Psychiatric Mental Health, part 4: Nurse/Client Relationship, Therapeutic Communication
by Cathy Parkes July 22, 2021 Updated: December 29, 2021 13 min read
In this article, we'll explain what you should and shouldn't say to patients in the mental health setting. We'll also explain the phases of the nurse-client relationship, which will help you understand what to do along the timeline of working with a new patient.
This series follows along with our Psychiatric Mental Health Nursing Flashcards which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Phases of the nurse-client relationship
In the mental health setting, you will get assigned new patients and work with them for some duration of time. It's important to understand the phases of this relationship, because each phase requires different tasks and interpersonal interactions. The phases of the nurse-client relationship are pre-orientation, orientation, working, and termination.
During the pre-orientation phase, you will prepare for your meeting with the patient. You will review their chart, and examine your thoughts and feelings about working with the patient.
During the orientation phase, you will perform introductions with the patient, establish a rapport, establish boundaries, and explain patient confidentiality.
You will set mutually agreed-upon goals with the patient and establish the date, time, place and duration of meetings.
During the working phase, you will gather data and identify and practice problem-solving skills and coping skills with your patient.
You will provide education to the patient, and then evaluate the progress being made towards the agreed-upon goals.
The termination phase of the nurse-client relationship comes at the end, and during this phase you will summarize goals that were achieved during the relationship, discuss incorporation of new coping mechanisms and problem-solving skills into the patient's life, and discuss their discharge plans.
During the termination phase, allow time for the patient to share their feelings regarding termination of the relationship. The termination of the relationship may elicit a sense of grief from the patient.
Transference vs. Countertransference
Transference and countertransference are important concepts in psychiatric mental health nursing.
In the mental health care setting, transference is when a patient redirects (transfers) their feelings about a person from their past onto the nurse.
For example, if a patient had a parent that was abusive, and the nurse reminds the patient of the abusive parent, the patient might transfer their feelings about their parent, onto the nurse, and treat the nurse with hostility.
Transference may interfere with the nurse-client relationship if it results in anger or hostility.
Countertransference is the inverse of transference. Countertransference is the nurse transferring feelings about a person from their past, onto the patient. In this case, the nurse's feelings and responses towards the patient are influenced by their past relationships, and this causes them to treat the patient differently.
This can be a problem if it causes the nurse to treat the patient differently or unjustly. The reason we learn about countertransference is so that if it happens, we can recognize it in ourselves and take steps to ensure that a therapeutic relationship and quality of care is maintained.
In the video, Cathy provides an example from her wound care team. One of Cathy's partners on the team might have a hard time with a certain personality or certain patient, but it may not be something that bothers Cathy. So Cathy can step in to help with this patient. And vice versa. This helps to ensure the patient receives just (fair) care.
Therapeutic communication is a communication style that is helpful, effective, and promotes the well-being of the patient.
Therapeutic communication techniques
There are a wide variety of therapeutic communication techniques you can use as a nurse. When you are in the learning stage, they may be new to you, and you might feel stilted or rehearsed, but over time they will become easier. You probably already employ some of these communication techniques in other scenarios without even realizing it!
Broad opening remarks
To use the communication technique of broad opening remarks, begin the conversation with a broad question that will allow the patient to direct the conversation where they choose. For example, on meeting with your patient you could begin with, "What would you like to talk about today?"
Here's a hint from outside of the nurse-patient relationship that you'll probably recognize: Broad opening remarks-style questions are often how job interviews begin! "So tell me about yourself/Tell me about your background."
Open-ended questions are questions that cannot be answered with only a Yes, No, or single-word answer. They are exploratory questions that prompt the patient to open up and share their thoughts. Open-ended questions more commonly begin with What, How, or "Tell me more about…"
For example, in the mental health setting, if you have a patient who hears voices, you might say, "Tell me more about the voices that you're hearing." This will prompt the patient to begin talking, telling you what the voices are saying to them, which will help you determine if the patient is at risk for harm, or if others are at risk for harm, so you can get the patient the help they need.
Sharing observations is when you say an observation about how the patient looks, sounds, or acts. You might say, "You seem a little sad to me today," which opens the door for the patient to share more about how they're feeling. They may also share why they are feeling that way.
Clarification or validation is when you seek understanding for something that the patient has said that is vague or confusing.
For example, you might ask the clarifying question, "Do I understand you correctly when you say this?"
Reflection is a technique to reflect a question back to the patient. For example, if a patient asks, "Do you think I should try that new medication?" then you might respond, "Well, what are your thoughts on that?"
It would not really be appropriate for you to give your opinion or advice, which we will cover later, as a direct answer to their question. You could say, "I can't answer that," which would immediately shut the conversation down, but a reflection is a more therapeutic technique because it keeps the conversation open and allows the patient to make their own decision.
Offering self is making yourself available to the patient. If your patient is scared or anxious, the simple act of being there (keeping them company) can be therapeutic.
Restating is repeating what the patient said back to them, to confirm understanding. Sometimes your wording might change from their wording, and this can help to further clarify.
For example, a patient might say "I'm so anxious that I can't get to sleep," and your restating response might be, "Your anxiety is keeping you up at night."
If it's right, the patient will probably confirm for you, but also, they feel that they have been understood. If it's not right, the patient will correct the record for you.
Presenting reality is an important communication technique in the mental health setting. It helps a patient to differentiate the real from the unreal. If a patient shares something that does not reflect reality, you can acknowledge that their perception of reality is real to them, but explain what reality actually is.
For example, if you have a patient that is hearing voices, you want to acknowledge that they are hearing voices, but you don't want to validate that there are voices. So you could say, "I understand that you're hearing voices, but I do not hear any voices."
In presenting reality you are stating the facts calmly, not belittling their experience or arguing with them.
Other therapeutic techniques
Silence, eye contact, and therapeutic touch are therapeutic communication techniques that may sometimes be appropriate, but not all the time. Whether or not these are appropriate will vary across individuals, different cultures, religions and more.
Non-therapeutic communication techniques
Non-therapeutic communication techniques are types of communication that you want to avoid as a nurse. We learn about them so we can recognize them and know not to do them!
If you were to say to your patient, "Everything is going to be just fine in the end," that would be false reassurance, and that is not therapeutic.
Passing judgement is approving or disapproving of the patient or their actions. Approving may seem positive, but it is a judgement and therefore not appropriate. If you were to say, "Yes, you did the right thing," that would not be therapeutic.
Giving advice is something that nurses should avoid. If it starts with "you should" or "you shouldn't," it's not therapeutic.
Close-ended questions are yes/no questions, and sometimes questions that can be answered with only one word. The reason that close-ended questions are not therapeutic is that they shut off the conversation when we want to open it up.
Obviously sometimes as a nurse you will need to ask your patient a yes/no question (clarification/validation is an example from the list above) but they should be avoided in cases where you need a patient to open up, provide information or share thoughts and feelings.
Asking a patient a question beginning with Why is not therapeutic. For example, "Why are you so angry?" or "Why didn't you follow your treatment plan?" These types of questions will put a patient on the defensive.
Sometimes using the therapeutic technique of sharing observations, will actually elicit the answer to a why question. Sharing observations is therapeutic, while asking direct Why questions is not. Sharing observations is a gentler delivery that uses indirect speech which helps to avoid putting people on the defensive.
We use indirect speech to varying degrees in our lives all the time, but it can be especially important when in the mental healthcare setting.
Leading or biased questions
Leading or biased questions are questions phrased in such a way that you are communicating that you expect a specific answer. This is not therapeutic because patients may not feel safe or accepted to give the true answer. For example, "You don't smoke, do you?"
Changing the subject
The last non-therapeutic communication technique we'll share here is changing the subject. For example, if your patient brings something up and you said, "Let's talk about something else," that would be changing the subject. It's not therapeutic because it blocks communication and dissuades the patient from sharing again in the future.
I am Cathy with Level Up RN, and in this video, I'm going to talk about the nurse-client relationship, as well therapeutic communication.
And at the end of the video, I'll give you guys a little quiz to check your knowledge about some of the key concepts that I'm going to cover in this video.
So let's first talk about a nurse-client relationship. Within that relationship, there are four phases.
The first phase is Pre-orientation. This is where you prepare for your meeting with the patient. You will do a chart review, and then you also want to examine your thoughts and feelings about working with the patient.
Then, during the Orientation Phase, you would perform introductions, establish rapport with the patient, also establish boundaries, and talk about patient confidentiality.
You will set mutually agreeable goals with the patient and also establish the date, time, place, and duration of meetings.
Then, when we get to the Working Phase, which is next, this is where we gather data and identify and practice problem-solving skills and coping skills.
We would provide education to the patient, and then we would evaluate progress being made towards those goals during that Working Phase.
And then, finally, we have the Termination Phase of the nurse-client relationship and during this time we would summarize the goals that were achieved during the relationship.
We can discuss incorporation of those new coping mechanisms and problem-solving skills into their life and discuss their discharge plans.
And then we also want to allow time for the patient to share their feelings regarding termination of their relationship because termination of the relationship may elicit a sense of grief from the patient.
Now let's talk about the concepts of transference and countertransference.
Transference is where the patient redirects or transfers their feelings about a person from their past onto the nurse. So let's say a nurse reminds a patient of their abusive mom and it causes that patient to treat the nurse in a very negative way. That's an example of transference.
And then countertransference is where the nurse's feelings and response towards the patient are influenced by their past relationships.
So if a patient reminded the nurse of somebody from their past it may cause the nurse to treat that patient differently. That is countertransference.
So within my wound care team, we have several team members and sometimes one of my partners on the team. They have a really hard time with a certain personality or a certain person, but it's not a really big deal for me.
So I'm like, "Let me take them. That's not a big deal," and vice versa. If there's somebody that kind of gets under my skin or I have a harder time with, then sometimes my partner will take that patient.
That doesn't happen a lot, but every once in a while it does. And it's kind of nice that we can share that burden and help each other out when counter-transference becomes an issue.
Alright. Next, let's talk about therapeutic communication. So I'm going to go through some therapeutic communication techniques, and then we'll go through non-therapeutic communication techniques.
So therapeutic communication is so important in the mental health setting, but it's also important in any setting, and so you'll need to know these techniques for all your classes in nursing school, not just psychiatric nursing.
And then it's also going to be important to know these techniques for your nursing practice. So let's go through some of them.
First, we have broad opening remarks. So this could be saying something like, "What would you like to talk about today?" And that helps to engage the patient and get them talking, which is really the goal with a lot of these techniques.
Then we have open-ended questions. So, "Tell me more about the voices that you're hearing," and that's important to get the patient talking and telling you what those voices are saying to he or she so that you can determine if they're at risk for harm, or if others are at risk for harm so that you can get the patient the help they need.
Then we have sharing observations, and an example of this would be, "You seem a little sad to me today." And then that kind of opens the door for the patient to share more about how they're feeling and why they're feeling that way.
Then we have a technique called clarification, which is also referred to as validation, and this is where you seek understanding for something that is vague or confusing.
So you can say something like, "Do I understand you correctly when you say this?" Right?
So if the patient is giving you a lot of information and you really just want to clarify that you're understanding them correctly, then clarification or validation are good techniques.
Reflection is a technique you would use to refer a question back to the patient. So if the patient's like, "Do you think I should try that new medication?" then I might say, "Well, what are your thoughts on that?" And that's kind of like reflection.
So they ask me a question, and I kind of reflect it back to them so that they can really think about it and make that decision.
Another technique is offering self, and and this is where you make yourself available to the patient. And an example of this would be-- I had a patient at the hospital. I had just finished some wound care, and he was in ICU, and he was getting ready to get an IJ vascular access put in, and he was really scared.
And I told him-- I was like, "I will wait here with you while you get that done," even though I was done with wound care. He was really scared, and I was just there, and I held his hand. So that was like offering of myself.
Then we have restating. This is where you repeat what the patient said to confirm your understanding. So if the patient says, "I'm so anxious that I can't get to sleep," you could say something like, "So your anxiety is keeping you up at night?" So kind of restating what they said to confirm my understanding.
And then lastly, we have presenting reality, which is really important in the mental health setting. So this is where you are correcting a patient's misconception. So if they are saying that they're hearing voices, you want to acknowledge that they are hearing voices, but you don't want to validate the fact that there are voices.
So you can say, "I understand that you're hearing voices, but I do not hear any voices."
So again, you want to acknowledge that their perception of reality is real to them, but you also want to let them know that you don't hear those voices, right?
You want to present that reality.
And then other therapeutic communication techniques can include silence as well as eye contact and therapeutic touch if appropriate.
And this will vary across individuals, different cultures, religions, so you really want to not make any assumptions that these techniques would be okay for every single patient. But they can be helpful for many patients.
Alright. Let's now talk about non-therapeutic communication techniques.
So you do not want to use these techniques. These are not therapeutic.
So false reassurance. If you were to say to your patient, "Everything is going to be just fine in the end," that would be false reassurance, and that is not therapeutic.
Also, passing judgement, so approving or disapproving is not therapeutic. So if you were to say to your patient, "Yes, you did the right thing," that is not what we want to be doing.
Giving advice is also something we shouldn't do. So "you should or shouldn't" should not be something that you say to your patient.Of course, I'm giving you advice right now, but this is not therapeutic. But you shouldn't use "you should or shouldn't" when talking to your patient in a therapeutic way.
Then we have close-ended questions. So these are like yes/no questions. "Are you feeling sad and they're like, "Yes," and that's the end of the conversation.
That's not what we want. We really want them to talk. So asking those close-ended questions really shuts off the conversation when we want to open it up.
Then we have why questions. "Why are you so angry?" It really puts the patient on the defensive when you use these why questions. So that is definitely not a therapeutic way to phrase a question. No why questions.
And then we have leading or biased questions like, "You don't smoke, do you?" And we're kind of biased and leading the patient towards a certain answer. And that is also non-therapeutic.
And then finally, changing the subject is also not therapeutic. So, "Let's talk about something else," is not something you're going to want to do.
Alright. Quiz time. First question. During which phase of the nurse-client relationship do you discuss confidentiality with the patient?
If you answered... the orientation phase, you are right.
Okay. Now we're going to do a little speed round. I want you to give me a thumbs up if the statement or question I give you is therapeutic and a thumbs down if it is not therapeutic. So we're going to do four different question statements.
First one. "You seem sad to me today." Therapeutic, because you're sharing observations.
"Why are you so angry?" Not therapeutic. The question starts with why, which is always a warning sign, and it really just puts the patient on the defensive.
Third statement. "Everything will be okay in the end." Not therapeutic, right. It's false reassurance, and you don't actually know that things will be okay in the end.
And then, "Tell me more about how you're feeling." Therapeutic, because it encourages open communication, encourages the patient to share more.
Alright. That's it for this video. Thank you so much for watching, and I'll see you soon.
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