therapeutic relationships
TRANSCRIPT
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 relationshipRespect 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
1. Genuineness = sincerity and honesty
2. Concreteness= ability to identify client’s feelings
3. Respect= shown through consideration of patient as unique being
Therapeutic Relationships
PHASES OF THE THERAPEUTIC RELATIONSHIP
1. Pre-Interaction- Pre-orientation
2. Orientation- Interaction
3. Working
4. Termination
Therapeutic RelationshipsPhase 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
1. Sender- the source of message
2. Message- the information transmitted
3. Receiver- recipient of message
4. Feedback- receiver’s response to the message
Therapeutic Relationships
NON VERBAL COMMUNICATION
1. Proxemics- the physical space between the sender and receiver
2. Kinetics- the body movements such as gestures, facial expressions and mannerisms
3. 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 of perception
What are these voices telling you
Presenting reality The sound is produced by the carNo 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 nightN: You cant sleep at night ?
General leads GO on… then…. Hmm….you were saying….
Focusing Lets talk more about what you think of your problems
Non-therapeutic communication
These are blocks to communication Usually, these are the common pitfalls of communicating non-therapeutically:
Giving adviseTalking about selfTelling client is wrongFalse 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 surgeryN: 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 todayN: everyone feels sad at times
Proxemics
DistancesINTIMATE= 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 ASSESSMENTRefers 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 ASSESSMENTLevel of consciousnessGeneral appearanceBehaviorSpeechMood and affectJudgment Memory insight
Psychiatric Nursing Process
MENTAL STATUS ASSESSMENTObservation 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 ASSESSMENTEmotional status
Cognitive assessment
Socio-cultural assessment
Psychiatric Nursing Process
Physical ExaminationObservation for key signs
Diagnostic TestsCT, MRI, PET, EEG
Laboratory tests= CBC, Electrolytes, Drug levels
Psychiatric Nursing Process
Other diagnostic testsBeck depression inventory
Minnesota multiphasic personality inventory
Draw-a person test
Sentence completion test
Thematic aperception test
Psychiatric Nursing Process
Nursing DiagnosesAnxiety
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 InterventionsUse of therapeutic communication
Therapeutic Groups
Psychotherapy: Family, Milieu, Behavioral modification, Crisis intervention, Psychopharmacology
Electroconvulsive therapy
Psychiatric Nursing Process
Nursing EvaluationDetermine 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
1. Therapeutic Environment- Milieu
2. Therapeutic Groups
3. Crisis intervention
4. Family therapy
5. Behavioral modification
6. Cognitive therapy
7. 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
1. The clients’ physical needs are met
2. The client is respected
3. Decision making authority is clearly defined
4. 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 staff
Therapeutic Modalities
Milieu therapyTotal environment has an effect on the person’s behavior- physical, emotional, relationships
Purposes of therapy1. Improve client’s behavior2. Involve client in decision making3. Increase autonomy and communication4. Set structure of unit and behavioral
limits
Therapeutic Modalities
Milieu therapyThe surrounding is made positive to effect behavioral changes in the prescribed directionsGoals 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 therapyThe 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
PurposesTo increase self-awareness
To improve interpersonal relationships
To make changes in behavior
To enhancing group teaching and learning
Therapeutic Groups
Structure of the Therapeutic GroupOne leader chosen by the group
Members
Size is usually 10
Physical arrangement
Time and place of meeting
Therapeutic Groups
Phases of group development1. Beginning phase
Info given, anxiety heightened
2. Middle phaseConfrontation, cohesiveness, trust and self-reliance
3. Termination phaseGoals of the group are achievedIndividuals 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 INTERVENTIONA 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 modalitiesGoal of Crisis intervention: help the patient go back to
his state of optimum level of functioningIDENTIFY 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 personIMPLEMENT the plan- the alternative is put into action. The nurse may need to support and encourage patient to take actionEVALUATE 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 therapyFocuses on the client as a ‘family”
Involvement of family members
Purposes of family therapy
1. Improve relationships among family members
2. Promote family functions
3. Resolve family problems
4. 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 ModificationTherapy 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 therapyTherapy 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
1. Psychoanalysis
2. Client centered therapy
3. Rational emotive therapy
4. Gestalt therapy
5. Reality therapy
6. Transactional analysis
Therapeutic Modality: Psychotherapy
1. PsychoanalysisTHE 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 therapyThe 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 behavior
Therapeutic Modality: Psychotherapy
3. Rational-Emotive therapyThis 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 TherapyThe 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 AnalysisA 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