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Therapeutic Relationships

This is a nurse-client interaction


that is directed toward enhancing
the client’s well-being (Isaacs)
A relationship established between
a health care professional and a
client for the purpose of assisting
the client to solve his problems
Therapeutic Relationships

The nurse- patient relationship is


characterized by a helping process
The nurse and client work together
for his benefit
The nurse uses herself
therapeutically and this is achieved
by self-awareness
Therapeutic Relationships

The nurse- patient relationship


Respect the client and vale as
individual
Maintain appropriate limits
Convey empathy not sympathy
Maintain honest and therapeutic
communication
Encourage expression of feelings
Therapeutic Relationships

ELEMENTS OF THE THERAPEUTIC


RELATIONSHIP
Boundaries
Confidentiality
Therapeutic Behaviors
Therapeutic Relationships
ELEMENTS OF THE THERAPEUTIC
RELATIONSHIP
Therapeutic Behaviors
 Genuineness = sincerity and honesty
 Concreteness= ability to identify
client’s feelings
 Respect= shown through
consideration of patient as unique
being
Therapeutic Relationships

PHASES OF THE THERAPEUTIC


RELATIONSHIP
 Pre-Interaction- Pre-orientation
 Orientation- Interaction
 Working
 Termination
Therapeutic Relationships
Phase Nursing Activities

Pre-interaction Nurse obtains data from


secondary sources
Interaction- Orientation Nurse establishes trust,
assess client, establishes
mutual agreement
Working Nurse assists the client to
meet goals and resolve
problems
Termination Nurse and client express
feelings about termination,
observes regressive
behaviors
Orientation

Establishment of goals, rules,


boundaries etc..
Rapport is built
Identify expectations
Trust is gained
Assessment is done
Goals are defined
Working/Exploration/Identification

Problems are identified


Solutions are explored, applied
and evaluated
Nurse assists the client to develop
coping skills, positive self concept
and independence
Promote insight and the use of
adaptive coping mechanisms
Termination/Resolution

Nurse terminates the relationship


based on mutually agreed goals
when these are already achieved
Client may become anxious and
reacts
Nurses must help patient resolve
the anxiety and ends the
relationship professionally
Therapeutic Communication

Therapeutic communication
Dynamic process of exchanging
information
Composed of verbal and non-verbal
techniques that the nurse uses to
focus on the client’s needs
Therapeutic Relationships

Therapeutic communication :
ELEMENTS
 Sender- the source of message
 Message- the information
transmitted
 Receiver- recipient of message
 Feedback- receiver’s response to
the message
Therapeutic Relationships

NON VERBAL COMMUNICATION


 Proxemics- the physical space
between the sender and receiver
 Kinetics- the body movements
such as gestures, facial
expressions and mannerisms
 Touch- intimate physical contact
Therapeutic Relationships

NON VERBAL COMMUNICATION


4. Silence
5. Paralanguage- voice quality (tone,
inflection) or how a message is
delivered
Therapeutic Relationships

VERBAL COMMUNICATION
Use of therapeutic communication
techniques
Effective communication should be
therapeutic, appropriate, simple,
adaptive, concise and credible
Therapeutic Communication

Open ended questions


Focus on FEEELINGS
State behaviors observed
Reflect, restate, rephrase
Neutral responses
Therapeutic Communication
Offering self I am here to help you

Active listening Eye to eye contact

Exploring Tell me more about…,.

Broad Openings What do you want to talk about

Making observation You seemed depressed


Therapeutic Communication
Summarizing A few minutes ago, we
were talking about..
Then…
Voicing doubt I find it hard to believe

Encouraging description What are these voices


of perception telling you
Presenting reality The sound is produced by
the car
No one is in the room
Seeking clarification I am not sure of what you
mean
Therapeutic Communication
Verbalizing the implied Are you saying you
want to kill yourself?
Reflecting Do you think you
should?
Restating P: I cant sleep at night
N: You cant sleep at
night ?
General leads GO on… then….
Hmm….you were
saying….
Focusing Lets talk more about
what you think of your
Non-therapeutic communication
These are blocks to
communication
Usually, these are the common
pitfalls of communicating non-
therapeutically:
Giving advise
Talking about self
Telling client is wrong
False reassurance

Asking ‘Why’
Non-therapeutic communication
Making judgment You are wrong

False reassurance It’s going to be alright

Invalidation I cannot talk now, I’m busy

Focusing on self I am the best nurse to care


for you
Changing the subject P: I’m afraid of the surgery
N: How many children do
you have
Giving advice If I were you, I will
Non-therapeutic communication
Agreeing Yes I think you are right

Disapproving I don’t want you to do that

Defending This hospital is the best

Requesting explanation “why”

Cliché There is the sun after the


rain
Belittling feelings P: I’m so depressed today
N: everyone feels sad at
times
Proxemics
Distances
INTIMATE= Touching to 1 ½ ft

PERSONAL= 1 ½ to 4 ft

SOCIAL= 4 to 12 ft

PUBLIC= 12 to 15 ft
Psychiatric Nursing Process

Applies to all clients


Utilizes unique process for
psychological assessment
Similar to other types of nursing
process approaches
Psychiatric Nursing Process

Nursing ASSESSMENT
Nursing History
Physical Examination including the
Neurological examination
Laboratory Examination
Psychiatric Nursing Process

Nursing ASSESSMENT
Refers to the scientific process of
identifying a patient’s psychosocial
problems, strengths an concerns
Interview is done to acquires broad
information about a client
Psychiatric Nursing Process
MENTAL STATUS ASSESSMENT
Level of consciousness
General appearance
Behavior
Speech
Mood and affect
Judgment
Memory
insight
Psychiatric Nursing Process

MENTAL STATUS ASSESSMENT


Observation of mood and affect
Assessment of thought, sensorium
and intelligence
Speech and content
Assess developmental status and
family-cultural-spiritual background
Psychiatric Nursing Process

MENTAL STATUS ASSESSMENT


Emotional status
Cognitive assessment
Socio-cultural assessment
Psychiatric Nursing Process

Physical Examination
Observation for key signs

Diagnostic Tests
CT, MRI, PET, EEG
Laboratory tests= CBC, Electrolytes,
Drug levels
Psychiatric Nursing Process
Other diagnostic tests
Beck depression inventory
Minnesota multiphasic personality
inventory
Draw-a person test
Sentence completion test
Thematic aperception test
Psychiatric Nursing Process

Nursing Diagnoses
Anxiety
Ineffective coping- individual, family
Fatigue
Fear
Sleep pattern disturbance
Altered thought process
Etcetera
Psychiatric Nursing Process

Nursing Objectives
Short term goals are set for
immediate problems, feasible and
within client's capabilities
Long term goals are related to
discharge planning and prevention
of recurrence of symptoms
Psychiatric Nursing Process

Nursing Objectives: The client will:


Participate in treatment program
Becomes oriented to three spheres
and exhibit reality-based behaviors
Recognize reasons for behavior
Maintain self-care activities
Psychiatric Nursing Process

Nursing Interventions
Use of therapeutic communication
Therapeutic Groups
Psychotherapy: Family, Milieu,
Behavioral modification, Crisis
intervention, Psychopharmacology
Electroconvulsive therapy
Psychiatric Nursing Process

Nursing Evaluation
Determine if goals are met by
collecting data and comparing them
to baseline
Clients’ behavior should demonstrate
optimal orientation to reality and
interaction with others appropriately
Treatment Modalities
 Therapeutic Environment- Milieu
 Therapeutic Groups
 Crisis intervention
 Family therapy
 Behavioral modification
 Cognitive therapy
 Psychotherapy
Therapeutic environment

Research has documented that the


environment in which the mentally
ill person is treated is a major
factor in enhancing or impeding
the therapeutic effects of other
treatment modalities
Therapeutic environment

Characteristics of a Therapeutic
environment
 The clients’ physical needs are
met
 The client is respected
 Decision making authority is
clearly defined
 Client is protected from injury
(self and others)
Therapeutic environment

Characteristics of a Therapeutic
environment
5. Clients are allowed freedom of
choice commensurate to his
ability to decide
6. Nursing Personnel remain
constant and assignments are
stable
7. Emphasis is placed on social
interaction between clients and
Therapeutic Modalities
Milieu therapy
Total environment has an effect on
the person’s behavior- physical,
emotional, relationships
Purposes of therapy
 Improve client’s behavior
 Involve client in decision making
 Increase autonomy and
communication
 Set structure of unit and
behavioral limits
Therapeutic Modalities
Milieu therapy
The surrounding is made positive
to effect behavioral changes in
the prescribed directions
Goals of milieu therapy: to help
patient develop sense of self-
esteem, personal growth,
improve ability to relate to others
and return to the community
better prepared
Therapeutic modalities

Milieu therapy
The nurse involves the client in
decision making
The nurse promotes the
involvement of staff in care
Social skills are developed and
sense of community is fostered
Therapeutic Groups
A treatment approach in which the
entire milieu is used as treatment
This includes the physical
environment and the others clients
Therapeutic Groups
Group Therapy
Involves meaningful interaction
between members of a group as they
relate their personal experiences to
each other
The main objective is for each group
member to examine his own behavior
and relationship. The group can
influence to change his behavior and
relationships
Therapeutic Groups

Groups of clients meet with one or


more therapists to work together to
solve client problems
Therapeutic Groups

Purposes
To increase self-awareness
To improve interpersonal
relationships
To make changes in behavior
To enhancing group teaching and
learning
Therapeutic Groups

Structure of the Therapeutic Group


One leader chosen by the group
Members
Size is usually 10
Physical arrangement
Time and place of meeting
Therapeutic Groups
Phases of group development
 Beginning phase
Info given, anxiety heightened
 Middle phase
Confrontation, cohesiveness, trust
and self-reliance
 Termination phase
Goals of the group are achieved
Individuals leave the group when
work is done
Therapeutic modalities

CRISIS
A disturbance caused by a
precipitating event such as perceived
loss, a threat of loss or a challenge that
is perceived as a threat to self.
Therapeutic modalities

CRISIS
Can be classified as to maturational
crisis, situational crisis or adventitious
crisis
Maturational= role changes
Situational= loss of job, death
Adventitious= fires, earthquakes and
floods
In a crisis, the person’s usual methods of
coping are INEFFECTIVE
Therapeutic Modalities

Characteristics of Crisis:
It is sudden
It is short term may last for 4-6 weeks
Individualized
The person becomes dependent and
overwhelmed
Therapeutic Modalities

Factors that can produce crisis


1. Hazardous EVENTS
2. Threat to the individual’s equilibrium
3. Inadequate coping skills
Therapeutic Modalities

There are four PHASES of Crisis (DIDA)


Denial
Increased Tension- when the person
knows the existence of crisis and still
continues ADL
Disorganization= pre-occupied and unable
to perform function
Attempts to Reorganize= by mobilizing
previous coping mechanisms
Therapeutic Modalities

CRISIS INTERVENTION
A technique of helping the person go
through the crisis
To mobilize his resources
To help him deal with the here and now
A five step problem solving technique
designed to promote a more adaptive
outcome including improved abilities to
cope with future crises
Therapeutic modalities
Goal of Crisis intervention: help the patient go back to
his state of optimum level of functioning
IDENTIFY the problem- A solution is not possible
unless the problem be identified.
LIST alternatives- all possible solutions to the
problem need to be listed.
CHOOSE from among the alternatives- each
options is carefully considered, and the
alternative chosen is usually highly
individualized, based on priorities and values of
the person
IMPLEMENT the plan- the alternative is put into
action. The nurse may need to support and
encourage patient to take action
EVALUATE the outcome- the effectiveness of the
plan is evaluated.
Therapeutic modalities

Family therapy
An approach in which the
therapist focuses on the behavior
of the entire family as a system
instead of focusing on the
pathology of one member
Therapeutic modalities
Family therapy
Focuses on the client as a ‘family”
Involvement of family members
Purposes of family therapy
 Improve relationships among family
members
 Promote family functions
 Resolve family problems
 Help family find ways to cope with
problems
Therapeutic modalities

Family therapy
Problems are identified by each
family members and each
discusses his/her involvement in
the problem
Members discuss how problems
affect them and they explore how
to solve them
Therapeutic Modalities

Family therapy
The nurse functions to assess the
family interactions, makes
observations and encourages
expression of feelings
Helping the family resolve the
problem is the goal
Therapeutic Modalities

Behavioral Modification
Therapy to change the unacceptable
behavior to acceptable
The nurse determines the
unacceptable behaviors and she
identifies adaptive behaviors
Punishment is given to
unacceptable behavior
Reward is given to acceptable
behavior
Therapeutic Modalities

Behavioral Modification
Other Behavioral therapies
1. Self-control therapy
2. Aversion therapy
3. Desensitization
4. Modeling
5. Operant conditioning
Therapeutic Modalities

Cognitive therapy
An active, directive, time-limited
approach
Therapeutic techniques are used
to identify reality testing
The nurse helps the patient think
and act more realistically and
adaptively about his problems
Therapeutic Modalities

Play therapy
Therapy with children in which they
are helped to express themselves or
their behavior through play
Therapeutic Modality:
Psychotherapy
A method of treating mental illness
in which verbal and expressive
techniques are used to help the
person resolve inner conflict and
modify behaviors
Therapeutic Modality:
Psychotherapy
 Psychoanalysis
 Client centered therapy
 Rational emotive therapy
 Gestalt therapy
 Reality therapy
 Transactional analysis
Therapeutic Modality:
Psychotherapy
 Psychoanalysis
THE therapist obtains information
about the past and present
experiences that have repressed in
the person’s subconscious mind
By learning the source of the
problem, the problems can be
brought to the conscious where the
therapist helps the individual dealt
with them
Therapeutic Modality:
Psychotherapy
2. Client Centered therapy
The therapist work with one client
Accepting, non-judgmental
environment aimed at reducing the
anxiety and reducing negative
defenses
The patient is encouraged to
express his feelings and increase
self-awareness
When the person is aware of what
he feels, he can work on improving
Therapeutic Modality:
Psychotherapy
3. Rational-Emotive therapy
This is based in the assumption that
a person’s behavior is due to his
own thinking
Problems arise as the person
believes about eh events
The therapy aims to change the
person’s belief system
Therapeutic Modality:
Psychotherapy
4. Gestalt Therapy
The mind receives experiences as a
whole
When the experience is complete,
the problem will arise
The goal of the therapy is to help
patients complete the experience
through awareness
Therapeutic Modality:
Psychotherapy
5. Transactional Analysis
A group therapy method
Helps people “analyze” their
transaction or interaction with
others and guides them to the
conclusion: I’m OK you are OK
Responses to Illness

Stress
Anxiety
Crisis
Anger and hostility