Poor communication

THERAPEUTIC
RELATIONSHIPS &
COMMUNICATION

DIFFERENT TYPES OF
THERAPY

By: Brittani Bromley

NURSE-PATIENT
RELATIONSHIP

Therapeutic relationships are goal oriented.

Ideally, the nurse and patient decide together

what the goal of the relationship will be. Most

often, the goal is promotion of learning and

growth to bring about change in the patient’s

life. In general, the goal of a therapeutic

relationship may be based on a problem-

solving model.

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ESTABLISHING THERAPEUTIC RELATIONSHIPS

RAPPORT

TRUST

RESPECT

EMPATHY &
GENUINENESS

Trying to connect on topics of interest;

treating patient as a person and not their

diagnosis

Nursing interventions that convey a sense of warmth and
caring to the patient i.e., providing blanket when patient is
cold; being honest; being consistent in adhering to unit
guidelines; listening to preferences, requests, opinions

Spending time with the patient, calling them by name;

giving patients sufficient time; promoting privacy;

listening; always being open and honest; striving to

understand the patient

Stepping into the patient’s shoes; understanding

their perspective; remain emotionally separate

from another person in doing so; being open,

honest, and real with the patient

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PHASES OF NURSE RELATIONSHIP

Pre-interaction Phase

Preparation for first encounter

Obtaining information on client

Reflecting on own perceptions and feelings

Orientation/Introductory Phase

Nurse and client become acquainted.

Rapport is established.

Layout expectations and responsibilities

Formulate nursing diagnoses; interventions and goals

Set action up action plan

Working Phase

Therapeutic work accomplished during this phase Provide
education about disorder

Promote patient’s insight and perception of reality
Problem-solving and promote symptom management

Continuously evaluating progress

*Transference and Countertransference may occur in this
stage*

Termination Phase

Goals have been reached;

Client discharged from hospital;

Goal is to bring therapeutic conclusion to

relationship

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NURSE-PATIENT
RELATIONSHIP

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• Transference occurs all the time in our everyday
interactions and is where we may be reminded of
someone in the behavior of others. So specifically
in nursing, it is when a patient will view the nurse
as someone who is similar to an important person
in their life.

• Countertransference in nursing is whenever the
nurse unknowingly transfers their unresolved
thoughts, feelings, and emotions onto a client.
This can be a problem because it can lead to a
nurse potentially pushing a patient into action
before they are ready, harshly condemning or
judging a patient, desiring a relationship outside
of the appropriate boundaries, or even
transferring bad moods onto the patient

NURSING PROCESS – ATI TEXTBOOK

Assessment

• Assess verbal and nonverbal communication

needs

• Identify cultural considerations that can impact

communication (eye contact, personal touch)

• Assess congruency between verbal/non-verbal

message

• Consider developmental level

• ADULT:

• How they perceive mental health diagnosis and if
affecting relationship with peers

• Older adults minimize distractions, face client when
speaking

• Assess for impaired communication

• CHILDREN:

• Simple, straightforward language

• Aware of own nonverbal messages – sensitive to this

• Incorporate play in interactions

• Childs level of development

Planning

• Minimize distractions

• Provide privacy

• Identify mutually agreed-upon client outcomes

• Set priorities according to clients needs

• Plan for adequate time for interventions

Implementation

• Establishing trusting nurse-client relationship

• Provide empathetic responses and explanations

to client using observations, hope, humor, and

information

• Manipulate environment to decrease distractions

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THERAPEUTIC COMMUNICATION –
BASIC LEVELS OF COMMUNICATION

Intrapersonal Communication

Occurs within an individual. “Self-Talk”.

Internal discussion when an individual has

internal discussion, thinking thoughts and

not outwardly verbalizing them. Allows nurse

to perform a self-assessment of their

values/beliefs prior to caring for a client

whose diagnosis can trigger an emotional

response

Interpersonal Communication

Occurs one-on-one with another individual.

Used when nurse obtains psychosocial

history from a client or when listening to a

client discuss their feelings.

ESSENTIAL
COMPONENTS TO
EFFECTIVE
COMMUNICATION

Time

Adequate time to communicate; patient doesn’t feel rushed and

feels heard

Active listening
Non-verbal means of conveying interest; eye contact depending on
situation/culture; body language and posture; vocal quality; verbal tracking
(restating/summarizing)

Caring attitude – Empathy

Show concern; objective awareness and understanding of feelings,

emotions of others

Honesty – Trust – Nonjudgmental Attitude

Be open, direct, and truthful, demonstrate reliability;

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ACTIVE LISTENING

SIT SQUARELY FACING PATIENT

Gives message that nurse is there to listen and interested in what

patient says

OBSERVE AN OPEN POSTURE

Arms and legs uncrossed. Nurse is open to what patient is saying;

not defensive

LEAN FORWARD TOWARD THE PATIENT

Coverys nurse is involved in interaction and interested

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ESTABLISH EYE CONTACT

RELAX

Intermittent; conveys involvement and willingness to listen

Sense of eing relaxed and comfortable will help ease the client into

sharing

THERAPEUTIC
COMMUNICATION

NONVERBAL COMMUNICATION

Body language, eye contact, touch; important to check for congruence in

verbal and nonverbal responses – 70-80% of communication is nonverbal

THERAPUETIC COMMUNICATION
STRATEGIES

Silence, open-ended questions, rephrasing, restating, reflecting,

responses beneficial in verbal communication

NON-THERAPUETIC COMMUNICATION
STRATEGIES

Displacement, interpreting, minimizing – responses that impede

further communication and create barriers

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MOTIVATIONAL INTERVIEWING

evidence-based, patient-centered style of communicating that

promotes behavior change by guiding patients to explore their

motivation for change and the advantages and disadvantages of

their decisions. Incorporates active listening and verbal therapeutic

communication techniques, focused on what the patient wants (his

or her current level of motivation) rather than on what the nurse

thinks should be the next steps in behavior change

SIMPLE STRATEGIES FOR VERBAL
COMMUNICATION

SIMPLE LANGUAGE – AVOID JARGON

CLARITY/BREVITY – SHORT AND SIMPLE

TIMING/RELEVANCE

PACE OF SPEECH

INTONATION – TONE OF VOICE

SIMPLE STRATEGIES FOR NON-
VERBAL COMMUNICATION

POSTURE

FACIAL EXPRESSIONS

EYE CONTACT

PERSONAL SPACE

Make sure conversation is client centered (not social or reciprocal) and its purposeful, planned, and

goal directed

PRODUCT BENEFITS

Cool and stylish product

Areas for community connections

Online store and market swap

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COMPANY
OVERVIEW

20XX Pitch Deck 14

NON-THERAPEUTIC STRATEGIES CONT.

STRESS & DEFENSE MECHANISMS

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• Altruism: dealing with anxiety by reaching out to others (nurse who last a family member in a fire is a volunteer

firefighter)

• Sublimation: dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of

expression (person has feelings of anger/hostility toward supervisor sublimates those feelings by working out at gym)

• Splitting: Demonstrating an inability to reconcile negative and positive attributes of self or others into a cohesive image

• Adaptive: N/A

• Maladaptive: client tells a nurse that the nurse is the only one who cares about them, yet following day, the client

refuses to talk to that nurse

• Regression: sudden use of childlike or primitive behaviors that do not correlate with person’s current developmental level

• Adaptive: a young child temporarily wets the bed when they learn that their pet died

• Maladaptive: a person who has a disagreement with a co-worker begins throwing things at their office

• Suppression: Voluntarily denying unpleasant thoughts and feelings

• Adaptive: A student puts off thinking about a fight they had to focus on a test

• Maladaptive: person lost their job states they will worry about paying bills next week

• Denial: pretending truth is not reality to manage unpleasant, anxiety-causing thoughts/feelings

• Adaptive: person initially says “no that cant be true” when told they have cancer

• Maladaptive: parent informed their child was killed in combat tells everyone month later child is coming home for

the holidays

• Displacement: shifting feelings related to an object, person, or situation to another less threatening object, person or

situation

• Adaptive: adolescent angrily punches a punching back after losing a game

• Maladaptive: a person who is angry about losing their job destroys anothers personal property

BOUNDARIES

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There are professional boundaries in the Nurse-Client

Relationship. Nurses must be consistently conscientious

in avoiding any circumstance in which they might

achieve personal gains. Concerns regarding the nurse

boundaries with the client include self- disclosure, and

gift giving and receiving. Always remember you are the

nurse, and this relationship is a unique, professional one,

with you as the nursing care provider. Also, in mental

health, touch is generally avoided. This approach is

often inappropriate with clients with a mental health

disorder. It can be misinterpreted as affection or

aggression.

https://youtu.be/LirG9tc88Ms –

Example Video of Crossing

Boundaries

DIFFERENT TYPES OF
THERAPY

MILIEU THERAPY

Creates an environment that is supportive,

therapeutic, and safe. Fancy word for

therapeutic environment

Management of milieu refers to management

of total environment of mental health unit in

order to provide least amount of stress, while

promoting greatest benefit for all clients

Goal: while client in therapeutic environment,

client will learn tools necessary to cope

adaptively, interact more effectively, and

appropriately, and strengthen relationship

skills

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Characteristics:

Physical Setting:

• Unit should be clean and orderly,

• Furniture safe/secure/clean

Health care team responsibilities:

• Promote independence for self-care

• Allow choices for clients with daily

routine/treatment plans

• Apply rules of fair treatment to all clients

• Model good social behavior for clients

• Maintain boundaries with clients

• Promote feelings of self-worth

Emotional Climate

• Clients should feel safe from harm

• Clients should feel cared for and accepted by

staff

PSYCHOTHERAPY

Involves more verbal therapist-to-

client interaction than classic

psychoanalysis. Client and the

therapist develop a trusting

relationship to explore the client’s

problems

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Psychodynamic psychotherapy

Interpersonal psychotherapy

Cognitive Therapy

Behavioral Therapy

Cognitive-Behavioral Therapy

Dialectical Behavior Therapy

PSYCHODYNAMIC
VERSUS INTERPERSONAL
PSYCHOTHERAPY

Classical Psychoanalysis: therapeutic process of assessing unconscious thoughts/feelings and

resolving conflict by talking to a psychoanalyst. Clients attend many sessions over the course

of months to years. Often reflect on past relationships.

Psychodynamic: employs the same tools as psychoanalysis, but it focuses more on the client’s

present state, rather than their early life. This type of therapy tends to last longer than other

treatment approaches

Interpersonal: assists clients in addressing specific problems. Can improve interpersonal

relationships, communication, role-relationship, and bereavement. Premise is that many

mental health disorders are influenced by interpersonal interactions and the social context.

Goal is to improve interpersonal and social functioning which will reduce the psychiatric

manifestations

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COGNITIVE THERAPY
BEHAVIOR THERAPY
COGNITIVE-BEHAVIORAL THERAPY

Cognitive Therapy: Based on cognitive model, focusing on individual thoughts and behaviors to
solve current problems. Belief is that thoughts come before feelings and actions. It treats
depression, anxiety, eating disorders, and other issues that can improve by changing a client’s
attitude toward life experiences

Behavioral Therapy: Changing behavior is key to treating problems. Based on theory that
behavior is learned and has consequences. Abnormal behavior results from an attempt to avoid
painful feelings. Changing abnormal or maladaptive behavior can occur without need for insight
into the underlying cause of behavior. Teach clients ways to decrease anxiety or avoidant
behavior and give clients opportunity to practice techniques. Help reduce anxious and avoidant
behavior like relaxation training and modeling. Used for phobias, substance use, or addictive
disorders.

Cognitive-behavioral Therapy: Both cognitive and behavioral approaches to assist client with
anxiety management. Considers what clients think influences their feelings and behaviors.
Dialectical behavior therapy is in this category and used with those that have personality
disorder and exhibit self-injurious behavior. Focuses on gradual behavior changes and provides
acceptance and validation for these clients.

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Goal: modify

maladaptive behavior

patterns by reinforcing

adaptive behavior

Goal: individual taught to

control negative thoughts

to maintain/manage

emotions

USE OF COGNITIVE THERAPY

Cognitive Reframing:

Changing cognitive distortions can decrease anxiety. Cognitive

reframing assists clients to identify negative thoughts that

produce anxiety, examine the cause, and develop supportive

ideas that replace negative self-talk.

Ex: client has depressive disorder says they are a “bad person”

who has “never done anything good” in their life. Through

therapy, client can change their thinking to realize that they

might have made some bad choices, but they are not a “bad

person”.

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Techniques:

Priority Restructuring: Assists

clients to identify what

requires priority

Journal keeping: helps clients

write down stressful thoughts

and has positive effect on

well-being

Assertiveness training:

teaching clients to express

feelings and solve problems in

a nonaggressive manner

Monitoring thoughts: helps

clients to be aware of negative

thinking

TYPES AND USES OF
BEHAVIORAL THERAPY

Modeling: therapist or other serve as a role model for a client, who

imitates this modeling to improve behavior

Operant Conditioning: Client receives positive rewards for positive

behavior (positive reinforcement) – ex: tokens for good behavior and can

exchange for privileges

Systematic Desensitization: planned, progressive, or graduated exposure

to anxiety-provoking stimuli in real-life situations or by imagining events

that cause anxiety. During exposure, client uses relaxation techniques to

suppress anxiety response; first masters relaxation techniques, then client

exposed to increasing levels of anxiety producing stimulus to help

overcome anxiety.

Aversion Therapy: Pairing of maladaptive behavior with a punishment or

unpleasant stimuli to promote a change in behavior. Ex: therapist or

treatment team can use unpleasant stimuli (bitter taste) as punishment

for behaviors (alcohol use disorder, violence, self mutilation). With

aversion therapy, ongoing supervision and evaluation essential.

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OTHER TECHNIQUES

Flooding: Exposing a client, while in the company of a therapist, to a
great deal of an undesirable stimulus to turn off the anxiety response

Response Prevention: Preventing a client from performing a compulsive
behavior with the intent that anxiety will diminish

Thought stopping: Teaching a client, when negative thoughts or
compulsive behaviors arise, to say or shout, “Stop”, and substitute a
positive thought. Goal over time is for client to use the command silently.

Validation Therapy: Useful for clients with neurocognitive disorders.
Process of communication with a disoriented older adult client by
respecting and validating their feelings in a time or place that is real to
them, even though it does not relate to actual reality.

Electroconvulsive Therapy: Last resort treatment; can be very effective
with individuals experiencing severe depression. Monitoring and
anesthesia used with this.

Transcranial magnetic stimulation (TMS): involves use of short magnetic
energy to stimulate nerve cells in brain. Approach does not result in
seizure activity. Treatment used for major depressive disorder

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VIDEOS TO
REVIEW

Introduction, Patient Rights

https://www.leveluprn.com/blogs/psychiatric-mental-

health/principles-1-introduction-patient-rights

Informed Consent , Ethical Principles

https://www.leveluprn.com/blogs/psychiatric-mental-

health/principles-2-informed-consent-nursing-ethical-principles

Torts and Restraints

https://www.leveluprn.com/blogs/psychiatric-mental-

health/principles-3-torts-restraints

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We have covered a lot of

great information. Now

please take the time to

review these videos to recap

what was learned. This will

help you store this in your

long-term memory and better

prepare you for your exams!

Nurse/Client Relationship, Therapeutic
Communication

https://www.leveluprn.com/blogs/psychiatric-mental-health/principles-

4-nurse-client-relationship-therapeutic-communication

VIDEOS TO
REVIEW

Therapies, Part 1: Relaxation, Milieu,
Group, and Behavioral

https://www.leveluprn.com/blogs/psychiatric-mental-

health/therapies-1-relaxation-techniques-milieu-group-behavioral

Therapies, Part 2: CBT, EMDR, TMS

https://www.leveluprn.com/blogs/psychiatric-mental-

health/therapies-2-cbt-emdr-tms

Therapies, Part 3: ECT, VNS

https://www.leveluprn.com/blogs/psychiatric-mental-

health/therapies-3-ect-vns

27

We have covered a lot of

great information. Now

please take the time to

review these videos to recap

what was learned. This will

help you store this in your

long-term memory and better

prepare you for your exams!

Defense Mechanisms

https://www.leveluprn.com/blogs/psychiatric-mental-

health/principles-8-defense-mechanisms

A NURSE IN AN ACUTE MENTAL HEALTH FACILITY IS
COMMUNICATING WITH A CLIENT. CLIENT STATES “I CANT SLEEP.
I STAY UP ALL NIGHT.” THE NURSE RESPONDS, “YOU ARE HAVING

DIFFICULTY SLEEPING?” WHICH OF THE FOLLOWING
THERAPEUTIC COMMUNICATION TECHNIQUES IS THE NURSE

DEMONSTRATING?

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A. Offering general leads

B. Summarizing

C. Focusing

D. Restating

A NURSE IS TEACHING A CLIENT WHO HAS AN ANXIETY DISORDER
AND IS SCHEDULE TO BEGIN CLASSICAL PSYCHOANALYSIS. WHICH
OF THE FOLLOWING STATEMENTS INDICATES AN UNDERSTANDING

OF THIS FORM OF THERAPY?

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A. Even if my anxiety improves, I will need to continue this therapy for 6 weeks

B. The therapist will focus on my past relationships during our sessions

C. Psychoanalysis will help me reduce my anxiety by changing my behaviors

D. This therapy will address my conscious feelings about stressful experiences

A CHARGE NURSE IS CONDUCTING A CLASS ON THERAPEUTIC
COMMUNICATION WITH A GROUP OF NEWLY LICENSED NURSES.

WHICH OF THE FOLLOWING ASPECTS OF COMMUNICATION
SHOULD THE NURSE IDENTIFY AS A COMPONENT OF VERBAL

COMMUNICATION

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A. Personal Space

B. Posture

C. Eye Contact

D. Intonation

A NURSE IS COMMUNICATING WITH A CLIENT WHO WAS
ADMITTED FOR TREATMENT OF A SUBSTANCE USE DISORDER.
WHICH OF THE FOLLOWING COMMUNICATION TECHNIQUES

SHOULD THE NURSE IDENTIFY AS A BARRIER TO THERAPEUTIC
COMMUNICATION?

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A. Offering advice

B. Reflecting

C. Listening attentively

D. Giving information

A NURSE IS CARING FOR A CLIENT WHO HAS ANOREXIA NERVOSA.
WHICH OF THE FOLLOWING EXAMPLES DEMONSTRATES THE

NURSE’S USE OF INTRAPERSONAL COMMUNICATION?

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A. The nurse discusses the client’s weight loss during a health care team meeting

B. The nurse examines their own personal feelings about clients who have anorexia nervosa

C. The nurse asks the client about personal body image perception

D. The nurse presents an educational session about anorexia nervosa to a large group of adolescents

A NURSE IS PREPARING TO IMPLEMENT COGNITIVE REFRAMING
TECHNIQUES FOR A CLIENT WHO HAS AN ANXIETY DISORDER.
WHICH OF THE FOLLOWING TECHNIQUES SHOULD THE NURSE

INCLUDE IN THE PLAN OF CARE? SELECT ALL THAT APPLY

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A. Priority Restructuring

B. Monitoring Thoughts

C. Diaphragmatic breathing

D. Journal Keeping

E. Meditation

A CLIENT SAYS TO THE NURSE, “I’VE BEEN OFFERED A
PROMOTION, BUT I DON’T KNOW IF I CAN HANDLE IT.” THE NURSE
REPLIES, “YOU’RE AFRAID YOU MAY FAIL IN THE NEW POSITION.”

THIS IS AN EXAMPLE OF WHICH THERAPEUTIC TECHNIQUE?

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A. Restating

B. Making Observations

C. Focusing

D. Verbalizing the implied

CONNEY WITH BORDERLINE PERSONALITY DISORDER WHO IS TO
BE DISCHARGED SOON THREATENS TO “DO SOMETHING” TO

HERSELF IF DISCHARGED. WHICH OF THE FOLLOWING ACTIONS BY
THE NURSE WOULD BE MOST IMPORTANT?

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A. Ask a family member to stay with the client at home temporarily

B. Discuss the meaning of the client’s statement with her

C. Request an immediate extension for the client

D. Ignore the client’s statement because it’s a sign of manipulation

AN ADOLESCENT WHO HAS JUST RETURNED FROM GROUP
THERAPY IS CRYING. SHE SAYS TO THE NURSE, “ALL THE OTHER
KIDS LAUGHED AT ME! I TRY TO FIT IN, BUT I ALWAYS SEEM TO

SAY THE WRONG THING. I’VE NEVER HAD A CLOSE FRIEND. I
GUESS I NEVER WILL.” WHICH IS THE MOST APPROPRIATE

RESPONSE BY THE NURSE?

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A. What makes you think that you will never have any friends?

B. You’re feeling down on yourself right now

C. I’m sure they didn’t mean to hurt your feelings

D. Why do you feel this way about yourself?

A NURSE IS CARING FOR A CLIENT WHO HAS A NEW
PRESCRIPTION FOR DISULFIRAM FOR TREATMENT OF ALCOHOL

USE DISORDER. THE NURSE INFORMS THE CLIENT THAT THIS
MEDICATION CAN CAUSE NAUSEA AND VOMITING WHEN ALCOHOL
IS CONSUMED. WHICH OF THE FOLLOWING TYPES OF TREATMENT

IS THIS METHOD AN EXAMPLE?

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A. Aversion Therapy

B. Flooding

C. Biofeedback

D. Dialectical behavior therapy

A DEPRESSED CLIENT WHO HAS BEEN UNKEMPT AND UNTIDY FOR
WEEKS COMES TO GROUP THERAPY TODAY WEARING MAKEUP AND A

CLEAN DRESS WITH HAIR WASHED AND COMBED. WHICH OF THE
FOLLOWING RESPONSES BY THE NURSE IS MOST APPROPRIATE?

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A. I see that you have put on a clean dress and combed your hair

B. You look wonderful today

C. I’m sure everyone will appreciate that you have cleaned up for the group today

D. Now that you see how important it is, I hope you will do this everyday

A NURSE IS ASSISTING WITH SYSTEMATIC DESENSITIZATION FOR A
CLIENT WHO HAS AN EXTREME FEAR OF ELEVATORS. WHICH OF THE
FOLLOWING ACTIONS SHOULD THE NURSE IMPLEMENT WITH THIS

FORM OF THERAPY

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A. Demonstrate riding an elevator, and then ask the client to imitate the behavior

B. Advise the client to say “stop” out loud every time they begin to feel an anxiety response related to

an elevator

C. Gradually expose the client to an elevator while practicing relaxation techniques

D. Stay with the client in an elevator until the anxiety response diminishes

A CLIENT ASKS THE NURSE, “DO YOU THINK I SHOULD TELL MY
HUSBAND ABOUT MY AFFAIR WITH MY BOSS?” WHICH IS THE

MOST APPROPRIATE RESPONSE BY THE NURSE?

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A. What do you think would be best for you to do?

B. Of course you should. Marriage has to be based on trust and truth

C. Of course not. That would only make things worse.

D. I cant tell you what to do. You have to decide for yourself

LINDA IS PACING THE FLOOR AND APPEARS EXTREMELY ANXIOUS. THE
DUTY NURSE APPROACHES IN AN ATTEMPT TO ALLEVIATE LINDA’S

ANXIETY. THE MOST THERAPEUTIC QUESTION BY THE NURSE WOULD
BE?

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A. Would you like to watch TV?

B. Would you like me to talk with you?

C. Are you feeling upset now?

D. Ignore the client

A MALE CLIENT WHO IS EXPERIENCING DISORDERED THINKING ABOUT
FOOD BEING POISONED IS ADMITTED TO THE MENTAL HEALTH UNIT.

THE NURSE USES WHICH COMMUNICATION TECHNIQUE TO
ENCOURAGE THE CLIENT TO EAT DINNER?

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A. Focusing on self-disclosure of own food preference

B. Using open-ended questions and silence

C. Offering opinions about the need to eat

D. Verbalizing reasons that the client may not choose to eat

NURSE TINA IS CARING FOR A CLIENT WITH DELIRIUM AND
STATES THAT “LOOK AT THE SPIDERS ON THE WALL”. WHAT

SHOULD THE NURSE RESPOND TO THE CLIENT?

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A. You’re having a hallucination, there are no spiders in this room at all

B. I can see the spiders on the wall, but they are not going to hurt you

C. Would you like me to kill the spiders

D. I know you are frightened, but I do not see spiders on the wall