One of the most important skills of a nurse is developing the ability to establish a therapeutic relationship with clients. For interventions to be successful with clients in a psychiatric facility and in all nursing specialties it is crucial to build a therapeutic relationship.

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Therapeutic and Non-Therapeutic Communication
Effective Communication:
1. Open ended questions
2. Focus on feelings
3. State behaviors observed
4. Reflect, restate, rephrase verbalization of
patient
5. Neutral responses
6. Appropriate
7. Simple
8. Adaptive
9. Concise
10.Credible
Therapeutic relationship – is a relationship that is established between a
health care professional and a client for the purpose of assisting the client to solve
his problems.
Components of a Therapeutic Relationship
One of the most important skills of a nurse is developing the ability to establish a
therapeutic relationship with clients. For interventions to be successful with clients
in a psychiatric facility and in all nursing specialties it is crucial to build a
therapeutic relationship. Crucial components are involved in establishing a
therapeutic nurse-patient relationship and the communication within it which
serves as the underpinning for treatment and success. It is essential for a nurse to
know and understand these components as it explores the task that should be
accomplish in a nurse-client relationship and the techniques that a nurse can utilize
to do so.
TRUST
Without trust a nurse-client relationship would not be established and interventions
won’t be successful. For a client to develop trust, the nurse should exhibit the
following behaviors:
Friendliness

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Caring
Interest
Understanding
Consistency
Treating the client as human being
Suggesting without telling
Approachability
Listening
Keeping promises
Providing schedules of activities
Honesty
GENUINE INTEREST
Another essential factor to build a therapeutic nurse-client relationship is showing
a genuine interest to the client. For the nurse to do this, he or she should be open,
honest and display a congruent behavior. Congruence only occurs when the nurse’s
words matches with her actions.
EMPATHY
For a nurse to be successful in dealing with clients it is very essential that she
empathize with the client. Empathy is the nurse’s ability to perceive the meanings
and feelings of the client and communicate that understanding to the client. It is
simply being able to put oneself in the client’s shoes. However, it does not require
that the nurse should have the same or exact experiences as of the patient. Empathy
has been shown to positively influence client outcomes. When the nurse develops
and utilizes this ability, clients tend to feel much better about themselves and more
understood.
Some people confuse empathizing with sympathizing. To establish a good nurse-
patient relationship, the nurse should use empathy not sympathy. Sympathy is
defined as the feelings of concern or compassion one shows for another. By
sympathizing, the nurse projects his or her own concerns to the client, thus,
inhibiting the client’s expression of feelings. To better understand the difference
between the two, let’s take a look at the given example.
Client’s statement:
“I am so sad today. I just got the news that my father died yesterday. I should have
been there, I feel so helpless.”

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Nurse’s Sympathetic Response:
“I know how depressing that situation is. My father also died a month ago and until
now I feel so sad every time I remember that incident. I know how bad that makes
you feel.”
Nurse’s Empathetic Response:
“I see you are sad. How can I help you?”
When the nurse expresses sympathy for the client, the nurse’s feelings of sadness
or even pity could influence the relationship and hinders the nurse’s abilities to
focus on the client’s needs. The emphasis is shifted from the client’s to the nurse’s
feelings thereby hindering the nurse’s ability to approach the client’s needs in an
objective manner.
In dealing with clients their interest should be the nurse’s greatest concern. Thus,
empathizing with them is the best technique as it acknowledges the feelings of the
client and at the same time it allows a client to talk and express his or her
emotions. Here a bond can be established that serves as a foundation for the nurse-
client relationship.
ACCEPTANCE
Clients are unpredictable. There are times that they outburst with anger or act out
their inappropriate desires. A nurse, who does not judge the client or person no
matter what his or her behavior, is showing acceptance. Acceptance does not mean
accepting all the inappropriate behavior but rather acceptance of the person as
worthy. When the client displays an improper behavior, the nurse can
communicate with the client by being firm and clear without anger or judgment. In
this way, the nurse allows the client to feel intact but at the same time aware that
his certain behavior is unacceptable. Let’s take a look at the given example.
Situation: A client tries to kiss the nurse.
Inappropriate response: What the hell are you doing?! I’m leaving maybe I’ll see
you tomorrow.
Appropriate response: Adam, do not kiss me. We are working on your relationship
with your girlfriend and that does not require you to kiss me. Now let us continue.
POSITIVE REGARD
Positive regard is an unconditional and nonjudgmental attitude where the nurse
appreciates the client as a unique worthwhile human being that shows respect for

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the client regardless of his or her behavior background and lifestyle. The following
ways are example of how to promote respect and positive regard to a client:
Calling the client by name
Spending time with the client
Listening to the client
Responding to the client openly
Considering the client’s ideas and preferences when planning care
SELF-AWARENESS
Self-awareness is the process of understanding one’s own values, beliefs, thoughts,
feelings, attitudes, motivations, prejudices, strengths and limitations. Before a
nurse can understand clients he or she should be able to understand him or herself.
The first step in preparing oneself to build a therapeutic nurse-patient relationship
is to understand oneself.
THERAPEUTIC USE OF SELF
A nurse can only use his or her personality, experiences, values, feelings,
intelligence, needs, coping skills and perceptions to build a relationship with
clients (therapeutic use of self) when he or she has developed self-awareness and
self-understanding.
Therapeutic Technique
1. Offering Self
making self-available and showing interest and concern.
“I will walk with you”
2. Active listening
paying close attention to what the patient is saying by observing both verbal
and non-verbal cues.
Maintaining eye contact and making verbal remarks to clarify and encourage
further communication.
3. Exploring
“Tell me more about your son”

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4. Giving broad openings
What do you want to talk about today?
5. Silence
Planned absence of verbal remarks to allow patient and nurse to think over
what is being discussed and to say more.
6. Stating the observed
verbalizing what is observed in the patient to, for validation and to
encourage discussion
“You sound angry”
7. Encouraging comparisons
· asking to describe similarities and differences among feelings, behaviors,
and events.
· “Can you tell me what makes you more comfortable, working by yourself
or working as a member of a team?”
8. Identifying themes
asking to identify recurring thoughts, feelings, and behaviors.
“When do you always feel the need to check the locks and doors?”
9. Summarizing
reviewing the main points of discussions and making appropriate
conclusions.
“During this meeting, we discussed about what you will do when you feel
the urge to hurt your self again and this include…”
10. Placing the event in time or sequence
asking for relationship among events.
“When do you begin to experience this ticks? Before or after you entered
grade school?”
11. Voicing doubt

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voicing uncertainty about the reality of patient’s statements, perceptions and
conclusions.
“I find it hard to believe…”
12. Encouraging descriptions of perceptions
asking the patients to describe feelings, perceptions and views of their
situations.
“What are these voices telling you to do?”
13. Presenting reality or confronting
stating what is real and what is not without arguing with the patient.
“I know you hear these voices but I do not hear them”.
“I am Lhynnelli, your nurse, and this is a hospital and not a beach resort.
14. Seeking clarification
asking patient to restate, elaborate, or give examples of ideas or feelings to
seek clarification of what is unclear.
“I am not familiar with your work, can you describe it further for me”.
“I don’t think I understand what you are saying”.
15. Verbalizing the implied
rephrasing patient’s words to highlight an underlying message to clarify
statements.
Patient: I wont be bothering you anymore soon.
Nurse: Are you thinking of killing yourself?
16. Reflecting
throwing back the patient’s statement in a form of question helps the patient
identify feelings.
Patient: I think I should leave now.
Nurse: Do you think you should leave now?
17. Restating
repeating the exact words of patients to remind them of what they said and
to let them know they are heard.

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Patient: I can’t sleep. I stay awake all night.
Nurse: You can’t sleep at night?
18. General leads
using neutral expressions to encourage patients to continue talking.
“Go on…”
“You were saying…”
19. Asking question
using open-ended questions to achieve relevance and depth in discussion.
“How did you feel when the doctor told you that you are ready for discharge
soon?”
20. Empathy
recognizing and acknowledging patient’s feelings.
“It’s hard to begin to live alone when you have been married for more than
thirty years”.
21. Focusing
pursuing a topic until its meaning or importance is clear.
“Let us talk more about your best friend in college”
“You were saying…”
22. Interpreting
providing a view of the meaning or importance of something.
Patient: I always take this towel wherever I go.
Nurse: That towel must always be with you.
23. Encouraging evaluation
asking for patients views of the meaning or importance of something.
“What do you think led the court to commit you here?”
“Can you tell me the reasons you don’t want to be discharged?
24. Suggesting collaboration
offering to help patients solve problems.

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“Perhaps you can discuss this with your children so they will know how you
feel and what you want”.
25. Encouraging goal setting
asking patient to decide on the type of change needed.
“What do you think about the things you have to change in your self?”
26. Encouraging formulation of a plan of action
probing for step by step actions that will be needed.
“If you decide to leave home when your husband beat you again what will
you do next?”
27. Encouraging decisions
asking patients to make a choice among options.
“Given all these choices, what would you prefer to do.
28. Encouraging consideration of options
asking patients to consider the pros and cons of possible options.
“Have you thought of the possible effects of your decision to you and your
family?”
29. Giving information
providing information that will help patients make better choices.
“Nobody deserves to be beaten and there are people who can help and places
to go when you do not feel safe at home anymore”.
30. Limit setting
discouraging nonproductive feelings and behaviors, and encouraging
productive ones.
“Please stop now. If you don’t, I will ask you to leave the group and go to
your room.
31. Supportive confrontation
acknowledging the difficulty in changing, but pushing for action.

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“I understand. You feel rejected when your children sent you here but if you
look at this way…”
32. Role playing
practicing behaviors for specific situations, both the nurse and patient play
particular role.
“I’ll play your mother, tell me exactly what would you say when we meet on
Sunday”.
33. Rehearsing
asking the patient for a verbal description of what will be said or done in a
particular situation.
“Supposing you meet these people again, how would you respond to them
when they ask you to join them for a drink?”.
34. Feedback
pointing out specific behaviors and giving impressions of reactions.
“I see you combed your hair today”.
35. Encouraging evaluation
asking patients to evaluate their actions and their outcomes.
“What did you feel after participating in the group therapy?”.
36. Reinforcement
giving feedback on positive behaviors.
“Everyone was able to give their options when we talked one by one and
each of waited patiently for our turn to speak”.
Avoid pitfalls:
1. Giving advise
2. Talking about your self
3. Telling client is wrong
4. Entering into hallucinations and delusions of client
5. False reassurance
6. Cliché
7. Giving approval

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8. Asking WHY?
9. Changing subject
10.Defending doctors and other health team members.
Non-therapeutic Technique
1. Overloading
talking rapidly, changing subjects too often, and asking for more information
than can be absorbed at one time.
“What’s your name? I see you like sports. Where do you live?”
2. Value Judgments
giving one’s own opinion, evaluating, moralizing or implying one’s values
by using words such as “nice”, “bad”, “right”, “wrong”, “should” and
“ought”.
“You shouldn’t do that, its wrong”.
3. Incongruence
sending verbal and non-verbal messages that contradict one another.
The nurse tells the patient “I’d like to spend time with you” and then walks
away.
4. Underloading
remaining silent and unresponsive, not picking up cues, and failing to give
feedback.
The patient ask the nurse, simply walks away.
5. False reassurance/ agreement
Using cliché to reassure client.
“It’s going to be alright”.
6. Invalidation
Ignoring or denying another’s presence, thought’s or feelings.
Client: How are you?
Nurse responds: I can’t talk now. I’m too busy.

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7. Focusing on self
responding in a way that focuses attention to the nurse instead of the client.
“This sunshine is good for my roses. I have beautiful rose garden”.
8. Changing the subject
introducing new topic
inappropriately, a pattern that may indicate anxiety.
The client is crying, when the nurse asks “How many children do you
have?”
9. Giving advice
telling the client what to do, giving opinions or making decisions for the
client, implies client cannot handle his or her own life decisions and that the
nurse is accepting responsibility.
“If I were you… Or it would be better if you do it this way…”
10. Internal validation
making an assumption about the meaning of someone else’s behavior that is
not validated by the other person (jumping into conclusion).
The nurse sees a suicidal clients smiling and tells another nurse the patient is
in good mood.
Other ineffective behaviors and responses:
1. Defending – Your doctor is very good.
2. Requesting an explanation – Why did you do that?
3. Reflecting – You are not suppose to talk like that!
4. Literal responses – If you feel empty then you should eat more.
5. Looking too busy.
6. Appearing uncomfortable in silence.
7. Being opinionated.
8. Avoiding sensitive topics
9. Arguing and telling the client is wrong
10.Having a closed posture-crossing arms on chest
11.Making false promises – I’ll make sure to call you when you get home.
12.Ignoring the patient – I can’t talk to you right now
13.Making sarcastic remarks

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14.Laughing nervously
15.Showing disapproval – You should not do those things.