Mental Health Mental Health Nursing IINursing II

NURS 2310NURS 2310

Unit 3Unit 3

Therapeutic Therapeutic CommunicationCommunication

Objective 1Objective 1

Defining therapeutic milieu

The therapeutic milieu is a scientific structuring of the environment in order to effect behavioral changes and to improve the psychological health and functioning of the individual.

Within this structured environment, the client is expected to learn adaptive coping, interaction, and relationship skills that can be generalized to other aspects of his or her life.

Objective 2Objective 2

Analyzing the nurse’s role in maintaining the therapeutic

milieu in an inpatient psychiatric/mental health setting

The nurse maintains the therapeutic milieu in

the inpatient setting by: Encouraging health promotion Providing therapeutic interaction Allowing clients to participate in governing the

unit Expecting the client to take responsibility for his

or her own behavior Utilizing peer pressure or peer support as a tool

to bring about acceptable group norms Dealing with inappropriate behaviors as they

occur Avoiding restrictions and punishments

Objective 3Objective 3

Reviewing the componentsof nurse-client relationship development and therapeutic communication

Therapeutic use of self: Ability to use one’s personality consciously

and in full awareness in an attempt to establish relatedness and to structure nursing interventions

Therapeutic communication: Consists of verbal and nonverbal techniques

that focus on the client’s needs and advance the promotion of healing and change

Encourages the exploration of feelings and fosters understanding of behavioral motivation

Promotes trust, discourages defensiveness, and is nonjudgmental

Active listening: Being attentive to what the client is saying

both verbally and nonverbally Facilitative skills include –

– facing the client squarely– observing an open posture– leaning toward the client– establishing eye contact– maintaining a relaxed demeanor

Feedback: Communication method that helps the

client consider a modification of behavior

Therapeutic relationship: Interaction between two people in which

input from both participants contributes to a climate of healing, growth promotion, and/or illness prevention

Goal-oriented– goal of the relationship determined jointly

by nurse and client– goal is most often directed at learning and

growth promotion in an effort to bring about some type of change in the client’s life

– may be based on a problem-solving model

Conditions essential to the development of a

therapeutic relationship include: Rapport

– special feelings on the part of both the client and nurse based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude

– establishing rapport may be accomplished by discussing non-health-related topics

Genuineness– the ability to be open, honest, and “real” in

interactions

Developing therapeutic relationships Developing therapeutic relationships (cont’d) (cont’d)

Trust– confidence in another person’s

presence, reliability, integrity, veracity, and sincere desire to provide assistance when requested providing a blanket when the client is

cold providing food when the client is hungry keeping promises being consistent ensuring confidentiality

Developing therapeutic relationships Developing therapeutic relationships (cont’d) (cont’d)

Respect– unconditional positive regard

calling the client by name spending time with the client allowing sufficient time to answer the client’s

questions or concerns always being open and honest striving to understand the motivation behind

the client’s behavior Empathy

– process in which one is able to see beyond outward behavior and accurately sense another’s inner experience

Objective 4Objective 4

Exploring the phases of the therapeutic relationship

Phases of the therapeutic relationship:

Preinteraction phase– Preparation for the first encounter with

the client Orientation (Introductory) phase

– The nurse and client become acquainted Working phase

– Accomplishment of the therapeutic work of the relationship

Termination phase– Bringing a therapeutic conclusion to the

relationship

Boundary issues within a professional relationship may include:

Transference– When the client unconsciously attributes to

the nurse feelings and behavioral dispositions formed toward a person from his or her past

Countertransference– The nurse’s behavioral and emotional

response to the client which may be related to unresolved feelings toward significant others from the nurse’s past, or may be generated in response to transference feelings on the part of the client

Boundary issues (cont’d)

Self-disclosure– May be appropriate when the

information to be shared is judged to be therapeutically beneficial to the client

– Never used for the purpose of meeting the nurse’s own needs

Gift-giving– Professional judgment– Institutional policy– Never financial

suggest a donation elsewhere

Boundary issues (cont’d)

Touch– Caring touch with no associated physical

need can be therapeutically appropriate– Beware of situations in which touch may

be misinterpreted, culturally unacceptable, or dangerous paranoid patient psychotic client

Warning signs that may indicate a potential breech in professional boundaries in the nurse-client relationship include:

Favoring one client’s care over another’s Swapping assignments with another nurse

to care for a particular client Giving special attention or treatment to one

client over others Spending free time with one particular

client Sharing personal information or work

concerns with a client Continuing contact/communication with a

client after discharge

Objective 5Objective 5

Correlating appropriate modes of therapeutic communication

with specific psychiatric behaviors

Modes of therapeutic communication: Using silence

– gives the client the opportunity to collect and organize thoughts

Accepting– conveys an attitude of reception and regard

Giving recognition– acknowledging

Offering general leads– offers the client encouragement to continue

Making observations– verbalizing what is observed or perceived

Restating– repeating the main idea of what the client has

said Encouraging description of perceptions

– asking the client to verbalize what is being perceived

Therapeutic communication (cont’d)

Reflecting– referring questions and feelings back to the

client so that they may be recognized and accepted

Focusing– taking notice of a single idea or a single word– works well with the client who is moving

rapidly from one thought to another– not to be used with a client who is anxious

Presenting reality– when a client has a misperception of the

environment, the nurse defines reality Voicing doubt

– expressing uncertainty as to the reality of percpetions

Objective 6Objective 6

Exploring theconcept oftherapeuticcommunity

The therapeutic community holds that everything that happens to the client or within the client’s environment is considered to be part of the treatment program.

Community factors, such as social interactions, the physical structure of the treatment setting, and schedule of activities may generate negative responses which are used as examples to help the client learn how to manage stress more adaptively in real-life situations.

Conditions that promote the therapeuticcommunity include: The fulfillment of basic physiological

needs The conduciveness of the physical

facilities to achievement of the goals of therapy

The existence of a democratic form of self-governance

The assignment of responsibilities based on each client’s capabilities

The scheduling of a structured program of social and work-related activities

The inclusion of community and family with regards to discharge planning

Objective 7Objective 7

Examining the use of groups as a therapeutic tool

Group: Collection of individuals whose association

is founded on shared commonalities of interest, values, norms, or purpose

Membership is generally– by chance (born into the group)– by choice (voluntary affiliation)– by circumstance (the result of life-cycle events

over which an individual may or may not have control)

Group Therapy = a form of psychosocial treatment in which a number of clients meet together with a therapist for purposes of sharing, gaining personal insight, and improving interpersonal coping strategies.

Use of a group as a therapeutic tool:

Instillation of hope Universality Imparting of information Altruism Corrective recapitulation of the primary

family group Development of socializing techniques Imitative behavior Interpersonal learning Group cohesiveness Catharsis Existential factors

Objective 8Objective 8

Identifying group types, roles, functions, development and

stages

Functions of a group:

Socialization Support Task completion Camaraderie Informational Normative

– enforcement of established norms Empowerment Governance

– rules committees

Types of groups: Task Groups

– accomplishing a specific outcome or task– focus on problem-solving and decision-making

Teaching Groups– exist to convey knowledge and information to a

number of individuals Supportive/Therapeutic Groups

– concerned with preventing future upsets by teaching effective ways of dealing with emotional distress

Self-Help Groups– allow clients to talk about their fears and relieve

feelings of isolation while receiving comfort and advise from others undergoing similar experiences

Member roles within groups:Task Roles Coordinator Evaluator Elaborator Energizer Initiator Orienter

Individual Roles Aggressor Blocker Dominator Mute/Silent member

Maintenance Roles

Compromiser Encourager Follower Gatekeeper Harmonizer

Monopolizer Recognition

Seeker Seducer

Phases of group development:Phase I

Initial or Orientation PhaseGroup activities – leader and members work

together to establish the rules that will govern the group

Leader expectations – leader expected to orient members to specific group processes, encourage members to participate without disclosing too much too soon, promote an environment of trust, and ensure group rules don’t interfere with goal fulfillment

Member behaviors – members have not yet established trust; fear of not being accepted by the group

Phases of group development (cont’d)Phase II

Middle or Working PhaseGroup activities – productive work toward

completion of the task is undertaken; problem-solving and decision-making occur

Leader expectations – role diminishes and becomes one of facilitator

Member behaviors – trust established among members; members turn to each other more often, and less so to the leader; members accept criticism from others and use it constructively to create change

Phases of group development (cont’d)Phase III

Final or Termination PhaseGroup activities – termination process

discussed in depth for several meetings before the final session

Leader expectations – the leader encourages group members to reminisce about what has occurred, review the goals, and discuss actual outcomes

Member behaviors – grief response may be evident; may lead to discussion of previous losses; successful termination of the group may help members develop the skills needed when losses occur in other dimensions of their lives.