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WAP / Vocational training for community based psychiatric nursing

Further Training of Ambulatory Psychiatric Service Providers

TRAINING MODULE

FAMILY INTERVENTION TECHNIQUES

AUTHORS

Nilgün SARP
Professor
Ankara University, Faculty of Health Sciences

Ruhi Selçuk TABAK, Ph. D.

Associate Professor
Muğla University, Fethiye School of Health Sciences

Deniz Kader Şarlak, M Sc

Muğla University, Fethiye School of Health Sciences

Muğla/Fethiye/Ankara

September - 2008
Contents

Instructions for Trainers

Introduction
Family
FAMILY INTERVENTION TECHNIQUES

Objectives:

1. Trainees will understand the conceptual basics of family intervention techniques in

the frame of mental health.
2. Trainees will understand the family dynamics in multilateral perspectives.
3. Trainees will have knowledge and skills about the leading and new approaches
and models of family interventions
4. Trainees will improve their awareness about family mental health various problems
and their causing factors,
5. Trainees will have knowledge and skills about the specific mental health problems
of the family, and of their causing factors.
6. Trainees will improve their skills on the family evaluations, care plans and
interventions.

Learning Outcomes
Cognitive:
 Nurses will list the kinds of families.
 Nurses will count the risk factors of mental health in the family.
 Nurses will count the family interview techniques.
 Nurses will count the family intervention techniques.

Affective
 Nurses will express their willingness to carry out community based mental health
services to the families.
 Nurses will accept to employ the holistic approach for the mental health problems of
families.
Psychomotor
 Nurses will employ the family interview techniques.
 Nurses will employ the family intervention techniques in the frame of community
based mental health services.
For the trainer:

In this handbook you will find the whole content of the module “Family Intervention
Techniques”. In addition in blue letters there are written down instructions for the
trainer.

In many chapters it can be helpful to let the trainees work together in groups. In the
following you find an overview about the idea of working in groups.

Philosophy of group learning

Group learning, or working in groups, involves shared and/or learned values,

resources, and ways of doing things. Effective groups learn to succeed by combining
these factors. However, each group, and each individual, will only be as effective as
they are willing to embrace and/or respect differences within the group.

Interaction within the group is based upon mutual respect and encouragement.
Often creativity is vague. A group's strength lies in its ability to develop ideas
individuals bring.

Conflict can be an extension of creativity; the group should be aware of this

eventuality. Resolution of conflict balances the end goals with mutual respect. In
other words, a group project is a cooperative, rather than a competitive, learning
experience.

The two major objectives of a group project are:

What is learned: factual material as well as the process

What is produced: written paper, presentation, and/or media project

Role of trainers

The success of the outcome depends on the clarity of the objective(s) given by
teachers, as well as guidelines on expectations. The group's challenge is to interpret
these objectives, and then determine how to meet them.

The process of group work is only as effective as trainers manage and guide the
process.

Group projects are not informal collaborative groups.

Students must be aware of, and prepared for, this group process.

Cooperative group projects should be structured so that no individual can coast on

the efforts of his/her team-mates.

You will find explanations concerning the exercises for the trainees at the end of each
chapter.

During the chapter you will find remarks if necessary and proposals of the parts you
could present by some kind of projection (PowerPoint, overhead projector, etc.).
These parts are marked by a blue frame.
 50 minutes for this
INTRODUCTION
part in total
Theory: 20 minutes
- Introduction by the trainer 20 minutes
Practise: 30minutes
- ex1: concepts and different kinds of family interventions 30 minutes
Requirements in equipment:
paper, pen
beamer, laptop
INTRODUCTION

Audio-Visually supported presentation.

Family

In general, family, which is considered a core structure within the

community based mental health care, is the environment for the
individual to gain the social experiences. Beside its unignorable
importance for mental health for individuals, family is a quite fragile
institute due to mental disorders and/or hard life conditions.

Literally, family is social institute which consists of individuals who have close relations trough
blood, marriage and/or adoption, who live in the same house; share the incomes, and who
interact each other in the frames of their roles. Psycho-social and legal ties build up the
power in families rather than organic ties. The professionals in mental health services are
expected to be aware of the family dynamics.

All families have basically same functions each family and every individuals in families are
unique. They all have different backgrounds and traits.

A family can be analyzed in 4 dimensions according to structural-functional approach:

a) Values system: The factors that constitute are the social norms such as culture,
moral, law, religion (beliefs, traditions, punishments). Values are not stable. They
change continuously. While values guide the behaviours, they lead the necessities for
norms and rules in families. For example, if an individual feels him-/herself as
necessary for the family he/she will surely take care of him-/herself more and adopt
better health behaviours.
b) Role structure: Role is the expected behaviour of an individual who has a position in
a group. Roles in a family are both formal and informal. Among the formal roles are
provision of incomes, responsibility for care, parentship, spouseship, etc. The informal
roles are encouragement, share, partnership, friendship, governing, sacrifaction,
agreement, etc.
c) Power structure: Money providing and decision making are the sources for the
power. Love, security, clarity bring the family members closer. Toughness weakens
the relations, destroys the power structure.
d) Communication structure: Samples of the relations such as democratic, share,
emphatic, pressure, tough, irrespective etc. are important in being healthy or
unhealthy of families.

General specifications of families:

Family
 is universal,
 is based on emotions,
 has the character of formation,
 is the smallest of social structures, and has limited capacity,
 has the core specificity in social life,
 members have responsibilities,
 is surrounded by social norms and rules,
  has both tentative and permanent natures.

Common characteristics of family;

 Each member can be stimulated by the behaviours of others.

 Interactions in family affect the behaviours of family members.
 Each family has its own structure and functions.
 Families have specific strategies for dealing with conditions such as stress, crisis,
conflicts etc.

Family has some functions beside these characteristics. Fulfilment of these functions prevent
conflicts and ensures the harmony.

Characteristics of a Functional Family

A family which carries out its functions;
 is social and efficient in establishing relations with others.
 has members with proper identity feelings and self-values.
 gives chances to its members for self-expression and self-disciplines.
 encourages its members’ independency and sufficiency.
 gives freedom to children according to their development levels.

For a healthy family, mental well-being of parents is especially important as the basic
members of a family.

Mental well-being of parents is affected by the;

 acceptance of mother her identity as a woman.
 preparedness for the parenthood.
 relationships with their own parents.
 relationships as spouses.
 use of alcohol, drug, cigarette; abuse, unemployment, immigration, diseases.
 sickness of a family member.
 missing or divorce of a family member.
 marriages between relatives.
 situations of fear, anxiety, depression.

Family and its life are important and prior constructions in the primary prevention approach.

There three basic family types in the present Turkish society: Rural Family, City Family,
Squatter (Transition) Family.

There are specific factors in these family types which are affecting the arousal of mental
disorders. These are;
 endogamies, premature and matchmaking style marriages, especially in rural
families,
 functions of women and their increasing responsibilities,
 payments to bride’s families, especially in eastern region,
 increasing divorces in city families,
  adaptation problems, conflicts, weakening relationships in squatter families.

There are, in general, four approaches in defining the concept of a family:

1. Defining the family considering the opinions, feelings and fantasies of a member of a
family. This approach is commonly used in psychiatry as the way for identifying and defining
the family

2. Cultural approach which considers family as social institute with its cell and large
dimensions. This definition is used generally in sociology and social psychology.

3. The approach which considers family as social unit. According to this approach, family is a
system constructed by various segments. It is taken into account as a small group and
studied by social-psychology in terms small group behaviours.
4. The approach which accepts family as a group limited by the social values. According to
this approach, beside rules defined by and in the laws, each family has its own clear or
unclear norms and rules.
Today, the term ‘family intervention’ is used for two concepts: The first concept is used in
situations where a member of family is need of definition and treatment of a mental health
disorder. In this case, family intervention comprises the approaches and types of explanation
and treatment in defining and management of dynamics in family. The second concept
includes the approach and treatment types in defining and management of conflicts, troubles
and complaints in and about the relations in family. This second one is also called as
‘marriage therapy’.
Family intervention is not solely to give amateur speeches and advices based on the nurses
own common-sense through gathering the family members. Even, it does not consist of the
self-expressions of family members to overcome the symptoms or problems appeared in one
or all members of a family after a group discussion. It requires sufficient psychotherapy
training and experience as well as the awareness of family intervention techniques and
clinical efficiency to an extent.

Effects of Mental Disorders to Family

As interactions among the family members affect the mental health of each
member individually, a disorder appeared in a member may easily affect the
whole family and cause some defects in family functions. While,
sometimes, the problem is created through overtaking the patient role a
member by another member of the family, generally feelings and thoughts
of the member with a mental disorder such as the refusal of sickness,
feeling guilty, fearing from the environment affect the whole family.
However, families can create another balance to carry out the basic
functions by learning to live with the problem or finding new solutions for the mental troubles.
Whatever they employ as techniques, family interventions have the following aims:
 To deal with to decrease the symptoms mental and functional disorders of individuals
in the frame of the family relations.
 To solve the conflicts in family and spouses as well as the conflicts of the family with
its proximal environment and community,
 To define and mobilize the sources and behaviours to be used by family in solving
their mental health complaints.
  To ease the perception and satisfaction of the emotional needs of family members.
 To improve problem solving skills and communication competencies of families and
its individual members in case of hardening life conditions and mental disorders.
 To ensure the development of independency of family members as well as their skills
for healthy relations.
 To help for promotion of compliances among family members in terms of role
distribution by gender and generation.
 To facilitate the integration of the family to the community.

Group discussion on on the effects and improtance of family dynamics on mental

health.
To remember

Family is social group which has its own unique characteristics,

norms, rules, dynamics and life style.

Questions and assignments

List and describe the different kinds of families.

Give examples for each.

Exercise:

Let the nurses write down the different kinds of families and 1-2 examples for
each. After they have finished let them present to each other what they have written
down and discuss the results.

The aim is to let them understand the categories and to “translate” them in concrete
crisis situations from the daily life.

If necessary you can help them giving examples.

Questions:

1- A family can be analyzed in 4 dimensions according to structural-functional approach.

Which of the concepts given below is not included among these dimensions?

 Beliefs system
 Values system
 Role structure
 Power structure
 Communication structure

2- Which of the items given below is not included among the general specifications of
families?

 Family is based on emotions,

 Family has the character of formation,
 Family is the smallest of social structures, and has limited capacity,
 Family has the core specificity in social life,
 Family is local,
 Family is surrounded by social norms and rules.

3- For a healthy family, mental well-being of parents is especially important as the basic
members of a family. Mental well-being of parents is not affected by the;

 acceptance of mother her identity as a woman.

 preparedness for the parenthood.
 relationships with their own parents.
 relationships as spouses.
 use of alcohol, drug, cigarette; abuse, unemployment, immigration, diseases.
 softness of a family member.
 missing or divorce of a family member.
 marriages between relatives.
 situations of fear, anxiety, depression.

4- Which of the items given below is not included among the aims of family interventions?

 To ease the perception and satisfaction of the emotional needs of family members.
 To improve problem solving skills and communication competencies of families and its
individual members in case of hardening life conditions and mental disorders.
 To control the development of independency of family members as well as their skills
for healthy relations.
 To help for promotion of compliances among family members in terms of role
distribution by gender and generation.
 To facilitate the integration of the family to the community.

FAMILY AND RISK

FAMILY AND RISK 50 minutes in total
Theoretical knowledge 20 minutes
Theoretical explanation by the trainer 20 minutes
Practice 30 minutes
Group discussion on fundamental risk factors 30 minutes
regarding mental health
Equipment required
Paper, pen
Beamer, laptop

Audio-Visually Supported Presentation.

Information to be gathered about the psycho-social status of the family constitute data to be used in
planning treatment and cure. Individuals under psychiatric treatment have been away from their family
and interaction with the family members (at least for a while) due to their individual psycho-
pathological reasons. Nurses working in the field of mental health will often work with patients and
their families. A family with a member who suffers from Alzheimer, a family with an inner-family
violence, a family with a child suffering from lack of concentration, and families with members who
have chronical mental disorder constitute much of families at risk mental health nurses face. There are
many risky situations which damage biopsycho-social and moral balance and mental health of the
families.
Family Development Periods and Risky Life Changes
Developmental Tasks Life Periods
Healthy birth---------------------------------------------------Babyhood and early childhood
Development of language skills-----------
Development of impulse control----------
School age------------------------------------
Early literate---------------------------------- School child
Development of social skills-------------------

Puberty--------------------------- Adolescence
Interest in opposite sex-----------------
Development of independence--------
Leaving home----------------------------

High education--------------------------- Early Adolescence

Selecting a job-------------------------
Marriage-------------------------------
Birth-------------------------------------
Becoming parents----------------------
Becoming parents to a school child-----

Becoming parents to a child in the early adolescence---- Middle Age

Becoming parents to a child who left the family---------

Becoming parents to a child to a child who is just married---------

Providing treatment to sick parents------------------------------
Becoming grand parents-----------------------------------------
Retirement----------------------------------------------------

Busy with sicknesses------------------------ Old age

Looking after a sick spouse---------------

Coping with death of the spouse---------

Coping with death of one of the peers------

One way of planning primary preventive measures and organizing them systematically is to consider
developmental tasks required in every period of life and life changes.

Risk Factors Damaging Mental Health of the Family:

a) Family Factors;
- Lack of harmony in the family
- Mental illnesses in the family
- Abuse in the family
- Economical problems in the family and unemployment
- Low level of education
- Overcrowded family
- Marriage with relatives
- Lack of parents
- Rigit family
- Poor communication

b) Environmental and Social Factors;

-Homelessness
-Discrimination
-Deprivation
-Migration
-Earthquake
-Fire
-Floods
-Environmental pollution
-Weak social support
-Education difficulty of the family with disabled child

Mental health nurse should evaluate the family with totalitarian (integrated) approach.
Woman and Risk:
Women of our country are those who have problems in productivity, enterprising, self-expression, and
satisfaction and problem solving skills. The fact that women apply health services due to depression
often met in women and somatic complaints support this view. Protection of this group suffering due
to their psychological social status is very important in the development of healthy families and
generations. As the psychological satisfaction or dissatisfaction of women is important, problems or
failures in the satisfaction levels given below and problems seen in those contexts are the risky
situations for the mental health of women.
Satisfaction Contents

Love relationships - To love and be loved

- Satisfaction in sexual life
- Relationship with the loved ones

Individual achievement -Success in life

-Job satisfaction
- Self-awareness and acceptance
- Individual development

Physical health -nutrition

-general health and physical attractiveness

-Physical activity

-Being parents
Parents-child relation
-Relation with children

- Sparing time for oneself

Personal time
- Setting the balance in issues concerning work,
family, home and environment

-Relations with close friends

Social relations
-Relations with colleagues
-Social life with highly valued individuals

Motherhood:

The motherhood period is rather stressful for women. Pregnancy and post-natal period may bring
about some crises. The following are the main causes of stress:
1. Hormonal changes
2. Changes in body features
3. Psychologicdal conflicts concerning pregnancy
 4. Not being prepared for the role of motherhood.

These causes of stress frequently lead to depression during the pregnanacy and post-natal period. It is
possible to recognise women who are under the risk of depression during their pregnancy and post-
natal period. Very young unemployed women who have not received a good education and have
children are under the risk of developing depression. These risk factors enables the nurses diagnose the
depression and gives them the opportunity for an early treatment, thus enhancing the physical and
mental health of the mother to be.

Working Mothers: Due to their economic situation and their personal choice of carrier, the number of
working women is increasing. Having a job may give a woman positive feelings and a sense of
security and independence. However, it may, at the same time, develop a guilty conscience and anxiety
in working women who think they ignore their husbands and children. It is a well-known fact that the
working woman in the family is held responsible for everything which goes wrong. Undertaking a
role, being uncertain and inefficient and having contradictions are problems which working women
face frequently.

Mental Symptoms among the Working Women:

1. Women staying at home for a long period and suffering from anxiety when they go back to
work
2. Fear and anxiety in connection with turning of a carrier success into a social failure
3. Conflict between what are expected from them socially, and their own necessities and rights
4. Conflict between being a woman and her professional identity and feelings which threaten her
marriage and family independence
Three defence mechanisms are seen among such women :
In rationalisation: she sees the behaviour of a mother as an issue which is socially accepted. For
example, (she may say) “ If I were at home I would find a work which I could do voluntarily”, or “I
am a working woman, I have no time for doing the cleaning.”

When revealed: she constantly blames others.

In compensation: she tries to make up for it by other things. For example, constantly buys gifts for
her children.

Nurses can help working mothers who cannot cope with their roles. First of all they should be helped
to understand their conflicts. The mother should be provided with the information that she should
understand that in the mother-child relation quality is more important than quantity.

Child – Adolescent and Risk

The source of problems for many adults is the childhood period. The period of childhood and
adolescence is the time for attaining the learning capacity for coping. The following are the assessment
of the primary protection attempts in childhood:

1. Anti-social behaviour
a. Physical aggressiveness ( fighting, being destructive)
b. Other anti-social behaviours
2. Learning disorder
3. Mental retardation
4. Childhood schizophrenia
5. Suicide
6. School failure
7. Addiction
8. Neurotic disorder
Some of these problems may be related to the biological development. Others may have to do with the
mental development and the family and social circle. The risk factor concerning these situations may
be related to separation of parents and child, loss of parents, abuse of children and divorce of parents.
Factors concerning the childhood and adolescence period protection can be regarded as a capacity for
solving problems, social skills, a pleasant relation and achieving positive experiences outside the
child’s home.

Group discussion on the practical effects of risk factors from the point of view of mental health.

VISITING THE FAMILY

___________________________________________________________________________

VISITING THE FAMILY 50 minutes

total
Theorethical Information 20 minutes
- Theoreticl explanation of the specialist 20 minutes
___________________________________________________________________________

Application 30 minutes
_________________________________________________________________________
Group discussion on realistic applictions in 30 minutes
family visiting techniques
Necessary Materials:
Paper, pen
Projector, laptop

From the point of view of therapeutic intervention to the family,

among the qualities a nurse should have, priority is given to the
following skills :

º Communiction Skills
º Problem- Solving Skills
º Consultancy Skills

º Discussion Skills
º Adult (mother and father) Education
º Psychiatric Care and Training (especially in connection with serious mental
disorders like schizophrenia)

Therapeutic Techniques in Communication

Therapeutic communication techniques are verbal and non-verbal communication techniques which
make it easy for the person seeking consultancy to express his/her feelings, ideas and intention. They
are used in the meeting of the public mental health nurses with their patients or persons seeking
consultancy.
The attitude that sets the basis for curatory communication is predicated on protecting the Larson self
respect of the parties involved. The understanding, emphaty and helping skills of the society mental
health specialist nurse are transmitted to the consultee. The consultee feels that he or she is respected,
trusted and valued. This, in turn, helps the individual to feel “good”, “precious” and “special”. It’s
crucial that the individual is assured taht he or she won’t be punished, laughed at or accused of his or
her expressed feelings and thoughts. There’s open communication when the consultee can voice his or
her feelings, thoughts and needs and which technnique is used is not that important. Here, the aim and
responsibility of the society mental health specialist nurse is to provide and maintain an open
communication.

The communication techniques and approaches presented below are the communicative skills that are
affective in reaching the consultee and keeping an open communication with him or her. They provide
feedback to the consultee and makes it easier for him or her to express himself or herself.
(Smitherman, Colleen (1981) Larson 2000).

1. Transmission of observations : These observations can be about the consultee or the situation due
to the fact that it has the means for observing many facts about the consultant. In either case, it is
important that these observations are displayed.
Observations about the consultee: These are useful for starting a conversation. Expansions
based on observations makes it easier for the individual to express himself or herself.
“You got up early today”
“You look troubled today”
“In my last visit last week, you didn’t seem enthusiastic about talking when you were with your
mother-in-law”
Observations about the situation: You can use them to “make a prologue” to the topic the
individual wants to talk about. These also are useful for starting a conversation.
“I would like to talk to you about your reaction about using psychiatric medicine.”

2. Encouraging the conversation: This is useful especially in the beginning phase of the relationship.
With short expressions meaning “Continue, I’m listening” the person is encouraged to continue
talking.
“Please continue”, “Yes”, “Hıh hı”, “Really?”, “What happened then?”
In addition to these expressions, the use of body language – nodding, bending towards the consultee,
reveals the willingness of the nurse in showing interest and listening.

3. Discovering: This technique encourages the consultee to know about himself / herself and his / her
problems in depth.
“Would you tell me about your job?”
“You mentioned that there’s a patient diagnosed with schizophrenia in your family”

4. Recognitive attitude: This doesn’t mean that we approve the attitude or agree with the thoughts of
the consultee. We accept that the individual has the right to feel the way he or she feels and he or she
acts the way he/ she does.

5. Concentrating on emotions: In stating what the consultee’s emotions might be, the society mental
health specialist nurse has to prepare questions in such a way that they help him/ her to concentrate on
topics important for the consultee.
Consultee : “This is unacceptable”
Nurse : “You seem to distressed of all these”

6. Demystifying: This is used when what the consultee talks or complains about are not clearly
understood.
“You tell me you’re distressed. Could you please explain how you feel.”
“Have I understood you right? You tell me whatever you’d done your father didn’t think you
were successful. Is it so?”
7. Summarizing: This is to highlight the basic counsels of the topic discussed with the consultee. It
helps to to revise the basic issues discussed during the interview. It’s useful to summarize the previous
session at the beginning so that the consultee remembers previous issues and the nurse has the
opportunity to see how he or she synthasizes. Summarizing helps the parties not to miss the aim of the
session.
“In our last meeting you had concerns about how your wife would respond to you”
“Today you asserted three main points. These are....”

8. Listening: This is far beyond hearing and is the action of catching the meaning of what’s told. It’s
important that, during the interaction, the nurse mostly listens and the consultee mostly tells. Listening
is standing still however it is not a passive process. The nurse has to continue observing and try to
understand the meaning of what he / she hears and observes.

9. Reflecting the scope: This iterates the basic thought in the consultee’s scope. It resembles the self
iteration with words technique.
“You think everything will be all right soon”
“You say finding a part-time job will be good”

10. Reflecting the emotions: This is used to to give voice to the evident and implicit emotions in
consultee’s statements. Whether the individual understands is displayed and also empathy, interest and
respect is communicated.
“As far as I understand you seem to be angry with your brother”

11. Informing: It is sufficient to respond to the queries of the consultee by giving direct and desired
information.
“I’ll visit you once in a forthnight on Tuesdays”

12. Restating with oneselves own words: This is repeating the main thought of what the consultee
talked about with your own words.
“That is to say you’re not comfortable with their treating you like a child”
“You tell me that your mother left you when you were five.”

Checking the perceptions: The perception of the consultee about his or her behaviors, thoughts and
feelings is shared and the nurse checks whether his or her understanding is correct.
“You’re smiling but I feel that you’re angry with me.”

13. Asking questions: It is necessary to collect all the information so as to help the consultee.

14. Feedback: This, informs the consultee about how his or her attitude affects others and develops
open and confidence inspiring relationships.

The main principles of interviews for the purposes of family and mental health service (therapeutics –
educational intermeddling) are as follows:

1. Starting the education in accordance with interview principles (greeting the family)
2. Asking open - ended questions so that family members express their concerns about
medicine use at home (Could you tell me about your concerns about the use of medicine?
What difficulties do you have in using medicine?...)
3. Learning about the knowledge level of the person/people who will provide patient care
about medicine (What do you know about the medicine the patient takes?)
4. Supporting the existing valid knowledge of the family members about medicine.
5. Explaining the family why that particular medicine is prescribed and how it will affect
treatment.
 6. Explaining how important it is to use the medicine regularly so that positive effects of it
can be realized. (Especially emphasizing that initial effect will be seen after a week or 10
days)
7. Explaining that in the initial use of the medicine before the expected positive effects side
effects might occur and the side effects and their strength may vary from person to
person.
8. Explaning the necessary changed the patient needs to make in his or her daily routine to
the family (driving, alcohol-drug interaction, the effect of the drug on motor skills)
9. Explaining what to do in the case of side-effects (depending on the type of the medicine)
10. Explaning the family that they should consult the doctor if the side-effects are seriously
affecting the patient (drug intoxication, acut dystonia)

11. Giving the family a chance to ask questions

12. Answering the family's questions

13. Finalizing the interview within the principles of interview

LISTENING TO THE FAMILY EFFECTIVELY

EFFECTIVE LISTENING SKILLS A total of 50 minutes

Theoretical Information 20 minutes

- Theoretical instructions 20 minutes
Practice 30 minutes
Group discussion on listening to the family effectively 30 minutes
Required materials
Pen and paper
Projector and laptop computer

OBJECTIVES

Distinguishing between listening and hearing

Raising awareness for the mistakes committed during listening
Finding out different listening types
Evaluating self-listening behaviour
Evaluating effective listening bahaviours during interpersonal relations

LISTENING

Listening is to understand what one wishes to express exactly in the same way as it is transmitted.
Listening is, rather than hearing something somebody utters, to hear what somebody expresses.
Listening requires active involvement. We should show attentive behaviour to the speaker’s words
through both verbal and non-verbal responses. For effective listening we need a quiet place and
appropriate time. The number of people are quite high who try to offload their worries and give
advice through some immature responses, who think they have found out the root of the problem after
a few spoken words and make comments and guesses impatiently.

Functions of listening

1. Listening shows that people understand or try to understand you.

2. Listening encourages you to see what other people tell you and to be aware of your own
experiences

3. While listening, you can create openness both for yourself and the speaker. This will reveal some
important issues in the situation and the problem. This will also lead to openness regarding the
situation. As a result, you can raise some awareness to help others solve their own problems.

Principles of Listening

Listening should show genuine attention. It is not possible to have an understanding of the
conversational issue through pretended listening. Open statements are needed during listening. This
will allow us to understand the purpose of the listener.

Eye contact:

It is a way to show we pay attention and show interest to the other person.

Show your interest though your body posture

Your body posture will impress others. It is very important that you have an open posture and your
body faces the other person.

Encouraging talk

The important points in this section can be clarified with two examples: While talking on the phone,
you expect the other person to indicate attentive listening using affirmative words such as yeah, yes.
This sort of affirmation though verbal and non-verbal behaviour is also important in face to face
communication. It encourages the speaker and also helps the listener to follow the conversation.

Asking for clarification for lack of understanding

Asking for clarification when you have not understood something is not perceived negative. On the
contrary it produces positive outcomes. We can try to clarify some issues through confirmation checks
such as "What did you mean exactly?" or "could you tell me what the important point is?"

Do not hesitate to ask about the details of the problem

While talking to somebody, try to understand exactly what they mean. Listen and ask for the details
through questions such as "What kind of experiences did he/she enjoy?, What does he/she expect?',
Does he/she have any fears? These sort of questions will help if you want to find out what the exact
problem is? Instead of trying to elaborate on what you have told, lısten to the other person because you
will only find out what the he/she means through listening. You need to be an active listener for not
only understanding the messages conveyed but their contextual and emotional meanings. Questions
should be posed only to understand the speaker not to satisfy the listener's curiosity.

Summarizing the present

When especially jumping from one topic to another or diverging from the topic, it is important to put
the conversation together in a summary form.

Control your feelings

Everybody's opinion is right for himself. You should be able to accept this point even though others'
opinions are different from yours. Being overwhelmed by your opinions, you may not hear what the
other person is saying.

Never hurry up

Do not act in a hurry while listening. Checking the time or tidying up indicates impatience when you
talk to people stuttering or groping for words.

Frequently made mistakes

Inattentive listening

Among the effective listening behaviours are eye contact and attentive listening. Sometimes people
watch TV when somebody is talking to them. Some do not reveal any facial expressions. These are
examples of some ineffective listening behaviours. Another ineffective listening behaviour is to get
engaged with another activity while somebody is talking to you. For example playing with a pen or a
paper clip or doodling.

Failure to allow others to finish conversation

Another frequent mistake while listening is to interrupt others before they have a chance to finish their
speech. This usually occurs when we know what the other is going to say and when we think it is
unnecessary for the other person to continue. Another reason is that we prefer to hear what we say
instead of listening to others. This happens when the topic of conversation is emotional and relevant to
our personal life. This is also common in group discussions when people do not allow to finish each
other's conversation. People may wait for a short time, but afterwards they will get a chance to
interrupt.

Beginning to tell our own story: One of the characteristics of listening is to provide the
opportunity for someone else to tell their story. This story is sometimes unavoidable because
it reminds us of our relationships and certain other things. When someone tells you about the
emotions they experience and ask you how you feel about it, you tend to say that you have
also experienced something like that and then tell your own story.
Inability to remember: You may not be interested in the other person s story, and may not
be able to continuously keep that information in your memory. We often experience
inadequacies in telling other people that we are not in a position to listen. We give them the
opportunity to talk and murmur something in return, pretend to be listening but in fact, can
not. If you do not have time or if you do not feel well enough to listen to someone, it is best to
tell them. Listening behaviour should always be practiced genuinely.

Categories of Listening: There are a variety of listening categories. The most widespread is
“apparent listening”. Sometimes, the person opposite you looks as if he\she is listening on
the outlook but their inner world is somewhere else or has a more important issue on their
mind than what you are saying. Some people are not interested in things other than what
they will say or have said. You would think they talk to the person in front of them. They
appear to be talking but are in fact not. The aforementioned is not a dialogue, but is the
person talking to themselves, a form of lecture. The society names this as “Lecturing”.

Some people only hear the part of what has been said which only interests them, and not the
other parts. Such listeners can be categorized as selective listeners. These people remain to
be “apparent listeners” until a word or an expression which attracts their attention is revealed.

EFFECTIVE QUESTIONING SKILLS IN INTER-FAMILY COMMUNICATION

QUESTIONING SKILLS IN INTER-FAMILY COMMUNICATION Total of 50
minutes

Theoretical Knowledge 20 minutes

-Theoretical explanations of the educator 20 minutes
Application 30 minutes
Group discussion and dramatization of the skills in effective questioning in 30 minutes
inter-family communication
Materials required
Paper, pencil
Projector, laptop

TARGETS:
1. Understanding the function of asking questions

2. Being able to discuss the importance of asking the right questions

3. Being able to discuss question types

4. Being able to ask new questions appropriate for the answers given

EFFECTIVE QUESTIONING SKILLS IN INTER-FAMILY COMMUNICATIONS

We can have more time for others and ourselves and gather more useful information related
to the issue by asking effective questions. In this way we can make our encounter more
effective. We can gather the correct information we need when we collect data by asking
questions effectively. The helping relationship with the family members develops with
questioning skills. We can obtain objective information focused on the family member with
appropriate questions. In provisions of a quality care for the family member or the individual
who need psychiatric help in the family, special data can be obtained by means of asking
appropriate questions.

Categories of Questions

Open-ended questions

These are questions that can not be answered with “Yes” or “No”. Basically, they are geared
towards understanding the individual’s views, thoughts and feelings in relation to a specific
issue. Their use is particularly appropriate at the beginning of the communication and makes
transition to the later stages of communication easier. Open-ended questions clarify
expression without any prejudgment. It is imperative to move onto complete listening with
open-ended questions in order to understand the person in front of us. This type of questions
is necessary for introduction to the issue and for changing it. We facilitate the spontaneous
expression of the patient’s story by asking open-ended questions.
Closed-ended questions
Open-ended questions are useful in moving onto listening and understanding in
communication. However, there can be unclear emotions and thoughts within the answers
given to an open-ended question which require clarification. In such situations, closed-ended
questions come into play in order to clarify the concepts provided in a general and unclear
manner or to gather relevant information. Closed-ended questions are used with the aim of
clarifying unclear concepts which can be interpreted in different ways. Closed-ended
questions are important in the provision of clarity to the information transferred. Such
questions, which transform the information transfer to data, should be asked without too
much detail and should not be threatening.

1. The questions we ask should be in such a way as to reveal all the necessary
details within the encounter. The place, quality, quantity, chronology, environment,
conditions and the variables related to the issue should be clarifying.
2. The questions asked should be understandable by the person in front of us.
Medical language should not but a simple and clear language should be used.
The answer to a question should not be obviously present within the question.
“You must be feeling happy for being released from the clinic?”. “You must be in
belief that children should not be smacked?”.
3. The questions should not be directed at overcoming our curiosity; piercing
questions should not be asked. “Why did your husband leave you?”.
4. Numerous questions should not be asked at the same time. “Have you conformed
to the suggestions I made?, Have you been careful with your diet?, Did you go for
your check-ups?”
5. The questions should not start with expressions such as why and what for. The
family member should not feel that he or she is being questioned. “Why didn’t you
come for your check-up all this time? Why are you not following your diet?”

The questions we need to ask ourselves before we pose it to someone else.

WHY did you choose this question?

WHAT exactly did you want to ask? HOW did you want to ask it?

TO WHOM do you want to ask?

WHEN should it be asked?

WHERE should it be asked?

Questions which does not involve personal interest

The person is prevented from talking about his/her personal life unless it is absolutely
necessary. The interest indicated by health service staff can be professional, not personal.
For example, health service staff might be interested in knowing whether or not the patient’s
wound has healed, the abscess has got better, his/her situation has improved. Interest in
such matters indicates that the health service staff cares for the patient (counseled
individual), is interested in the patient, and is following the improvements in the patient’s
condition. Such attitudes contribute to the patient’s well-being and self-worth.

“Why did your wife leave you?”

“Why aren’t you still married at this age?”

Such questions are not appropriate since they are directed at satisfying the curiosity of the
person asking the question rather than gathering information about the individual being
counseled. However, if you need to gather information about such issues, it would be more
appropriate to reformulate the questions above in the following manner:

“Would it be useful to talk about your wife’s leaving?”

“What do you think about marriage?”

FAMILY INTERVIEW QUESTIONS

Family Interview Questions Total 50 minutes

Theoretical Information 20 minutes

- Educator’s theoretical explanations 20 minutes

Practice 30 minutes
- Presenting family interview questions to the group 30 minutes

Required Materials:
- Paper, Pencil/Pen
- Projection Equipment
- Lap Top

FAMILY INTERVIEW QUESTIONS

These sample questions below have necessary qualities to submit for the health care personnel during
the interview. It is necessary to remind that open-ended questions has advantages on patients who has
high-functioning level. But, close-ended questions which we can answer with “yes”or “no”, are
advantageous for deorganized patients with low-level of functioning. However, close-ended questions
can include an extra questions, such as “Can you give me some more details about it?” in order to gain
more information about the patient.

PSYCHOLOGICAL DIMENSION:

1) Do you have any specific problem that you think on frequently and openly lately?
2) Is there any relationship between your current problem and your problems from the past? Do
you have any example for it? Is this example close to your conflicts with your parents in the
past?
3) Did you experience many changes in your life lately?
4) How you view yourself now? Did your experiences effected your self-esteem?

SOCIAL DIMENSION:

1) Do you usually spend many times with other people?

2) Do other people respond you in a different way?
3) Is there any changes in your close relationships lately?
4) What are your friends thinking about your situation?
5) Do you criticize yourself much?
6) What do you think about the things that you can be with in this life (on the earth)?
7) Do you feel that, other people are responsible from your problems today?
 8) Are you behaving with other’s influences or with your own values?

BIOLOGICAL DIMENSION:

1) Does any member of your family is experiencing the same or similar problem with you? Did
any member of your family hospitalized because of having a psychiatric disorder?
2) Do you notice any change in your appetite and sleep lately? Do you experience an excessive
sadness and happiness lately in your life?
3) Did you have any extreme experience in your life which you had difficulty in explaining to
others? Do your thoughts seem that are changing very rapidly or very slowly from general?
4) Have you ever had the feelings of not having control of some of your thoughts?
5) Do you feel yourself under pressure because of other’s expectations from you?
6) How often (and how much) do you drink alcohol? Do you use any other substances? Do you
have any problem related with alcohol and other substances?
7) Are you using any recommended/prescribed drug?

CULTURAL DIMENSIONS:

1) How different is your life now from the time when you were raising? Do your family and your
friends have problems that you can be able to understand and advise?
2) How were the responses of people from your previous culture which you were living in for
these kinds of problems? How they are explaining this kind of situation and how they feel
toward it?

BEHAVIORAL DIMENSION:

1) Do you have any specific behavior which causes problems in your life? Do you have any
behavior that you want to stop or prevent yourself not to do it? Do you have any difficulty In
case of behaving in a manner which you really don’t want to do?
2) How others respond you? Is it easy to have a friend?

PSYCHOLOGICAL (SPIRITUAL) DIMENSIONS:

1) Do you believe that you have any superior or exalted power for something? What is your view
on these kind of feelings and beliefs?
2) Does your religion in this life (on the earth) can be able to understand you?

EVALUATION OF THE EMOTIONAL STATES OF THE INDIVIDUALS AND THEIR

FAMILY MEMBERS
Evaluation of the emotional states of the Total : 50 minutes
individuals and their family members
Institutional Information 20 minutes
- The conceptual acknowledgements of the 20 minutes
educator
Application 30 minutes
-The discussion of the evaluation of the emotional 30 minutes
states of the individuals and their family members
in the group
Necessary materials: Paper, pencil, overhead
projector, laptop

GOALS
1. The properties of the emotional state evaluation
The Emotional State Evaluation(ESE)
The ESE is a recognition tool from the medical view.The aim of the evaluation is to define the
psychopatalogical symptoms and then to evaluate the emotional states of the patient/applicant as well
as his/her mental and emotional functions. This tool is very efficient in defining the patient’s acute
psychotic characteristics and, also, in making a distinction between his/her functional states and
organic states.
As in all other data collecting and evaluation tools, ESE can be best realized when the applicant’s
history is connected with his/her sociocultural status and physical condition. Nurses should prepare the
ESE questionairre according to the patients’cultural background, personality, needs, desires, and
interaction levels.

a) Projective Tests:
Projective tests are organized by focusing the verbal expressions of the patients on their interpretations
of some vague shapes, and these tests project the patient’s mental functions. Projective tests define the
samples of the non-standardized thoughts and also the behaviors which are based on real or predictory
situations.

APPEAREANCE: General appearence, psycho-motor behaviors, attitude and speech, posture, is

observed and evaluated and finally, recorded as the general impressions.

BEHAVİOR: Speech samples, tone, slang usage, fluency, eye contact, body language, and reactions to
the environment and other stimuli are observed and compared with the behavioral data of the
applicant.

ORIENTATION: The awareness of the reality of the connection with other people, places, time and
situations is observed with direct questioning.

MEMORY: Previous memory, recent memory, and far memory is evaluated through direct
questioning.
SENSUOUSNESS: Sensing the inner and outer stimuli, concentration, getting interested in things is
evaluated through direct questioning.

PERCEPTIVE PROCESS: The examining of the data obtained perceptively, involves self-awareness
and the thoughts of others, reality and fantasy.

b) Personality Survey Forms:

Personality Survey Forms measure the attitudes, habits and tendencies behind the actions, and they
are objective tests which are standardized. They are generally in the form of questionairres.The
difficulty of these surveys come from asking the questions in artificial situations and necessity of
choosing the answers from the given,limited answers.These can create cultural bias. However, thses
tests consist the secure samples of the potential acts and opinions.

c) Intelligence Tests

Intelligence Tests measure the mental functions in verbal and non-verbal levels.These tests are
standardized according to the age. Generally, the effects of the individuals’ sociocultural
characteristics on the logic can not be evaluated in intelligence tests.The aim of the intelligence tests is
to identify the role of the mental functions causing the problems in the mind of a patient.

Orientation:
1. Have you ever had any problems with realizing where you are or what is happening around
you? Can you tell where you are now?

COGNITIVITY:
 1. Are you worrying for yourself?

Memory
1. Do you remember what you have had for breakfast this morning?
2. What was the day yesterday?

The content of thoughts:

1. Do you have any recent thoughts which are reoccuring to you often?
2. Do your thoughts travel in your mind slower or faster than usual?
3. Do you feel like empty-minded lately?
4. Do you experience any problems with proceeding or understanding your thoughts?
5. What is my name?
6. What is the name of the college that you graduated from?

Sensitivity:
1. Do you have any concentration or focusing problems? Can you read a book or watch a film till
its end?
2. Do you experience any problems while you are communicating with others?

Perception:
1. Are there things that other people can not see or hear, but you can do?

Pages 30-32
2. Do you think you have extraordinary abilities and experiences recently?
3. Do you believe there are some people who say completely wrong things? Do you believe
there are people who try to hurt you?
4. Are there any situations lately in which you see a person like a shadow or something as it
is something else?

Insight:

1. What do you think is the real problem for being here today?
2. How do you interpret the situation at the moment and what are your feelings about it?

Criticism:

1. What would you do if a policeman stops you for an exceeding speed?

2. What would you do if you received a 10.000 dollar check from mail?

Nature and Affect:

1. How would you define your recent emotional-condition? Are you more emotional or less
emotional compared to the normal situation?

History:

1. How many sisters and brothers do you have? Where were you born? When you were a
small child how were your parents like? What do you remember about your childhood?
 2. Were you successful in your school life? What was your success level? Were you playing
too much (a lot) with other children? What were the things that you liked at home? What
was your primary school like? What did you like about it? How were your grades? Did
you have any problems?

3. Lisede size neye okudunuz sorusunu anlayamadim

Intellectual Knowledge:

1. What is the name of your mayor? What is the most important recent news?
2. Can you deduct 7 from 100 until I say “stop” (can you count 7 by 7 backwards starting
from IA)?
3. What do you understand from the saying “It does no good to cry over a spilled milk”?

Result:

1. Is there anything you want to tell me which will help me to understand you better?
2. Is there anything you want to add to this session? Can you tell me what this session is like
or mean to you?
3. Are there any questions you want to ask me?

Counseling with the Family

Counseling with the Family Total 50 minutes

Institutional Information 20 minutes
-Institutional information given by the educator 20 minutes
Application 30 minutes
-Group discussion between the family and the 30 minutes
counselor
Necessary Materials
Paper, pens/pencils
Projector, laptop

Goals:

1. Being able to explain the principles of counseling.

2. Being able to apply the principles of counseling.

COUNSELING

Counseling can be defined as providing help to the applicants who need help by those who experts in
the field to encourage the individuals applicants to gain the necessary knowledge and skill to become
conscious about their own ideas, choices and decisions. The aim of counseling is:

- to provide information to the applicant and the family

- to provide answers to the questions of the applicant and ease the worries
- to explain what the applicant’s next step will be
 - to give information about any possible unpleasant situation(s)

-Duration of Counseling

Counseling must be provided confidentially under a comfortable and secure environment where the
member(s) of the family feel secure and the communication techniques are used effectively. This
environment must be quiet and clean and it must have appropriate lighting and heating.

Characteristics of the Counselor:

The counselor must be reliable and protect confidentiality of the individuals. The counselor must
possess the essential knowledge. The counselor must be able to use the communication skills
effectively. Principles of the counselors are:

- to treat the family member(s) well

- to create a strong communicative environment
- to give appropriate information to the family member(s) when necessary
- to help to the family member(s) to understand and remember

Counselor Evaluating the Interview (Session) with the Family Member(s)

Pages 33-35

Did the counselor form proximity/communication with the client?

Did the counselor reflect the client’s feelings?

Did the counselor share the client’s feelings?

Did the counselor communicate with the client without any judgement?

Did the counselor form an association between the stressors and the client’s emotional

responses?

Did the client and the counselor agree on the definition of the problem?

Did they understand each other about the definition of the problem?

Did the counselor allow the client to talk and define himself/herself clearly?

Did the client reach the helpful choices or solution at the end of the session?

Intervention to the individual or family having the crisis

Intervention to the individual or family having the crisis Total 50 minutes

The Theoretical Information 20 minute

The theoretical explanations of the trainer 20 minute

Application 30 minute

Discussion with the group about

the intervention to the

individual/family having the crisis. 30 minute

Necessary Materials

Paper, pencil, projector, laptop

Aims

1. Understand the crisis’s reason

2. Understanding of how to deal with the individual/family with appropriate

3. Direct the individual or family, who having the crisis to the proper place

Intervention to the individual or family having the crisis

Crisis is the position that an individual’s mental state needs to be restructured again, and it is

the temporary situation that the individual’s expectations from himself/herself suddenly

change. Even, it can be defined that it is a turning point in our life. The crisis threats the

individual/family, and destroys the balanced situation. If the individual can not cope with the

problem, this creates an opportunity for the personal development.

Caplan defined four steps, which lead the crisis.

1. Individual is face to face with the crisis’s situation. Individual uses the past

experiences to cope with the tension and the anxiety.

2. The crisis situation continues cause of anxiety and creates tension.

3. It is used urgent problem solving mechanisms. The individual looks for help. All

the internal/external resources are started to move/activate. The problem is

redefine again if it has any similarities with the past experiences. Individual

organizes himself/herself according to the problem and can abound some of the

goals. Sometimes the problem is solved and balance is provided. If they can not

solve the problem, the tension starts to increase and individual might have of

depression.

4. It will be resulted with the active crisis if the problem can not solved and continue

to increase. In this crisis situation the individual feels himself/herself helpless and

h/s can not know what h/s can do. The individual’s emotional state might be

destroyed. Using of inappropriate coping strategies to decrease his/her tension

might risk his/her future social functioning.

After the crisis was happened, it can be finished during the 2 days or 2 weeks. Mostly,

the crisis takes place 24-56 hours, but sometimes it can be continue 5-8 weeks.

Every individual can live the crisis situation during their life. The individual, who is in

the crisis situation, it does not mean that has a psychological problem. The individual

does not have pathology that leads the diagnosis. Individual can live temporary

tension because of the conditions that h/s is living. Baldwin defined six different types

of crisis to provide a plan for care and evaluation.

Specific Crisis: In this situation individual faces with problem which is appear /come

up with the result of specific situation. For example, individual has an alcoholic wife.

Vital Crisis: This crisis is divided form the specific crisis because they are related with

the psychological problems. To be a partner and father, divorce and cronical illness

can be given as an example.

 Traumatic stress crisis: They appear when individual can not wait or control any kind

of situations/conditions. The unexpected death of family members, natural disaster,

and rape are traumatic crisis.

Developmental Crisis: Developmental crisis appears when individual could not solve

the problem which is happened in the past. For example, addiction, value conflicts,

sexual identity conflicts.

Psychopathological Crisis: Refers to crisis, which have happen at the end of the

previous psychopathology, such as neurosis and personality disorder.

Psychiatric Urgent/Emergency: In this crisis the individual’s psychological, social, and

emotional functions are seriously destroyed.

For instance, like attempted suicides or acute psychosis circumstances.

The Interference to the Crisis

There are two aims interference the crisis. The first one is to reduce the pain of the individual and the
environment with an immediate first aid and the second aim is working to increase individual’s power
of harmony and fight during the crisis.

Crisis in the work of the first step is to define the meaning of ‘crisis’ for people and for the relatives of
them. The crisis assessment of the present time problem story begins with the involvement.

“When have these symptoms started? How are they defined by the patient? What has begun in the
patient’s life at the same time?”

Receiving information about the past story and the coping with mechanism:

“Has the similar crisis incident been experienced before? Are there similar crisis situations in the life
of important somebody for the patient? How did the patient cope with out the past crisis situations?
What are the results of using the present dealing with methods? Is there anybody who causes to
continuing of the problem?”

The social support level assessment of the family

“To whom did you apply during the crisis? Who is the most important and available person in the
individual life? How is the home environment? How is the patient's business environment and social
environment?”

Some ways should be followed to explain the crisis situation by the nurse.

The Therapeutic Intervention Approaches to the Family

Psychodynamic and Insight Oriented Approaches

The fundamental concepts of this school have been taken from the individual patients’ psychoanalytic
treatments. The family now existing problems are explained by unconscious conflicts of the man and
woman and associations of the reflections stemming from the family in the past. For example, a
mother who finds the world unsatisfying with her unconscious conflicts can place her own child in a
feeling of desperation and guiltiness to fulfil her narcissistic delight. Three criteria are suggested
psychoanalytically to be considered for a family therapist. The first one is the assessment of the
dynamics of the relations between people based on the psychoanalytic theory. The second, the
awareness of the respondents for their unconscious conflicts and providing the possible solutions for
them. And the third is therapeutic framework is the fact that psychoanalytical.

The family therapists using this approach aim to make a change on the family system to help the
individuals and couples to gain insight by using confrontation, interpretation, clarifying techniques.

Thanks to this therapy, it is aimed to provide the autonomy and the proximity needs of individuals in a
more advanced form, to enable having more empathetic relations, to decrease emotional reactions and
to advance cognitive mechanism.

The Structuralism Approaches

In the structuralism model, the family system interplays various and more complex behaviour patterns
which is accepted as a whole integral. The family therapy is a helpful theory tries to understand the
complex patterns of behaviour processes. 3 basic concepts of this theory as follows:

1. Family structure
2. Lower systems and
3. Borders
The family structure is ingrained behaviour patterns occurred as a result of the family behaviour
patterns. It also supplies the interaction between family members by putting arrangements related to
this relation. The structure of a family of the system completes its functions with the infrastructure
systems formed by the individuals. Within a family each individual on his own is accepted as a lower
system, three general lower systems can be mentioned about. These lower systems are; husband and
wife sub system, father and mother sub system, brothers and sisters sub system. There is a border of
existing subsystems and systems. The borders are divided into three dramatic borders regarding
solidity, uncertainty and certainty according to how much emotion and knowledge will be conveyed
from a lower system to another; who has a relationship with whom and how. Due to the lack of
permeability between lower systems and systems restricted by solid borders, the individuals cannot
assist each other and cannot learn despite having independence. If it remains uncertain border a kind
of inside to go through appears and although the infrastructure systems/systems help each other,
learning another they cannot protect their haecceities and differences. On the other hand, in the
families who have considerable border characterics, the individuals remain split succeed to have a
relationship without breaking out from each other. To the situations in which the limitations and
hierarchy are destroyed as an example of over protective, supervisory parents’ sub-system and passive
or rebellious child a family structure may be given. It aims to increase of the structuralist therapeutic
parental intervention in relations and sorting triangulation out. Among the techniques used can be
respected animation, focusing and the creation of border. During the therapeutic intervention in the
family of problems of the revival, representing the problem of a situation and refocused on
clarification of borders (daughter of for example speaking on behalf of the mother, daughter to help
but where it's daughter that he should do to speak) are provided.

Cognitive-behavioural Approaches

This therapeutic approach intervenes in the learning principles. Communication skills, problem
solving skills, consolidating bilateral and computational conditioning techniques are used. Therefore,
rewarding the appropriate behaviour with a prize, unrewarding the inappropriate ones is one of these
techniques. The focus of the initiatives is the behaviours that cause to problems. A nurse who is expert
at communication teaches the family members to describe their opinions and behaviours in a clear
way. Problem solving consists of five phases: identification of the problem, the determination of the
goal, making a proposal of possible solutions, application of these proposals, and assessment of the
results. For behaviour changes positive reinforcements and home tasks are used.
Pages 39-41
Strategic Approaches

The approaches focus on the complaint or the problem that causes the rise of complaints in the family.
According to this approach some reason of the symptoms are failing to solve problems, inability to
adjust to changes life brings and malfunctioning hierarchy in the family. In order for the family to
solve the problem they have to change this pattern and adopt a new pattern. This goal entails sub-
goals, prevention of strong feedback, changing the continuity of the symptom with new results and a
clearer definition of hierarchy. Family structure is kept intact; yet the family is free to reorganize itself.
Reframing the problem, behavioral assignments are some techniques used to provide change.
Communication-language and meaning are especially important in this approach.

Systemic Approach

Family is a system of information exchange and active communication. The fact that psychological
symptoms are related with the individual’s social environment is emphasized, which helps treatment.
Psychological problems arise from the system and the people sharing the same system in which the
individual lives. In etiological approach, members of the family or malfunctioning family are not
responsible for the symptoms, it is rather tha “family game”. The family is imprisoned in the vicious
circle of permanent interactive patterns. This approach takes for granted that the systems evolve and
improve, yet they appear to be stable. Systemic treatment helps the family develop an ability to change
and frees the family’s potential for change. Instead of forcing the family to accept external solutions, it
helps them develop their own solutions.

Experimental/Humanistic Approach

This approach defines family as an interactive communication system among the individuals.
Communication demonstrates whether a family is healthy or not.Although communication is rather
comlex, it is regarded as based on learning. This treatment also emphasizes self-respect.
There three communication levels:

1. meaning (verbal communication/ words and meaning)

2. Association (body language and the voice carrying the message)
3. environment (where communication takes place and when)

Apart from these there five types of communication between individuals:

1. Consolation: the self is not important, what’s important is the environment and the others.
Here the individual agrees with everything.
2. Accusation: the others and the environment are not important, what’s more important is the
self. The individual holds everything and everybody, even his/her own existence accountable.
3. Logical communication: the self and the other are not important, the environment is more
important. In this type of communication, the individual is strict, objective and obssessive
compulsive.
4. Indifference: the self, the others, the environment are not important. The individual simply
does not communicate.
5. Proper communication: the self, the others and the environment are important. The first four
of these communication types are used by malfunctioning families.

The treatment has two goals: First, it helps every member express his/her feelings about
himsel/herself and the others in the presence of other people. Secondly, it helps decisions made
through negotiation/research rather than through force which is more appropriate in a self-
respecting environment.
 Educational approaches

New studies stress this approach. The families of the patients are told that they are not responsible
for the problems just as they can’t be held responsible for illnesses such as diabetes or high blood
pressure. Informative model replaces etiological-patogenic model. Workshop, texts, guides are
used in informing. These approaches are applied in psychological cases as well as child
development and communication.

The characteristics of Treatment

Family treatment comprises of meeting of all the family members and their interaction with the
nurse. Some nurses find it helpful to bring all the members of the extended family (such as
grandparents, uncles, aunts, et cetera) together and some think that single individual or the core
family can be treated only because dealing with individuals and relationships is more important. In
the treatment of a marriage, the couple (married or not) is treated together. It is important for the
therapist or therapists and those who conduct the treatment to cooperate.

The nurses who treat the family must have the ability to sympathize, must have psychiatric
knowledge, must be strong enough to take complications and must be eager to contribute to and
influence the process of treatment.

During the evaluation phase, the nurse talks with a group who has a common past. Therefore, she
has to understand the values of the family and their way of communication. She can use some
techniques such as speaking the same language with them, emphasizing and praising the values of
the family as a whole or each member, interactive questioning instead of judging (for eg. She can
ask ‘when your wife does that, what do you do’ type of questions), which help her communication
with the family. During the evaluation phase each member is asked to describe the problem and
the history of the problem from their own perspective. The members should be all asked the same
question. They are asked to use the “I” language. Each is asked to suggest solutions. When they
talk to each other, it must be observed whether what they say is heard in the same way or not.
Role-changing and psycho-drama are very helpful in understanding the ways in which the
individuals are affected by each other.

By observing the way individual people interact in the nurse consultation room, he specifies and
comments on the problem. This sort of comment is usually one that turns the negatively impacted
behavior to a positive one, providing a new perspective, focusing on the functional use of the behavior.
In this way, the technique helps alleviate the impact of negative emotions in people and enables them
to change. In family therapies focus should be on behavioral patterns. The individual behavior of the
family members results in interactive changes in others. The period of change will materialize in the
recognition of the consecutiveness of behavioral patterns.
During the therapy the family is assigned certain homework which would help the individual members
change. The homework intends to track down and show that they can be held in check.
The nurse should also be an influential guide during the family consultation. For instance, she may
propose certain changes in the way family members sit, the way they can communicate, and be
prohibitive and restrictive in domestic violence. She might as well suggest that arguments should be
limited to a certain time period and make sure that they can actually manage the problem.
Communication skills are actually of crucial importance in enabling changes in behavioral patterns.
Clear and lucid communication, the ability to ask questions are of methods will help with the way
people understand what they each mean what they say. The nurse should set a good model that would
provide family members with communication skills.
Family Evaluation Form
1. Demographic Data

2. Roles Rules and Relations

 Decision-making pattern,

Communication pattern

Rules and roles

3. Socio-economic and cultural factors

Health care provision status

Role, responsibility, values,

Relationship between religion and health

Value system

4. Environmental Factors

5. Health and health history

Health and sickness history of the family

Whether the family seeks for health care

The way the family perceives health care providers

Health priorities of the family.

6. Risk Families

Family with multiple problems

Unhealthy family (dysfunctional)

Immigrant Family

Unregistered family

Family with chronic illnesses

Aged family

Family with no socio-economic means

Family with domestic violence

7. Evaluation of Domestic Violence

Molested, abused children: observation of the problem, frequency of violence, and treatment
Molested women. Observation of the problem, personality traits of the woman,
sources/action.
Molested elderly: observation of the problem, characteristics.

PSYCHO-EDUCATIONAL NURSING PROTOCOLS FOR FAMILY AND INDIVIDUAL

1. Seeking for informed approval and suitability

Participation of patients

The way the family members define the patient

Permission (Approval) of the family members

2. History based on records (information)

Days of hospitalization within the last year

Number of hospitalization

First hospitalization.

Health checks since the last hospitalization (clinical records)

Psychiatric diagnosis

Nurse diagnosis

Medical history, anamnesis,

Other medical problems.

3. Clinical Evaluation of the patient

The way the patient perceives the illness

The way the patient perceives the causes of hospitalization

Recognition of the symptoms by the patient

The methods the patient discovers in handling the symptoms

The patient’s reaction to the illness

Diagnosis of the nurse

Psychiatric symptoms (scale of symptom evaluation)

Patient’s objective

Patient’s social and leisure activities.

4. The visitation of the family member (upon consent)

The way the family member perceives the illness

The way the family member perceives the causes of hospitalization

Recognition of the symptoms by the family member

The methods the family member discovers in handling the symptoms

 The family member’s objectives vis-à-vis the treatment

The time the family member allocates to the patient

The family’s reaction to the illness

The way the family perceives social and leisure activities and
expectations

5. The information synthesis of the expert clinical nurse and psycho

educational practice

Reciprocal Objectives for psychological training (Patient, family planning

and evaluation of the clinical nurse)

Planning and developing psychological training for the patient and the
family

6. Discharging the patient and its aftermath

Interdisciplinary discharge plan

Public health care, psychological health and contact with the nurse
during domestic healthcare.

Phone contact with the expert when needed

Annual evaluation after the discharge

Meeting the Family

14. Beginning the training with greeting principles (greeting the family)

15. Asking open-ended questions about the family member’s anxiety

about medication (Would you like to talk about your reservations about
medication? Do you have any problems with medication?)

16. Learning about the individuals who will provide the patient with
medication (What do you know about the drugs the patient takes?)

17. Supporting the family members correct knowledge about the drugs

18. Explaining to the family members lucidly what the patient takes
drugs and its effects in the treatment

19. Dwelling on the regular use of the drugs to optimize the effects of
the drugs (Explaining that the effects of the drugs will be marked after
a week or ten days)

20. Explaining that there is possibility that before the positive effects
the side effects may appear
21. Explaining the family that there will be changes in the daily routine
of the patient and rules the patient must abide by (driving, alcohol-drug
interaction, and delicate motor skills

22. Explaining them what to do when side effects appear (according to

the drug variety)

23. Advising them to certainly contact the doctor when the side effects
are serious (drug intoxication, acute distony)

24. Giving the family the opportunity to talk

25. Responding to the questions of the family

Concluding the meeting in accordance with the consultation principles

TRAINING THE PATIENT ABOUT THE DISCHARGE

1. Helping the patient express their feelings about the discharge (in
accordance with consultation principles)

2. Specifying the patients need for information

3. Explaining the patient status of the patient and effects of the

treatment

4. Explaining the functionality, role and responsibility and their effect on

the interaction with other people

5. Explaining how he will be living certain extraordinary circumstances

with the illness at home, workplace.

6. Providing information on cases which might increase the illness

(problems with the work and family life, ceasing to take drugs,
unavailability of spouse or friend support

7. Explaining the suitability of the other prescribed drugs and treatment

with other kinds of the symptoms

8. Explaining the symptoms of reappearance of the illness (sleep

patterns, eating habits, emotional changes, introversion, suicidal
thoughts or attempts, excessive uncontrolled behaviors)

9. Reminding that the patient should contact hospital when such

symptoms appear

10. Letting the patient ask questions

11. Responding to the questions

12. Concluding the consultation in accordance with the consultation

principles.