Therapeutic Communication Day 2. Objective #14 Discriminate between hearing and listening

Therapeutic Communication

Day 2

Objective #14

• Discriminate between hearing and listening

Becoming a better listener

• Hearing– Sensing sound

• Listening– “A process that involves sensing,

interpreting, evaluating and reacting to spoken messages.”

Stages of Listening

• Sensation• Interpretation• Evaluation• Reaction

Active Listening

1. Attention • Eye contact• Control

distractions• Focus • Observe

Active Listening

1. Attention2. Demonstrate

• Body language

Active Listening

1. Attention2. Demonstrate3. Feedback

• Paraphrase• Reflect• ?

Ask questions

• “The most important types of question you will ask are…–CLARIFYING QUESTIONS”

Active Listening

1. Attention2. Demonstrate3. Feedback4. Defer judgment

• Don’t interrupt

Objectivity

• “The process of remaining open…”

Active Listening

1. Attention2. Demonstrate3. Feedback4. Defer judgment5. Respond

Objective #15

• Relate how therapeutic communication differs from social communication

Style of Communication

Social• Family• Friends

Therapeutic• Client

Focus

Therapeutic• Client

Social• Equal

Therapeutic• Planned• Directed by nurse

Social• Spontaneity

Therapeutic• Confidentiality– Tx team

• Advocates• Do NOT keep

secrets!

Social• Mutual confidentiality

Therapeutic Communication

Client• Discloses

information

Professional• Emotional distance– Objective

Objective #16

• Define and describe the importance of each of the following:–Readiness skills, Attending skills, Active

listening skills, Reflecting skills: content and emotion

Readiness

• Establishing a therapeutic relationship• Choosing a quiet, safe setting

Attending Skills

• 90% Non-verbal– “You are important to me!”

#1 Attending Skills

• Four Basic Components:1. Eyes2. Posture3. Expressions4. Prompts

Attending RulesEye contact

Do• Make eye contact• Be culturally aware• Look at patient

frequently

DONT• Stare• Flutter • Darting

Attending SkillsPosture

DO

• RelaxedDONT

• Fidget• ?Notes?

Prompts

• Encouraging prompts–Non-verbal–Verbal

Encouraging Leads

NON-VERBAL• Head nods• Um-hum’s• Hand movements• Smile• Smile/head nod• A half-head nod• Puzzled expression

Verbal• “good”• “yes”• “ok”• “wonderful” • “I see”• “go on”

Verbal following

• Silent listening • Repeat few words

Verbal following - Echoing

• Finding a word or few words• toward the end of the senders

sentence/sentences • that you can use to encourage more

clarification or discussion.


• Patient: “about a week ago my wife left me.”• P.T. “Left you”? (slight questioning

tone)


• Patient: “My girl friend is great with my son. She has really been a life-saver to both of us.”• P.T. “Life-saver”?

• Think before you speak• Take your time. – “You are important to me. I

will be patient and consider my response”.

• Silence is OK!

Reflective (mirroring) Statements

• “Empathic communication”

• Convey interest

• Build rapport

• Help person clarify information

• Help person express feelings


• Only mirror client

• Don’t add!!!!

Responding Skills(action-oriented skills)

• “listen” for the feeling• reflect the feeling • feeling vocabulary


Feeling• “you’re

feeling….”

Content“… about ______”


Patient: (angrily) “why does everyone try to bully me? I can’t make head or tails of anything anymore”!

• P.T. “You’re angry about being confused”?• P.T. “You are confused about being bullied

and angry about that”?


Depressed Patient: “I feel like just sleeping or doing nothing but I can’t sleep at night though. It’s ridiculous. Maybe it’s because I worry too much”

• Feeling?• Content?

A response using reflection of feeling and content could be:

• Nurse: “You’re feeling really lethargic, but you can’t sleep?”

• (condensed version)

Responding SkillsExample

• Child: “I went to my grandma’s and she wasn’t home”.

• Nurse: “No one was home at grandma’s. You were disappointed.(?)”

Responding Skills example

• Patient: “ I hate being in this hospital”• Nurse: “I know that you just

arrived, I’m wondering if you’re scared and missing your family (?)”

Responding Skills example

• Patient: ”I don’t want any students looking in my chart”

• Nurse: “Could you be feeling embarrassed about someone you don’t know looking in your chart because you don’t know me? Let’s have a conversation to remedy that (?)”

Paraphrasing (Reflection of Content)

• Use our own words • Helps clarify inconsistencies

Intervention Skills:

• Intervention skills are as individualized as there are patients and various mental illnesses. Many interventions will be taught, discussed, and practiced in 3rd semester!

Perception Checking

Responding Skills Checking out perceptions

• Perception checking –prevent misunderstanding –Prevent conflict–Goal •Mutual understanding

3 partsPerception checking

• Description –Behavior

• Interpretation –Provide two possible

• Clarification–Request

ExamplePerception Checking

• “When you stomped out of the room and slammed the door…..”– (Describe behavior)

• “I wasn’t sure whether you were mad at me….”– (interpretation #1)

• “or just in a hurry” – (interpretation #2)

• “What were you feeling”? Or “what was going on”?– (request clarification)

Sample:Perception Checking

• Describe behavior• Interpretation #1• Interpretation #2• Request clarification

–Description–When you walked out of the room

without saying “goodbye...”–2 possible interpretations– “I didn’t know if you were mad at me”– “or if you were in a hurry and forgot.”

• Request clarification– “What was up?”

Objective #17

• Explain the concept of the therapeutic self.

Use of Self

• 1o therapeutic agent

Psychotherapeutic management3 interventions

1. Therapeutic relationship2. Psychopharmacology3. Milieu Management

Therapeutic listening

Therapeutic Use of Self

• Objectivity

Therapeutic use of Self

• Empathy–“ability to recognize & understand the

patient’s feelings and point of view objectively”

Compare & ContrastEmpathy

• Accurately perceives• Understand

• Objective

• Emotionally separate

Sympathy• Shares feelings

• Shared experiences• “Taking on other

problems”• Emotionally involved

Course Objective #18

• Describe and give examples of each of the following communication techniques and where they are commonly used in the nursing process.

Giving Information

• Making available facts the patient needs• Skill–Readiness

ExamplesGiving information:

• "My name is..." • "Visiting hours are..." • "My purpose in being here is..." • "I'm taking you to group. Here is

what you can expect today…”

ExamplesGiving information:

• “I notice you’re looking at my name badge, my name is ______ .. I’m a Psychiatric Technician student”

• “I notice your stomach was growling, can I show you the times for meals and the menu”?

Giving information

• “Susie is getting an echocardiogram right now which is a test that uses painless sound waves to create a moving picture of her heart structures and valves and should tell us what is causing her murmur”.

Giving recognition

• Acknowledging, indicating awareness

Giving recognition

• Better than a compliment• Skill–Readiness

ExamplesGiving recognition:

• “Good morning Mr. Jones”• “You’ve tooled a leather wallet”• “I see that you’ve made your bed”• “I notice that you are out of your

bedroom today”

Showing acceptance

• Giving indication of reception• Skill–attending

Accepting examples:

1. “Yes, I understand what you said.” 2. Making eye contact + nodding3. “I follow what you said”4. “Go on”?5. “And then”?6. “Tell me about it”

Offering Self

• Making one's self available

Offering self

SilenceTouchTime

Offering self

• I’ll sit with you awhile.”• “I’ll go with you to the cafeteria”• “I’ll stay awhile if you’d like.”• "I'm interested in your comfort."

Making Observations

• Verbalizing what is perceived• Skill–Reflecting

Making observations

• “You seem tense.”• “You are trembling”• "I notice that you're biting your lips.“• “You seem deep in thought” • "You appear more comfortable with me

today,"

General Leads

• Encouragement to continue• 1-2 words

General leads

• “Go on.”• “And then…”• “You were saying”• “And after that...”• “Tell me more…”

Broad openings

• Allows the patient to take the initiative in introducing the topic

• Empowerment• Readiness Skill

ExamplesBroad Openings

• "Is there something you'd like to talk about?"

• "What are you thinking about?" • "Where would you like to

begin?“• “What’s on your mind?”

Asking broad questions

–Open-ended questions•Cannot be answer with 1 or

2 words

Don’t close the question

• Tell me how your week has gone.• Did you go to see that movie last

night?

Encouraging description of perceptions

• Asking the patient to verbalize what he perceives• Helpful with–Hallucination

ExamplesEncouraging description

• “Tell me when you feel anxious." • "What is happening?" • "What does the voice seem to be

saying?"

Clarifying

• Seeking information to understand

ClarifyingExamples

• “Could you explain?• I’m not sure I understand?• The main point is?

Clarifying Questions

• Questions – clarify misunderstanding– continue conversation– ‘reflection’ techniques–Open-ended

• Avoid overanalyzing• Helps patient become more aware of

their feelings

Clarifying

• Pt - “There is no point in asking for pain medication”

• “Are you saying no one give you medication when you have pain or do you mean the medication doesn’t help your pain?”

Validation examples:

1. “What would you say is the main point of what you said”?

2. “Are you using this word to mean _____”?

3. “Does my understanding of this agree with yours”?

4. “Has the diarrhea stopped?”

Reflecting

• Directing back to the patient questions, feelings, and ideas• Helpful–Patient asks for advice

Reflecting examples:

• When the patient asks what he should think or do or feel, the nurse can ask….. “What do you think”? Or “What are your feelings”?

Reflecting examples:

• Patient: “Do you think I should tell my therapist”?• Nurse: “Do you think you

should”?

Reflecting

• Pt – “My sister won’t help with our mother’s care.”

• Nrs – “You feel angry. Have you discussed this with her?”

• Nrs – “I sense that you feel angry”

Restating

• Paraphrasing• Repeating the main idea

Restating

• Pt – “I couldn’t eat supper last night.”• Nrs – “You had difficulty

eating.”

Restating

• Pt – “I was awake most of the night.”• Nrs – “You have trouble sleeping.”

Restating

• Patient: “I can’t study. My mind keeps wandering.”• Nurse: “You have difficulty

concentrating”?

Exploring

• Delving further into a subject or idea

Restating

• Patient: “I can’t take that new job. What if I can’t do it”?• Nurse: “You’re afraid you will fail

in this new position”?

Exploring

• Helpful • with patients who remain on a

superficial level of communication

Exploring

• If the patient chooses not to delve –Don’t push or probing

Exploring

• Expanding –clearly –Insight–solutions

Exploring examples:

1. “Please explain that situation in more detail”2. “Tell me more about that particular

situation”3. “Tell me more about that”4. “Would you describe it more fully”?5. “What kind of work”?6. “What do you think your options are”?

Verbalizing the implied

• Voicing what the patient has hinted at or suggested


• Patient: I can't talk to you or to anyone. It's a waste of time. • Nurse: Is it your feeling that no

one understands?


• Patient: My wife pushed me around just like my mother and sister did. • Nurse: Is it your impression that

women are domineering?


• Makes less obscure• Be direct • Express only what is obvious

Verbalizing the Implied

• Helpful –Mute –Impaired verbal communication

Encouraging comparison

• Asking that similarities and differences be noted

Examplescomparison:

• “Was this something like……”• “Have you had similar experiences”• “How does this compare to the time

when you……..”• “Does this experience feel similar to

an experience that happened before”?

Translate words into feelings

• Decode• Find clues to the underlying meaning


• Patient: “I’m way out in the ocean.” • Nurse: “You must be feeling very

lonely now.”


• Patient: “I’m dead.” • Nurse: “Are you suggesting that you

feel lifeless?” or “Is it that life seems without meaning?”

Sequencing

• "What seemed to lead up to...?" • "Was this before or after...?" • "When did this happen?"

Sequencing

• Placing events in sequence of time• Clarifying • Gives perspective

Stating reality• Offering for consideration that which is

real.

Stating reality

• Patient: misperception• Nurse: defines reality or

perception

Examples Stating reality:

• “I understand that the voices are real to you, but I do not hear what you are hearing”

• “There is no one else in the room that you and I are in”

• “That sound was a car backfiring”• “You’re mother is not here. I am a nurse”

Voicing doubt• Expressing uncertainty as to the

reality of the patient's perceptions.

Voicing Doubt

• CAREFUL! –Delusional

• Benefits–Awareness

ExamplesVoicing Doubt

1. “I find that hard to imagine”2. “That seems rather doubtful to me”3. “Isn’t that unusual”?4. “Really”?

Focusing

• Concentrating on a single point• idea/word• Helpful –Patient moving rapidly from one thought to

another.

Focusing examples:

• “I’d like to hear more about the comment you made about your roommate”

• “You had mentioned that you like habit burger. What’s your favorite burger there”?

Focusing

• "This point seems worth looking at more closely.“

Silence

• Absence of verbal communication

Silence

1. Encourages 1. Talking2. Focus3. Discovery

2. Slows pace3. Gives time

Silence is Golden

• Silence – uncomfortable• "silent" (latin - sinere)– “to let go"

• When we feel uncomfortable with silence, we may be having difficulty letting go of something.

Silence is Golden

• Multiple meaning• Valuable tool

• “You’ve planted a window box.”• “Good morning, Mrs. J.”• “I’ve noticed you manicured your

nails.”

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What is a common mistake students make when first practicing therapeutic communication techniques?

A. Using too many techniquesB. Focusing on what the patient is saying

rather than on the techniquesC. Giving advice rather than encouraging

patients to problem solveD. Or changing the subject before the patient

becomes anxious

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Course OBJECTIVE #19

• Recognize and list non-therapeutic interventions

Blocks to CommunicationROAD BLOCKS

Red Flag Words• We• But• Should, Ought to• Why• Hard Work• Always/Never• Try

ROAD BLOCKS

Belittling

• Dismissing, mocking, Minimizing• Patient feels – inferior– Questions validity feelings

Belittling

• 3 yrs old says he is afraid of monsters.• Mom - “You’re acting like a baby, there

are no monsters.”

Belittling

• Pt “I won’t leave here alive.”• Nrs “That’s ridiculous. You shouldn’t

even think that way.”

Giving literal responses

• Pt: “They’re looking in my head with a TV”. • Nrs: “What channel?”

Giving literal responses

• Patient: “That doctor is a pain in the neck.”

• Nurse: “Would you like your pain medication?”

Challenging

• Demanding proof

Challenging

• “If you’re dead, why is your heart beating?”

Disagreeing

• Opposing the patient’s ideas

Disagreeing

• Teenage girl “My boyfriend is terrific”• Mom – “I think he is a loser. You can

do better.”

Disagreeing

• Pt: “Why am I here? Nothing is being done for me and I’m not getting any better.”• Nrs: “You’re getting better.”

Disagreeing

• ‘You should stop worrying like this.”• "That's wrong." • "I definitely disagree with..." • "I don't believe that."

Disapproving

• Be non-judgmental –piercings, tattoo’s, sexual

preference, pregnancy issues, sexual misconduct etc.

• Word, tone & Body language

ROAD BLOCKS

Agreeing

• Statements that show you believe the person is correct

ROAD BLOCKS

Examples Disapproving

“Don’t you know how bad drugs are for you”?

“How could you even think of killing yourself when you have those 2 beautiful children that need you”

ROAD BLOCKS

Agreeing

• To neighbor “I’m thinking of divorcing my husband.”

• “I’d get rid of him too.”

ROAD BLOCKS

Agreeing

• Pt – “I don’t think the doctor will send me home tomorrow.”

• Nrs – “I am sure you are correct. I doubt he will let you go home so soon.”

ROAD BLOCKS

Examples Approving

“I’m so glad you’ve decided to keep your baby”

“I’m excited for you that you’re going back to church”

ROAD BLOCKS

Agreeing/Disagreeing

• Shuts door • Places value judgment on behavior• Nurse assumes responsibility

ROAD BLOCKS

Defending

• Justification • Counter reply to a verbal attack

ROAD BLOCKS

Defending

• Teenage to day “I don’t get as much of an allowance as Paul does.”• Dad – “I’m doing the best I can.”

ROAD BLOCKS

Defending

• Pt – “I’ve had my call light on for 15 minutes.”

• Nrs – “I am doing the best I can. You are not the only patient here.”

ROAD BLOCKS

Giving Authoritative Responses

• Nurse = superior • Patient = intimidated & powerless.

ROAD BLOCKS

Authoritarian examples:

“I’m an educated nurse and know more than you do about why you’re here”

“ Who do you think you’re talking to”?

ROAD BLOCKS

Stereotyped Responses

• Clichés• Superficial

ROAD BLOCKS

Stereotyped Responses

• “I know what is happening to you.”• “All 2 year olds are terrible.”

ROAD BLOCKS

Stereotyping• Pt - “I am really worried about my

children. I came to the hospital so quickly and didn’t get to see them. They just wont understand. I wish I could talk to them”

• Nurse: “I know exactly how you feel.”

ROAD BLOCKS

Stereotyping• “Keep your chin up”• “Men don’t cry”• “It’s for your own good”• “You’ll have the best doctor in town

with your insurance”• “All clients with anxiety worry about

that”

ROAD BLOCKS

Giving false reassurance

• Without sincerity• Sympathy

ROAD BLOCKS


• “Don’t worry. Everything will be all right. You will feel better soon.”

ROAD BLOCKS


• Pt – “What will I do if this is malignant?”• Nrs – “Don’t you worry. Everything will

work out just fine.”

ROAD BLOCKS

Giving advice

• Telling the patient what to do

ROAD BLOCKS

Giving advice

• What’s so bad about that?–Judgmental–Arrogant–Pt. incapable

ROAD BLOCKS

Giving advice

• “If I were you…”• “Why don’t you…”

ROAD BLOCKS

Giving Advice

• “What you should do is…• “You know what would be the right

thing to do…

ROAD BLOCKS

Changing the subject

• Introducing a new topic

ROAD BLOCKS

Changing the subject

• Pt – “They are doing a biospy tomorrow. I hope it isn’t cancer.”

• Nrs – “Are these pictures of your children? They are such a nice looking family.”

ROAD BLOCKS

Asking closed-ending questions

• Questions with one-word answers

ROAD BLOCKS


• What’s so wrong with this?

ROAD BLOCKS


–“What time are you suppose to come out of your room”?

ROAD BLOCKS


–Patient: “I’m upset that my roommate got restrained”–Nurse: “Are you suppose to be

talking about that”?

ROAD BLOCKS

Asking “why” questions

• Requesting an explanation?• Puts them on the defensive

ROAD BLOCKS

Asking “why” questions

• “Why did you fall?”

ROAD BLOCKS

Probing

• Seeks information beyond what is necessary.

ROAD BLOCKS

Course Objective #20

• Recognize communication deficits in clients and teach appropriate social skills.

Use feeling words

“I” messages positive

• Honest

“You” messages negative• Guilt• Blame• Disrespect

Guidelines for giving constructive feedback

• Immediately• Private• Be specific• Explain the consequences

constructive feedback

• Avoid bringing up past• Evaluate performance, not the

performer• Use firsthand knowledge• Agree on how to avoid it happening

again

Giving praise

• Be honest• Attention• Unconditional • Areas of importance • Be specific

Documents

Therapeutic Communication Day 2. Objective #14 Discriminate between hearing and listening