Therapeutic Communication and Milieu Therapy Notes

Therapeutic Communication

  • Goal directed communication where you are in charge, focused on client needs, and oriented toward helping the client identify and explore feelings. It is non-judgmental, discourages defensiveness, promotes trust, and facilitates exploration of feelings that are always present.

Verbal vs Nonverbal Communication

  • Which communicates more? Both verbal and nonverbal cues convey messages, but nonverbal communication often carries more weight in perception and interpretation.

Nonverbal Communication Cues (Key elements)

  • Physical appearance
  • Touch
  • Body movement/posture
  • Facial expressions
  • Eye behavior
  • These cues significantly influence how messages are received and interpreted by clients.

Active Listening

  • To listen actively is to be attentive to what the client says verbally and nonverbally.
  • Nonverbal behaviors are designed as facilitative skills for attentive listening.
  • Active listening enhances understanding and engagement with the client.

S.O.L.E.R. Active Listening Framework

  • S – Sit squarely facing the client
  • O – Observe an open posture
  • L – Lean forward toward the client
  • E – Establish eye contact
  • R – Relax

Therapeutic Communication Techniques

  • Using silence: allows client to take control of the discussion if they desire
  • Accepting: conveys positive regard
  • Giving recognition: acknowledging awareness of client
  • Offering self: making oneself available
  • Giving broad openings: allows client to select topic

Additional Facilitative Techniques (Therapeutic Communication)

  • Offering general leads: encourages client to continue
  • Placing the event in time or sequence: clarifies temporal relationships
  • Making observations: verbalizing what is observed or perceived
  • Encouraging description of perceptions: ask client to verbalize what is perceived
  • Encouraging comparison: explore similarities and differences in ideas/experiences
  • Restating: confirms understanding of client statements
  • Reflecting: returns questions or feelings to the client for recognition/acceptance
  • Focusing: notice a single idea or word
  • Exploring: delves deeper into subject, idea, experience, or relationship
  • Seeking clarification and validation: clarifies vague points and seeks mutual understanding
  • Presenting reality: corrects misconceptions the client may express
  • Voicing doubt: expresses uncertainty about the reality of client’s perception
  • Verbalizing the implied: articulates what the client has implied but not stated

Non-Therapeutic Communication Techniques

  • Giving reassurance: may discourage further expression of feelings
  • Requesting an explanation: asking ‘why’ implies defense of behavior or feelings
  • Giving advice: implies nurse knows what is best and client cannot self-direct
  • Making stereotyped comments, clichés, and trite expressions: meaningless in nurse-client relationships
  • Giving approval or disapproval: implies judgment on client behavior
  • Probing: pushes for answers the client may not wish to discuss
  • Rejecting: refuses to consider client ideas or behavior
  • Agreeing/disagreeing: implies nurse can judge if ideas are right or wrong

How to Learn to Communicate Better

  • Weekly assignment of a new Therapeutic Communication Technique (TCT) for clinical use
  • Techniques facilitate data gathering during mental status assessments
  • Practice with peers, significant others, siblings, children, and parents

Relationship Development

  • Key components: Rapport (the flow of comfortable interaction), Trust, Respect, Genuineness
  • Empathy vs Sympathy: what is the difference?
    • Empathy involves understanding and sharing feelings; sympathy involves concern from a distance

Interpersonal Interactions and Distances

  • Interpersonal distances (zones):
    • Intimate distance: closest distance allowed between individuals
    • Personal distance: for personal interactions (e.g., close friends)
    • Social distance: for conversations with strangers or acquaintances
    • Public distance: for speaking in public or addressing a distant audience

Phases of the Relationship

  • Four phases:
    • Pre-interaction: you explore yourself and chart data
    • Orientation: trust-building; schmoozing and small talk
    • Working: beginning of personal change; promoting insight, reality testing, problem solving
    • Termination: conclusion of the relationship

Psychiatric Medications and Compliance

  • Psychiatric medications are powerful with potential serious side effects; nurses must know them, recognize manifestations, and maximize patient compliance. Non-compliance can lead to relapse.

4 Phases of Drug Treatment

  • 1. Initiation: Psychiatric evaluation; labs (hemoglobin, electrolytes, LFTs, thyroid function, urinalysis); cognitive functioning; history of side effects; support network assessment
  • 2. Stabilization: Symptom response; dosage adjustment vs drug change; vital signs monitoring; drug levels if indicated; assess for side effects and adverse reactions
  • 3. Maintenance: Assess/teach regarding return of target symptoms and action steps; teach signs of late-appearing side effects (e.g., tardive dyskinesia)
  • 4. Discontinuation: Taper dose; assess for re-emergence of symptoms; some disorders may require lifetime medication; all phases involve nursing actions including assessment and teaching

Common Reasons for Non-Compliance

  • Denial of need
  • Emotional dulling
  • Cognitive slowing
  • Disordered thought processes
  • Sexual dysfunction
  • Specific side effects (e.g., dry mouth, insomnia, sleepiness)
  • Fear of becoming addicted
  • Religious reasons
  • Interference with work
  • Inability to use alcohol or recreational drugs
  • Pregnancy
  • Financial barriers

Simplify the Regimen

  • Prefer once-daily pills when possible
  • Use combination drugs (e.g., Fluoxetine (antidepressant) + Olanzapine (antipsychotic))
  • Match dose times to client activities (meals, sleep)
  • Utilize medication boxes
  • Consider depot injections when appropriate

Imparting Knowledge (Patient Education)

  • Determine readiness to learn
  • Limit instructions to 3–4 major points
  • Use simple, everyday language
  • Supplement with written materials (drug company resources may help)
  • Involve patient’s family members (with consent)
  • Summarize teaching

Modifying Beliefs about Treatment

  • Help clients believe they can perform healthy behaviors
  • Positive treatment benefits reinforce adherence
  • Relapse risk exists if medications are not taken as prescribed
  • Acknowledge that illness is real and serious

Leaving the Bias

  • There is no clear relationship between demographics (race, sex, education, intelligence, marital status, occupation, income, ethnicity, culture) and compliance
  • Question: how to assess compliance effectively if bias is not predictive?

Evaluating Compliance (Clinical Questions)

  • Do you forget to take your medications?
  • How many doses did you miss last week?
  • When do you take your medications? Morning, evening, with meals?
  • When you feel better, do you stop taking medications?
  • When you feel worse, do you stop taking medications?

Client Communication and Engagement

  • Ask the client about feelings and concerns
  • Look for denial of problem
  • Conduct follow-up phone calls
  • Encourage family involvement

Milieu Therapy (Therapeutic Community)

  • Definition: Milieu therapy is the scientific structuring of the environment to effect behavioral changes and improve psychological health and functioning. In this setting, patients learn adaptive coping, interaction, and relationship skills transferable to other life areas.

Basic Assumptions of Milieu Therapy

  • Health of each individual should be realized and encouraged to grow
  • Every interaction is an opportunity for therapeutic intervention
  • The client owns their environment
  • The client owns their behavior
  • Peer pressure is a useful and powerful tool
  • Inappropriate behaviors are addressed as they occur
  • Restrictions and punishment are to be avoided

Conditions That Promote a Therapeutic Community

  • Basic physiological needs fulfilled
  • Physical facilities conducive to therapy goals
  • Democratic self-government exists
  • Unit responsibilities assigned according to patient capabilities
  • Structured program of social and work-related activities is part of treatment
  • Community and family involvement to facilitate discharge

The Program of Therapeutic Community

  • Treatment plan directed by an interdisciplinary team
  • Plan formulated by the team; team members sign the plan and meet weekly to update
  • Disciplines may include psychiatry, psychology, nursing, social work, occupational therapy, recreational therapy, art therapy, music therapy, dietetics, chaplaincy, and family
  • Core team members: psychiatry, nursing, and social workers; conduct treatment team meetings

Role of the Nurse in Milieu Therapy

  • Utilize the nursing process to manage the therapeutic environment 24/7
  • Ensure patients' physiological and psychological needs are met
  • Medication administration
  • Develop a one-to-one relationship with clients
  • Set limits on unacceptable behavior
  • Recognize and reinforce positive behaviors
  • Provide client education