Therapeutic communication and crisis

Blocks, and better choices

Other blocks: Sympathy, judging with should and shouldn't, getting defensive, arguing, personal questions to satisfy curiosity, stereotypes. Nonverbal: checking your watch, crossing your arms.

Therapeutic techniques

Listening, touch and space

• Therapeutic communication has a goal and a purpose, unlike social chat.
• Active listening shows interest, in words and body language, and checks understanding by restating.
• SOLER: sit squarely, open posture, lean in, eye contact, stay relaxed.
• Ask permission before touch: it may feel threatening after trauma.
• No touch when a client is becoming agitated, or is manic or psychotic: it can escalate things.
• Keep more personal distance with a client who is paranoid or psychotic.
• Sympathy focuses on the nurse's feelings; empathy stays with the client.

Four levels of anxiety (Peplau)

Talking someone down: Validate ("I can see this is overwhelming"), rather than saying calm down. One question at a time. Grounding: "Tell me three things you see." Don't argue with irrational fears; offer support and safety.

Peplau's phases of the relationship

Boundaries

• Boundaries are the nurse's responsibility: limit self-disclosure; no personal or business ties with clients.
• Warning signs: keeping secrets with a client, favoritism, flirting, extra time with one client, believing you're the only one who can help.
• Meeting a client outside work, or speaking poorly of colleagues to them, crosses a line.
• In small communities, openly acknowledge any dual relationship.

Crisis intervention

• A crisis is when usual coping fails. It's time-limited: usually days, and no longer than 4 to 6 weeks.
• Goals: ensure safety, then help the person return to their prior level of functioning.
• Stay calm, hands open and visible. Keep your distance, avoid touch, approach from the side, don't joke.
• Escalating: set clear limits instead of threats. "Please sit down; I'll have to call for help if you can't control your emotions."
• Give space, don't argue or reason, and get help if you can't de-escalate. If there's no immediate danger, call a psychiatric clinician who knows the person.
• Restraint may be needed for safety, and any talk of suicide is taken seriously; 988 offers crisis support.
• Warning signs: rapid mood swings, sudden calm after depression, threats, isolation.

Defense mechanisms

The milieu and motivational interviewing

• Orient clients to the unit, staff roles, schedules, expectations, and their rights. Round at varying times, often every 15 to 60 minutes, per policy and observation level, and remove cords and drawstrings.
• Advocate for the least restrictive environment. Restraint or seclusion only in an emergency, on a physician's or other licensed practitioner's order, never standing or as needed; stop restraints at the earliest possible time.
• Motivational interviewing draws out the client's own reasons to change: express empathy, highlight the gap between behavior and goals, roll with resistance, support confidence. Assess readiness first; resist giving advice.