COMMUNICATION PURPOSE OF THERAPEUTIC

 A reciprocal process of sending & receiving  To allow the pt to express thoughts & feelings in a
messages between 2 or more persons & their meaningful way in order to promote health growth
environment; the vehicle for establishing a  To understand the significance of the pt’s problems
therapeutic relationship (Fortinash & Worret)  To assist in the identification & resolution of the pt’s
 Refers to the reciprocal exchange of problems
information, ideas, feelings, & attitudes CHARACTERISTICS OF SOCIAL & THERAPEUTIC
between 2 persons or among a group of persons COMMUNICAITION
(Taylor) SOCIAL THERAPEUTIC
WHO Friends, family, Therapist & client
COMPONENTS OF COMMUNICATION acquaintances
1. Sender Initiates the transmission of info SETTING Home, away from Clinical setting:
2. Message Info being sent & received work, any type of private, quiet,
3. Medium Method by w/c the info is sent (written, setting confidential, safe
verbal, tactile) environment
4. Receiver Receives & interprets the message w/c PURPOSE Maintain Promote growth &
has been sent relationships change in client
5. Feedback Measure by w/c the effectiveness of the Mutual sharing of
message is gauged info thoughts,
beliefs, ideas
MODES OF COMMUNICATION CONTENT Social talk, focus Therapeutic talk, pt
1. Verbal Refers to written & spoken messages on children, expresses
exchanged in the form of word as the vacations, family, thoughts, feelings,
elements of language leisure fear & identifies
2. Non-verbal Refers to messages that do not needs
involve the spoken/ written word, SKILL Uses a variety of Specialized
but are conveyed by behavior, such resources during professional skills,
as the presence/ absence of body socialization primarily TIC
language/ through any of the 5
senses CHARACTERISTICS  Superficial  Learned skill
FACTORS THAT INFLUENCE COMMUNICATION  Light, not goal-  Purposeful
1. Environment 2. Socio-economic status directed  Client-
3. Relationship bet. the 4. Context in w/c the message  Spontaneous focused
sender & receiver is sent  Enjoyable  Client sets
5. Content of the 6. Knowledge level  Two-way, goals
message focusing on both  Planned
7. Family dynamics 8. Ability to relate to others send & receiver,  Difficult
9. Attitude 10. Own value perceptions giving  Intense
11. Ethnic background 12. Other life experience suggestions,  Disclosure of
advice; personal info
TYPES OF COMMUNICATION personal/ by pt
1. Intrapersonal Individuals give themselves all types of intimate  Meaningful &
positive & negative messages; self-talk relationship personal, but
occurs occurs not intimate
2. Interpersonal Occurs bet. 2 or more persons & relationship
contains both verbal/ non-verbal occurs
messages
a) Social Occurs in everyday OBSTACLES OF THERAPEUTIC COMMUNICATION
situations, usually away 1. Resistance Pt consciously/ unconsciously
from the work settings maintain lack of awareness of
b) Collegial Occurs among problem they are having to
colleagues in the avoid anxiety
professional work 2. Transference Unconscious response whereby
setting pt associate the therapist c
c) Therapeut Occurs bet. the someone significant in their lives
ic therapist & the pt
3. Countertransference Initiated by the therapist’s 5 TYPES OF TOUCH
emotional response to a specific Functional- Professional Used in examinations/
pt touch procedures
4. Boundary violations Occur when the therapist goes Social polite touch Used in greetings such as a
beyond the established handshake, air kisses/
therapeutic relationship gentle hand to guide
standards & enters into a social/ someone in the correct
personal relationship c the pt direction
Friendship-warmth touch Involves a hug in greeting,
THEORIES OF COMMUNICATION an arm around the
shoulder of a good friend/
RUESCH’S THEORY (J. RUESCH) back slapping to greet
 Communication is defined as a circular process friends & relatives
beginning c internal events w/in one person, Love-intimacy touch Involves tight hugs & kisses
transmitted to another & the other person, after being bet. lovers/ close relatives
affected by internal events, result in a response message Sexual-arousal touch Used by lovers
back to the original sender
FACTORS THAT MAY AFFECT COMMUNICATION THERAPEUTIC COMMUNICATION
1. Disturbed communication PURPOSE:
a. Interference c sending/ receiving messages  Establish TNCR
caused by the diagnosis, trauma/ physical  Client-centered goal
malformations  Assess pt’s perception of the problem; includes detailed
b. Insufficient mastery of the language actions of people involved & pt’s thoughts
c. Insufficient/ incorrect info about self/ others  Facilitate pt’s expression of emotions
d. Insufficient use of meta-communication devices  Teach pt & SO self-care skills
e. Inability to correct info through feedback circuits  Recognize pt’s needs
2. Anticipatory adaptation  Implement interventions
a. Momentary adaptation- the ability to be
 Guide pt toward identifying POA to satisfying & socially
effective at the moment a distressing situation
acceptable resolution
occurs
b. Leverage- the influence of the helping person on
VERBAL COMMUNICATION SKILLS
the pt
1. Using concrete messages
2. Using therapeutic communication techniques
DOUBLE-BIND COMMUNICATION
3. Interpreting signals/ cues
(Bateson Group)
 The simultaneous communication of conflicting NONVERBAL COMMUNICATION SKILLS
messages
 verbal= 1/3; non-verbal=2/3
 active observation- observe speaker’s non-verbal actions
KINESIS
while communicating
 The study of gestures, body languages & movements of
1. Interpreting facial expression
people when they communicate. Kinesic behaviors are
a. Expressive face
gestures/ body languages that convey meaning in
b. Impassive face (apathetic)
communication
c. Confused face
PROXEMICS
2. Interpreting/using body language
 Study of distance zones, between when they a. Closed body position-(ex. crossed legs/arms)
communicate c one another indicates the listener is threatened & is
TOUCH offensive, the nurse/pt who does the crossing of
 Conveys energy & meaning such as warmth, affection, legs signals he/she is rejecting the interaction &
empathy, understanding, restraint, reassurance & is guarding a potential invasion of the lower
emphasis body
 Therapeutic touch is a touch c the intent to heal b. Open posture- sitting facing the pt c both feet
on the floor, knees parallel, hands at side of
body, legs uncrossed/ crossed only at the ankles.
This demonstrates unconditional positive
regard, trusting, caring & acceptance. This can
 be done by the nurse slightly leaning forward reactions of pt gently do/ not do to meet
while maintaining non-threatening eye contact but directly pt’s needs
5. Redirection of needs
3. Interpreting vocal cues to more appropriate
Volume Speed (# of words/min) persons
Tone Circumstantiality
Intensity Pressured speech 3. Counter transference
Emphasis Slow hesitant responses  This happens when the nurse develops
counterproductive fantasies, feelings & attitudes in
4. Interpreting eye contact response to pt’s transference/ personality

THERAPEUTIC IMPASSES & THEIR SOLUTIONS

Therapeutic impasse Common Transference Reactions
 Roadblock in the progress of a nurse-client relationship 1. Boredom 2. Over identification
that arises for a variety of reasons & may take different 3. Rescue 4. Misuse of honesty
forms 5. Over involvement 6. Anger
1. Resistance
 Phenomena that interfere c & disrupt the smooth THERAPEUTIC COMMUNICATION TECHNIQUES
flow of feelings, memories & thoughts 1. Using silence Gives the pt time to collect
thoughts
Manifestations of Resistance(Keltner/Stuart) 2. Accepting Indicates that the pt has been
 Forgetting events  Falling in love c the understood
nurse 3. Giving recognition Indicates awareness of change
 Focusing on the past to  Suppression & & personal efforts
avoid talking about the repression of 4. Offering self Offers presence, interest, & a
present & vice versa pertinent desire to understand. Is not
info/intellectual offered to get the person to
inhibitions talk/ behave in a special way
 Consistently avoiding  Introduction of 5. Offering gen. lead Allows the person to take
certain topics crisis/ new direction in the discussion
problems 6. Giving broad Clarifies that the lead is to be
 Expressing antagonism  Flirtatious/ openings taken by the pt
towards the nurse seductive behavior 7. Placing the events in Puts events & actions in better
 Withdrawal time/sequence perspectives
8. Making observations Nurse calls attention to the pt’s
Strategies behavior
1. Encourage pt to talk 2. If repeated & 9. Encouraging Increases the nurse’s
about impulse rather dangerous, consider description of understanding of the pt’s
than act them out withdrawing from perceptions perceptions
the relationship 10. Encouraging Brings out recurring themes in
unless pt sets limits comparison experiences/ interpersonal
on these relationships
3. Encourage 4. Look for evidence of 11. Restating Repeats the main idea
identification of feeling transference expressed
before putting them to phenomena 12. Reflecting Direct questions, feelings &
action ideas back to the pt
5. Increase freq. of 13. Focusing Concentrates attention on a
contact single point
14. Exploring Examines certain ideas,
2. Transference experiences/ relationships
more fully
Intervention & Strategies for Transference 15. Giving info Make available facts the pt
1. Recognize 2. Limit setting need
transference 16. Seeking clarification Helps pt clarify their own
3. Examine Transference 4. State what you can thoughts & maximizes mutual
understanding between nurse
 & pt
17. Presenting reality Indicates what is real
18. Voicing doubt Undermines the pt’s beliefs by
not reinforcing the
exaggerated/false perceptions
19. Seeking consensual Clarifies that both the nurse &
validation pt share mutual understanding
of communications
20. Verbalizing the Puts into concrete terms what
implied the pt implies making the pt’s
communication more explicit
21. Encouraging Aids the pt in considering
evaluation people & events w/in his/her
own set of values
22. Attempting to Responds to the feelings
translate into expressed. Often termed
feelings “decoding”
23. Suggesting Emphasizes working c the pt,
collaboration not doing things for the pt.
encourages the view that
change is possible through
collaboration
24. Summarizing Brings together important
points of discussion to enhance
understanding. Allows the
opportunity to clarify
communications so that both
nurse & pt leave the interview
c the same ideas in mind
25. Encouraging Allows the pt to identify
formulation of POA alternative actions for
interpersonal situations they
find disturbing
26. Suggesting Presentation of alternative
ideas for the pt’s
considerations relative to
problem solving
27. Listening attentively Facilitated by maintaining eye
contact remaining related &
using appropriate touch
technique
NON-THERAPEUTIC COMMUNICATION TECHNIQUES
1. Reassuring Underrates the pt’s feelings &
belittles a pt’s concerns
2. Giving approval Indicates that what the pt is
doing now is “good” & implies
that nod doing it is “bad”
3. Rejecting May make the pt feel rejected
by the nurse because he/ she is
unable to express personal
thoughts & feelings
4. Changing the subject When the nurse changes the
topic, pt is usually threatened
by an anxiety-provoking topic
5. Giving literal The nurse feeds into a pt’s
responses delusion/hallucination, denies
pt opportunity to see reality
6. Judging Responses are filled c his/her
own values & judgments. It
demonstrates lack of
acceptance of pt’s differences
7. Making superficial Suggests lack of understanding
comments pt as an individual
8. Defending The nurse may believe he/she
must defend himself, the staff/
the hospital
9. Challenging Stems from nurse’s belief that
if pt is challenged regarding
their unrealistic beliefs, they
will be coerced into seeking
reality
10. Minimizing problem The nurse may use this when it
is difficult to hear the enormity
of a particular problem
11. Moralizing Passing judgment by using your
values as to what is right/
wrong
12. Probing Persistent questioning of pt.
tends to make the pt feel used
& valued only for what he can
give
13. Testing Improper appraising of the pt’s
degree of insight; may
communicate that the nurse
demands the pt to have insight
into his very lack of insight
14. Requesting an Asking the pt to provide the
explanation reasons for thoughts, feelings,
behaviors & events
15. Indicating the Attributing the source of
existence of an thoughts, feelings & behavior
external source to others or to outside
influences
16. Interpreting Seeking to make conscious that
w/c is unconscious, telling the
pt the meaning of his
experience
ETIOLOGY:  MANIA- mood is persistently elevated w/c lasts for a
I. BIOLOGIC THEORIES: week accompanied w/ at least 3 of the ff (pressured
A. Genetic theory speech, inflated self-esteem, flight of ideas, distracted,
Twins: Identical=50% psychomotor agitation)
Fraternal=15%  HYPOMANIA- mood is persistently elevated w/c lasts for
Parent 1 parent=15% 4 days
1 parent=35%
1. MAJOR DEPRESSIVE D/O
1st deg. Relatives: 3-10% 2. BIPOLAR D/O- “manic-depressive illness” extreme mood
Distant relatives: 3% swings from mania to depression
Gen. population: 1% a. BIPOLAR MIXED- alternate cycle
b. BIPOLAR TYPE 1- mania w/ 1 depressive ep
B. Neurotransmitter studies c. BIPOLAR TYPE 2- recurrent depression w/ 1
*Dopamine Hypothesis- “overactivity of dopamine” hypomania
3. OTHER RELATED D/O
C. Neuroanatomical theories a. Dysthymic d/o- 2yrs of usually depressed mood
*schizo is a brain disease w/ at least 1 sx
a. Enlargement of lateral & 3rd ventricles b. Melancholia/ endogenous depression- 40-
b. Atrophy in the frontal lobe, cerebellum & limbic 60y.o. & 3 or more of the ff:
c. Increase in the fissures on the surface of brain i. Insomnia
d. Decrease brain volume ii. Excessive guilt
e. Asymmetry of brain iii. Anorexia, wt loss, amenorrhea
iv. High suicide risk
II. PSYCHODYNAMIC THEORIES: v. Marked psychomotor retardation
a. Freud- “weak ego can’t handle conflicts from id” vi. Early awakening
b. Erikson-“trust v. mistrust” (child deprived vii. Depression worst in AM
nurturing” c. Cyclothymic d/o- 2yrs of numerous hypomanic
periods
Schizophrenia Subtypes: d. Substance-induced mood d/o- disturbance in
 Paranoid mood (alcohol, drugs, etc)
 Catatonic e. Mood d/o d/t gen. medical condition- because
 Disorganized/ Hebephrenic of degenerative disease & etc
 Undifferentiated f. Seasonal affective d/o- “winter depression”/
 Residual “spring depression”
g. Postpartum blues- after delivery
General characteristics: “ depression- w/in 4 wks after delivery
Alterations in thought pattern Loose association “ psychosis- w/in 3 wks after delivery
Difficulty abstracting
Ideas of reference I. BIOLOGICAL THEORIES:
Perceptual alteration Illusions A. Genetic theories:
hallucinations Monozygotic twins= 45-60%
Emotional response Restricted expression Dizygotic twins= 12%
Inappropriate affect Gen. pop.= 6%
Flat affect B. Biochemical theories:
Communication problem Difficulty communicating Decrease in neurotransmitter
clearly  SEROTONIN
Inappropriate response  NOREPINEPHRINE
Irrelevant responses
Neologism II. PSYCHODYNAMIC
Possible behavioral alteration Disorganized behavior a. AGGRESSION-TURNED-INWARD THEORY-FREUD
Peculiarities b. PERFECTIONIST- BIBRING
Catatonic posturing c. POWERLESS SELF- JACOBSON
Catatonic excitement d. DISTRESSING LIFE EXPERIENCE- MEYER
e. REJECTED BY PARENT-HORNEY
 III. COGNITIVE THEORY
stress reactivation
a. BECK’S TRIAD
i. Pessimistic view of self
ii. Pessimistic view of word
iii. Pessimistic view of future
DISTORTIONS ADDRESSED BY COGNITIVE THERAPY
EXTERNALIZATION OF SELF- Value based on other’s
WORTH approval
MIND READING Believing that one knows
the thoughts of others
MAGNIFICANTION/ Over exaggerate events
MINIMIZATION
DICHOTOMOUS THINKING Extreme thinking
(all/nothing)
PERSONALIZATION Akoon niya tanan
CATASTROPHIZING Thinking worst
OVERGENERALIZATION Forming conclusions w/o
basis
SPECIFIC ABSTRACTION Focus on minor detail
ARBITRARY INFERENCE Drawing specific conclusion
w/o sufficient evidence

 LEARNED HELPLESSNESS
 OBJECT LOSS THEORY- loss/ separation

PRECIPITATING STRESSOR:
 Loss of attachment
 Inhibiting factors (internal/ external)
 Life events
 Role strain
 Physiological changes

PROJECTION- defense mech. Being all high but low inside

TANGENTIALITY
SUICIDE BEHAVIOR
*15%- severely depressed
*25-50%- bipolar d/o
 SUICIDE IDEATION- idea
 SUICIDE THREAT- warning
 SUICIDE ATTEMPTS- action

S ex: men 4x
A ge: 19-45, 65 above
D epression: 35-79%
P revious attempts: 65-70%
E TOH(alcohol): 65 % successful
R ational thinking loss
S ocial support lacking
O rganized plan
N o spouse
S ickness