Therapeutic Relationships

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Transcript of Therapeutic Relationships

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Therapeutic Relationships

This is a nurse-client interaction that is directed toward enhancing the client’s well-being (Isaacs)

A relationship established between a health care professional and a client for the purpose of assisting the client to solve his problems

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Therapeutic Relationships

The nurse- patient relationship is characterized by a helping process

The nurse and client work together for his benefit

The nurse uses herself therapeutically and this is achieved by self-awareness

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Therapeutic Relationships

The nurse- patient relationshipRespect the client and vale as individual

Maintain appropriate limits

Convey empathy not sympathy

Maintain honest and therapeutic communication

Encourage expression of feelings

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Therapeutic Relationships

ELEMENTS OF THE THERAPEUTIC RELATIONSHIP

Boundaries

Confidentiality

Therapeutic Behaviors

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Therapeutic Relationships

ELEMENTS OF THE THERAPEUTIC RELATIONSHIP

Therapeutic Behaviors

1. Genuineness = sincerity and honesty

2. Concreteness= ability to identify client’s feelings

3. Respect= shown through consideration of patient as unique being

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Therapeutic Relationships

PHASES OF THE THERAPEUTIC RELATIONSHIP

1. Pre-Interaction- Pre-orientation

2. Orientation- Interaction

3. Working

4. Termination

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Therapeutic RelationshipsPhase Nursing Activities

Pre-interaction Nurse obtains data from secondary sources

Interaction- Orientation Nurse establishes trust, assess client, establishes mutual agreement

Working Nurse assists the client to meet goals and resolve problems

Termination Nurse and client express feelings about termination, observes regressive behaviors

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Orientation

Establishment of goals, rules, boundaries etc..

Rapport is built

Identify expectations

Trust is gained

Assessment is done

Goals are defined

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Working/Exploration/Identification

Problems are identified

Solutions are explored, applied and evaluated

Nurse assists the client to develop coping skills, positive self concept and independence

Promote insight and the use of adaptive coping mechanisms

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Termination/Resolution

Nurse terminates the relationship based on mutually agreed goals when these are already achieved

Client may become anxious and reacts

Nurses must help patient resolve the anxiety and ends the relationship professionally

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Therapeutic Communication

Therapeutic communication Dynamic process of exchanging information

Composed of verbal and non-verbal techniques that the nurse uses to focus on the client’s needs

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Therapeutic Relationships

Therapeutic communication : ELEMENTS

1. Sender- the source of message

2. Message- the information transmitted

3. Receiver- recipient of message

4. Feedback- receiver’s response to the message

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NON VERBAL COMMUNICATION

1. Proxemics- the physical space between the sender and receiver

2. Kinetics- the body movements such as gestures, facial expressions and mannerisms

3. Touch- intimate physical contact

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Therapeutic Relationships

NON VERBAL COMMUNICATION

4. Silence

5. Paralanguage- voice quality (tone, inflection) or how a message is delivered

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Therapeutic Relationships

VERBAL COMMUNICATION

Use of therapeutic communication techniques

Effective communication should be therapeutic, appropriate, simple, adaptive, concise and credible

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Therapeutic Communication

Open ended questions

Focus on FEEELINGS

State behaviors observed

Reflect, restate, rephrase

Neutral responses

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Therapeutic Communication

Offering self I am here to help you

Active listening Eye to eye contact

Exploring Tell me more about…,.

Broad Openings What do you want to talk about

Making observation You seemed depressed

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Therapeutic Communication

Summarizing A few minutes ago, we were talking about.. Then…

Voicing doubt I find it hard to believe

Encouraging description of perception

What are these voices telling you

Presenting reality The sound is produced by the carNo one is in the room

Seeking clarification I am not sure of what you mean

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Therapeutic Communication

Verbalizing the implied Are you saying you want to kill yourself?

Reflecting Do you think you should?

Restating P: I cant sleep at nightN: You cant sleep at night ?

General leads GO on… then…. Hmm….you were saying….

Focusing Lets talk more about what you think of your problems

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Non-therapeutic communication

These are blocks to communication Usually, these are the common pitfalls of communicating non-therapeutically:

Giving adviseTalking about selfTelling client is wrongFalse reassurance

Asking ‘Why’

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Non-therapeutic communication

Making judgment You are wrong

False reassurance It’s going to be alright

Invalidation I cannot talk now, I’m busy

Focusing on self I am the best nurse to care for you

Changing the subject P: I’m afraid of the surgeryN: How many children do you have

Giving advice If I were you, I will

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Non-therapeutic communication

Agreeing Yes I think you are right

Disapproving I don’t want you to do that

Defending This hospital is the best

Requesting explanation “why”

Cliché There is the sun after the rain

Belittling feelings P: I’m so depressed todayN: everyone feels sad at times

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Proxemics

DistancesINTIMATE= Touching to 1 ½ ft

PERSONAL= 1 ½ to 4 ft

SOCIAL= 4 to 12 ft

PUBLIC= 12 to 15 ft

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Psychiatric Nursing Process

Applies to all clients

Utilizes unique process for psychological assessment

Similar to other types of nursing process approaches

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Psychiatric Nursing Process

Nursing ASSESSMENT

Nursing History

Physical Examination including the Neurological examination

Laboratory Examination

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Psychiatric Nursing Process

Nursing ASSESSMENTRefers to the scientific process of identifying a patient’s psychosocial problems, strengths an concerns

Interview is done to acquires broad information about a client

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Psychiatric Nursing Process

MENTAL STATUS ASSESSMENTLevel of consciousnessGeneral appearanceBehaviorSpeechMood and affectJudgment Memory insight

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Psychiatric Nursing Process

MENTAL STATUS ASSESSMENTObservation of mood and affect

Assessment of thought, sensorium and intelligence

Speech and content

Assess developmental status and family-cultural-spiritual background

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Psychiatric Nursing Process

MENTAL STATUS ASSESSMENTEmotional status

Cognitive assessment

Socio-cultural assessment

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Psychiatric Nursing Process

Physical ExaminationObservation for key signs

Diagnostic TestsCT, MRI, PET, EEG

Laboratory tests= CBC, Electrolytes, Drug levels

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Psychiatric Nursing Process

Other diagnostic testsBeck depression inventory

Minnesota multiphasic personality inventory

Draw-a person test

Sentence completion test

Thematic aperception test

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Psychiatric Nursing Process

Nursing DiagnosesAnxiety

Ineffective coping- individual, family

Fatigue

Fear

Sleep pattern disturbance

Altered thought process

Etcetera

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Psychiatric Nursing Process

Nursing Objectives

Short term goals are set for immediate problems, feasible and within client's capabilities

Long term goals are related to discharge planning and prevention of recurrence of symptoms

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Psychiatric Nursing Process

Nursing Objectives: The client will:Participate in treatment program

Becomes oriented to three spheres and exhibit reality-based behaviors

Recognize reasons for behavior

Maintain self-care activities

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Psychiatric Nursing Process

Nursing InterventionsUse of therapeutic communication

Therapeutic Groups

Psychotherapy: Family, Milieu, Behavioral modification, Crisis intervention, Psychopharmacology

Electroconvulsive therapy

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Psychiatric Nursing Process

Nursing EvaluationDetermine if goals are met by collecting data and comparing them to baseline

Clients’ behavior should demonstrate optimal orientation to reality and interaction with others appropriately

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Treatment Modalities

1. Therapeutic Environment- Milieu

2. Therapeutic Groups

3. Crisis intervention

4. Family therapy

5. Behavioral modification

6. Cognitive therapy

7. Psychotherapy

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Therapeutic environment

Research has documented that the environment in which the mentally ill person is treated is a major factor in enhancing or impeding the therapeutic effects of other treatment modalities

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Therapeutic environment

Characteristics of a Therapeutic environment

1. The clients’ physical needs are met

2. The client is respected

3. Decision making authority is clearly defined

4. Client is protected from injury (self and others)

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Therapeutic environment

Characteristics of a Therapeutic environment

5. Clients are allowed freedom of choice commensurate to his ability to decide

6. Nursing Personnel remain constant and assignments are stable

7. Emphasis is placed on social interaction between clients and staff

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Therapeutic Modalities

Milieu therapyTotal environment has an effect on the person’s behavior- physical, emotional, relationships

Purposes of therapy1. Improve client’s behavior2. Involve client in decision making3. Increase autonomy and communication4. Set structure of unit and behavioral

limits

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Therapeutic Modalities

Milieu therapyThe surrounding is made positive to effect behavioral changes in the prescribed directionsGoals of milieu therapy: to help patient develop sense of self-esteem, personal growth, improve ability to relate to others and return to the community better prepared

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Therapeutic modalities

Milieu therapyThe nurse involves the client in decision making

The nurse promotes the involvement of staff in care

Social skills are developed and sense of community is fostered

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Therapeutic Groups

A treatment approach in which the entire milieu is used as treatment

This includes the physical environment and the others clients

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Therapeutic Groups

Group Therapy

Involves meaningful interaction between members of a group as they relate their personal experiences to each other

The main objective is for each group member to examine his own behavior and relationship. The group can influence to change his behavior and relationships

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Therapeutic Groups

Groups of clients meet with one or more therapists to work together to solve client problems

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Therapeutic Groups

PurposesTo increase self-awareness

To improve interpersonal relationships

To make changes in behavior

To enhancing group teaching and learning

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Therapeutic Groups

Structure of the Therapeutic GroupOne leader chosen by the group

Members

Size is usually 10

Physical arrangement

Time and place of meeting

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Therapeutic Groups

Phases of group development1. Beginning phase

Info given, anxiety heightened

2. Middle phaseConfrontation, cohesiveness, trust and self-reliance

3. Termination phaseGoals of the group are achievedIndividuals leave the group when work is done

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Therapeutic modalities

CRISIS

A disturbance caused by a precipitating event such as perceived loss, a threat of loss or a challenge that is perceived as a threat to self.

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Therapeutic modalities

CRISIS

Can be classified as to maturational crisis, situational crisis or adventitious crisis

Maturational= role changes

Situational= loss of job, death

Adventitious= fires, earthquakes and floods

In a crisis, the person’s usual methods of coping are INEFFECTIVE

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Therapeutic Modalities

Characteristics of Crisis: It is sudden

It is short term may last for 4-6 weeks

Individualized

The person becomes dependent and overwhelmed

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Therapeutic Modalities

Factors that can produce crisis

1. Hazardous EVENTS

2. Threat to the individual’s equilibrium

3. Inadequate coping skills

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Therapeutic Modalities

There are four PHASES of Crisis (DIDA)Denial

Increased Tension- when the person knows the existence of crisis and still continues ADL

Disorganization= pre-occupied and unable to perform function

Attempts to Reorganize= by mobilizing previous coping mechanisms

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Therapeutic Modalities

CRISIS INTERVENTIONA technique of helping the person go through the crisis

To mobilize his resources

To help him deal with the here and now

A five step problem solving technique designed to promote a more adaptive outcome including improved abilities to cope with future crises

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Therapeutic modalitiesGoal of Crisis intervention: help the patient go back to

his state of optimum level of functioningIDENTIFY the problem- A solution is not possible unless the problem be identified.LIST alternatives- all possible solutions to the problem need to be listed. CHOOSE from among the alternatives- each options is carefully considered, and the alternative chosen is usually highly individualized, based on priorities and values of the personIMPLEMENT the plan- the alternative is put into action. The nurse may need to support and encourage patient to take actionEVALUATE the outcome- the effectiveness of the plan is evaluated.

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Therapeutic modalities

Family therapy

An approach in which the therapist focuses on the behavior of the entire family as a system instead of focusing on the pathology of one member

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Therapeutic modalities

Family therapyFocuses on the client as a ‘family”

Involvement of family members

Purposes of family therapy

1. Improve relationships among family members

2. Promote family functions

3. Resolve family problems

4. Help family find ways to cope with problems

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Therapeutic modalities

Family therapy

Problems are identified by each family members and each discusses his/her involvement in the problem

Members discuss how problems affect them and they explore how to solve them

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Therapeutic Modalities

Family therapy

The nurse functions to assess the family interactions, makes observations and encourages expression of feelings

Helping the family resolve the problem is the goal

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Therapeutic Modalities

Behavioral ModificationTherapy to change the unacceptable behavior to acceptable

The nurse determines the unacceptable behaviors and she identifies adaptive behaviors

Punishment is given to unacceptable behavior

Reward is given to acceptable behavior

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Therapeutic Modalities

Behavioral Modification

Other Behavioral therapies

1. Self-control therapy

2. Aversion therapy

3. Desensitization

4. Modeling

5. Operant conditioning

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Therapeutic Modalities

Cognitive therapy

An active, directive, time-limited approach

Therapeutic techniques are used to identify reality testing

The nurse helps the patient think and act more realistically and adaptively about his problems

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Therapeutic Modalities

Play therapyTherapy with children in which they are helped to express themselves or their behavior through play

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Therapeutic Modality: Psychotherapy

A method of treating mental illness in which verbal and expressive techniques are used to help the person resolve inner conflict and modify behaviors

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Therapeutic Modality: Psychotherapy

1. Psychoanalysis

2. Client centered therapy

3. Rational emotive therapy

4. Gestalt therapy

5. Reality therapy

6. Transactional analysis

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Therapeutic Modality: Psychotherapy

1. PsychoanalysisTHE therapist obtains information about the past and present experiences that have repressed in the person’s subconscious mind

By learning the source of the problem, the problems can be brought to the conscious where the therapist helps the individual dealt with them

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Therapeutic Modality: Psychotherapy

2. Client Centered therapyThe therapist work with one client

Accepting, non-judgmental environment aimed at reducing the anxiety and reducing negative defenses

The patient is encouraged to express his feelings and increase self-awareness

When the person is aware of what he feels, he can work on improving behavior

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Therapeutic Modality: Psychotherapy

3. Rational-Emotive therapyThis is based in the assumption that a person’s behavior is due to his own thinking

Problems arise as the person believes about eh events

The therapy aims to change the person’s belief system

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Therapeutic Modality: Psychotherapy

4. Gestalt TherapyThe mind receives experiences as a whole

When the experience is complete, the problem will arise

The goal of the therapy is to help patients complete the experience through awareness

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Therapeutic Modality: Psychotherapy

5. Transactional AnalysisA group therapy method

Helps people “analyze” their transaction or interaction with others and guides them to the conclusion: I’m OK you are OK

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Responses to Illness

Stress

Anxiety

Crisis

Anger and hostility