ELEMENTS OF COMMUNICATION PROCESS

Communication is a dynamic process. It involves these three elements:

1. Perception
2. Evaluation
3. Transmission

Perception occurs by activation of the sensory organs of the receiver. Then the impulse is
transmitted to the brain. When the sensory impulse reaches the brain, evaluation takes place.
The receiver analyses and categorizes the message in the terms of its meaning. Evaluation
results in cognitive response and an effective response. The cognitive response relates to the
informational aspect of the message, and the effective response relates to the relationship
aspect of the messages.

When the evaluation of the message is complete, transmission takes place. This is perceived by
the sender as feedback, thereby influencing the continued course of the communication cycle.
This feedback stimulates perception, evaluation, and transmission by the original sender. The
cycle continues till the participants agree to end it.

From this discussion, you can identify the functional components of communication. These
are:

The sender : The originator of the messages.

The receiver : The perceiver of the message.
The message : The information that is transmitted from the sender to the receiver.
Feedback : The verbal or behavioral response of the receiver to the sender.
It is also a new message initiated by the receiver, who then becomes the
sender.
Context : The setting in which communication takes place. It includes physical and
psychological setting, the relationship between the sender and the receiver.

THERAPEUTIC COMMUNICATION TECHNIQUES:

These techniques in psychiatric nursing aim at preserving the self respect of the
patients and nurses. Secondly, they help in the formation of the nurse-patient relationship and,
the implementation of the nursing process. They are keys to the successful psychiatric nursing
skills.
Now let us discuss the therapeutic communication techniques:

I. Listening: - It is an active process of receiving information. The complete attention of

the nurse is required and there should be no preoccupation with oneself. Listening is a
sign of respect for the person who is talking and is a powerful reinforcer of
relationships. It allows the patient to talk more, without which the relationship cannot
progress.

II. Broad openings: - These encourage the patient to select topics for discussion, and
indicate that nurse is there, listening to him and following him. For example, questions
 such as what shall we discuss today? “Can you tell me more about that”? “And then
what happened?” from the part of the nurse encourages the patient to talk.

III. Restating: - The nurse repeats to the patient the main thought he has expressed. It
indicates that the nurse is listening. It also brings attention to something important.

IV. Clarification: - The patient’s verbalization, especially when he is disturbed or feeling

deeply, is not always clear. The patient‘s remarks may be confused, incomplete or
disordered due to their illness. So, the nurse needs to clarify the feelings and ideas
expressed by the patients. The nurses need to provide correlation between the patient’s
feelings and actions. For example,” am not sure what you mean”? “Could you tell me
once again?” Clarifies the unintelligible ideas of the patients.

V. Reflection: - This means directing back to the patient his ideas, feelings, questions and
content. Reflection of content is also called validation. Reflection of feelings consists of
responses to the patient’s feelings about the content.
Reflection of the content is for the patient to know that we have heard and that we have
understood the content.

Reflection of feeling is also for telling the patient that we are aware of what he is
feeling. It signifies understanding, empathy, interest and respect for the patient. It also
increases our level of involvement with the patient.

VI. Focusing: - It means expanding the discussion on a topic of importance. It helps the
patient to become more specific, move from vagueness to clarify and focus on reality.
Encouraging a description of the patient’s perceptions, encouraging comparisons, and
placing events in a time sequence, are focusing techniques that promote specificity and
problem analysis.

VII. Sharing perceptions; - These are the techniques of asking the patient to verify the
nurse understands of what he is thinking or feeling. For example, the nurse could ask the
patient, as “You are smiling, but I sense that you are really very angry with me”.
It helps to confirm the nurse understands and allows the patient to correct their
perception, if necessary. It further clarifies confusing communication.

VIII. Theme identification: - This involves identifying the underlying issues or problems
experienced by the patient that emerge repeatedly during the course of the nurse patient
interaction. Once we identify the basic themes, it becomes easy to decide which of the
patient’s feelings and thoughts to respond to and pursue.
Theme can relate to feelings like depression or anxiety, behavior (rebelling against
authority or withdrawal) and experiences (being loved, hurt, or raped), or combinations
of all three. So you need to identify the theme to understand the patient better.

IX. Silence: - This is lack of verbal communication for a therapeutic reason. Then the
nurse’s silence prompts patient to talk. For example, just sitting with the patient without
talking, nonverbally communicates our interest in the patient.
 Silence gives time for the patient to think and gain insight. It encourages the patient to
initiate conversation. It is also helpful to the nurse when she is unsure how to respond to
a patient’s comments; a safe approach is to maintain silence.

X. Humour:-This is the discharge of energy through the comic enjoyment of the imperfect.
It is a socially acceptable form of sublimation. It is a part of nurse-patient relationship. It
is a constructive coping behavior, and by learning to express humor, a patient learns to
express how others feel.
Humor resolves paradoxes, tempers, aggression, and reveals new options to the patients.
For example, joking allows the nurse and the patient to retain their uneasy security in
their unchanging individual existences.

XI. Informing: - This is the skill of giving information. The nurse shares simple fact with
the patient.
For example, the nurse saying to the patient ‘I think you need to know more about how
your medication works’ is helpful in health teaching or patient education. This is
considered as one of the essential nursing techniques in communication.

XII. Suggesting: - This is the presentation of alternative ideas related to problem solving. It
is the most useful communication technique when the patient has analyzed his problem
area, and is ready to explore alternative coping mechanisms. At that time suggesting
techniques increase the patient’s choices.

BARRIERS TO COMMUNICATION:

From this discussion of the therapeutic communication techniques you have learnt how
one can promote the patient’s verbal expression. Now let us look into nursing behavior that
poses threats to the therapeutic value of communication.

I. Failure to listen: - Without listening, there is no communication. You should give

complete attention to the patient, and you should not be preoccupied with yourself. If
you do not listen to the patient, the relationship between the two of you will not
progress.

II. Rejecting response: - If you continue to dominate while interacting with the patient
and reject his responses by saying, let us not discuss………..and I do not want to hear
about….. The patient would experience your unacceptance and go away from you.

III. Reassurance: - To reassure a psychiatric patient is considered as lack of validation of

the nurse’s interpretation of the message. Telling the patient that everything will be all
right, or you are coming along fine, do not contribute towards the therapeutic
interpersonal relationship.

IV. Probing:- Too much probing like,” Tell me your life history further”, or no probing and
assuming that you have understood everything about the patient, makes you draw
 subjective, immature conclusions about the patient’s problems. Usually that goes
wrong.

V. Stereotyping the patient’s response: - In the process of directing back the patient’s
ideas and feelings, you may make stereotyped comments. This indicates you have no
interest in understanding and empathizing with the patient but are merely reflecting his
statement.
A few examples are,” Nice weather we are having”, “just listen to your doctor and take
part in the activities”, and “you will be home in no time”.

VI. Changing topics: - While the patient is expressing his views and problems, you need to
question him, which would help him to expand on a topic. Instead, if you keep
changing topics or bringing in unrelated topics, the patient will be discouraged from
discussing his problem further.

VII. Challenging the patients: - Asking the patient to verify your understanding must not
sound like challenging the patient.
For example, a paranoid schizophrenic patient might express his delusion of grandeur
by saying that he is the Prime Minister of the country. In response, you might ask, “But
how can you be the Prime Minister?”

VIII. Advising: - It encourages dependency relationship of the patients with you. Some
patients, who seek help, do not really expect to work out their own problems; rather
they expect some pronouncement from the health care professionals what to do. In
these instances, giving advice shift the responsibility to the nurse, end reinforces the
patient’s dependence on her.

IX. Belittling the patient: - When a depressive patient is talking to you, he might say, “I
have nothing to live for……I wish I were dead”. You answers, like, “everyone goes
down in his life, I have felt that way too some how”, are belittling feelings expressed by
the patients. It reinforces his withdrawal features.

X. Using Denial: - Patient with nihilistic ideas might say to you, “I am dead”. Your
response of “don’t be silly”, communicates your unacceptance and disapproval of his
sick behavior. This does not enhance communication between you and the patient.

Therapeutic communication: characteristics.

The nurse must achieve certain skills or qualities to initiate and continue a therapeutic
relationship. These skills or qualities incorporate verbal and nonverbal behavior and the
attitudes and feelings, behind communication.
Traux, Carkhoff and Brenson have identified specific core conditions for facilitative
interpersonal relationships. They broadly divided these conditions into:
A. Responsive Dimensions- Genuineness, respect, empathic understanding and
concreteness.
B. Action Dimensions- Confrontation, immediacy, therapist self-disclosure, catharsis
and role playing.
TYPES OF NURSE-PATIENT RELATIONSHIP

Three possible types of relationship- social, intimate, and therapeutic can occur between
individuals.

1. Social Relationship:-
The social relationship is the most common kind between individuals in everyday life.
Both individuals are equally involved in this relationship and are concerned with
meeting their own need through the relationship. There is no predetermined goal or
focus in the relationship, and the continuation of the relationship is not determined at
the onset. Platonic friends, work colleagues, and neighbors who help each other out are
examples of this kind of relationship.

2. Intimate relationship:-
An intimate relationship is a relationship between two individuals committed to one
another, caring for and respecting each other. Intimacy is usually exclusive to those
involved and implies that they love each other.

3. Therapeutic relationship:-
In a therapeutic relationship, the nurse and client work together toward the goal of
assisting the client to regain the inner resources to meet life challenges and facilitate
growth. The interaction is purposefully established, maintained, and carried out with the
anticipated outcome of helping the client gain new coping and adaptation skills. There are
two basic assumptions underlying the therapeutic relationship:-
I. The client’s difficulties are expressed in the relationship
II. The previous, learned difficulties of former relationships are amenable to change in
this relationship.

GOALS, PHASES, TASKS, THERAPEUTIC TECHNIQUES.

Goals of Nurse Patient Relationship:-

1. The nurse helps the patient to cope with the present problem:-
The nurse accepts the patient as “here and now”. That is, “what are the patient’s
problems, which have hospitalized him/her?” “How does the patient perceive the
problems?” the nurse does not go back to the past history from secondary sources.
These sources are collecting information from the patient’s relatives and past records.
She tries to collect the information from the patient. If the patient talks about his or her
past the nurse tries to use this knowledge in helping him/her.

2. The Nurse Helps the Patient to understand his Problem:-

The nurse develops this goal throughout her care of the patient. She helps the patient to
identify his or her problem. Many a time the patient may say that he is admitted here
for a check up or investigation and refuses the psychiatric care he or she is getting. As
 the patient continues on treatment the nurse tries to help him/her to identify why he/she
is admitted in this hospital or psychiatric unit. She makes the patient understand the
problem he/she going through.

3. The Nurse helps the Patient to Understand his Active Participation in an

experience:-
For example-A patient who gets violent, throws things here and there may be helped
to find out the reason for his behavior what he thinks can control him? The moment the
patient suggests a remedy, he can be made to realize that he is active in making a decision
for his care. This helps him to regain sufficient courage and realize that he is still a worthy
person capable of taking decisions.

4. The Nurse Assists the Patient to Identify Emerging Problems Realistically:-

During the relationship a patient may identify his actual problem as different. For
example: The patient who gets violent find out that his violence is due to loss of
money in business which is leading him to insecurity or due to the fear that his
children’s education in a good school may be affected. So he identifies the problem,
which he needs to handle.

5. The Nurse Helps the Patient to find out a Alternative for his or her Problem:-
If the patient has any problem, he must have tried all the usual methods to solve it. But
when he failed to do so, probably he started feeling helpless, worthless and depressed.
The therapist cannot find a solution for the patient’s problem, but she can help him
with an alternative solution. She can ask the patient, what else can you do to solve the
problem? Who can help you? The nurse is trying to make the patient understand that
there are many alternate solutions to his problem and he has to choose the best, which
suits him.

6. The Nurse Helps the Patient to Try Out New Patterns of Behavior:-
While interacting with the patient the nurse is able to identify the nursing needs of her
patient. If she finds the patient is not able to socialize and is depressed she starts taking
him to the day care room just for observation. She calls other patients in the same unit
to talk about their problems. Gradually she encourages the patient to go to her
neighboring patient and ask for a magazine. The patient picks up courage and goes to
the patient, comes back to the nurse and says, “I have done it but I was very nervous.”
The nurse gives a positive reinforcement to the patient by saying, “Good, you could
this, it’s not that difficult as you think”. The patient develops confidence and may
gradually start socializing with a few people. Patients adopt this new pattern of
behaviors to reduce his worthlessness and depression.

7. The Nurse helps the Patient to Communicate:-

Mentally ill patients have difficulty in communicating with others, because of thought
problems. The patient who is also getting treatment needs help to talk clearly and
logically with others. For example-Help the patient to describe clearly, step by step, his
progress in job.
 8. The Helps the patient to socialize:-
It is known that some of the mentally ill patients have difficulty in socialization. The
nurse can use the approach as one-to-one socialization and one to many socialization.
That means she helps the patient to socialize with person to start with, then with two or
three other patients or people and gradually in the group.

9. The Nurse helps the Patient to find a Meaning in his Illness:-

It is assumed that an ill person wants to find out the reason or meaning of his suffering.
The patient may blame his relatives, his fate or “Karma”. Though it is difficult not to
blame anyone, once the patient is able to find out “Why he must live”, probably his
acceptance to illness will not be that difficult. The patient may be explained to accept
that his suffering can be due to physical, social, mental or spirituals factors. It will also
provide him with a learning experience to solve the problem on future.

PHASES AND TASKS AND THERAPEUTIC TECHNIQUES IN

NURSE-PATIENT RELATIONSHIP:-

In Nursing, relationship refers to connectedness in interaction where each person has an

effect upon the other.
A helping relationship in psychiatric Nursing may be defined as an interpersonal process,
in which one person(the nurse) facilitates the personal development or growth of another (the
patient) over time, by assessing that person(patient) to mature, to become more adaptive,
integrated and open personal experience, and able to find meaning in that situation. Thus the
nurse Patient relationship results from a series of interactions between Nurse and Patient over a
period of time, with the nurse focusing on the needs and problems of patient and his family,
while using the scientific knowledge and specific skills of nursing profession.

Establishing Nurse- Patient Relationship:-

Establishing and maintaining relationships with the psychiatric patients are most
challenging. Some patient responds to very slowly.
The nurse move through the various phases of the therapeutic relationship with the
patient. There are four goal-directed phases, namely-

1) Orientation, initial or establishment phase

2) Identification phase
3) Working or therapeutic phase
4) Termination or maintenance phase

While you are progressing through these phases, be a humanistic therapist. You cannot force or
hurry the patient to move from one phase to another, because he is not a machine. To work with
the patient there is no standardized plan. Apply the nursing principles and knowledge in an
individualized way. Every phase is interlinked with other phase, besides the patient can start
the relationship from any phase.
Phase of Nurse Patient Relationship-

1. Orientation, Initial or Establishment Phase;-

This Phase begins at the first meeting with the patient. Explain the nature and purpose
of your relationship with him. Tell him about the role of the nurse and his
responsibilities during the course of his stay in the hospital.

The main tasks of the nurse in this phase are;

 Introducing the patient to every one,
 Learning his needs, expectations and goals,
 Orienting him with the ward/hospital structure and function,
 Developing care plans
 Making contracts with him getting the consent for therapy signed.

The nurse starts establishing a rapport with the patient. Show unconditional positive regard to
him. Remember the patient would try to test your ability, sincerity and honesty. You too keep
introspecting the types of experiences you have. This stage of relationship is compared with the
infancy stage. The patient depends on the nurse and starts giving information about himself and
also need to share information about your self with him.

2. Identification phase:-
The nurse is considered as a surrogate parent, and the patient, finds her as identification
figure in his life. The nurse as well as the patient mutually explores deeper feelings,
needs and goals. The patient starts to accept her decisions and considers her as an ago-
ideal. This is a positive transference. If the past experience of the patient was traumatic,
he takes more time to enter into transference. If at all he enters into this stage, it would
most probably be a negative transference.
This phase is compared with the childhood phase. The patient is more dependent on the
nurse. So teach him coping skills and provide him with self care opportunities.

3. Working or Therapeutic Phase:-

The patient’s problems are explored. He is more independent. He tries to make use of
all the services and resources within him and around him. He is more assertive and self
–reliant. He tries out with new ways of behaving. In this phase, he regains health and
functions optimally. This phase is compared with the adolescence stage.
As a nurse, you work with the patient as a partner. Be a counselor and resource person,
and support him in his endeavour. Help him to change his dysfunctional behavior.
Assign him therapeutic tasks in between the counseling’s session. Appreciate him
where ever needed, to re-strengthen his ego.
Usually, the patient gives the lead to what is to be talked. You maintain silence. Give
feedback. Observe his verbal and non-verbal consistency. During interaction point out
the unused strength and any discrepancies between his thought and action. Give him
alternative options, and ask him to try these out. Teach problem solving skills.
Encourage expression of his feelings. Depending on his ability, either enters into
termination phase or maintenance phase.
 4. Maintenance Phase:-
This is for those patients who have no termination till they reach their potential or
death. So you need to actively implement care to maintain their emotional and social
well-being.

5. Termination Phase:-
Now, the patient has moved into the last phase of the relationship. It is also compared
with the adulthood stage. He is independent in his deeds and ready to get discharged
from the hospital. You have got much to do in this phase:-
 Summarize the course of interaction to him.
 Explore his future plans, coping strategies and life pattern.
 Test his abilities to stand-alone and face the realities of life through temporary
short discharge or parol or short leave of absence.
 Express your confidence in his ability. Do not show regret about his discharge.
 Plan regarding the follow up care.
 Look for the sign of need for continued relationship like grief, guilt, depression,
wanting to receive punishment or expressing the feeling or rejection.

THERAPEUTIC IMPASSES AND ITS INTERVENTION

Therapeutic impasses are blocks in the progress of the nurse patient relationship. They arise for
a variety of reasons and may take many different forms, but they all create stalls in the
therapeutic relationship. Impasses provoke intense feelings in both the nurse and the patient
that may range from anxiety and apprehension to frustration, love, or intense anger. Five
specific therapeutic impasses and ways to overcome are to be learnt to develop therapeutic
nurse-patient relationship.
Therapeutic impasses are five:-
1. Resistance
2. Transference
3. Counter transference
4. Gift giving
5. Boundary violations

1. Resistance:-
Resistance is the patient’s attempt to remain unaware of anxiety-producing aspects
within him self. It is a natural or learned reluctance to avoidance of verbalizing or even
experiencing troubled aspects of self.
Primary resistance is often caused by the patient’s unwillingness to change when
the need for changer is recognized. Patients usually display resistance behaviors during
the working phase of the relationship, because this phase encompasses the greater part
of the problem-solving process.
Resistance may also be a reaction by the patient to the nurse who has moved too
rapidly or too deeply into the patient’s feelings or who has intentionally or
unintentionally communicated a lack of respect, or the nurse may be an inappropriate
role model for therapeutic behavior.
 Secondary gain is another cause of resistance. Favorable environment,
interpersonal and situational changes occur, and material advantages may be secured as
a result of the illness. Types of secondary include financial compensation, avoiding
unpleasant situations, increased sympathy or attention, escape from responsibility,
attempted control of people, and lessening of social pressures.
Secondary gain can become a powerful force in the perpetuation and propagation
of an illness, since it makes the environment more comfortable.

Wolberg identified forms of the resistance displayed by the patients:- they are,

1) Suppression and repression of pertinent information.

2) Intensification of symptoms.
3) Self-devaluation and a hopeless out look on the future.
4) Forced flight in to health where there is sudden, but short-lived recovery by the
patient.
5) Intellectual inhibitions-Forgetful, late for sessions, silent or sleepy.
6) Actions out or irrational behavior
7) Superficial task
8) Use of defense of intellectualization where there is no insight.
9) Patient has developed insight but refuses to assume responsibility.
10) Transference reactions.

2. Transference:-
Transference is an unconscious response of the patient in which he experiences
feelings and attitudes toward the nurse that were originally associated with significant
figures, in his early life. Such response utilizes the defense mechanism of displacement.
Transference reduces the patient’s self-awareness by helping him maintain a
generalized view of the world in which all people are seen in similar terms. Thus the nurse
may be viewed as an authority figure from the past, such as parent figure, or as a lost love
object, such as a former spouse.
Transference reactions are harmful to the therapeutic process only if they remain
ignored and unexamined. There are two types of transference that present particular
resistance in the nurse-patient relationship.
First is the hostile transference. If the patient internalizes his anger and hostility, he
may express this resistance as depression and discouragement.
He may ask to terminate the relationships on the ground that he has no chance of
getting well.
If the patient externalizes his hostility, he may become critical, defiant, and
irritable. He may express doubt about the nurse’s training, experience or personal
adjustment. Hostility may also be expressed by the patient in detachment forgetfulness,
irrelevant chatter or preoccupation with childhood experiences.
A second difficult type of transference is the dependent reaction transference. This
resistance is characterized by patients who are submissive, subordinator, and ingratiating
and who regard the nurse as a “godlike: figure. The patient overvalues the nurse’s
characteristics and qualities. Nurse is expected to live up to the patients overwhelming
expectations and patient continues to demand more of the nurse, and when he or she not
meet his needs, he is filled with hostility and contempt.
 Interventions for Resistance and Transference

1) The nurse must be prepared to be exposed to powerful negative and positive emotional
feelings coming from the patient.
2) Make therapeutic contracts, develop a mutually acceptable goals or plans of action,
defining the goals, purpose and roles of the nurse and patient in the relationship.
3) Listen to patient’s analysis of the resistance or transference. Use clarification and
reflection of feelings.
4) Explore the possible reasons for resistance and work through the transference reactions
with the patient.

3. Counter Transference:-
Counter transference is a therapeutic impasse created by the nurse. It refer’s to the
nurse’s specific emotional response generated by the qualities of the patient. In this case
the nurse identifies the patient with individuals from his or her past, and personal needs
will interfere with therapeutic effectiveness. The nurse’s unresolved conflicts about
authority, sex, assertiveness. And independence tend to create problems rather than
solve them.

Three types of counter transference-

1) Reactions of intense love or caring
2) Reactions of intense hostility or hatred
3) Reactions of intense anxiety often in response to resistance by the patient.

Through the use of immediacy the nurse can identify counter transference in one of its various
forms.

Forms of Counter Transference Displayed by Nurse’s;

1) Inability to empathize with the patient in certain problem areas.
2) Depressed feelings during or after the session.
3) Carelessness about implementing the contract by being late, running overtime etc.
4) Drowsiness during the sessions.
5) Feelings of anger or impatience because of the patient’s unwillingness to change
6) Encouragement of the patient’s dependency, praise or affection.
7) Arguing with the patient or a tendency to push the patient before he is ready.
8) Trying to help the patient in matters not related to the identified nursing goals.
9) Involvement with the patient on a personal or social level
10) Dreaming about or preoccupation with the patient.
11) Sexual or aggressive fantasies toward the patient.
12) Recurrent anxiety, unease or guilt feelings about the patient.
13) A tendency to focus repeatedly on only one aspect or way of looking at the information
presented by the patient.
14) A need to defend nursing interventions with the patients to others.

Advantages of Counter Transference;

Different forms of counter transference occur because the nurse is involved with the
patient as a participant observer, and not as a detached by sender. They function as-

1) Powerful tools in exploration and potent instruments for uncovering inner states. They
are destructive only if they are brushed aside, ignored, or not taken seriously.
 2) Counter transference can lead to further information, can bring to light new materials,
and help in developing insight.
3) Nurse understanding of counter transference and her own feelings help to maintain a
working relationship with the patient.

Interventions to Counter Transference;

1) Experience of working with psychiatry patients.
2) Constantly lookout for counter transference.
3) Hold counter transference in obeyance or utilize it for promoting therapeutic goals.
4) Apply self-examination through out the course of relationship.
5) Pursue to find out the source of problem
6) Exercise control over counter transference
7) Have individual or group supervision.
8) Weekly clinical seminars, peer consultation, and professional meetings can also offer
emotional support.

4. Gift giving:-
Receiving a gift from the patients make the nurse to inhibit independent decision making,
and create a feeling of anxiety or guilt. Gift is that something of value is voluntarily offered to
another person, usually to convey a gratitude.

Forms of Gifts;
 Gifts can be tangible or intangible; Lasting or temporary.
 Tangible gifts-box of sweets, a bouquet of flowers.
 Intangible gifts-Patient’s expression of thanks.

Gift as an Impasse;
The timing of the particular situation, the intent of giver, and the contextual meeting of
the giving of the gift.

5. Boundary Violations:-
Boundary violations occur when a nurse goes outside the boundaries of the therapeutic
relationship and establishes a social, economic or personal relationship with a patient. As a
general rule, whenever the nurse is doing or thinking of doing something special, different or
unusual for a patient, a boundary is involved. A nurse should consider the possibility of a
boundary violation if he or she encounters the following-
 Receives feedback that his or her behavior is intrusive with patient or their families.
 Has difficulty in setting limit with a patient.
 Relates to a patient like a friend or family member
 Has sexual feeling toward a patient.
 Feels that he or she is the only one who understands the patient.
 Receives feedback that he or she is too involved with a patient or family.
 Feels that other staffs are too critical of a particular patient.
 Believes that other staff members are jealous of his or her relationship with a patient.
JOHARI WINDOW

The therapeutic nurse-patient relationship is a mutual leaning experience and corrective

emotional experience for the patient. In this relationship, the nurse uses personal qualities and
clinical techniques in working with the patient to bring about insight and behavioral change.
One such quality is ‘self-awareness.
The nurse who cares for the biological, psychological and socio-cultural needs of the patient
sees a broad range of human experiences; she must learn to deal with anxiety, anger, sadness
and joy in helping patients at all intervals of health illness continuum.
Self awareness is a key component of the psychiatric experience. To promote self-awareness,
“the Johari Window” could be illustrated. It is based on the concept of “No one ever
completely knows his/her inner self”

1. 2.
Known to self Known only to
and others others
3. 4.
Known only to Known neither to
self self nor to others

Johari Window (Each quadrant, or each window plane describes one aspect of self).

Quadrant 1. Is the open quadrant; it includes the behaviors, feelings, and thoughts known to
the individual and those around him.

Quadrant 2. Is called the behind quadrant; because it includes all those things that others know
but the individual does not know.

Quadrant 3. Is the hidden quadrant; it includes those things that only the individual knows
about himself.

Quadrant 4. Is the unknown quadrant, containing aspects of self, unknown to the individual
and to the others.

The following three principles may help clarify how the self functions in this representation;
1. A change in any one quadrant affects all other quadrants.
2. The smaller the first quadrant, the poorer the communication.
3. Interpersonal learning means that a change has taken place, so that quadrant is larger
and one or more of the other quadrants are smaller. The goal of increasing self-
awareness is to enlarge the area of quadrant 1, while reducing the size of the other
three quadrants. To increase knowledge of self, one begins by listening to one self.
This means allowing oneself to experience genuine emotions, identify and accept
personal needs, and move one’s body in free, joyful and spontaneous ways. It includes
exploring one’s own thoughts, feelings, memories and impulses.