NCM 117 Care of Clients with

Maladaptive Patterns of
Behavior
Acute and Chronic

SL Week 1: Development of
Communication Skills
 Effective Communication
• Composed of verbal and nonverbal
techniques that the nurse uses to focus on
the client’s needs

Basic Elements
1. Sender
2. Message
3. Receiver
4. Feedback
 Effective Communication
Communication
(1) Appropriate
(2) Simple
(3) Adaptive
(4) Concise
 Therapeutic Communication
1. Offering Self
•making self-available and showing interest and
concern.
 
2. Accepting
•Indicates reception
 
3. Exploring
•Delving further into a subject or
an idea
Therapeutic Communication
4. Giving broad openings
• Allowing the client to take the initiative in
introducing the topic

5. Silence
• Planned absence of verbal remarks to
allow patient and nurse to think over what
is being discussed and to say more. 

6. Verbalizing the implied

• Verbalizing what is observed in the patient
to, for validation and to encourage
discussion
 Therapeutic Communication
7. Encouraging comparisons
• Asking to describe similarities and differences among
feelings, behaviors, and events.

8. Summarizing
• Reviewing the main points of discussions and making
appropriate conclusions.
 Therapeutic Communication
 
10. Placing the event in time or sequence
• Asking for relationship among events

11. Voicing doubt

• Voicing uncertainty about the reality of patient’s statements,
perceptions and conclusions.
• “I find it hard to believe…”
 
 Therapeutic Communication

12. Encouraging descriptions of perceptions

• Asking the patients to describe feelings, perceptions and
views of their situations.

13. Presenting reality or confronting

• Stating what is real and what is not
without arguing with the patient
 Therapeutic Communication

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”.
 Therapeutic Communication
15. Verbalizing the implied
• Rephrasing patient’s words to highlight an underlying
message to clarify statements.
 
16. Reflecting
• Throwing back the patient’s statement
in a form of question helps the patient
identify feelings.
 Therapeutic Communication
17. Restating
• Repeating the exact words of patients to remind them of
what they said and to let them know they are heard.
• 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.
 Therapeutic Communication
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”.
 Therapeutic Communication
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.
 Therapeutic Communication
23. Encouraging evaluation
• Asking for patients views of the meaning or importance of
something.

 
24. Suggesting collaboration
• Offering to help patients solve problems.
• “Perhaps you can discuss this with your children so they
will know how you feel and what you want”.
 Therapeutic Communication
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?”
 Therapeutic Communication
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?”
 Therapeutic Communication
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.
 Therapeutic Communication
31. Supportive confrontation
• acknowledging the difficulty in changing, but pushing for
action.
• “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”.
 Therapeutic Communication
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”.
 Therapeutic Communication
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”.
Therapeutic Communication
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
8.Asking WHY?
9.Changing subject
10.Defending doctors and other health team members.
 Non - Therapeutic Communication
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”.
 Non - Therapeutic Communication
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.
 Non - Therapeutic Communication
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.
 Non - Therapeutic Communication
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?”
 Non - Therapeutic Communication
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.
 Other ineffective behaviors and responses:

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
 Other ineffective behaviors and responses:

1. Making false promises – I’ll make sure to call you when you
get home.
2. Ignoring the patient – I can’t talk to you right now
3. Making sarcastic remarks
4. Laughing nervously
5. Showing disapproval – You should not do those things.
(EGO) DEFENSE MECHANISMS
 methods of attempting to protect the self and cope
with emotionally painful thoughts
 mental mechanisms that operate to protect the
ego
 operate at an unconscious level and help ward
off unpleasant feelings
 DEFENSE MECHANISMS
1. REPRESSION
– excluding emotionally painful
or anxiety-provoking thoughts
and feelings from conscious
awareness

2. REGRESSION
– moving back to a
previous developmental
stage to feel safe or have
needs met.
 DEFENSE MECHANISMS
3. REACTION FORMATION
‒ acting the opposite response
of what one thinks or feels

4. DISPLACEMENT
‒ ventilation of intense
feelings toward persons
less threatening than
the one who aroused
those feelings
 DEFENSE MECHANISMS
5. IDENTIFICATION
‒ modeling actions and opinions of influential others

6. DENIAL
‒ failure to acknowledge an
unbearable condition
‒ failure to admit the reality of
a situation or how one
enables the problem to
continue
 DEFENSE MECHANISMS
7. ISOLATION
‒ Separation of emotions from precipitating event or
situation
8. INTELLECTUALIZATION
‒ use of thinking to avoid experiencing unpleasant
emotions.
‒ separation of the emotions of a painful event or
situation from the facts.
9. RATIONALIZATION
‒ Attempts to justify one’s behavior by presenting
reasons that sounds logical
 DEFENSE MECHANISMS
10. PROJECTION
‒ unconscious blaming of
unacceptable inclinations
or thoughts on an external
object.

11. INTROJECTION
‒ accepting another person’s
attitudes, beliefs and values as
one’s own.
 DEFENSE MECHANISMS
12. SUBLIMATION
‒ substituting constructive and socially acceptable
behavior strong impulses that are unacceptable
in their original form.

13. SUBSTITUTION
‒ replacing the desired
gratification with one that
is more readily available
 DEFENSE MECHANISMS
14. UNDOING
‒ exhibiting acceptable
behavior to make up for
unacceptable behavior

15. FIXATION
‒ immobilization of a portion of the personality
resulting from unsuccessful completion of task