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Chapter: Psychiatric Mental Health Nursing : Therapeutic Communication

What Is Therapeutic Communication?

Therapeutic communication is an interpersonal interaction between the nurse and the client during which the nurse focuses on the client’s specific needs to promote an effective exchange of information.



Therapeutic communication is an interpersonal interaction between the nurse and the client during which the nurse focuses on the client’s specific needs to promote an effective exchange of information. Skilled use of therapeutic com-munication techniques helps the nurse understand and empathize with the client’s experience. All nurses need skills in therapeutic communication to effectively apply the nurs-ing process and to meet standards of care for their clients.


Therapeutic communication can help nurses to accom-plish many goals:


·    Establish a therapeutic nurse–client relationship.


·    Identify the most important client concern at that mo-ment (the client-centered goal).


·    Assess the client’s perception of the problem as it unfolds. This includes detailed actions (behaviors and messages) of the people involved and the client’s thoughts and feel-ings about the situation, others, and self.


·    Facilitate the client’s expression of emotions.


·    Teach the client and family necessary self-care skills.


·    Recognize the client’s needs.


·    Implement interventions designed to address the client’s needs.


Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution.

Establishing a therapeutic relationship is one of the most important responsibilities of the nurse when work-ing with clients. Communication is the means by which a therapeutic relationship is initiated, maintained, and ter-minated. To have effective therapeutic communication, the nurse also must consider privacy and respect of boundaries, use of touch, and active listening and observation.


Privacy and Respecting Boundaries


Privacy is desirable but not always possible in therapeutic communication. An interview or a conference room is optimal if the nurse believes this setting is not too isolative for the interaction. The nurse also can talk with the client at the end of the hall or in a quiet corner of the day room or lobby, depending on the physical layout of the setting. The nurse needs to evaluate whether interacting in the cli-ent’s room is therapeutic. For example, if the client has difficulty maintaining boundaries or has been making sex-ual comments, then the client’s room is not the best set-ting. A more formal setting would be desirable.


Proxemics is the study of distance zones between peo-ple during communication. People feel more comfortable with smaller distances when communicating with some-one they know rather than with strangers (DeVito, 2008). People from the United States, Canada, and many Eastern European nations generally observe four distance zones:


·    Intimate zone (0 to 18 inches between people): This amount of space is comfortable for parents with young children, people who mutually desire personal contact, or people whispering. Invasion of this intimate zone by anyone else is threatening and produces anxiety.


·    Personal zone (18 to 36 inches): This distance is com-fortable between family and friends who are talking.


·    Social zone (4 to 12 feet): This distance is acceptable for communication in social, work, and business settings.


·    Public zone (12 to 25 feet): This is an acceptable dis-tance between a speaker and an audience, small groups, and other informal functions (Hall, 1963).


People from some cultures (e.g., Hispanic, Mediterra-nean, East Indian, Asian, and Middle Eastern) are more comfortable with less than 4 to 12 feet of space between them while talking. The nurse of European American or African American heritage may feel uncomfortable if cli-ents from these cultures stand close when talking. Con-versely, clients from these backgrounds may perceive the nurse as remote and indifferent (Andrews & Boyle, 2007).


Both the client and the nurse can feel threatened if one invades the other’s personal or intimate zone, which can result in tension, irritability, fidgeting, or even flight. When the nurse must invade the intimate or personal zone, he or she always should ask the client’s permission. For example, if a nurse performing an assessment in a community setting needs to take the client’s blood pressure, he or she should say, “Mr. Smith, to take your blood pressure I will wrap this cuff around your arm and listen with my stethoscope. Is this acceptable to you?” He or she should ask permission in a yes/no format so the client’s response is clear. This is one of the times when yes/no questions are appropriate.


The therapeutic communication interaction is most comfortable when the nurse and client are 3 to 6 feet apart. If a client invades the nurse’s intimate space (0 to 18 inches), the nurse should set limits gradually, depend-ing on how often the client has invaded the nurse’s space and the safety of the situation.



As intimacy increases, the need for distance decreases.


Knapp (1980) identified five types of touch:


·    Functional-professional touch is used in examinations or procedures such as when the nurse touches a client to assess skin turgor or a masseuse performs a massage.


·    Social-polite touch is used in greeting, such as a hand-shake and the “air kisses” some women use to greet acquaintances, or when a gentle hand guides someone in the correct direction.


·    Friendship-warmth touch involves a hug in greeting, an arm thrown around the shoulder of a good friend, or the backslapping some men use to greet friends and relatives.


·    Love-intimacy touch involves tight hugs and kisses between lovers or close relatives.


·    Sexual-arousal touch is used by lovers.


Touching a client can be comforting and supportive when it is welcome and permitted. The nurse should observe the client for cues that show whether touch is desired or indicated. For example, holding the hand of a sobbing mother whose child is ill is appropriate and therapeutic. If the mother pulls her hand away, how-ever, she signals to the nurse that she feels uncomfort-able being touched. The nurse also can ask the client about touching (e.g., “Would it help you to squeeze my hand?”).


Although touch can be comforting and therapeutic, it is an invasion of intimate and personal space. Some cli-ents with mental illness have difficulty understanding the concept of personal boundaries or knowing when touch is or is not appropriate. Consequently, most psy-chiatric inpatient, outpatient, and ambulatory care units have policies against clients touching one another or staff. Unless they need to get close to a client to perform some nursing care, staff members should serve as role models and refrain from invading clients’ personal and intimate space. When a staff member is going to touch a client while performing nursing care, he or she must ver-bally prepare the client before starting the procedure. A client with paranoia may interpret being touched as a threat and may attempt to protect himself or herself by striking the staff person.



Active Listening and Observation


To receive the sender’s simultaneous messages, the nurse must use active listening and active observation. Active listening means refraining from other internal mentalactivities and concentrating exclusively on what the client says. Active observation means watching the speaker’s nonverbal actions as he or she communicates.


Peplau (1952) used observation as the first step in the therapeutic interaction. The nurse observes the client’s behavior and guides him or her in giving detailed descriptions of that behavior. The nurse also documents these details. To help the client develop insight into his or her interpersonal skills, the nurse analyzes the infor-mation obtained, determines the underlying needs that relate to the behavior, and connects pieces of informa-tion (makes links between various sections of the conversation).


A common misconception by students learning the art of therapeutic communication is that they always must be ready with questions the instant the client has finished speaking. Hence, they are constantly thinking ahead regarding the next question rather than actively listening to what the client is saying. The result can be that the nurse does not understand the client’s concerns, and the conversation is vague, superficial, and frustrat-ing to both participants. When a superficial conversa-tion occurs, the nurse may complain that the client is not cooperating, is repeating things, or is not taking responsibility for getting better. Superficiality, however, can be the result of the nurse’s failure to listen to cues in the client’s responses and repeatedly asking the same question. The nurse does not get details and works from his or her assumptions rather than from the client’s true situation.


While listening to a client’s story, it is almost impossi-ble for the nurse not to make assumptions. A person’s life experiences, knowledge base, values, and prejudices often color the interpretation of a message. In therapeutic com-munication, the nurse must ask specific questions to get the entire story from the client’s perspective, to clarify assumptions, and to develop empathy with the client. Empathy is the ability to place oneself into the experience of another for a moment in time. Nurses develop empathy by gathering as much information about an issue as pos-sible directly from the client to avoid interjecting their personal experiences and interpretations of the situation. The nurse asks as many questions as needed to gain a clear understanding of the client’s perceptions of an event or issue.


Active listening and observation help the nurse to


·    Recognize the issue that is most important to the client at this time.


·    Know what further questions to ask the client.


·    Use additional therapeutic communication techniques to guide the client to describe his or her perceptions fully.


·    Understand the client’s perceptions of the issue instead of jumping to conclusions.


·        Interpret and respond to the message objectively.


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