PSYCHIATRIC

NURSING

THERAPEUTIC RELATIONSHIPS

To relate therapeutically with a patient, it

is necessary for the nurse to understand
his or her role and its relationship to
patients illness. They describe the role
of the nurse as providing the client with
opportunity to:
Identify and explore problems in relating
to others.
Discover healthy ways of meeting
emotional needs.
Experience a satisfying interpersonal
relationship.

Components/Essential conditions to development of

therapeutic relationship

Trust
Respect
Genuine

Interest

Empathy
Acceptance
Positive

regard
Self-awareness
&Therapeutic use of self

Trust:

develops when the client believes that the

nurse will be consistent in his/her words and actions
and can be relied on to do what he or she says.

Genuine

Interest: the nurse should be open and

honest and display congruent behavior.
Empathy: ability of the nurse to perceive the
meanings and feelings of the client and to
communicate that understanding to the client.
Acceptance: conveyed by not becoming upset or does
not respond negatively to a clients outburst, anger or
acting out and avoiding judgments of the person.
Positive regard: the unconditional nonjudgmental
attitude; the nurse appreciates the client as a unique
human being regardless of his/her behavior. (E.g.
calling the client by name, spending time with the
client, maintaining eye contact, being relaxed and
being interested.

Empathy, Sympathy Difference

B.J. is a client on the psychiatric unit
with a diagnosis of major depressive
disorder. She is 55 tall and weighs 295
lbs. BJ has been overweight all her life.
She is single, has no close friends and
has never had an intimate relationship
with another person. It is her first day
on the unit, and she is refusing to come
out of her room. When she appeared for
lunch in the dining room following
admission, she was embarrassed when
several of the other clients laughed out
loud and call her fatso.!

Sympathetic Response
Nurse: I can certainly identify with
what are you feeling. Ive been
overweight most of my life, too. I just
get so angry when people act like
that. They are so insensitive! Its just
so typical of skinny people to act that
way. You have a right to want to stay
away from them. Well just see how
loud they laugh when you get to
choose what movie is shown on the
unit after dinner tonight.

Empathetic response
Nurse: You feel angry and
embarrassed by what happened at
lunch today. As tears fills B.J.s eyes,
the nurse encourage her to cry if she
feels like it and express her anger at
the situation. She stays with B.J., but
does not dwell on her own feelings
about what happened. Instead she
focuses on B.J. and what the client
perceives at her most immediate
needs.

Self-awareness
&Therapeutic Use of
Self-awareness :theself:
process of developing an
understanding of ones own values, beliefs, thoughts,

feelings, attitudes, motivations, prejudices, strength

and limitations and how these qualities affect others.
Therapeutic use of self: a therapeutic tool to establish
therapeutic relationship with clients and to help
clients grow, change and heal.
JOHARI WINDOW by Joseph Lutt and Harry Ingharn
Representation of communication: a graphical
representation of how people give and receive
information, used to help people understand
interpersonal communication.
Name after the two person invented the system on
late 20th century

SELF - AWARENESS
The

nurses goal is to achieve

authentic, open, and personal
communication;

The

nurse must be able to

examine personal feelings and
reactions;

good understanding and

acceptance of self allow the
nurse to acknowledge a patients
differences and uniqueness;

JOHARI WINDOW

10

Open/public

self: aspects of self known by

both self and others
Blind/unaware self- qualities known only by
others ( hidden from self)
Hidden/private self aspect known by
individual but deliberately hidden from others
Unknown self qualities unknown to both self
and others
Note; arena is increased by group disclosures
and soliciting feedbacks from others (blind
spot, faade and unknown also decreased as
result of this

TYPES OF RELATIONSHIP
Social

relationship

Initiated for the purpose of friendship, socialization,

companionship, or accomplishment of a task.
Communication: superficial, focuses on sharing of
ideas, feelings and experience.
Nurse-patient: should be limited
Intimate

relationship

Involves two people who are emotionally committed to

each other; concerned about having their individual
needs.
Nurse-patient: should not exist.
Therapeutic

relationship

Focuses on the needs, experiences, feelings and ideas

of the client

Establishing

the therapeutic

relationship
The nurse who has self- confidence
rooted in self awareness is ready to
establish appropriate therapeutic
relationship with clients.
Hildegard Peplau studied and wrote
about the interpersonal process and
the phase of the nurse-client
relationship for 35 years.

NURSE CLIENT
RELATIONSHIP

Phychiatric

nurse uses
interpersonal relationship
development as a primary
intervention with the clients in
various psychiatric/mental health
settings.
The therapeutic interpersonal
relationship is the means by
which the nursing process is
implemented. Through the
relationship, problems are

Phases of Therapeutic Relationship

A. ORIENTATION

or Assessment or analysis;

The nurse establishes trust with

the client;

The nurse assesses the client;

Formulation of nursing diagnosis;

Prioritization of the clients

problems;

The nurse and the client establish

mutually agreed goals;

16

Tasks include:
Obtaining

available information
about the client from his or her
chart, significant others, or other
health team members. From this
information, the initial
assessment is begun. This initial
information may also allow the
nurse to become aware of
personal responses to knowledge
about the client.

B. WORKING PHASE

Pertains to planning and

intervention;

the nurse plans outcomes and

related interventions to assist
client to meet goals;

The nurse facilitates the clients

expression of problems, thoughts,
and feelings;

The nurse uses problem-solving

approach;

18

C. TERMINATION PHASE

Pertains to evaluation;

The nurse evaluates

outcomes, reassess the
problems, goals and
interventions;

Needs close attention to avoid

destroying the benefits gained
from the relationship;
19

The nurse and client express

feelings regarding the termination
of the interactions;

The nurse observes the client for

negative behaviors:
Regression
Anger
Inappropriate expressions
(laughter)

The nurse evaluates the entire

nurse-client relationship;
20

TRANSFERENCE
is the unconscious transfer of
special feelings from a client to the
nurse or therapist.

COUNTERTRANSFERENCE
Is the projection of the therapists
feelings about a significant other to
the patient during therapy;

21

THERAPEUTIC COMMUNICATION
Communication:

the process used to exchange information.. Messages

are simultaneouslynsent and receive on two levels: verbally through the
use of words and nonverbally by behaviors that accompany the words.
Verbal communication: consists of words a person uses to speak to one or
more listeners.
Content: the literal words that a person speaks.
Context: the environment in which communication occurs (e.g. time and
physical, social, emotional, and cultural environments)
Nonverbal communication: the behavior that accompanies verbal
content; indicates the speakers thoughts, feelings, needs, and values
that he or she acts out mostly unconsciously.
Body language
Eye contact
Facial expression
Tone of voice
Speed and hesitations in speech
Grunts and groans
Distance from the listeners

An

interpersonal interaction between the nurse and client during

which the nurse focuses on the clients specific needs to
promote an effective exchange of information
Considerations:
Privacy and respecting boundaries
Proxemics: the study of distance zones between people during
communication
4 distance Zones:
Intimate zone (0-18 inches): comfortable for parents with young
children, people who mutually desire personal contact, or people
whispering. Invasion is threatening and produces anxiety.
Personal zone (18-36 inches): comfortable between family and
friends who are talking.
Social zone (4 -12 feet): acceptable for communication in social,
work, and business settings.
Public zone (12-25 feet): acceptable distance between a speaker
and an audience, small groups, and other informal functions.
3-6 feet: used in nurse-patient interaction.

Touch

Types:
Functional-professional

touch: used in examinations

or procedures (e.g. assess skin turgor, performing
massage)
Social-polite touch: used in greeting (e.g.
handshake)
Friendship-warmth touch: involves hug in greeting,
an arm thrown around the shoulder of a good
friend, or the back slapping some men use to greet
friends and relatives.
Love-intimacy touch: involves tight hugs and kisses
between lovers or close relatives.
Sexual-arousal touch: used by lovers
Active listening and observation
Active listening: refraining from other internal
activities and concentrating exclusively on what the

BOUNDARIES IN N-C R
Material

boundaries are physical

property that can be seen, such as fences
that border land.
Social boundaries are established within
a culture and define how individuals are
expected to behave in social situations.
Personal boundaries- are those that
individuals define for themeselves.
Professional boundaries limit and outline
expectation for appropraite professional
relationships with clients.

Concerns regarding professional

boundaries:
Self-disclosure

may be
appropraite when it is judge that
the information may be
therapeutically benefit the client.
It should never be undertaken for
the purpose of meeting the nurse
need.
Gift giving.
Touch.
Friendship or romantic

Warning that professional relationship may be in

jeopardy
Favoring

aclients care over anothers

Keeping secret with a client
Changing dresstyle for working with a particular
client
Swapping clients assignment to care for a
particular client
Giving special attention or treatment to one
client over others
Spending free time with the client
Frequently thinking about the client when away
from work.
Sharing personal information or work concerns
with the client

The Power of
THERAPEUTIC
COMMUNICATION
TECHNIQUES

Therapeutic Communication :
(T.E. A. C. H.)
Communication

- described as the
process of sharing information
Information comes from the sender
(encoder) of the message and is
delivered to the receiver (decoder).
Feedback is required to sustain the
process.
Message is sent in either two modes:
verbal and non-verbal.

Characteristics of Communication
Purpose
Types
/modes

Exchange of information
Verbal or non-verbal

Communicat Reading, writing, listening and

ion skills
speaking
1.Encoder sends a message
2.Message is delivered through a
medium
Process
3.Decoder receives the message
4.Decoder may or may not give
feedback to the encoder, but
feedback is important to sustain

Goals

of therapeutic
communication: T.E.A.C.H.
T- TEACH the client and his/her family
E- Enumerate the clients identified
concerns
A- Assess the clients perception of
the problem
C- Carry put or implement nrsg
interventions
H-Help the client formulate a plan.

Verbal and Non-verbal communication

VERBAL
Uses words,
whether spoken or
written

NON-VERBAL
Does not use words
instead uses signs,
symbols, body
language, tone of voice,
facial expressions
Content
Body language is
composed of literal usually more honest
words that a
than words. You body
person speaks or
without using words,
writes
often articulates how
you really feel.

Verbal

Non-verbal

Context is the
environment in which
communication
occurs and includes
the time, physical
surroundings, social
milieu, culture and
emotional
atmosphere.

As they say, even the

pores of your skin
speak.
A word of CAUTION
though: non-verbal
com., esp. body
language, is also
more prone to
misinterpretation
than verbal com
Sender has less
control over certain
forms of non-verbal
com (body language)

The sender has lot

more control over
verbal com.

Kinesics
Refers

o the study of body movement in

communications
Categories:
a. Facial expressions

Convey emotional messages such as happiness,

sadness , interest, fear, concern and others.
Shows less cross-cultural variation that most other
modes of nonverbal communication
Eye contact is a special type of facial expression.
( focus of interest to another person.

Kinesics (Cont)
B.

Gestures

Involves the hands, arms, feet and head

Supplement verbal communication
May indicate either general emotional arousal
or specific emotional stress.
C.Body stance
includes posture, configuration of arms and legs,
distribution of body wtg and overall quality of
movement.
Ones ways of standing , sitting and lying can
communicate interpersonal attitudes and emotional
state
Can indicate ones openness, interest and involvement
in an interaction.

Paralanguage

Includes

voice qualities such as

speaking range, pitch variety rhythm
and tempo of speaking, raspness and
tone.
Includes giggling and whimpering as
well ass vocalized pauses, (um, er,
eh, throat clearing) which are useful
to fill in spaces between words and
phrases.
Involves use of silence.

Haptics
Involves

the use of touch in

communication
Powerful messages are relayed
through touch
Culturally varied.
CHRONEMICS
Study of how people use time in
communication

Proxemics
Study

of the distance people

maintain between themselves and
oters and how they defend their
territories to maintain preferred
distances.

1.

Personal space influenced by the following

factors
a.
b.
c.
d.
e.

Personal preference
Relationship between communicators
Nature of the topic discussed
Cultural heritage of the participants
Nature of the communication contex.

Proxemics (Cont)
2.

Territories
a. Public territory open to anyone like
restaurants, parks, bars, hosp. lobbies.
b. Interactional territory
a. Space reserve for particular people during
a specific time or period like discussion
rooms, classrooms, and aegs. rooms.
b. People can generally control the distances
they maintain between themselves and
others
c. Home territory space in which one live
and work.

Therapeutic /
Non
Therapeutic
Communicati
on

THERAPEUTIC
COMMUNICATIO
N
TECHNIQUES

Situation

:
Patient upset and crying
uncontrollably

Nurse

Action : Remain
silent until the patient can
gain control over his or
her feelings

Using SILENCE

Nursing Action : Sit Quietly,

while
attentive to the patient

Listen attentively, while the

patients talks without
attempting to compete with him

Remain silent until the patient

calms down

ACCEPTING
Yes.
I

follow what you said.

BROAD OPENINGS
Is

there something youd

like to talk about?

Where

begin?

would you like to

EXPLORING
Tell

me more about
that.

Would

you describe it
more fully?

What

kind of work?

FOCUSING
Of

all the concerns youve

mentioned, which is most
troublesome?

GENERAL LEADS
Go

on.

And
Tell

then?
me about it.

GIVING
INFORMATION
My

name is

Visiting
My

is

hours are

purpose in being here

GIVING RECOGNITION
NURSE:

I see that you have

changed your dress and
combed your hair before
coming to breakfast.

You have painted a

picture.

MAKING OBSERVATIONS
Nurse

:
You seem very
concerned about
something this morning.
You

seem quiet this

evening.

You

are touching my knee

with your hand.

OFFERING SELF
Nurse

will stay with you for a

while.

Its

time to go to your
therapy, I will go with
you.

REFLECTING
Situation

: Patient angry
and demands his
breakfast. The nurse had
observed the patient
eating that morning.
Nurse: You seem hungry.
It has been several hours
since you had breakfast.
Come, let me give you
some tea or milk.

REFLECTING
Situation

: Patients states
angrily that he or she is
now the head nurse and
everyone must follow his
directions.

Nurse

: You seem angry

when you talk about being
a nurse.

REFLECTING
Patient

: Who do you
people think you are,
forcing patients to work
like this? How dare you?

Nurse

: You sound
furious about your
assignment.

RESTATING
Patient

: The aide slept

all night long. I know
because I watched him
sleep.

Nurse:

You seem to have

difficulty sleeping at
night.

RESTATING

Patient : Ive messed up

my life, my job, and my
love life. Im just going to
make a new beginning.

Nurse

: Youre saying that

your experiences have
been disturbing you.

RESTATING
Patient:

Im really mad,
Im really upset.

Nurse:

Youre really mad

and upset.

GIVING
INFORMATION
Nursing

Action: SHORT,
SIMPLE DIRECTIONS.
BRIEF, CONCISE
EXPLANATION.

GIVING
INFORMATION
Patient:

My arms dont feel

like a part of me. What could
this strange feeling be
caused by and when will it
go away?

Nurse:

This strange feeling

you have concerning your
arms is a part of your
illness. It will go away as
you become better.

GIVING
INFORMATION
Patient:

Hey Buddy! Lets

go to the mall.

Nurse:

You seemed
confused, I am your nurse,
You are in the Pototan
Mental Health Unit.

PRESENTING REALITY
Patient:

I am hearing
voices calling me filthy
names.

Nurse:

I dont hear voices.

You
sound as if you are
frightened.

PRESENTING REALITY
Patient:

I demand a trial. I
cannot be executed without
trial.

Nurse:

You are not going

to be executed. You seem
frightened.

REDIRECTING
Patient:

Nurse, you look

very tired.

Nurse:

Yes, I am tired.
We are busy discussing
your feelings about the
staff.

NON
THERAPEUTIC
COMMUNICATIO
N
TECHNIQUES

REASSURING

Patient : Everyone here

wants to see me dead.

Nurse : This is a
hospital. The staff is here
to help you and protect
you from all harm.

REASSURING
Patient

: I see my Doctor
everyday. How can you
help me to get back my
memory?

Nurse

: I understand
exactly what you are
feeling. Youll find our
talks will help you.

REASSURING
Patient

: I refuse to take
those psychological
exams, why should I take
anyway?

Nurse

: It will help you to

get better and you will be
able to go home sooner.

GIVING APPROVAL
NURSE:

Oh, you look

beautiful. I like your new
dress.

You have done a good

job.

REJECTING
Situation:

The nurse/patient
approach in 2 persons parallel
another patient joins them,
where shall the nurse sit?

Inappropriate

action: The
nurse sitting on the other
side of the new patient

Nurse:

I see that you are

quite anxious and upset so I
will leave you alone.

DISAPPROVING

Nurse

: Gently Inquire
from the patient, How
could you say such a thing
to me?

AGREEING
Patient:

You know that

the President invited me
to the White House,

Nurse:

Have you decided

to accept the invitation?

DISAGREEING
Patient:

The aide slept

all night long. I watched
her sleep.

Nurse:

Thats hard to
believe, but I will look into
it.

DISAGREEING
Patient:

I hear voices
calling me dirty names.

Nurse:

You only think

that you hear voices. Its
all in your imagination.

ADVISING
Nurse:

I think it would
be a good idea for you to
go home on a weekend
pass.

Nurse:

Therapy is very
nice. Why dont you give it
a try?

PROBING
Nurse:

Why did
you.

Nurse:

When did
you..

Nurse:

Now tell me about

this problem. You know I
have to find out.

GIVING
INFORMATION
Inappropriate

Action:
Giving detailed, scientific
explanation.

INTRODUCING AN
UNRELATED TOPIC
Patient:
Nurse:

Id like to die.

Did you have

visitors last evening?

THREATENING
Nurse:

If you dont eat,

we will be forced to tube
feed you.

BELITTLING FEELINGS
EXPRESSED
But

how can you be

president of the United
states?
If youre dead, why is
your heart beating?

REINFORCING
Nurse:

Since you claim that

your arm is paralyzed, and
cant dial the phone, Ill call
your wife for you.

Nurse:

I know that you are

afraid of having a heart attack,
so Ill listen to your heart and
take your pulse frequently.

Best responses are those

that:

Encourage clients to express more

fully
Reflect or re-state what the client has
earlier said
Reflect the feelings that are identified
and encourage expression of feelings
Clarify clients statement
Acknowledge clients non verbal
behavior
Use silence but expresses being there
Inform
Clarify and validate

Never:
Give

responses that
belittle, negate or devalue
Advice or show approval or
disapproval
Ask for explanation or
why
Avoid
Be defensive