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Chapter: Psychiatric Mental Health Nursing : Therapeutic Communication

Verbal Communication Skills

When speaking to the client the nurse should use words that are as clear as possible so that the client can understand the message.



Using Concrete Messages


When speaking to the client the nurse should use words that are as clear as possible so that the client can understand the message. Anxious people lose cognitive processing skills—the higher the anxiety, the less the ability to process concepts—so concrete messages are important for accurate information exchange. In a concrete message, the words are explicit and need no interpretation; the speaker uses nouns instead of pronouns—for example, “What health symptoms caused you to come to the hospital today?” or “When was the last time you took your antidepressant medications?” Concrete questions are clear, direct, and easy to understand. They elicit more accurate responses and avoid the need to go back and rephrase unclear questions, which interrupts the flow of a therapeutic interaction.


Abstract messages, in contrast, are unclear patterns of words that often contain figures of speech that are difficult to interpret. They require the listener to interpret what the speaker is asking. For example, a nurse who wants to know why a client was admitted to the unit asks, “How did you get here?” This is an abstract message: the terms how and here are vague. An anxious client might not be aware of where he or she is and might reply, “Where am I?” or might interpret this as a question about how he or she was conveyed to the hospital and respond, “The ambulance brought me.” Clients who are anxious, from different cul-tures, cognitively impaired, or suffering from some mental disorders often function at a concrete level of comprehen-sion and have difficulty answering abstract questions. The nurse must be sure that statements and questions are clear and concrete.

The following are examples of abstract and concrete messages:


Abstract (unclear): “Get the stuff from him.”


Concrete (clear): “John will be home today at 5 pm, and you can pick up your clothes at that time.”


Abstract (unclear): “Your clinical perfor-mance has to improve.”


Concrete (clear): “To administer medications tomorrow, you’ll have to be able to calculate dosages correctly by the end of today’s class.”


Using Therapeutic Communication Techniques

The nurse can use many therapeutic communication tech-niques to interact with clients. The choice of technique depends on the intent of the interaction and the client’s ability to communicate verbally. Overall, the nurse selects techniques that facilitate the interaction and enhance com-munication between client and nurse. Table 6.1 lists these techniques and gives examples. Techniques such asexploring, focusing, restating, and reflecting encourage the client to discuss his or her feelings or concerns in more depth. Other techniques help focus or clarify what is being said. The nurse may give the client feedback using tech-niques such as making an observation or presenting reality.

Avoiding Nontherapeutic Communication


In contrast, there are many nontherapeutic techniques that nurses should avoid (Table 6.2). These responses cut off communication and make it more difficult for the inter-action to continue. Responses such as “Everything will work out” or “Maybe tomorrow will be a better day” may be intended to comfort the client, but instead may impede the communication process. Asking “why” questions (in an effort to gain information) may be perceived as criti-cism by the client, conveying a negative judgment from the nurse. Many of these responses are common in social interaction. Therefore, it takes practice for the nurse to avoid making these types of comments.

Interpreting Signals or Cues


To understand what a client means, the nurse watches and listens carefully for cues. Cues (overt and covert) are ver-bal or nonverbal messages that signal key words or issues for the client. Finding cues is a function of active listening. Cues can be buried in what a client says or can be acted out in the process of communication. Often, cue words introduced by the client can help the nurse to know what to ask next or how to respond to the client. The nurse builds his or her responses on these cue words or con-cepts. Understanding this can relieve pressure on students who are worried and anxious about what question to ask next. The following example illustrates questions the nurse might ask when responding to a client’s cue:

Client: “I had a boyfriend when I was younger.”

Nurse: “You had a boyfriend?” (reflecting) “Tell me about you and your boyfriend.”(encouraging description)

“How old were you when you had this boy-friend?” (placing events in time or sequence)


If a client has difficulty attending to a conversation and drifts into a rambling discussion or a flight of ideas, the nurse listens carefully for a theme or a topic around which the client composes his or her words. Using the theme, the nurse can assess the nonverbal behaviors that accompany the client’s words and build responses based on these cues. In the following examples, the underlined words are themes and cues to help the nurse formulate further communication.

Theme of sadness:


Client: “Oh, hi, nurse.” (face is sad; eyes look teary; voice is low, with little inflection)

Nurse: “You seem sad today, Mrs. Venezia.”

Client: “Yes, it is the anniversary of my husband’s death.”

Nurse: How long ago did your husband die?” (Or the nurse can use the other cue.)

Nurse: “Tell me about your husband’s death, Mrs. Venezia.”

Theme of loss of control:

Client: “I had a fender bender this morning. I’m okay. I lost my wallet, and I have to go to the bank to cover a check I wrote last night. I can’t get in contact with my husband at work. I don’t know where to start.

Nurse: “I sense you feel out of control” (translating into feelings).

Clients may use many word patterns to cue the listener to their intent. Overt cues are clear, direct statements of intent, such as “I want to die.” The message is clear that the client is thinking of suicide or self-harm. Covert cues are vague or indirect messages that need interpretationand exploration—for example, if a client says, “Nothing can help me.” The nurse is unsure, but it sounds as if the client might be saying he feels so hopeless and helpless that he plans to commit suicide. The nurse can explore this covert cue to clarify the client’s intent and to protect the client. Most suicidal people are ambivalent about whether to live or die and often admit their plan when directly asked about it. When the nurse suspects self-harm or suicide, he or she uses a yes/no question to elicit a clear response.


Theme of hopelessness and suicidal ideation:

Client: “Life is hard. I want it to be done. There is no rest. Sleep, sleep is good . . . forever.”


Nurse: “I hear you saying things seem hope-less. I wonder if you are planning to kill your-self” (verbalizing the implied).


Other word patterns that need further clarification for meaning include metaphors, proverbs, and clichés. When a client uses these figures of speech, the nurse must follow up with questions to clarify what the client is trying to say.


A metaphor is a phrase that describes an object or a situation by comparing it to something else familiar.


Client: “My son’s bedroom looks like a bomb went off.”

Nurse: “You’re saying your son is not very neat” (verbalizing the implied).

Client: “My mind is like mashed potatoes.”

Nurse: “I sense you find it difficult to put thoughts together” (translating into feelings).

Proverbs are old accepted sayings with generally accepted meanings.

Client: “People who live in glass houses shouldn’t throw stones.”

Nurse: “Who do you believe is criticizing you but actually has similar problems?” (encourag-ing description of perception)

A cliché is an expression that has become trite and gen-erally conveys a stereotype. For example, if a client says, “she has more guts than brains,” the implication is that the speaker believes the woman to whom he or she refers is not smart, acts before thinking, or has no common sense. The nurse can clarify what the client means by saying, “Give me one example of how you see Mary as having more guts than brains” (focusing).


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