Therapeutic Relationships

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

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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 Nurse assists the client to meet goals and resolve problems Nurse and client express feelings about termination, observes regressive behaviors

Working

Termination

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 Voicing doubt

A few minutes ago, we were talking about.. Then… I find it hard to believe

Encouraging description of perception

What are these voices 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…. Lets talk more about what you think of your

Focusing

Non-therapeutic communication These are blocks to communication Usually, these are the common pitfalls of communicating nontherapeutically: 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 Changing the subject

I am the best nurse to care for you 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 P: I’m so depressed today N: everyone feels sad at times

Belittling feelings

Proxemics INTIMATE= PERSONAL= SOCIAL= PUBLIC=

Distances Touching to 1 ½ ft 1 ½ to 4 ft 4 to 12 ft 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 selfesteem, 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