Therapeutic  communication  is defined as the face-to-face process of interacting that focuses   on   advancing   the   physical   and emotional well-being of a patient.   This kind of communication has three general purposes:   collecting information to determine illness, assessing and modifying behavior, and providing health education.  By using therapeutic communication, we attempt to learn as much as we can about the   patient   in   relation   to   his   illness. To accomplish  this  learning,  both  the sender  and  the receiver  must  be consciously  aware  of  the  con- fidentiality of the information disclosed and received during the communication process.  You must always have  a  therapeutic  reason  for invading  a  patient’s privacy. When  used  to collect  information,  therapeutic communication requires a great deal of sensitivity as well  as  expertise  in  using interviewing  skills.     To ensure  the identification  and  clarification  of  the patient’s thoughts and feelings, you, as the interviewer, must observe his behavior. Listen to the patient and watch how he listens to you. Observe how he gives and receives both verbal and nonverbal responses.  Finally, interpret and record the data you have observed. As mentioned earlier, listening is one of the most difficult skills to master.  It requires you to maintain an open mind, eliminate both internal and external noise and distractions, and channel attention to all verbal and nonverbal messages.  Listening involves the ability to recognize pitch and tone of voice, evaluate vocabulary and  choice  of  words,  and recognize  hesitancy  or intensity of speech as part of the total communication attempt. The patient crying aloud for help after a fall is communicating a need for assistance. This cry for help sounds very different from the call for assistance you might  make  when requesting  help  in  transcribing  a physician’s order. The  ability  to  recognize and  interpret  nonverbal responses  depends upon  consistent  development  of observation skills.  As you continue to mature in your role and responsibilities as a member of the healthcare team, both your clinical knowledge and understanding of human behavior will also grow. Your growth in both knowledge and understanding will contribute to your ability  to  recognize  and  interpret many  kinds  of nonverbal   communication. Your   sensitivity   in listening with your eyes will become as refined as—if not better than—listening with your ears. The effectiveness of an interview is influenced by both  the amount  of  information  and  the  degree  of motivation  possessed  by  the  patient (interviewee). Factors that enhance the quality of an interview consist of  the participant’s  knowledge  of  the  subject under consideration;   his   patience, temperament,   and listening skills; and your attention to both verbal and nonverbal cues. Courtesy,   understanding,   and nonjudgmental attitudes must be mutual

goals of both the interviewee and the interviewer. Finally, to function effectively in the therapeutic communication process, you must be an informed and skilled practitioner. Your development of the required knowledge and   skills   is   dependent   upon   your commitment   to   seeking   out   and participating   in continuing education learning experiences across the entire spectrum of healthcare services.

Therapeutic Technique

1. Offering Self

making self-available and showing interest and concern.

“I will walk with you”

2. Active listening

paying close attention to what the patient is saying by observing both verbal and non-verbal cues.

Maintaining eye contact and making verbal remarks to clarify and encourage further communication.

3. Exploring

“Tell me more about your son”

4. Giving broad openings

What do you want to talk about today?

5. Silence

Planned absence of verbal remarks to allow patient and nurse to think over what is being discussed and to say more.

6. Stating the observed

verbalizing what is observed in the patient to, for validation and to encourage discussion

“You sound angry”

7. Encouraging comparisons

· asking to describe similarities and differences among feelings, behaviors, and events.

· “Can you tell me what makes you more comfortable, working by yourself or working as a member of a team?”

8. Identifying themes

asking to identify recurring thoughts, feelings, and behaviors.

“When do you always feel the need to check the locks and doors?”

9. Summarizing

reviewing the main points of discussions and making appropriate conclusions.

“During this meeting, we discussed about what you will do when you feel the urge to hurt your self again and this include…”

10. Placing the event in time or sequence

asking for relationship among events. “When do you begin to experience

this ticks? Before or after you entered grade school?”

11. Voicing doubt

voicing uncertainty about the reality of patient’s statements, perceptions and conclusions.

“I find it hard to believe…”

12. Encouraging descriptions of perceptions

asking the patients to describe feelings, perceptions and views of their situations.

“What are these voices telling you to do?”

13. Presenting reality or confronting

stating what is real and what is not without arguing with the patient.

“I know you hear these voices but I do not hear them”.

“I am Lhynnelli, your nurse, and this is a hospital and not a beach resort.

14. Seeking clarification

asking patient to restate, elaborate, or give examples of ideas or feelings to seek clarification of what is unclear.

“I am not familiar with your work, can you describe it further for me”.

“I don’t think I understand what you are saying”.

15. Verbalizing the implied

rephrasing patient’s words to highlight an underlying message to clarify statements.

Patient: I wont be bothering you anymore soon.

Nurse: Are you thinking of killing yourself?

16. Reflecting

throwing back the patient’s statement in a form of question helps the patient identify feelings.

Patient: I think I should leave now. Nurse: Do you think you should leave

now?

17. Restating

repeating the exact words of patients to remind them of what they said and to let them know they are heard.

Patient: I can’t sleep. I stay awake all night.

Nurse: You can’t sleep at night?

18. General leads

using neutral expressions to encourage patients to continue talking.

“Go on…” “You were saying…”

19. Asking question

using open-ended questions to achieve relevance and depth in discussion.

“How did you feel when the doctor told you that you are ready for discharge soon?”

20. Empathy

recognizing and acknowledging patient’s feelings.

“It’s hard to begin to live alone when you have been married for more than thirty years”.

21. Focusing

pursuing a topic until its meaning or importance is clear.

“Let us talk more about your best friend in college”

“You were saying…”

22. Interpreting

providing a view of the meaning or importance of something.

Patient: I always take this towel wherever I go.

Nurse: That towel must always be with you.

23. Encouraging evaluation

asking for patients views of the meaning or importance of something.

“What do you think led the court to commit you here?”

“Can you tell me the reasons you don’t want to be discharged?

24. Suggesting collaboration

offering to help patients solve problems.

“Perhaps you can discuss this with your children so they will know how you feel and what you want”.

25. Encouraging goal setting

asking patient to decide on the type of change needed.

“What do you think about the things you have to change in your self?”

26. Encouraging formulation of a plan of action

probing for step by step actions that will be needed.

“If you decide to leave home when your husband beat you again what will you do next?”

27. Encouraging decisions

asking patients to make a choice among options.

“Given all these choices, what would you prefer to do.

28. Encouraging consideration of options

asking patients to consider the pros and cons of possible options.

“Have you thought of the possible effects of your decision to you and your family?”

29. Giving information

providing information that will help patients make better choices.

“Nobody deserves to be beaten and there are people who can help and places to go when you do not feel safe at home anymore”.

30. Limit setting

discouraging nonproductive feelings and behaviors, and encouraging productive ones.

“Please stop now. If you don’t, I will ask you to leave the group and go to your room.

31. Supportive confrontation

acknowledging the difficulty in changing, but pushing for action.

“I understand. You feel rejected when your children sent you here but if you look at this way…”

32. Role playing

practicing behaviors for specific situations, both the nurse and patient play particular role.

“I’ll play your mother, tell me exactly what would you say when we meet on Sunday”.

33. Rehearsing

asking the patient for a verbal description of what will be said or done in a particular situation.

“Supposing you meet these people again, how would you respond to them when they ask you to join them for a drink?”.

34. Feedback

pointing out specific behaviors and giving impressions of reactions.

“I see you combed your hair today”.

35. Encouraging evaluation

asking patients to evaluate their actions and their outcomes.

“What did you feel after participating in the group therapy?”.

36. Reinforcement

giving feedback on positive behaviors. “Everyone was able to give their

options when we talked one by one and each of waited patiently for our turn to speak”.

Avoid pitfalls:

1. Giving advise2. Talking about your self3. Telling client is wrong4. Entering into hallucinations and

delusions of client5. False reassurance6. Cliché7. Giving approval8. Asking WHY?9. Changing subject10. Defending doctors and other health

team members.

Non-therapeutic Technique

1. Overloading

talking rapidly, changing subjects too often, and asking for more information than can be absorbed at one time.

“What’s your name? I see you like sports. Where do you live?”

2. Value Judgments

giving one’s own opinion, evaluating, moralizing or implying one’s values by

using words such as “nice”, “bad”, “right”, “wrong”, “should” and “ought”.

“You shouldn’t do that, its wrong”.

3. Incongruence

sending verbal and non-verbal messages that contradict one another.

The nurse tells the patient “I’d like to spend time with you” and then walks away.

4. Underloading

remaining silent and unresponsive, not picking up cues, and failing to give feedback.

The patient ask the nurse, simply walks away.

5. False reassurance/ agreement

Using cliché to reassure client. “It’s going to be alright”.

6. Invalidation

Ignoring or denying another’s presence, thought’s or feelings.

Client: How are you? Nurse responds: I can’t talk now. I’m

too busy.

7. Focusing on self

responding in a way that focuses attention to the nurse instead of the client.

“This sunshine is good for my roses. I have beautiful rose garden”.

8. Changing the subject

introducing new topic inappropriately, a pattern that may

indicate anxiety. The client is crying, when the nurse

asks “How many children do you have?”

9. Giving advice

telling the client what to do, giving opinions or making decisions for the client, implies client cannot handle his or her own life decisions and that the nurse is accepting responsibility.

“If I were you… Or it would be better if you do it this way…”

10. Internal validation

making an assumption about the meaning of someone else’s behavior

that is not validated by the other person (jumping into conclusion).

The nurse sees a suicidal clients smiling and tells another nurse the patient is in good mood.

Other ineffective behaviors and responses:

1. Defending – Your doctor is very good.2. Requesting an explanation – Why did

you do that?3. Reflecting – You are not suppose to

talk like that!4. Literal responses – If you feel empty

then you should eat more.5. Looking too busy.6. Appearing uncomfortable in silence.7. Being opinionated.8. Avoiding sensitive topics9. Arguing and telling the client is wrong10. Having a closed posture-crossing

arms on chest11. Making false promises – I’ll make sure

to call you when you get home.12. Ignoring the patient – I can’t talk to

you right now13. Making sarcastic remarks14. Laughing nervously15. Showing disapproval – You should not

do those things.