilitate the patient's expression of emotions
 Implement interventions designed to address the
patient's needs

5. PRINCIPLES OR CHARACTERISTICS
OF THERAPEUTIC COMMUNICATION
 The patient should be the primary focus of interaction
 A professional attitude sets the tone of the therapeutic relationship
 Use self-disclosure cautiously and 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

6. THERAPEUTIC COMMUNICATION
TECHNIQUES
1. Listening: It is an active process of receiving information. Responses on
the part of the nurse such as maintaining eye-to-eye contact, nodding,
gesturing and other forms of receptive non-verbal communication convey
to the patient that he is being listened to and understood.
Therapeutic value: Non-verbally communicates to the patient the nurse's
interest and acceptance.

7. 2. Broad openings: Encouraging the patient to select topics for discussion. For
example, “What are you thinking about?”
Therapeutic value: Indicates acceptance by the nurse and the value of patient's
initiative.
3. Restating: Repeating the main thought expressed by the patient. For example,
“You say that your mother left you when you were 5-year-old.”
Therapeutic value: Indicates that the nurse is listening and validates, reinforces
or calls attention to something important that has been said.

8. 4. Clarification: Attempting to put vague ideas or
unclear thoughts of the patient into words to enhance the
nurse's understanding or asking the patient to explain
what he means. For example, “I am not sure what you
mean. Could you tell me about that again?”
Therapeutic value: It helps to clarify feelings, ideas and
perceptions of the patient and provides an explicit
correlation between them and the patient's actions.

9. 5. Reflection: Directing back the patient's ideas,
feelings, questions and content. For example, “You
are feeling tense and anxious and it is related to a
conversation you had with your husband last
night.”
Therapeutic value: Validates the nurse's
understanding of what the patient is saying and
signifies empathy, interest and respect for the
patient.

10. 6. Humour: The discharge of energy through comic
enjoyment of the imperfect. For example, “That gives a
whole new meaning to the word ‘nervous’,” said with
shared kidding between the nurse and the patient.
Therapeutic value: Can promote insight by making
repressed material conscious, resolving paradoxes,
tempering aggression and revealing new options,
and is a socially acceptable form of sublimation.

11. 7. Informing: The skill of information giving. For example, “I think
you need to know more about your medications.”
Therapeutic value: Helpful in health teaching or patient education
about relevant aspects of patient's well-being and self-care.
8. Focusing: Questions or statements that help the patient expand on a
topic of importance. For example, “I think that we should talk more
about your relationship with your father.”
Therapeutic value: Allows the patient to discuss central issues and
keeps the communication process goal-directed.

12. 9. Sharing perceptions: Asking the patient to verify the nurses
understanding of what the patient is thinking or feeling. For
example, “You are smiling, but I sense that you are really very
angry with me.”
Therapeutic value: Conveys the nurse's understanding to the
patient and has the potential for clearing up confusing
communication.
10. Theme identification: This involves identification of underlying
issues or problems experienced by the patient that emerge
repeatedly during the course of the nurse-patient relationship.
For example, “I noticed that you said, you have been hurt or
rejected by the man. Do you think this is an underlying issue?”
Therapeutic value: It allows the nurse to promote the patient's
exploration and understanding of important problems.

13. 11. Silence: Lack of verbal communication for a
therapeutic reason. For example, sitting with a
patient and non-verbally communicating interest
and involvement.
Therapeutic value: Allows the patient time to think
and gain insight, slows the pace of the
interaction and encourages the patient to
initiate conversation while enjoying the nurse's
support, understanding and acceptance.

14. 12. Suggesting: Presentation of alternative
ideas for the patient's consideration relative to
problem solving. For example, “Have you
thought about responding to your boss in a
different way when he raises that issue with
you? You could ask him if a specific problem
has occurred.”
Therapeutic value: Increases the patient's
perceived notions or choices.

15. The nurse and patient interact with
each other in the health care
system with the goal of assisting
the patient to use personal
resources to meet his or her
unique needs.
THERAPEUTIC NURSE-
PATIENT RELATIONSHIP

16. TYPES OF RELATIONSHIPS
 Social relationships
 Intimate relationships
 Therapeutic relationships

17. Social Relationships
A social relationship can be defined as a
relationship that is primarily initiated with
the purpose of friendship, socialization,
enjoyment or accomplishing a task.
Mutual needs are met during social
interaction. For example, participants share
ideas, feelings and experiences.

18. Intimate Relationships
An intimate relationship occurs
between two individuals who have
an emotional commitment to each
other. Those in an intimate
relationship usually react naturally
with each other. Often, the
relationship is a partnership
wherein each member cares about
the other's need for growth and
satisfaction.
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Therapeutic Relationships
The therapeutic relationship between
nurse and the patient differs from both a
social and an intimate relationship in
that the nurse maximizes inner
communication skills, understanding of
human behaviour and personal
strengths, in order to enhance the
patient's growth. The focus of the
relationship is on the patient's ideas,
experiences and feelings.

19. Rapport
● Rapport is a relationship or communication, especially when useful and
harmonious. It is the crux of a therapeutic relationship between the nurse and
the patient.
Goals of therapeutic relationship
 » Facilitating communication of distressing thoughts and feelings
 » Assisting the patient with problem-solving
 » Helping patients examine self-defeating behaviours and test alternatives
 » Promoting self-care and independence
COMPONENTS OF THERAPEUTIC NURSE-PATIENT
RELATIONSHIP

20. Empathy
● Empathy is an ability to feel with
the patient while retaining the
ability to critically analyze the
situation. It is the ability to put
oneself in another person's
circumstances and feelings. The
nurse need not necessarily have to
experience it, but has to be able to
imagine the feelings associated with
the experience.
Sympathy
● Sympathy is often confused with
empathy. In sympathy, the nurse
actually feels what the patient feels
but in the process objectivity is lost,
and the nurse becomes focused on
relief of personal distress rather
than on assisting the patient to
resolve the problem

21. Warmth
● Warmth is the ability to help the
patient feel cared for and
comfortable.
● It shows acceptance of the patient
as a unique individual.
● It involves a non-possessive caring
for the patient as a person and a
willingness to share the patient's
joys and sorrows.
Genuineness
● Genuineness involves being one's
own self.
● This implies that the nurse is aware
of her thoughts, feelings, values and
their relevance in the immediate
interaction with a patient.
● It is also important that the nurse's
verbal and non-verbal
communication corresponds with
each other.

22. PHASES AND TASKS OF
THERAPEUTIC RELATIONSHIP
● Four phases of relationship process have been identified:
1. Pre-interaction phase
2. Introductory or orientation phase
3. Working phase
4. Termination phase

23. Pre-interaction Phase
● This phase begins when the nurse is assigned to initiate a therapeutic relationship
and includes all that the nurse thinks, feels or does immediately prior to the first
interaction with the patient. The nurse's initial task is one of self-exploration.
Nurse's tasks in the pre-interaction phase
 Explore own feelings, fantasies and fears
 Analyse own professional strengths and limitations
 Gather data about patient whenever possible
 Plan for first meeting with patient

24. Introductory or Orientation Phase
It is during the introductory phase that the nurse and the patient meet for the first
time. One of the nurse's primary concerns is to find out why the patient sought help.
Nurse's tasks in the orientation phase
 Establish rapport, trust and acceptance
 Establish communication; assist in the verbal expression of thoughts and feelings
 Gather data, including the patient's feelings, strengths and weaknesses
 Define patient's problems; set priorities for nursing intervention
 Mutually set goals

25. Working Phase
● Most of the therapeutic work is carried out during the working phase. The
nurse and the patient explore relevant stressors and promote the
development of insight in the patient.
Nurse's tasks in the working phase
 Gather further data; explore relevant stressors
 Promote patient's development of insight and use of constructive coping
mechanisms
 Facilitate behavioural change; encourage him to evaluate the results of his
behaviour

26. Termination Phase
This is the most difficult, but most important phase of the therapeutic nurse-patient
relationship. The goal of this phase is to bring a therapeutic end to the relationship.
Nurse's Tasks in the Termination Phase
 Establish reality of separation
 Mutually explore feelings of rejection, loss, sadness, anger and related behaviour
 Review progress of therapy and attainment of goals
 Formulate plans for meeting future therapy needs

27. THERAPEUTIC IMPASSES
 Therapeutic impasses are blocks in the progress of the nurse-patient
relationship.
 Impasses provoke intense feelings in both the nurse and the patient, which
may range from anxiety and apprehension to frustration, love or intense
anger.

28. 1. Resistance: Resistance is the patient's attempt to remain unaware of anxiety
producing aspects within the self.
2. Transference: Transference is an unconscious response in which the patient
experiences feelings and attitudes toward the nurse that were originally
associated with significant figures in the patient's early life.
3. Counter transference: refers to a specific emotional response by the nurse
towards the patient that is inappropriate to the content and context of the
therapeutic relationship or inappropriate in its emotional intensity.

29. Interventions to overcome Therapeutic Impasses
 Nurse must have knowledge of the impasses and recognize behaviours that
indicate their existence.
 Nurse must reflect on feelings, explore reasons behind such behaviour.
 Co-workers are more likely than others to recognize the phenomenon
initially and give feedback to the nurse about it.
 Nurses must examine their strengths, weaknesses, prejudices, and values
before they can interact more appropriately with patients.

30.  The transference reactions of patients must also be examined, gently but
directly.
 Nurses must be open and clear about their genuine reactions when patients
misperceive behaviour.
 Nurses should also state actions that they can and cannot take to meet patient's
needs.
 Limit setting is useful when patients act inappropriately towards the nurse.
 Maintain open communication with her supervisor, who can then guide her in
making adequate progress in handling such resistance reactions.

31. PROCESS RECORDING
Definition:
● Process recording is a written account or verbatim recording
of all that transpired, during and immediately following the
nurse-patient interaction.
● In other words, it is the recording of the conversation
during the interaction or the interview between the nurse
and the patient in the psychiatric setup with the nurse's
inference.

32. PURPOSE AND USES
 assists the nurse or student to plan, structure and evaluate the interaction on a
conscious rather than an intuitive level
 assists her to gain competency in interpreting and synthesizing raw data under
supervision
 helps to consciously apply theory to practice
 helps her to develop an increased awareness of her habitual, verbal and non-verbal
communication pattern and the effect of those patterns on others
 helps the nurse to learn to identify thoughts and feelings in relation to self and
others

33. PREREQUISITES FOR PROCESS RECORDING
 Physical setting
 Getting consent of the patient for the possibility of cassette recording
 Confidentiality

34. Suggested Outlines for Process Recording
Introductory Material
● This should include a short description of the patient, his name, age,
educational level, health problems and length of stay in the hospital. The
date, time, place of interaction and a short description of the milieu of
the ward immediately prior to the interaction will be helpful in
understanding the thoughts and feelings of the patient

35. Objectives
● Objectives should be formulated prior to meeting. It should be specific,
readily measurable change in the patient behaviour and function as a guide
for interaction.
Context of the Interaction
● Describe where the interaction took place, activities involving the patient
that occurred before the interaction, the patient's physical appearance and
how the interaction began, i.e. whether the patient approached you or you
initiated the interaction.

36. Record of interaction between nurse and the patient
● This should include truthful recording of what the nurse said and did and what
the patient said and did, including any non-verbal behaviour of the patient, such
as changing the position, looking at various things, eye contact, biting the nails,
pacing, tone of voice, rate of speech and changes in facial expressions.
Analysis of the Interaction
● An analysis of the interaction should include the interpretation of the verbal and
non-verbal behaviour and patient's thoughts and feelings as evident from the
process.