Therapeutic Communication PDF

Chapter 7 Therapeutic Communication \*\*\*\*\*\*\*What Is Communication? It has been said that individuals "cannot not communicate." Every word spoken, every movement made, and every action taken or not taken gives a message to someone. Interpersonal communication is a transaction between the sen...

Chapter 7 Therapeutic Communication \*\*\*\*\*\*\*What Is Communication? It has been said that individuals "cannot not communicate." Every word spoken, every movement made, and every action taken or not taken gives a message to someone. Interpersonal communication is a transaction between the sender and the receiver. In the transactional model of communication, both participants simultaneously perceive each other, listen to each other, and are mutually involved in creating meaning in a relationship. \*\*\*\*\*\*\*\*The Impact of Preexisting Conditions In all interpersonal transactions, the sender and receiver each bring certain preexisting conditions to the exchange that influence both the intended message and how it is interpreted. Examples of these conditions include one's value system, internalized attitudes and beliefs, culture and religion, social status, gender, background knowledge and experience, and age or developmental level. The type of environment in which the communication takes place may also influence the outcome of the transaction. \*\*\*\*\*\*\*\*Values, Attitudes, and Beliefs Values, attitudes, and beliefs are learned ways of thinking. Children generally adopt the value systems and internalize the attitudes and beliefs of their parents. Children may retain this way of thinking into adulthood or develop a different set of attitudes and values as they mature. Values, attitudes, and beliefs can influence communication in numerous ways. For example, prejudice is expressed verbally through negative stereotyping. Attitudes may be communicated by use of certain words and through the volume and tone of voice. Values may be communicated directly through behaviors such as a person who expresses their value for religion by attending religious services. One's value system may also be communicated with behaviors that are more symbolic in nature. For example, an individual who values youth may dress and behave in a manner that is characteristic of one who is much younger. People who value socioeconomic status may choose large homes, luxury cars, and other expensive personal possessions. In each of these situations, a message is being communicated. \*\*\*\*\*\*Culture and Religion Communication has its roots in culture. Cultural mores, norms, ideas, and customs provide the basis for our way of thinking. Cultural values are learned and differ from society to society. For example, in some European countries (e.g., Italy, Spain, France), men may greet each other with hugs and kisses; in the United States or Great Britain, shaking hands is a more culturally accepted style of greeting among men. Religion also can influence communication. Priests and ministers who wear clerical collars publicly communicate their mission in life. The collar may influence the way in which others relate to them, either positively or negatively. Other symbolic gestures, such as wearing a cross around the neck or wearing a hijab (a religious veil worn by some Muslim women in public), also communicate an individual's religious beliefs. \*\*\*\*\*\*Social Status Studies of nonverbal indicators of social status or power have suggested that individuals communicate status and power through body language such as eye contact and erect, open posture; louder voice pitch, and more frequent talking; approaching others and interacting with less interpersonal distance; as well as more covert cues such as formal dress and jewelry \* \*\*\*\*\*Gender Gender may influence how individuals communicate. Within cultures and families, gender signals may be communicated as either masculine or feminine, and these are socially reinforced. Examples may include differences in posture and social distance. Historically, many roles have been identified as either male or female. For example, in the United States traditional masculine roles included husband, father, breadwinner, doctor, lawyer, or engineer. Traditional female roles included those of wife, mother, homemaker, nurse, teacher, or secretary. Cultural beliefs about expected gender roles may also affect the communication process. However, gender signals are changing in U.S. society as roles become less distinct. Behaviors once considered typically masculine or feminine may now be generally accepted in members of both genders. Words such as nonbinary communicate a desire by some individuals to diminish the distinction between genders and minimize the discrimination of either. Gender roles are changing as both women and men enter professions that were once dominated by members of the opposite gender. Thus, making assumptions about gender-based communication styles could negatively affect the communication process. \*\*\*\*\*\*Age or Developmental Level Age influences communication, which is especially evident during adolescence. In their struggle to separate from parental confines and establish their own identity, adolescents generate a unique pattern of communication that changes from generation to generation. Words such as dude, dope, lit, and wasted have had special meaning for different generations of adolescents. The technological age has produced a whole new language for today's adolescents. Communication by text messaging includes such acronyms as BRB ("be right back"), BFF ("best friends forever"), and YOLO ("you only live once"). Developmental physiological alterations may also influence communication. One example is American Sign Language, the system of unique gestures used by many people who are deaf or hearing impaired. Individuals who are blind at birth never learn the subtle nonverbal gestures that accompany language, which can completely change the meaning of the spoken word. \*\*\*\*\*Environment in Which the Transaction Takes Place The place where communication occurs influences the outcome of the interaction. For example, some individuals who feel uncomfortable and refuse to speak during a group therapy session may be willing to discuss problems privately on a one-to-one basis with the nurse. Territoriality, density, and distance are aspects of the environment that communicate messages. Territoriality is the innate tendency to own space. Individuals lay claim to areas around themselves as their own. When an interaction takes place in the territory "owned" by one or the other, it often influences communication. Interpersonal communication can be more successful if the interaction takes place in a "neutral" area. For example, with the concept of territoriality in mind, the nurse may choose to conduct the psychosocial assessment in an interview room rather than in their office or the patient's room. Density refers to the number of people within a given environmental space. It has been shown to influence interpersonal interaction. Some animal studies indicate a correlation between prolonged high-density situations and certain behaviors, such as aggression or withdrawal Distance is the means by which various cultures use space to communicate. Hall (1966) identified four kinds of spatial interaction, or distances, that people maintain from each other in their interpersonal interactions and the kinds of activities in which people engage at these various distances. 1.  Intimate distance is the closest distance that individuals will allow between themselves and others. In mainstream American culture, this distance, which is restricted to intimate interactions, is 0 to 18 inches. 2.  Personal distance is approximately 18 to 40 inches and reserved for personal interactions, such as close conversations with friends or colleagues. 3.  Social distance is about 4 to 12 feet away from the body. Interactions at this distance include conversations with strangers or acquaintances, such as at a cocktail party or in a public building. 4.  Public distance is one that exceeds 12 feet. Examples include speaking in public or yelling to someone some distance away. This distance is considered public space, and communicants are free to move about in it during the interaction. \*\*\*\*\*\*\*Nonverbal Communication Various studies have identified nonverbal communication as more reliable than verbal communication in expressing one's attitudes and feelings, and some describe it as the single most powerful way in which communication occurs (Heathfield, 2019). Some aspects of nonverbal expression were discussed in the previous section on preexisting conditions that influence communication. Other components of nonverbal communication include physical appearance and dress, body movement and posture, touch, facial expressions, eye behavior, and vocal cues or paralanguage (such as intonation, pitch, and speed; a more detailed description follows). These nonverbal messages vary from culture to culture. \*\*\*\*\*Physical Appearance and Dress Physical appearance and dress are part of the total nonverbal stimuli that influence interpersonal responses, and under some conditions, they are the primary determinants of such responses. Body coverings, both dress and hair, are manipulated by the wearer in a manner that conveys a distinct message to the receiver. Dress can be formal or casual, stylish or unkempt. Hair can be long or short, and even the presence or absence of hair conveys a message about the person. Other body adornments that are also considered potential communication messages include tattoos, masks, cosmetics, badges, jewelry, and eyeglasses. Some jewelry worn in specific ways can give special messages (e.g., a gold band or diamond ring worn on the third finger of the left hand, a pin bearing Greek letters worn on the lapel, or the wearing of a ring inscribed with the insignia of a college or university). Individuals may convey a specific message with the total absence of any body adornment. \*\*\*\*\*\*Body Movement and Posture The way in which an individual positions their body communicates messages regarding self-esteem, gender identity, status, and interpersonal warmth or coldness. The individual whose posture is slumped, with the head and eyes pointed downward, conveys a message of low self-esteem. Specific ways of standing or sitting are considered to be either feminine or masculine within a defined culture. In the United States, to stand straight and tall with head high and hands on hips indicates a superior status over the person being addressed. Reece and Whitman (1962) identified response behaviors that were used to designate individuals as either a "warm" or "cold" person. Individuals who were perceived as warm responded to others with a shift of posture toward the other person, a smile, direct eye contact, and hands that remained still. Individuals who responded to others with a slumped posture, by looking around the room, drumming fingers on the desk, and not smiling were perceived as cold. \*\*\*\*\*Touch Touch is a powerful communication tool. It can elicit both negative and positive reactions, depending on the people involved and the circumstances of the interaction. It is a very basic and primitive form of communication, and the appropriateness of its use is culturally determined. Touch can be categorized according to the message communicated (Knapp & Hall, 2014):   Functional-professional: This type of touch is impersonal and businesslike. It is used to accomplish a task.   Social-polite: This type of touch is still rather impersonal, but it conveys an affirmation or acceptance of the other person.   Friendship-warmth: Touch at this level indicates a strong liking for the other person, a feeling that he or she is a friend.   Love-intimacy: This type of touch conveys an emotional attachment or attraction for another person.   Sexual arousal: Touch at this level is an expression of physical attraction only. Some cultures encourage more touching of various types than do others. The nurse should understand the cultural meaning of touch before using this method of communication in specific situations. The best practice is to ask the patient's permission before using touch as an intervention. \*\*\*\*\*\*\*\*Facial Expressions Next to human speech, facial expression is the primary source of communication. Facial expressions reveal an individual's emotional state, such as happiness, sadness, anger, surprise, and fear. The face is a complex multimessage system. Facial expressions serve to complement and qualify other communication behaviors and at times even take the place of verbal messages. A summary of feelings associated with various facial expressions is presented in Table 7--1. \*\*\*\*\*\*Eye Behavior Eyes have been called the "windows of the soul." It is through eye contact that individuals view and are viewed by others in a revealing way, creating an interpersonal connection. In American culture, eye contact conveys a personal interest in the other person. Eye contact indicates that the communication channel is open, and it is often the initiating factor in verbal interaction between two people. Eye behavior is regulated by social rules. These rules dictate where, when, for how long, and at whom we can look. Staring is often used to register disapproval of the behavior of another. People are extremely sensitive to being looked at, and if the gazing or staring behavior violates social rules, they often assign meaning to it, such as the following statement implies: "He kept staring at me, and I began to wonder if I was dressed inappropriately or had mustard on my face!" \*\*\*\*\*\*\*Vocal Cues or Paralanguage Paralanguage is the gestural component of the spoken word. It consists of pitch, tone, and loudness of spoken messages; the rate of speaking; expressively placed pauses; and the emphasis assigned to certain words. These vocal cues greatly influence the way individuals interpret verbal messages. A normally soft-spoken individual whose pitch and rate of speaking increase may be perceived as being anxious or tense. Verbal cues play a major role in determining responses in human communication situations. How a message is verbalized can be as important as what is verbalized. \*\*\*\*\*\*\*Therapeutic Communication Caregiver verbal and nonverbal techniques that focus on the care receiver's needs and advance the promotion of healing and change. Therapeutic communication encourages the exploration of feelings and fosters understanding of behavioral motivation. It is nonjudgmental, discourages defensiveness, and promotes trust. \*\*\*\*\*\*\*Therapeutic Communication Techniques Hays and Larson (1963) identified a number of techniques to assist the nurse in interacting more therapeutically with patients. These are important "technical procedures" carried out by the nurse working in psychiatry, and they should serve to enhance the development of a therapeutic nurse--patient relationship. Table 7--2 includes a list of these techniques, a short explanation of their usefulness, and examples of each. \*\*\*\*\*\*\*\*\*\*Nontherapeutic Communication Techniques Several approaches are considered to be barriers to open communication between the nurse and patient. Hays and Larson (1963) identified a number of these techniques, which are presented in Table 7--3. Nurses should recognize and eliminate the use of these patterns in their relationships with patients. Avoiding these communication barriers will maximize the effectiveness of communication and enhance the nurse--patient relationship. \*\*\*\*\*\*\*\*\*\*Using silence Silence encourages the patient to organize thoughts and put them into words and allows the patient time to think about the significance of events, thoughts, and feelings. Allowing the patient to break the silence often provides the nurse with important information about the patient's foremost concerns. Giving recognition Acknowledging and indicating awareness is better than complimenting; the former reflects an observation and the latter reflects the nurse's judgment. Giving broad openings Broad openings allow the patient to direct the focus of the interaction and emphasize the importance of the patient's role in the communication process. Encouraging the patient to identify the sequence of events and when they occurred in time facilitates organizing one's thoughts about their experiences. Making observations Verbalizing observations about a patient's behavior or appearance encourages the patient to develop awareness of how they are perceived by others and promotes exploration of issues that may be problematic. Encouraging description of perceptions Asking the patient to verbalize their perceptions facilitates the patient's ability to develop awareness and understanding. For the patient experiencing hallucinations, it can facilitate both nurse's and patient's clarification about what the patient's perceptual experiences are communicating. Encouraging comparison Asking the patient to compare similarities and differences in ideas, experiences, or interpersonal relationships helps the patient recognize life experiences that tend to recur and those aspects of life that are changeable. Restating Repeating the main idea of what the patient has said lets the patient know whether an expressed statement has been understood and gives them the chance to continue or to clarify if necessary. Reflecting Questions and feelings are referred back to the patient so that the patient is empowered to actively engage in problem-solving rather than simply asking the nurse for advice. Focusing Taking notice of a single idea or even a single word works especially well with a patient who is moving rapidly from one thought to another. However, focusing is very difficult for a patient with severe anxiety, so in this case the nurse should not pursue focusing until the anxiety level decreases. Exploring When the nurse hears the patient mention an issue or theme that seems relevant, the nurse asks the patient to explore this further. Exploring facilitates the patient's development of awareness and understanding about events, thoughts, and feelings. However, if the patient chooses not to disclose further information, the nurse should refrain from pushing or probing in an area that obviously creates discomfort. Seeking clarification and validation Striving to explain vague or incomprehensible statements and searching for mutual understanding of what has been said facilitates and increases understanding for both patient and nurse. Presenting reality When the patient has a misperception of the environment, the nurse defines reality by expressing their perception of the situation without challenging the patient's perceptions. Voicing doubt Expressing uncertainty as to the reality of the patient's perceptions is a technique often used with patients experiencing delusional thinking. Verbalizing the implied Putting into words what the patient has only implied or said indirectly is a technique that can be helpful with patients experiencing impaired verbal communication. Attempting to translate words into feelings When the patient has difficulty identifying feelings or feelings are expressed indirectly, the nurse tries to "desymbolize" what has been said and to find clues to the underlying true feelings. Formulating a plan of action Encouraging the patient to identify a plan for behavior change promotes developing better coping skills. TABLE 7--3    Nontherapeutic Communication Techniques Giving false reassurance False reassurance conveys that the nurse already knows the outcome of a situation and minimizes the patient's expressed concerns. It may discourage the patient from further expression of feelings if they believe the feelings will be downplayed or ridiculed. Rejecting Refusing to consider or showing contempt for the patient's ideas or behavior may cause the patient to discontinue interaction with the nurse for fear of further rejection. Approving or disapproving Sanctioning or denouncing the patient's ideas or behavior implies that the nurse has the right to pass judgment on whether the patient's ideas or behaviors are "good" or "bad" and that the patient is expected to please the nurse. The nurse's acceptance of the patient is then seen as conditional depending on the patient's behavior. Agreeing or disagreeing Indicating accord with or opposition to the patient's ideas or opinions implies that the nurse has the right to pass judgment on whether the patient's ideas or opinions are "right" or "wrong." Agreement prevents the patient from later modifying their point of view without admitting error. Disagreement implies inaccuracy, provoking the need for defensiveness on the part of the patient. Giving advice Telling the patient what to do or how to behave implies that the nurse knows what is best and nurtures the patient in the dependent role by discouraging independent thinking. Probing Persistent questioning of the patient and pushing for answers to issues the patient does not wish to discuss may contribute to the patient feeling used and valued only for what information the nurse is seeking and may place the patient on the defensive. Better alternative: The nurse should actively listen to the patient's response and discontinue the interaction at the first sign of discomfort. Defending Defending someone or something the patient has criticized minimizes or completely ignores the patient's concerns. Defending may cause the patient to think the nurse is taking sides against them. Requesting an explanation This technique involves asking the patient why they have certain thoughts, feelings, and behaviors. Asking "why" a patient did something or feels a certain way can be very intimidating and implies that the patient must defend their behavior or feelings. Indicating the existence of an external source of power Attributing the source of thoughts, feelings, and behavior to others or to outside influences encourages the patient to project blame for his or her thoughts or behaviors on others rather than accepting the responsibility personally. Belittling or minimizing feelings When the nurse minimizes the degree of the patient's discomfort, a lack of empathy and understanding may be conveyed. When the nurse tells the patient to "cheer up" or "everybody feels that way," the patient may feel that their concerns are insignificant or unimportant. Making stereotyped comments Trite expressions are meaningless in a nurse--patient relationship. When the nurse uses meaningless expressions, it encourages a similar response from the patient. Using denial Denying that a problem exists blocks discussion with the patient and avoids helping the patient identify and explore areas of difficulty. Interpreting Interpreting attempts to tell the patient the meaning of their experience. Erroneous interpretations may leave the patient feeling that the nurse doesn't understand them, or that the nurse is being smug. Introducing an unrelated topic When the nurse prematurely changes the subject, it conveys to the patient that the nurse does not want to discuss the original topic any further. This may occur in order to get to something that the nurse wants to discuss with the patient or to get away from a topic that the nurse would prefer not to discuss. Active Listening To listen actively is to be attentive and demonstrate a desire to hear and understand what the patient is saying, both verbally and nonverbally. Attentive listening creates a climate in which the patient can communicate. With active listening, the nurse communicates acceptance and respect for the patient, and trust is enhanced. A climate is established within the relationship that promotes openness and honest expression. Several nonverbal behaviors have been designated as facilitative skills for attentive listening. Those listed here can be identified by the acronym SOLER: S: Sit squarely facing the patient. This nonverbal cue gives the message that the nurse is there to listen and is interested in what the patient has to say. O: Present with an open posture. Posture is considered "open" when arms and legs remain uncrossed. This nonverbal cue suggests that the nurse is open to what the patient has to say. With a closed position, the nurse can convey a somewhat defensive stance, possibly invoking a similar response in the patient. L: Lean forward toward the patient. Leaning forward conveys to the patient that the nurse is involved in the interaction, interested in what is being said, and making a sincere effort to be attentive. E: Establish eye contact. Eye contact, intermittently directed, is another behavior that conveys the nurse's involvement and willingness to listen to what the patient has to say. The absence of eye contact or the constant shifting of eye contact elsewhere in the environment gives the message that the nurse is not actually interested in what is being said. Ensure that eye contact conveys warmth and is accompanied by smiling and intermittent nodding of the head and does not come across as staring or glaring, which can create intense discomfort in the patient. Active observation and listening to discern an individual's comfort level with eye contact facilitates adapting one's level of eye contact if it appears to increase the patient's anxiety. For example, patients experiencing paranoia and some individuals with autism spectrum disorder may be very sensitive to levels of eye contact that in other situations would seem appropriate. R: Relax. Whether sitting or standing during the interaction, the nurse should communicate a sense of being relaxed and comfortable with the patient. Restlessness and fidgetiness communicate a lack of interest and may convey a feeling of discomfort that is likely to be transferred to the patient. \*\*\*\*\*Motivational Interviewing Patient-centered care has been identified as an important focus in the quest to improve the quality of nurse communication and therapeutic relationships with patients (Institute of Medicine, 2003). Motivational interviewing is an evidence-based, patient-centered style of communicating that promotes behavior change by guiding patients to explore their motivation for change and the advantages and disadvantages of their decisions (Rubak et al., 2005). This style of communication incorporates active listening and verbal therapeutic communication techniques, but it is focused on what the patient wants (their current level of motivation) rather than on what the nurse thinks should be the next steps in behavior change. Motivational interviewing was originally developed for use with patients who have substance use disorders, primarily because this style of communication may decrease defensive responses. It has since gained widespread acceptance as a patient-centered communication strategy that promotes behavior change for patients with many different health-care issues. See the following "Real People, Real Stories" for an example of motivational interviewing described in a process recording format. \*\*\*\*\*\*Process Recordings Process recordings are written reports of verbal interactions with patients. They are verbatim accounts recorded by the nurse or student as a tool for improving interpersonal communication techniques. Process recording can take many forms but usually includes the verbal and nonverbal communication of both nurse and patient. The exercise provides a means for the nurse to analyze both the content and pattern of the interaction. Process recording, which is not considered documentation, is intended to be used as a learning tool for professional development. Feedback \*\*\*\*\*\*\*Feedback is a method of communication for helping the patient consider behavior modification by providing information about how they are perceived by others. Feedback can be useful to the patient if presented with objectivity by a trusted individual in a manner that discourages defensiveness. Characteristics of useful feedback include the following:   Feedback should be descriptive rather than evaluative and focus on the behavior rather than on the patient. Avoiding evaluative language reduces the need for the patient to react defensively. Objective descriptions allow patients to use the information in whatever way they choose. When the focus is on the person, rather than the behavior, patients may perceive that they are being judged as "good" or "bad