Therapeutic Environment,

Therapeutic Communication
 Therapeutic Environment
• The therapeutic environment is the ideal,
dynamic environment that aims to heal the
patient, improve her/him health, support
her/him self-esteem and self, and return the
patient to social life as soon as possible.
• Creating therapeutic environment is one of
the basic functions of psychiatric nurses.

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 Purpose of the therapeutic
environment
• To manage the environment,
• Helping the patient to increase self-esteem,
self-worth and self-confidence,
• To make her/him more active in society,
business life, and life,
• Developing the ability to relate to other
people.

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 The goals and principles of the
therapeutic envirment
• To meet the basic needs of the patient
• Making the patient express himself/herself
• To ensure the patient to benefit from the communication
between the patient and the staff at the maximum level
• Improving the patient's relationships with other patients
• Increasing the patient's self-esteem and self-confidence
• Ensuring that the patient can control their problematic
behavior
• Improving the patient's coping skills
• Enabling the patient to use more adaptive social skills
• Speeding up her/him socialization
• To increase the opportunities to participate in unit
management.
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 Elements of the Therapeutic
Environment
• 1. Security
• 2. Configured Environment
• 3. Norms
• 4. Limits
• 5. Balance
• 6. Flexibility / Changeability

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 1. Security:
• It means being away from danger and harm.
• It is an essential element in all therapeutic
settings.
• It includes being away from physical and
psychological damages.
• Protection from psychological damages is
protecting the patient from unnecessary
encounters,
• Being away from physical harm is provided by
clinical rules that do not allow physical violence.
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 Some measures to ensure physical
security are:
• Disposing of needles after use and keeping them
out of reach of patients,
• Limiting and observing the use of matches and
lighters,
• Smoking is not allowed in patient rooms,
• Do not keep materials such as mouthwash,
cologne, shaving lotion, bleach, detergent in the
rooms,
• Not using glass material (glass, vase, salt
shaker). 7
 2. Structured environment
• Unit regulations, schedule of daily group
activities and lessons.
• Goal: To avoid disappointment and
aggression, providing a calming and
supportive environment.

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There are four basic elements that make
up the structure of the environment:
• Physical layout of the unit
• A document containing the rules that
form the basis for the therapeutic setting
• Step system
• Group activities carried out regularly.

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 Regular group activities
• Social meetings, events (sweet Wednesday, excursions,
theater time)
• Activity groups (good morning meeting, division of labor
meeting)
• Social Skill Groups
• Physical Exercise Groups
• Psychoeducation Programs
• Healthy life trainings (nutrition, importance of exercise,
relaxation and breathing exercises, harms of smoking,
drug treatments, sleep hygiene, etc.)
• Job groups.

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 3. Norms:
• Norms aim to facilitate living in society
through socially acceptable behaviors.
• No violence
• Self-control and independence
• Clarity
• Privacy

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 4. Borders:

• Borders coincide conceptually with unit

norms and structure.
• Setting boundaries is the art of defining
acceptable and unacceptable behavior in
the environment.

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Behaviors that should be limited in
psychiatry clinics:
• Self-harm
• Physical aggression
• Non-adherence to treatment
• Use of alcohol and other substances
• Inappropriate sexual behavior
• Smoking
• Escape.

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 5. Balance:

• Balance is to provide an environment

permitting process gradually from dependent
to independent behavior.
• As the patient progresses, their independence
should be supported.

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 6. Flexibility / Changeability:

• Continuous review of unit norms, rules

and regulations is important to ensure
changeability.
• By providing flexibility in the unit, the
therapeutic environment is improved and
the patient can be shown that he/she is
valued.
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• Since nurses are the only occupational
group that remain in the environment
without interruption, they have the
responsibility to understand and
maintain the characteristics of the
therapeutic environment.

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Therapeutic Relationship

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- THE ABILITY TO ESTABLISH therapeutic
relationships with clients is one of the
most important skills a nurse can
develop.

- Effective interpersonal skills are central to

a mental health nurse’s ability to form a
sound therapeutic alliance and to the
role of mental health nurses.
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 Therapeutic Relationship
• Differs from the social or intimate
relationship in many ways because it
focuses on the needs, experiences,
feelings, and ideas of the clients only.
• Nurse and client agree about the areas to
communicate to work on and evaluate
the outcomes.

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• Nurse uses communication skills,
personal strengths, and understanding of
human behavior to interact with the
client.

• Parameters are clear: the focus is the

client’s needs, not the nurse’s.

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 Establishing the Therapeutic
Relationship
• The nurse who has self-confidence
rooted in self-awareness is ready to
establish appropriate therapeutic
relationships with clients.

• Awareness of his or her strengths at any

particular moment is a good start.
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• Many factors can enhance the nurse–
client relationship, and it is the nurse’s
responsibility to develop them.

• These factors promote communication

and enhance relationships in all aspects
of the nurse’s life.

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 Components of a
Therapeutic Relationship
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 Trust
• Trust builds when the client is confident in the
nurse and when the nurse’s presence conveys
integrity and reliability.
• Trust develops when the client believes that
the nurse will be consistent in his or her own
words and actions and can be relied on to
do what he or she says.
• Congruence occurs when words and actions
match.
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• Trust erodes when a client sees
inconsistency between what the nurse
says and does.
• Trust is difficult to establish in the
following:
– Paranoia
– Low self-esteem
– Anxiety
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 Trusting Behaviors (Nurse)
• Caring • Treating the client as
• Openness a human being
• Objectivity • Suggesting without
• Respect telling
• • Approachability
Interest
• • Listening
Understanding
• • Keeping promises
Consistency
• Honesty
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EMPATHY

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 Empathy
• The ability to perceive the meanings and
feelings of the client and to communicate
that understanding to the client.
• One of the essential skills a nurse must
develop.
• Both the client and the nurse give a “gift
of self” when empathy occurs.

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• Empathy has been shown to positively
influence client outcomes.

• Clients tend to feel better about

themselves and more understood when
the nurse is empathetic.

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Sympathy often shifts
the emphasis to the
nurse’s feelings,
hindering the nurse’s
ability to view the
client’s needs
objectively.

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 Acceptance
• Avoiding judgments of the person, no
matter what the behavior is.
–E.g., The nurse does not become upset
or respond negatively to a client’s
outbursts, anger or acting out.
• Does not mean acceptance of
inappropriate behaviors but acceptance
of the person as worthy.
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• The nurse must set boundaries for behavior in
the nurse-client relationship.
• By being clear and firm without anger or
judgment, the nurse allows the client to feel
intact while still conveying that certain
behavior is unacceptable.

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 Positive Regard
• The nurse who appreciates the client as a
unique worthwhile human being can
respect the client regardless of his or her
behavior, background or style.
• This unconditional nonjudgmental
attitude is known as positive regard and
implies respect.

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• Measures to convey respect and positive
regard:
– Calling client by name
– Spending time with client
– Listening and responding openly
– Considering client’s ideas
and preferences when planning
care.
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• The nurses use nonverbal and verbal
communication techniques to make the client
aware that he/she is receiving full attention.
• Nonverbal techniques: Leaning toward the
client, eye contact, being relaxed, having the
arms rested at the side, and interested but
neutral attitude.
• Verbally attending: Nurse avoids value
judgment about the client’s
behaviour.

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Phases of the Nurse-Client
Relationship
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• Pre-interaction Phase
• Orientation Phase
• Working Phase
• Termination

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 Pre-interaction Phase
• This phase begins when the nurse is
assigned to initiate a therapeutic
relationship and included all the nurse
thinks, feels or does immediately prior to
the first interaction with the patient.

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Nurse’s tasks in the pre-interaction phase:

• Explore own feelings, fantasies and fears.

• Analyse own professional strengths and
limitations.
• Gather data about patients whenever
possible.
• Plan for the first meeting with
patient.
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• Before the meeting:
– Read background materials available on the client
– Become familiar with the medications the client is
taking
– Gather necessary paper work
– Arrange for a quiet, private and comfortable
setting
– Self-assessment
– Examine preconceptions about the client and
ensure to put them aside and get to know the real
person.
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 Orientation Phase
• Begins when the nurse and client meet and
ends when the client begins to identify
problems to examine.
• Activities:
– Establish roles
– Establish the purpose of the meeting and the
parameters of the subsequent meeting
– Identify client’s problems
– Clarify expectations.
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• The nurse begins to build trust with the
client.
• Share appropriate information about
oneself: name, reason for being in the
unit, and level of schooling
• Listen closely to the client’s history,
perceptions and misconceptions.
• Be very empathetic and
understanding.
• It may take several sessions before a
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• Nurse-client Contracts
– Agree responsibilities in an informal or verbal
contract
– A formal or written contract may be appropriate
at times.
– State the following:
• Time, place, and length of sessions
• When session will terminate
• Who will be involved in the treatment plan
• Client responsibilities (arrive on time, end on time)
• Nurse’s responsibilities (arrive on time, end on time,
evaluate progress with client, document sessions).
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• Confidentiality:
– Respecting the client’s right to keep private
information about his or her mental and physical
care and related care.
– Allowing only those dealing with client’s care to have
access to the information that the client divulges.
– Only under precisely defined conditions can third
parties have access to this information.
– Adult clients can decide which family members, if
any, may be involved in treatment and may have
access to clinical information.
– The nurse must avoid any promises to keep
secret.
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• Document client problems with planned
interventions.
• The client needs to know the limits of
confidentiality in the nurse-client
interactions and how the nurse will use
and share this information with
professionals involved in the care.

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 “
Hello, Mr. AK. I am Sally Fourth, a
nursing student from NEU. I will be
coming to the hospital for the next six
Mondays. I would like to meet with
you each time I am here to help
support you as you work on your
treatment goals.

Establishing trust; placing boundaries on the

relationship and first mention of termination in 6 weeks
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 “
Mr. Ak, we will meet every Monday
from November 1 to January 15 at 11
AM in interview room 2. We can use
that time to work on your feelings of
loss since the death of your twin sister

Establishing trust; placing boundaries on the

relationship and first mention of termination in 6 weeks
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 “
Mr. Ak, it is important that I tell you I will be
sharing some of what we talk about with my
instructor, peers, and staff atclinical conference.
I will not be sharing any information with your
wife or children without your permission. If I
feel a piece of information may be helpful, I will
ask you first if I may share it with your wife.

Establishing confidentiality
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 Working Phase
• Two sub-phases:
– Problem identification: client identifies the
issues or concerns causing the problems.
– Exploration: the nurse guide the client to
examine feelings and responses and to
develop better coping skills and a more
positive self-image.
• Encourages behavior change and develops
independence.
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 Termination
• Final stage in the nurse-client relationship.
• Begins when the problems are resolved,
and it ends when the relationship is ended.
• Nurse and client usually have feelings about
ending the relationship.
• Clients may feel the termination as an
impending loss.
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• Clients may avoid termination by acting angry
or as if the problem is not resolved.
• Acknowledge the client’s angry feelings and
assure that this response is normal to ending a
relationship.
• If the client tries to reopen and discuss old
resolved issues, the nurse must avoid feeling
as if the sessions were unsuccessful; instead
he or she should identify the client’s stalling
maneuvers and refocus the client on newly
learned behaviors and skills to handle the
problem.
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• It is appropriate to tell the client that the
nurse enjoyed the time spent with the
client and will remember him or her,
but
• it is inappropriate for the nurse to agree
to see the client outside the
therapeutic relationship.
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 Well, Mr. Ak, as I am going to
you know I only miss you. I feel
have 1 week left to better when you
meet with you are here.

Sharing of the termination experience with the client

demonstrates the partnership and the caring of the
relationship 65
 Possible Warnings or Signals of
Abuse of the Nurse-Client
Relationship
• Secrets; reluctance to talk to others about the
work being done with the client.
• Sudden increase in phone calls between the
nurse and client calls outside the clinical
hours.
• Nurse making exceptions for client than
normal.
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 Cont…
• Inappropriate gift-giving between client and
the nurse.
• Loaning, trading, or selling goods or
possessions.
• Nurse disclosure of personal issues or
information.
• Inappropriate touching, comforting or physical
contact.
• Overdoing, overprotecting, or overidentifying
with the client.
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 Cont…
• Change in the nurse’s body language, dress or
appearance (with no other satisfactory
explanation).
• Extended one-on-one sessions or home visits.
• Spending off-duty time with the client.
• Thinking about the client frequently when
away from work.
• Becoming defensive if another person
questions the nurse’s care of the client.
• Ignoring agency’s policies.
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