THERAPEUTIC COMMUNICATION TECHNIQUES

1. USING SILENCE...utilizing absence of verbal communication.

Silence in itself often encourages the patient to verbalize if it is an interested, expectant silence.
This kind of silence indicated to the patient that the nurse expects him to speak, to take the initiative, to communicate that which is most pressing. It gives the patient the opportunity to collect and organize his thoughts, to think through a point, or to consider introducing a topic of greater concern to him than the one being discussed. A positive and accepting silence can be a valuable therapeutic tool. (1) It encourages the patient to talk; (2) directs his thoughts to the task at hand--the consideration of his problem; (3) reduces the pace of the interview when either the nurse or the patient is pressing or pushing too hard; (4) gives the patient time to consider alternative courses of action, delve deeply into his feelings, or weigh a decision; (5) and allows the patient to discover that he can be accepted even though he is silent, that even though he is shy and quiet, he has worth and is respected by another person.

Much nonverbal communication occurs during these interludes. The nurse needs to be alert to what she is communicating as well as perceiving. Even momentary loss of interest can be interpreted as indifference. Schwartz and Schockley state that the utilization of silence is often difficult for nursing personnel, since they think that nothing is happening and that they are wasting their time. In long periods of silence, they may become bored and their attention wanders from the patient. If the nurse could observe the patient and herself carefully, she might discover that a great deal happens between then at these times.

2. ACCEPTING...giving indication of reception.

"Yes."
"Uh hmm."
"I follow what you said."
Nodding.

An accepting response, such as "I'm with you" or "I follow what you're saying," indicates that the nurse has heard and has followed the trend of thought. Such responses signify that the nurse is attuned to the patient, that communication is occurring, and that she is a participant rather than a passive observer. Accepting does not indicate agreement but is nonjudgemental in character. "It is simply a verbalization of the attitudes of permissiveness and acceptance of the counselor which say in effect: "Go on, it's safe, you needn't be ashamed of expressing how you really feel." It should not need to be added that the nurse does not imply that she understands when she does not.Roger adds that accepting does not mean much until it involves understanding. It is only as I understand the feelings and thoughts which seem so horrible to you, or so weak, or so sentimental or so bizarre--it is only as I see them as you see them, and accept them and you, that you can feel really free to explore all the hidden nooks and frightening crannies of your inner and often times buried experiences.

Not only the words are important, but also the facial expression, the tone of voice and inflection, and the posture of the nurse. All must convey the same feeling of acceptance. If they do not, the words will be meaningless.

3. GIVING RECOGNITION...acknowledging, indicating awareness.

"Good morning, Mr. S."
"You've tooled a leather wallet."
"I notice that you've combed your hair."

To greet the patient by name, to indicate awareness of change, to note the efforts the patient has made--these and other similar indications by the nurse show that she recognizes the patient as a person, as an individual. Such recognition carries with it none of the burden for him that praise or approval imposes. It does not imply that one thing is "good" and its opposite "bad." Nor does it cause the patient to strive for more and more approval for its own sake. Peplau comments quite simply, "When a patient accomplishes something that is a fact, a nurse can say so."

4. OFFERING SELF...making one's self available.

"I'll sit with you awhile."
"I'll stay here with you."
"I'm interested in your comfort."

The patient may not be ready to communicate verbally with another person. Or the patient may not be able to make himself understood. Often the nurse can offer only her presence, her interest, and her desire to understand. To be therapeutic this offer must be made unconditionally,
i.e., without the patient's feeling that he must give in order to receive or that the nurse will stay only if he does or does not do this or that. (However, those conditions that do apply should be stated, e.g., all the nurse's time is not available to the patient.) On this point Peplau says, "The patient must deny her own feelings and needs in order to be accepted and liked by a nurse who is conditional in her relations with the patient."

5. GIVING BROAD OPENINGS...allowing the patient to take the initiative in introducing the topic. "Is there something you'd like to talk about?"
"What are you thinking about?"
"Where would you like to begin?"

Broad opening comments merely make explicit the idea that the lead is to be taken by the patient. For the patient who is hesitant or uncertain as to what role his is to play in the interaction, these openings, such as "Is there anything you'd like to discuss with me?" stimulate him to take the initiative and to feel that this is what is expected of him. The nurse should avoid the conventional pleasantries when greeting the patient and refrain from making "small talk." If the nurse does start the discussion, she can try to alter this situation by asking, "Would you like to talk about yourself now?" and then waiting silently until the patient takes over.

6. OFFERING GENERAL LEADS. . . . giving encouragement to continue.

"Go on."
"And then?"
"Tell me about it."

General leads, such as "And after that?" or "Go on" leave the direction of the discussion almost entirely to the patient. They indicate that the nurse is following what has been said and is interested in what is to come next.
Brown and Fowler comment:
...the verbal activity of the nurse is at a minimum with the patient doing most of the talking. The nurse encourages the patient to talk by her nonverbal activity such as nodding or various gestures. If verbal activity becomes necessary, sometimes just a word as "well" or "really" will enable the patient to continue.

Schwartz and Shockley state that the nurse "waits for" the patient's communication, "goes along with it" or follows his leads, and takes the cue from him rather than directing the discussion herself. 7. PLACING THE EVENT IN TIME OR IN SEQUENCE. . . clarifying the relationship of events in time.

"What seemed to lead up to...?"
"Was this before or after...?"
"When did this happen?"

Putting events in their proper sequence helps both the nurse and the patient to see them in perspective. The extent to which one event may have led to another can be viewed more objectively once a certain amount of chronologic ordering has occurred. And at times it will become obvious to the patient that previously accepted cause-and-effect relationships could not exist. The nurse may find that she is then able to identify a recurring pattern of interpersonal difficulties, giving her clues to the kind of satisfying experiences with others that the patient needs. 8. MAKING OBSERVATIONS. . . verbalizing what is perceived.

"You appear tense."
"Are you uncomfortable when you...?"
"I notice that you're biting your lips."
"It makes me uncomfortable when you..."

The nurse often makes observations that can be called to the patient's attention. The patient may be showing signs of anxiety--trembling, clenching his fists, biting his nails or lips, smoking endlessly, or other restless mannerisms--of which he is unaware. Or he may have begun to hallucinate actively. He may seem perplexed, fearful, far off in thought, angry or sad. On the other hand, the nurse herself may have become uncomfortable as the result of certain behavior on

the part of the patient. In any of these or similar instances, the nurse can bring her observations to the awareness of the patient and encourage their mutual understanding of the behavior or feeling through discussion. This technique is especially useful in relating to mute patients. By voicing her perceptions, such as, "You seem deep in thought," "Your expression conveys bewilderment to me," or "You appear more comfortable with me today," she offers the patient something to which he may respond when ready. Thus she avoids pressing questions on him, yet does not enter into a mutual state of muteness.

By calling the patient's attention to what is happening to him, the nurse seeks to encourage the patient's noticing for himself so that he can do the describing. Then the nurse and the patient can compare their observations.

9. ENCOURAGING DESCRIPTION OF PERCEPTIONS. . . asking the patient to verbalize what he perceives.

"Tell me when you feel anxious."
"What is happening?"
"What does the voice seem to be saying?"

If the nurse is to understand the patient, she must come to see things as they seem to him. The patient should feel free to describe his perceptions to the nurse. In addition to describing his past experiences, he should be alerted to becoming aware of signs of anxiety, thoughts that interrupt and normally would be pushed aside, hallucinatory phenomena, and other disturbing events, feelings, sensations, or ideas. When possible, these should be described to the nurse as they are occurring. Both the patient and the nurse need such descriptions if they are to come to understand the reasons for the patient's behavior. These descriptions are the raw material from which the understandings will be drawn.

Roger states:
It is natural to expect that with increasing security in clinical experience there will be an increasing variety of attempts to communicate the fact that the therapist is endeavoring to achieve the internal frame of reference of the client, and is trying to see with him as deeply as the client sees, or even more deeply than the latter is able at the moment to perceive.

He adds:
.... it would appear that for me, as counselor, to focus my whole attention and effort upon understanding and perceiving as the client perceives and understands, is a striking operational demonstration of the belief I have in the worth and significance of this individual client.

Nurses sometimes feel that encouraging the patient to describe his ideas tend to fix more firmly in his mind the irrational and delusional thoughts he may have. Suicidal and aggressive thoughts and feelings are especially anxiety-provoking for the nurse. However, Schwartz and Shockley point out that the patient may not have to act out if he feels free to talk about his difficulties.
Talking may make it unnecessary for the patient to behave in a manner harmful to himself and others. 10. ENCOURAGING COMPARISON. . . asking that similarities and differences be noted.

"Was this something like...?"
"Have you had similar experiences?"

Comparing ideas or experiences or interpersonal relationships brings out many recurring themes. Seeing the similarities helps the patient become aware of the continuity in his life, and noting differences helps him to evaluate the influence of each event or person individually.
Peplau emphasizes the nurse's "being herself" as another means of assisting the patient to become aware of likenesses and differences among people. Again, it is obvious that relationships are based on more than words alone. The whole person who is the nurse is relating to the patient. Her feelings and behavior communicate more than her words.

While comparisons are to be encouraged, it is rarely helpful for the nurse to introduce experiences from her own life for his purpose. Too frequently the result is a discussion focused on the needs and problems of the nurse.

11. RESTATING. . . repeating the main idea expressed.

Patient. "I can't sleep. I stay awake all night."
Nurse. "You have difficulty sleeping."

Patient. "The fellow that is my mate died at war and is pending me yet to marry."
Nurse. "You were going to marry him, but he died during the war."

What the patient has said is repeated in approximately or nearly the same words that he has used. This restatement gives evidence to the patient that an idea has been communicated effectively. He is encouraged to continue. Or, if his thoughts have been misunderstood, he can reword and restate them until he makes himself clear.

An additional benefit, Wolberg feels, is that, "Recasting certain statements into different words brings out related aspects of the material that may have escaped the patient's attention.

12. REFLECTING. . . directing back to the patient questions, feelings, and ideas.

Patient: "Do you think I should tell the doctor...?"
Nurse: "Do you think you should?"

Patient: "My brother spends all my money and then has the nerve to ask for more:
Nurse: "This causes you to feel angry."

Reflection encourages the patient to bring forth and accept as part of himself his own ideas and feelings. When the patient asks what he should think, or do or feel, the nurse can ask, "What do you think?" or "What are your feelings?" The nurse thereby indicates that it is the patient's point of view that has value. Thus she acknowledges his right to have opinions, to make decisions, and to think for himself. As the nurse shows that she expects him to be able to do these things,

he too comes to think of himself as a capable person--as a relatively integrated whole rather than the incorporated parts of others. When the patient expresses feelings and ideas, the nurse can recognize and accept them, acknowledge their existence and reflect them back by noting, "You think..." and "You feel..." This helps the patient to accept them as belonging to him. Karnosh and Mereness suggest that the nurse's skillful reflection of the patient's comments makes obvious her interest in hearing as much as the patient needs to tell.

Reflection, Brammer and Shostrom state:
....focuses on the subjective element of what the client says. Reflection emphasizes the pronoun
"you" in the phrases, "you feel" and "you think."

Reflection serves a useful purpose in that it leads the client to think of the feelings and ideas he is expressing as part of his own personality and not outside himself.

The patient is encouraged to separate himself from the personalities of others and to become a person in his own right.

13. FOCUSING. . .concentrating on a single point.

"This point seems worth looking at more closely."

Focusing on a single idea or even a single word can often be very valuable. In effect the nurse says, "This seems important. It is worth spending some time in understanding it now." It is an especially useful technique when the patient jumps rapidly from one thought to another. If severe anxiety is present, however, and the patient is thereby prevented from focusing, the nurse should not persist. As anxiety lessens, the nurse may again utilize this technique.

14. EXPLORING. . .delving further into a subject or idea.

"Tell me more about that."
"Would you describe it more fully?"
"What kind of work?"

Exploring more fully certain ideas, experiences, or relationships is frequently indicated. Many patients deal only superficially with each topic they bring up, as if testing to see whether the nurse is really interested enough to look further or as if to say that nothing of importance has ever happened in their lives. Wolberg suggests that once a theme or trend is identified, it should be explored in as elaborate detail as possible. While the nurse should recognize when to delve further, she should refrain from probing or prying. If the patient chooses not to elaborate, the nurse should respect the patient's wishes.

15. GIVING INFORMATION. . .making available the facts the patient needs.

"My name is..."
"Visiting hours are..."

"My purpose in being here is..."
"I'm taking you to the..."

Informing the patient of the facts when he asks questions--or in other ways indicates the need for information--builds up trust as well as gives the patient a greater body of knowledge from which to make decisions or come to realistic conclusions. Peplau states that a nurse, functioning in the role of resource person, may give specific, needed information that will assist the patient to understand his problem and the situation. If the nurse is not acquainted with the body of knowledge in question, she can truthfully state that she does not know. Then she can endeavor to find out or to refer the patient to someone who has the answers. Areas of information not to be neglected are the role of the nurse and the purpose of the nurse-patient relationship. The nurse should inform the patient of the amount of time she will spend with him, how frequently she will talk with him, and the length or duration of the relationship if this has been predetermined. If she will be recording the interaction, the patient should be told the purpose of the notes. A distinction should be made between this therapeutic relationship and other social relationships the patient may be establishing. In all these things the nurse will usually find that she can be quite direct, avoiding vague and misleading statements.

16. SEEKING CLARIFICATION. . . seeking to make clear that which is not meaningful or that which is vague.

"I'm not sure that I follow."
"What would you say is the main point of what you said?"

Clarification should be sought at each step of the way. The patient is usually quite aware when he is not being understood. Eventually he may cease trying to communicate. Peplau states that it is always possible to ask: What did you have in mind? Have I heard you correctly? Have I understood what you mean, let me repeat what you said? Perhaps you can help me to get clear on what you mean. Perhaps both of us are looking at this issue or problem from a different standpoint; maybe we'd better talk about its meaning to each.

Fromm-Reichmann notes that it is not necessary to understand everything the patient says as long as the nurse is frank about it and does not make pretenses. Not only is the nurse benefitted by clarification Sullivan points out, but attempts to discover what the patient is

talking about can lead to his becoming more clear himself on what he means. The patient's grasp on life is thus to some extent enhanced.

17. PRESENTING REALITY... offering for consideration that which is real.

"I see no one else in the room."
"That sound was a car backfiring."
"Your mother is not here; I'm a nurse."

When it is obvious that the patient is misinterpreting reality, the nurse can indicate that which is real. She does this not by way of arguing with the patient or belittling his own experiences, but rather by calmly and quietly expressing her own perceptions or the facts in the situation. The intent here is merely to indicate an alternate line of thought for the patient to consider, not to
"convince" the patient that he is in error.

18. VOICING DOUBT... expressing uncertainty as to the reality of the patient's perceptions.

"Isn't that unusual?"
"Really?"
"That's hard to believe."

Another means of responding to distortions of reality is to express doubt. Such expression permits the patient to become aware that others do not necessarily perceive events in the same way or draw the same conclusions that he does. This does not mean that he will alter his point of view, but at least he will be encouraged to reconsider and to re-evaluate what has occurred. And the nurse has neither agreed or disagreed, yet, at the same time, she has not let misinterpretations and distortions of reality pass uncommented upon. Sullivan expresses this quite well when he states that you should first confirm, by asking the most natural questions that would follow, that the patient intended to say what he did...Having made sure that the patient's statement was as bad as it sounded--that he is entertaining an idea which is not only wrong, but also, in a sense, does violence to the possibility of his living in a social situation among others--you do not the say,
"Oh, yes, yes. How interesting." You rather say, "I can scarcely believe it. What on earth gives you that impression:" You note a marked exception,...at least you note your exception and do not agree tacitly.

19. SEEKING CONSENSUAL VALIDATION... searching for mutual understanding, for accord in the meaning of words.

"Tell me whether my understanding of it agrees with yours."
"Are you using this word to convey the idea...?"

For verbal communication to be meaningful, it is imperative that the words conveying the ideas and concepts being discussed have essentially the same meaning for all participants. The nurse may have to suggest "Are you using this phrase to convey the idea...?" or "Perhaps my understanding of this word differs from yours." Otherwise, nurse and patient may find that each is using the same words differently and that no communication is taking place.

Sullivan suggests that the therapist listen with critical interest, asking himself whether what he hears could have any other meaning than that which first occurs to him, asking questions when indicated to be sure that he knows what he is being told. As the patient makes himself clearer to the listener, he becomes more clear in his own mind as to what he means. Peplau adds that both the nurse and patient have preconceptions about the meanings of words, but that a common reference for the word can usually be arrived at though observation and discussion. To facilitate such consensual validation, the nurse should make every effort to avoid expressions that can easily be misinterpreted or misunderstood.

20. VERBALIZING THE IMPLIED...voicing what the patient has hinted at or suggested.

Patient. I can't talk to you or to anyone. It's a waste of time.
Nurse. Is it your feeling that no one understands?

Patient. My wife pushed me around just like my mother and sister did.
Nurse. Is it your impression that women are domineering?

To put into words what has been implied or said only indirectly tends to make the discussion less obscure. The nurse should be as direct as she can be, without being obtuse, or unfeelingly blunt.
The patient himself may find it difficult to be direct--to find the appropriate words or the courage to say them--or he may be testing the nurse to see whether she is really striving to grasp what he says. The nurse should take care to express only what is fairly obvious; otherwise she gets into the realm of offering interpretations. In Sullivan's words,"...putting the obvious into words often markedly improves things." Verbalizing the implied goes one step beyond restatement in that it clarifies that which is implicit, rather that explicit, in that which has just been said. It reflects relationships or meanings for the patient that have been suggested or implied in the thoughts or feelings brought out by the patient's responses.

21. ENCOURAGING EVALUATION...asking the patient to appraise the quality of his experiences. "What are your feelings in regard to...?"
"Does this contribute to your discomfort?"

The patient is asked to consider people and events in the light of his own set of values and to evaluate the way in which they affect him personally. He is thereby discouraged from adopting without appraisal the opinions and values of others, including those of the nurse. Rogers notes that some patients make great efforts to have the therapist's task to consistently keep "the locus of evaluation" with the patient.

22. ATTEMPTING TO TRANSLATE INTO FEELINGS...seeking to verbalize the feelings that are being expressed only indirectly.

Patient. "I'm dead."
Nurse. "Are you suggesting that you feel lifeless?" or "Is it that life seems without meaning?"
Patient. "I'm way out in the ocean."
Nurse. "It must be lonely." or "You seem to feel deserted."

Often what the patient says, when taken literally, seems meaningless or far removed from reality. To understand, the nurse must concentrate on what the patient might be feeling in order to express himself as he does. Peplau suggests that the nurse ask herself what the patient is saying that he cannot say in any other way. She then must desymbolize what is actually said to find clues to the underlying meaning. Wolberg aptly speaks of this process as "reaching" for feelings that lie behind verbalization. Only then can the nurse attempt to verbalize the feelings that the patient has difficulty putting into words. For example, the patient who sees the

personnel as "giants" is likely to feel insignificant and powerless by comparison. For the nurse to introduce these feelings into the discussion is likely to have more value than for her to discuss the "giants" as such. It is the latent meaning of the expression rather than the actual content that demands the nurse's attention. Rogers points out that responding primarily in terms of the feelings expressed--rather that the content--gives the patient the satisfaction of feeling deeply understood and enables him to express further feelings.

23. SUGGESTING COLLABORATION...offering to share, to strive, to work together with the patient for his benefit.

"Perhaps you and I can discuss and discover what produces your anxiety."

The nurse seeks to offer the patient a relationship in which he can identify his problems in living with others, grow emotionally, and improve his ability to form satisfying relationships with others. She offers to do things not for him or to him, but with him. Peplau speaks of a cooperative relationship in which both the nurse and the patient can become aware of the nature of the problems or tasks and how they can be met. "To encourage the patient to participate in identifying and assessing his problem is to engage him as an active partner in an enterprise of great concern to him." Sullivan states that he always tries to outline for the patient what he sees as a major difficulty in his living with others with the implication that if the "work together," he has hopes that they will get somewhere with the problem.

24. SUMMARIZING...organizing and summing up that which has gone before.

"Have I got this straight?"
"You've said that..."
"During the past hour you and I have discussed..."

Summarization seeks to bring together the important points of the discussion and to give each participant an awareness of the progress made toward greater understanding. It omits the irrelevant and organizes the pertinent aspects of the interaction. It allows both nurse and patient to depart with the same ideas in mind and provides a sense of closure at the completion of each discussion. This summing up can be done periodically throughout the discussion or only at its close. But no matter who does it or how frequently it occurs, summarization is a valuable part of each exchange. For it is during periods of summarization that the nurse and the patient strive to grasp the significance of what has been said, to formulate the meaning of the data, and to achieve new understandings. Wolberg mentions that for the patient who rambles and becomes too engrossed in detail that he loses sight of the inter-relationship of the topics he's presenting, summarization is helpful. It pulls together what seems to be disorganized material.

Brammer and Shostron suggest three alternatives. The therapist himself can review the content and essential feelings expressed during the interview. The patient can be asked to relate what he feels he has accomplished or what the situation appears to be now. Or the therapist and the patient can look together at what has been achieved. Perhaps in the nursing relationship the summary can be less formal, but this does not mean that it should be omitted. A simple, "Have you and I learned anything from today's conversation?" may be quite sufficient.

25. ENCOURAGING FORMULATION OF A PLAN OF ACTION...asking the patient to consider kinds of behavior likely to be appropriate in further situations.

It may be helpful for the patient to plan for the future what he might do to handle various interpersonal situations that he finds disturbing, such as those in which he is provoked to anger or in which he is hesitant or shy or anxious. Talking over each situation in an attempt to better understand it will, of course, precede this "plan of action." And whatever plans are made should be the patient's, not the nurse's. While it should be recognized that preplanning in itself will not solve the problem, there is the likelihood that later behavior will be guided by such thinking rather than by impulse alone. In addition, the nurse may encourage the patient to role-play or act out with her such situations in advance, as another means of preparation. In a broad sense, the entire nurse-patient relationship is an experience of this sort--a preview of future relationships of a more reciprocal nature in which the patient may find--and give--acceptance, respect, and understanding. DETERRENTS TO THERAPEUTIC COMMUNICATION

1. REASSURING...indicating that there is no cause for anxiety.

"I wouldn't worry about..."
"Everything will be all right."
"You're coming along fine."

To attempt to dispel the patient's anxiety by implying that there is not sufficient reason for it to exist is to completely devaluate the patient's own feelings. Hence, no value is placed on the patient's judgment. The nurse communicates only her lack of understanding and empathy. If it is the patient's progress she wants to comment upon, she can offer concrete examples of changes that have occurred rather than state, "You're doing fine" or other equally vague reassurances that have little or no meaning. Burton tells us that giving reassurance is a common error. It makes the person giving it feel better for a short time but it is meaningless to the patient. She adds,

In the first place, the person giving the reassurance is not sure that someone will feel better, or will live, or will have a satisfactory outcome from an operation. It is hoped that he will, but that is all. Furthermore, the reassurance is belittling to the person who has the problem or worry...An immediate effort of this response is to block the person from expressing further feeling. If the person who is blocked by someone's reassurance there is a negative feeling stirred up which says, "There's no point in trying to tell her anything because she won't understand; she will ridicule my fear, making me feel foolish."

Sullivan concurs by stating that such verbalisms--the attempt to do magic with language-- reassures the therapist rather than the patient. Magic, he says, cannot be done with reassuring words. The real magic is done by the patient, not the therapist, and occurs in the interpersonal relationship. There is absolutely no justification for trying to reassure, unless you are able to

document what you say. "All in all, when you can't reassure a person except by magic, the sensible thing is not to try."

2. GIVING APPROVAL...sanctioning the patient's ideas or behavior.

"That's good."
"I'm glad that you.."

To state what the patient is doing, feeling, or saying is "good" is to imply that its opposite is
"bad." Approval, then tends to limit the patient's freedom to think, speak, or act in a way that displeases the nurse. It also leads the patient to strive for praise rather than progress. Peplau states that praise arouses undue ambition, competitiveness, and a sense of superiority. The possibilities for learning are closed off, as the patient speaks and acts in terms of what brings approval. Eventually, the patient comes to focus almost exclusively on what will bring approval. She adds, "Praise and blame, good and bad, right and wrong, leave nurses only a two- sided coin with which to operate in their relations with patients. Focusing on the steps in learning allows infinite variety in relations with patients.."

While approval and disapproval are likely to alter undesirable behavior, Burton notes that such changes, though they come about quickly, are not usually lasting. For as soon as the motivating force is removed, the original behavior returns. Hence, no learning has occurred.

* From Hays, Joyce and Kenneth Larson. Interacting With Patients.

3. REJECTING...refusing to consider or showing contempt for the patient's ideas or behavior.

"Let's not discuss..."
"I don't want to hear about..."

When any topic is rejected, it is closed off from exploration. When the patient himself is rejected, therapeutic interaction ceases. Fromm-Reichmann points out that the insecure therapist is likely to be afraid of the patient's anxiety-producing experiences. He thwarts the patient's expressions by giving premature reassurances that he needs himself. Consequently, certain areas of the patient's experience are not submitted to investigation.

According to Burton, the patient tends to feel rejected by the nurse when she is fearful of permitting him to express his feelings and to reveal his problems. He then may avoid help rather that risk further rejection. It is important for the nurse to know herself--to identify kinds of behavior of ideas that make her anxious-and to seed help for her problems. Otherwise, she is likely to add new problems to those with which the patient is already struggling.

4. DISAPPROVING...denouncing the patient's behavior or ideas.

"That's bad."
"I'd rather you wouldn't..."

Disapproval implies that the nurse has the right to pass judgment on the patient's thoughts and actions. It further implies that the patient is expected to please the nurse. Schwartz and
Shockley suggest that the nurse accept the patient for what he is, being neither moralistic nor conditional in this acceptance. They add,

It is important for a number of reasons to find an alternative to the moralistic attitude in relating with patients. The patient may have been criticized, condemned and rejected in the past, and these attitudes have contributed to his illness. A blaming and punishing attitude may reinforce his loneliness and hopelessness by confirming his feeling that people cannot or will not understand him. These moralistic attitudes might take the nurse's attention away from the patient's needs and from her relations with him and direct it toward her own feelings.

It is important for the nurse to acknowledge that the patient has a right to behave as he does, for a patient's sick behavior is no more right or wrong, good or bad, than is the pain of a somatic illness. Brammer and Shostrom add that approval and disapproval tend to "have unfortunate effect of rigidifying the client's thinking." At times the patient's behavior may be so extreme as to cause harm or discomfort to others. Rather that insist, "You're behaving badly" or "That's wrong," she might say, "You are hurting Mr. S., we cannot allow you to do this," or "We will have to move you from the dayroom for now, you're making Mr. S. very uncomfortable by speaking to him this way." Thus the nurse informs the patient of the effects of his actions instead of offering value judgments.

5. AGREEING...indicating accord with the patient.

"That's right."
"I agree."

While approval indicates that the patient is "good" rather that "bad," agreeing indicates that he is
"right" rather than "wrong." Furthermore, agreement gives the patient the impression the he is
"right" because his opinion is the same as that of the nurse. Opinions and conclusions should be exclusively the patient's, not of the nurse. When the nurse agrees with the patient, she leaves him with little opportunity to modify his point of view subsequently. Actual agreement tends to make the patient feel that he cannot later change his position without admitting error. Rather than take sides for or against the patient, the nurse can better use her time to help the patient gather the data needed to form his own opinions and draw conclusions. If she is aware of information the patient needs, she can make this available to him. But to evaluate the data is a task for the patient. This does not mean that she cannot say, "That's right," when the patient asks, "This is Thursday, isn't it?" This the acknowledgment of a fact. At no time, however, should the nurse agree with delusional ideas.

Since accord is involved in both, it is important to distinguish between agreement and consensual validation. To agree is to indicate accord with the patient's system of values--with his opinions, conclusions, or point of view. Consensual validation refers to shared understanding of the meaning of words. No value judgment is involved. It is not a question of whether a word or an expression is right or wrong but whether it conveys similar meaning to both nurse and patient.

Without consensual validation no communication can occur. Shared opinions and judgments are not necessary to effective communication.

6. DISAGREEING...opposing the patient's ideas.

"That's wrong."
"I definitely disagree with..."
"I don't believe that."

Conversely, to disagree is to imply that a patient is "wrong." Disagreement places the nurse in opposition to the patient. Consequently, he feels called on to defend himself. To defend one's ideas tends to strengthen them. If these are delusional ideas, the nurse may be building up what she had intended to tear down. Rogers feels that when the therapist thinks in evaluative terms,
i.e., becomes judgmental, he is seeing the patient as an object rather than as a person, and to that extent respects the patient less.

Acceptance of the patient as he is frees him to perceive new meanings and new goals. Roger states: ...only as the therapist is completely willing that any outcome, and direction, may be chosen-- only then does he realize the vital strength of the capacity and potentiality of the individual for constructive action. It is as he is willing for death to be the choice, that life is chosen; for neuroticism to be the choice that a healthy normality is chosen.

These are strong words--anxiety-provoking perhaps. But while disagreement confines the patient, acceptance frees him to grow emotionally. The nurse cannot grow for the patient. She can only provide a relationship in which growth is possible--not mandatory.

7. ADVISING...telling the patient what to do.

"I think you should..."
"Why don't you...?"

When the nurse tells the patient what he should think or how he should behave, she implies that she knows what is best for him and that he is incapable of any self-direction. Peplau states that advice acts to prevent the patient from struggling with and thinking through his problems.
Moreover, it is most likely that the patient has already received innumerable suggestions and advice from his family and friends. "If the matter were simply one of telling patients what is wrong with their feelings...most--if not all--of the psychiatric patients in psychiatric institutions would probably be well..." There is a difference between giving advice and giving information.
By giving advice, the nurse takes away from the patient the responsibility that is rightly his. To give advice is to keep patients in a state "of immature dependence upon the judgment and guidance of others..." To give information, on the other hand, is to supply the patient with additional data from which he can later formulate his own course of action.

8. PROBING...persistent questioning of the patient.

"Now tell me about..."
"Tell me your life history."

Probing tends to make the patient feel used. He feels valued only for what he can give. It places him on the defensive. He may respond with anger, with distortions or evasions, or cease to respond entirely. As Burton aptly notes, "Probing belongs in surgery, not in counseling." Arieti states, Each question is experienced by the schizophrenic as an imposition, or an intrusion into his private life, and will increase his anxiety, his hostility, and his desire to desocialize. The request for information is not seldom interpreted by the patient as "an attempt to take away something from him."

While the response of the schizophrenic patient may be extreme, it is not unusual for any person to resent this technique, particularly the patient under the stress of illness. Often the nurse is not aware that she has been persistently questioning the patient until she looks over the notes she has taken during the interaction. Especially when the patient is quiet or withdrawn and answers only briefly or not at all, the nurse tends to become increasingly anxious and increasingly persistent in her questioning, without being aware of what is happening. If the nurse can focus on the patient and his discomfort and can "put herself in his place" during the discussion, she is likely to find herself less anxious and more likely to be "in tune with" the patient.

9. CHALLENGING...demanding proof from the patient.

"But how can you be President of the United States?"
"If you're dead, why is your heart beating?"

Often the nurse feels that if she can challenge the patient to prove his unrealistic ideas and/or perceptions, he will realize that he has no "proof" and will be forced to acknowledge what is
"true." She forgets that delusional ideas serve a purpose for the patient and are not given up so readily. Moreover, these ideas conceal feelings and meet needs that are real. When challenged, the patient tends only to strengthen and expand his misinterpretations of reality, as he seeks support for his point of view. Only as the nurse is able to discover the unmet needs and help the patient meet them in reality is there likely to be less need for the unrealistic ideas and perceptions. 10. TESTING...appraising the patient's degree of insight.

"What day is this?"
"Do you know what kind of a hospital this is?"
"Do you still have the idea that...?"

It is not uncommon for the nurse to feel that she must convince the patient of the extent of his incapacity and have him agree that this is so. Actually the nurse is saying, "Admit that you are sick and need help." Paradoxically, she demands that the patient have insight into his very lack of insight. For him to agree that this is so--at her insistence--meets only the nurse's needs, not

those of the patient. It is preferable to assume the best about the patient, e.g., the nurse saying,
"Tell me about what took place," rather than asking, "Can you remember what happened?" The latter implies that the patient is probably not capable of recall. As Sullivan has noted, "There is not reason to pronounce the patient insane as a preliminary to helping him to regain his sanity."

11. DEFENDING...attempting to protect someone or something from verbal attack.

"This hospital has a fine reputation."
"No one here would lie to you."
"But Dr. B. is a very able psychiatrist."
"I'm sure that he has your welfare in mind when he..."

To defend what the patient has criticized is to imply that he has no right to express his impressions, opinions, or feelings. Telling the patient that his criticism is unjust or unfounded does not change his feelings. The feelings still exist and are in need of expression. But when the nurse becomes defensive, she causes the patient to feel that he should discontinue such expression. As a result the patient often feels only more strongly that his impressions are valid-- that he has uncovered a weakness that others are trying to conceal. Burton states that the nurse accepts the patient's right to feel as he does, without necessarily agreeing with him...When we fly to the defense of someone we are implying that the other person needs to be defended. Whereas if we really have faith in the person or profession criticized we should not feel that defense is necessary. Furthermore, when we defend someone we are usually lining ourselves up with the person against the person making the criticism.

12. REQUESTING AN EXPLANATION...asking the patient to provide the reasons for thoughts, feelings, behavior, and events.

"Why do you think that?"
"Why do you feel this way?"
"Why did you do that?"

There is a difference between asking the patient to describe what is occurring or has taken place and asking him to explain why. The former is to be encouraged. When an explanation is sought, however, it is often necessary for the patient to make up for his lack of sufficient understanding by inventing a reason, giving partial answers, or expanding his delusional system to provide the requested explanations. It is only after much learning has taken place that the patient is ready to attempt to explain what has happened. Peplau notes that the nurse often automatically asks,
"Why?" or "Why not?" she adds,

More often than not a "why" question has an intimidation effect. It has a ring of familiarity and is frequently reminiscent of earlier experiences when mother or teacher reiterated "Why don't you do this" or "Why can't you tell me" or some similarly coercing "why" question. Moreover, if the patient knew why he wasn't sleeping or hungry or comfortable, he would most probably deal with the situation. A "why" question asks for reasons which the patient is not likely to know immediately. He can discover them with help. But, in order to discover them, the patient

requires some raw data--he must recall, for example what actually went on... The reasons can be generalized from these data; then the "why" question can be answered.

13. INDICATING THE EXISTENCE OF AN EXTERNAL SOURCE...attributing the source of thoughts, feelings, and behavior to others or to outside influences.

"What makes you say that?"
"Who told you that you were Jesus?"
"What made you do that?"

The nurse can ask, "What happened?" or "What events led you to draw such a conclusion?" But to question "What made you think that?" seems to imply that the patient was made or compelled to think in a certain way--that someone or something was the cause for the patient's ideas, feelings, or actions. Usually the nurse does not intend to suggest that the source is external. She really thinks that she is asking the patient to describe the way in which something came about.
But its probably meaning to the patient is what must be considered. As Sullivan comments,
"...you don't know what people mean, or what your words mean to them, until you find out!"
Hence, the nurse should always strive to word her comments so as to avoid, insofar as possible, ambiguity. To actually suggest the reality of an external source is to encourage the patient to greater utilization of projection as a means of alleviation anxiety. Moreover, it relieves the patient of responsibility for his own thoughts and actions.

14. BELITTLING FEELINGS EXPRESSED...misjudging the degree of the patient's discomfort. Patient. "I have nothing to live for...I wish I were dead."
Nurse. "Everybody gets down in the dumps." or "I've felt that way sometimes."

When the nurse tries to equate the intense and overwhelming feelings expressed by the patient with those of "everybody" or herself, she implies that the discomfort is temporary, mild, and self- limiting. She then often tells the patient to smile "buck up" or think of something else. In this way she indicates her lack of empathy and understanding and can offer no constructive assistance. Sullivan warns that anything that causes a patient to feel "small" or insignificant is apt to leave a long-lasting wound. Therefore, the therapist should try very carefully not to belittle or humiliate. As Burton states,

When you are worried about your own problem whether big or little, it does not comfort you to know that others are, or have been, in the same boat...when you are concerned with and focusing on your own misery you are not capable of concern about the misery of others.

Of greater value would be comments such as, "You must be very uncomfortable" or "Would you like to talk about it?" Again, it is important for the nurse to perceive what is taking place from the patient's point of view, nor her own.

15. MAKING STEREOTYPED COMMENTS...offering meaningless cliches, trite expressions. "Nice weather we're having."
"I'm fine, and how are you?"
"It's for your own good."
"Keep your chin up."
"Just listed to your doctor and take part in activities--you'll be home in no time."

It is not unusual for conversations to contain a large proportion of trite expressions, empty words, meaningless cliches, and patterned replies. Such comments lack value in the nurse- patient relationship, just as they do elsewhere. Sullivan asks the therapist to avoid "all impractical meaningless comment..." For the nurse to make empty conversation is to encourage a like response from the patient. And as Sullivan notes, "The more conventional a person's statements are, of course, the more doubtful it is you have any idea of what he really means."
Consequently, many words of meaninglessness are exchanged, but nothing is really communicated. If the nurse has nothing meaningful to say, she should say nothing.

Schwartz and Shockley state that the nurse tends to become accustomed to the patient's behavior and adjusts to it by developing a few automatic approaches to him. These responses are of little value. They add,

Stereotyped responses are also indicated by the way a nurse talks to a patient. When a patient asks the nurse why he should do something which she asks of him the nurse may reply: "It's good for you." "The doctor ordered it." "It will get you well." "Because I want you to do it..."

None of these responses is necessarily stereotyped, but if her answer is given in a mechanical way as a substitute for a more reasonable and considered explanation, the response may easily become stereotyped attitudes.

16. GIVING LITERAL RESPONSES...responding to a figurative comment as though it were a statement of fact.

Patient. I'm an Easter egg.
Nurse. What shade? or You don't look like one.

Patient. They're looking in my head with television.
Nurse. Try not to watch television. or With what channel?

Often the patient is at a loss to describe his feelings. When, for example, it seems as though his every thought is known to others, he may say, "They're looking in my head all the time with television." To say that he is an Easter egg may mean that he feels closed away in a shell or conspicuous or less than human. (He says these things because at this time it is the best way he has of putting into words the way it seems or feels to him. The feelings he is having are so strange--so foreign to him--that conventional expressions seem highly unsuitable.) For the nurse to respond in kind is to indicate her inability to understand when anxiety-producing feelings are being described. Sullivan makes an apt remark:... "the patient may get the idea that the psychiatrist is a fool, poorly trained, or part of a plot--no one of which ideas is particularly helpful to therapeutic progress." This is not to imply that all delusional ideas are wholly without

literal meaning to the patient. Perhaps originally this may have been so, but now he undoubtedly takes them literally too. Even so, there is no reason for the nurse to acquire a similar manner of thinking. 17. USING DENIAL...refusing to admit that a problem exists.

Patient. I'm nothing.
Nurse. Of course you're something. Everybody is something.

Patient. I'm dead.
Nurse. Don't be silly.

We are familiar with the patient who denies that he is sick or has problems of any kind. The nurse, by her comment, tone of voice, or facial expression, often unwittingly uses the same defense to avoid discussion of a problem that she thinks should not exist or an idea that she considers meaningless or perhaps even frightening. In effect, she has closed both her eyes and her mind to the patient's problem. When the nurse uses denial, she shuts off an avenue of discussion and avoids helping the patient to identify and explore his difficulties. Peplau points out that when the nurse "denies the validity of the patient's feelings...in order to feel safe the patient may have to give up attending to what he feels and indicate verbal acceptance of what the nurse has indicated he should feel.

18. INTERPRETING...seeking to make conscious that which is unconscious, telling the patient the meaning of his experiences.

"What you really mean is..."
"Unconsciously you're saying..."

Fromm-Reichmann states that to interpret is to "translate the manifestations of that which is barred from awareness into the language of consciousness." The nurse, Peplau tells us, respects the patient's right to have his own feelings and to express them to those who may understand them, but she will not necessarily confront him with the intention of these feelings. While the psychiatrist may interpret directly to the patient, the nurse endangers her usefulness in her other roles--of resource person, mother surrogate--by doing so. She notes that only the psycho- therapist is prepared to try to aid in the "release and formulation into awareness of dissociated perceptions, i.e., with unconscious materials." Rogers points out that interpretation seems to indicate a limited confidence in the patient's capacity to cope with his problems. Matheney and
Topalis feel that the goal of therapy is helping the patient to develop sufficient emotional maturity so that he can develop and utilize an understanding of his behavior, but they note that such understanding does not come from without. Rogers concurs: "...insight is an experience which is achieved, not an experience which can be imposed." Brammer and Shostrom sum up this point of view by noting that a cardinal goal of all therapists for patients is "assisting them toward self-interpretation," since it is the patient who must get the insight, not the therapist.
Several drawbacks seem obvious: (1) the interpretation may be incorrect, (2) the patient may not be ready for it, (3) the patient is prevented from having the opportunity to achieve the insight on

his own. And as Sullivan notes, "The supply of interpretations, like that of advice, greatly exceeds the need for them."

19. INTRODUCING AN UNRELATED TOPIC...changing the subject.

Patient. I'd like to die.
Nurse. Did you have visitors this weekend?

When the nurse changes the subject or introduces one, she takes over the direction of the discussion. The initiative is taken from the patient. The nurse often does this in order to get to something that she wants to discuss or to get away from a topic that she would prefer not to discuss. Sometimes she just feels the need to say something.

* From Hays, Joyce and Kenneth Larson. (1963) Interacting With Patients. MacMillan: New York.