Therapeutic Paper
Introduction
For this therapeutic communication paper, I interviewed CW. CW is a single, white fifty-four female and living at her father’s house. She has a long history of schizoaffective disorder, bipolar type, with numerous hospitalizations, but no suicide attempts. She was brought to the OCS and was discharged after a week. The client made her way back to her father’s house, but her father brought her back to OCS. He tearfully explained to the nurse that he can no longer manage her mood or provide her housing. CW is very loud and hyperverbal, very disorganized, and restless. She denies use and abuse of drugs and alcohol and denies being a manic. She has a very low compliance with medications, as she cannot comply with how she is managed in the hospital.
DSM-IV-TR
Axis I (Identifies Clinical Disorders) – 295.70 Schizoaffective Disorder Bipolar Type could be seen in this client by her constant manic episodes. This disturbance includes a Manic or a Mixed Episode, which is evident in the client, such as being loud, manic, hyper-verbal, and restless.
Axis II (Identifies Personality Disorders) – Hypothyroidism is a general medical condition that results from the under-production or insufficient production of thyroid hormone by the thyroid gland.
Axis III (Identifies General Medical Condition) – None
Axis IV (Identifies Psychosocial and Environmental Problems) – A, B, E, K
Axis V (Identifies a global assessment of functioning) – The client was first brought to the OCS on 5150. He was given a score of 15/40, which signifies that the client has disorganized thoughts, showing signs of psychosis and verbal aggressiveness. She was found walking in the parking lot, barefoot.
Process Recording
I began my process recording of therapeutic communication with CW in one of the isolated rooms of the OCS. I sat in a chair with a table in front of me, and CW was sitting on a chair in front of me. The room looks empty with its white walls and white fluorescent lamps. The room was fairly cold and I can feel the cold steel of the chair touching my skin. CW was sitting right in front of me when I started the process recording.
Student Nurse Verbal/Nonverbal
Client Verbal/Nonverbal
Communication Technique Used
Analysis & Eval of Verbal/Nonverbal Communication & Eval of Therapeutic Effectiveness of Interaction
Me: “Hello CW! How are you?”
I sat in a forward position with my hands resting on my lap. I smiled at her and maintained eye contact.
CW: “Who are you?”
She was sitting across me, legs apart, and both her arms are crossed in front of her. She was looking at me curiously and intently.
Broad Opening
“Initiates conversation with the client, and puts him/her in control of the content (Frisch and Frisch, 2006, p. 93)
I believe that the beginning of the conversation was appropriate. I was trying to initiate a conversation, and the client was curious to know who I am because this is the first time we met. Her reactions were also normal as she wanted to know who I am. This is in the orientation phase. “We are just getting to know one another, for establishing trust” (Frisch and Frisch, 2006, p. 100)
Student Nurse Verbal/Nonverbal
Client Verbal/Nonverbal
Communication Technique Used
Analysis & Eval of Verbal/Nonverbal Communication & Eval of Therapeutic Effectiveness of Interaction
Me: “I am your new therapist. How are you feeling today?”
I introduced myself, offered to shake her hands, and smiled at her again. I was trying to give the impression that the client can trust me.
CW: “Therapist? What do I need a therapist for? Well, I feel great! As usual!”
She was relatively in the same position, except that she was making better eye contact. Her tone of voice was slightly raised, sounding ecstatic.
Broad Opening
“Initiates conversation with the client, and puts him/her in control of the content (Frisch and Frisch, 2006, p. 93)
I was still trying to initiate a good conversation with the client, as we are still in the orientation phase. “We are just getting to know one another, for establishing trust” (Frisch and Frisch, 2006, p. 100)
Student Nurse Verbal/Nonverbal
Client Verbal/Nonverbal
Communication Technique Used
Analysis & Eval of Verbal/Nonverbal Communication & Eval of Therapeutic Effectiveness of Interaction
Me: “Oh that’s very good! How come?”
I tried to smile a little wider to give her the impression that I was glad to hear that she feels great. I leaned forward to show gesture that I was trying to listen to her more intently.
CW: “I watch TV a lot. And you know what? I had a dream last night, a very good dream!”
She put her feet together in the floor, put her hand in her chin in a dreamy way, and looked at the ceiling. She smiled at her thought of the dream.
Reflection
“Presents themes that have emerged through a series of interactions” (Frisch and Frisch, 2006, p. 93)
At this point, both the verbal and nonverbal communication used was starting to get to a point where I can use some effective communication. By the looks of it, our conservation was getting into the working phase, wherein nursing interventions can be used to achieve outcomes (Frisch and Frisch, 2006, p. 100)
Student Nurse Verbal/Nonverbal
Client Verbal/Nonverbal
Communication Technique Used
Analysis & Eval of Verbal/Nonverbal Communication & Eval of Therapeutic Effectiveness of Interaction
Me: “What was your dream about?”
I placed my folded hands in the table in front of us, slightly leaned forward, and maintained eye contact with client. I was also trying to smile to encourage her.
CW: “I dreamt that I was flying, high, very high! And I was so happy! Can you see it? I am so happy!”
The client leaned back in her chair, raised both her arms in the air, and shouted her reply in an excited and elated manner.
Focusing
“Directs conversation back to an area of importance and explores a topic in depth” (Frisch and Frisch, 2006, p. 100)
I feel that the client already trusts me, as she shares her ideas and dreams with me. I can see. That she is also convinced that she can trust me that’s why she did not have hesitations to share her dreams and gestures with me. This is still in the working phase, wherein nursing interventions can be used to achieve outcomes (Frisch and Frisch, 2006, p. 100)
Student Nurse Verbal/Nonverbal
Client Verbal/Nonverbal
Communication Technique Used
Analysis & Eval of Verbal/Nonverbal Communication & Eval of Therapeutic Effectiveness of Interaction
Me: “What have you seen while you were flying?”
I sat forward in my chair, placed my hands in my lap again, sat straight, and gave my full attention to CW while she speaks.
CW: “I can see clouds, and I was a bird, a big one! I can fly in my dream!”
The client stood up and made a gesture as she was a bird. She moved around the room and acted like she was flying, re-enacting her dream.
Focusing
“Directs conversation back to an area of importance and explores a topic in depth” (Frisch and Frisch, 2006, p. 100)
I feel that our conversation is already established and that the client trusts me very well. She is already comfortable talking and expressing her ideas with me, even making big gestures to help express what she feels. This is still in the working phase, wherein nursing interventions can be used to achieve outcomes (Frisch and Frisch, 2006, p. 100)
Student Nurse Verbal/Nonverbal
Client Verbal/Nonverbal
Communication Technique Used
Analysis & Eval of Verbal/Nonverbal Communication & Eval of Therapeutic Effectiveness of Interaction
Me: “I think that it would be nice to be a bird and fly. What kind of bird? A swan perhaps?”
I smiled at her when I made my reply. I slightly tilted my head in a questioning manner and maintained eye contact with the client.
CW: “Yes a swan, a black one. I saw it splashing in the middle of the lagoon.”
The client sat back down her chair and nodded when she replied. When she said what the swan was doing in her dream, she looked at me straight in the eye with a big smile in her face.
Suggesting
“Presents new ideas and assists clients to consider alternative options” (Frisch and Frisch, 2006, p. 100)
The verbal and nonverbal communication I used here was to encourage her to listen to me and to trust me that I like her ideas. I was able to get a response from the client and then give her my own insight. This was all done in the working phase, wherein nursing interventions can be used to achieve outcomes (Frisch and Frisch, 2006, p. 100)
Student Nurse Verbal/Nonverbal
Client Verbal/Nonverbal
Communication Technique Used
Analysis & Eval of Verbal/Nonverbal Communication & Eval of Therapeutic Effectiveness of Interaction
Me: “Alright then, so what did the swan do next?”
I leaned backward and spoke in a questioning tone. I maintained eye contact with the client to encourage her to speak and expound on her dream.
CW: “I don’t know! I woke up and I am hungry! I want to eat!”
The client expressed her hunger in a loud manner. She stood up and shouted to the people outside the room that she is hungry and to give her food.
Informing
“Provides facts or recommendations” (Frisch and Frisch, 2006, p. 93)
I felt that the verbal and nonverbal communication between us were not compatible, as I was still trying to probe on her dream and she was expressing that she was hungry. I was also using a calm tone, while she was expressing her feelings in a loud and hyper manner. Although the client was responding to my question, I believe that she was getting bored and tired to talk about the details of her dream. This is still in the working phase, wherein nursing interventions can be used to achieve outcomes (Frisch and Frisch, 2006, p. 100)
The client was given food and this time was considered a short break time for our conversation. After a few minutes of eating her snacks, she came back inside the room with me and sat back down in the chair in front of me. This time, she wanted to move the table so that she can speak to me directly and in a more informal manner.
Student Nurse Verbal/Nonverbal
Client Verbal/Nonverbal
Communication Technique Used
Analysis & Eval of Verbal/Nonverbal Communication & Eval of Therapeutic Effectiveness of Interaction
Me: “How do you feel now after taking your meal?”
I asked the client in a relaxed tone and manner. I even smiled at her while asking the question.
CW: “It’s alright! I want to eat some more though.”
The client was smiling when she replied. She even touched her stomach, gesturing that she was still hungry. But after saying this, she laughed.
Informing
“Provides facts or recommendations” (Frisch and Frisch, 2006, p. 93)
I believe that the verbal and nonverbal communication used indicates that we have already established trust and a good relationship with each other. A good and positive result has been observed. This is being done in the working phase , wherein nursing interventions can be used to achieve outcomes (Frisch and Frisch, 2006, p. 100)
Student Nurse Verbal/Nonverbal
Client Verbal/Nonverbal
Communication Technique Used
Analysis & Eval of Verbal/Nonverbal Communication & Eval of Therapeutic Effectiveness of Interaction
Me: “What do you usually like to eat?”
I looked at the client with interest. I leaned a little forward and smiled at her while addressing the question.
CM: “I think I love to eat corn muffin, lettuce, and milk. They all taste good!”
The client smiled a little and replied with a loud voice. Exclaiming that these foods taste good.
Focusing
“Directs conversation back to an area of importance and explores a topic in depth” (Frisch and Frisch, 2006, p. 100)
I felt that the communication I used here is working very well. This is because I have encouraged the client to open up and become comfortable with me. This is being done in the working phase , wherein nursing interventions can be used to achieve outcomes (Frisch and Frisch, 2006, p. 100)
Student Nurse Verbal/Nonverbal
Client Verbal/Nonverbal
Communication Technique Used
Analysis & Eval of Verbal/Nonverbal Communication & Eval of Therapeutic Effectiveness of Interaction
Me: “Milk is good. You can also try other foods like fruits, bread, meat, and vegetables.”
I said this by looking at her and while nodding, to convince her. I placed my hands on top of my lap, while resting both my feet flat on the floor.
CW: “Oh yeah, milk is good. It makes my stomach feel fine. Yeah, those foods are good for me too.”
The client said this while nodding and smiling. She seemed delighted to hear the suggestion about trying other types of food.
Suggesting
“Presents new ideas and assists clients to consider alternative options” (Frisch and Frisch, 2006, p. 100)
In this part of the conversation, I was using a suggestive type of verbal communication with the client. I believe that I could give her some more advices on how to make herself better. This is being done in the working phase , wherein nursing interventions can be used to achieve outcomes (Frisch and Frisch, 2006, p. 100)
Student Nurse Verbal/Nonverbal
Client Verbal/Nonverbal
Communication Technique Used
Analysis & Eval of Verbal/Nonverbal Communication & Eval of Therapeutic Effectiveness of Interaction
Me: “Aside from good food, a visit and talk from your family, especially from your father can make you feel much better. What do you think of that?”
I said this by leaning forward and looking at the client straight in the eyes to nonverbally convince her that I was serious when I said that.
CW: “No I don’t. My father does not want me. He doesn’t want me at all.”
The client said this with raised voice, a little angry. She swung her head from left to right slowly and even tried to stand up to stress her opinion about what I said.
Suggesting
“Presents new ideas and assists clients to consider alternative options” (Frisch and Frisch, 2006, p. 100)
With the usual suggestive manner and tone of voice, I felt that the verbal communication I used provoked the client to express her feelings, particularly regarding her feelings toward her father. This is being done in the working phase , wherein nursing interventions can be used to achieve outcomes (Frisch and Frisch, 2006, p. 100)
Student Nurse Verbal/Nonverbal
Client Verbal/Nonverbal
Communication Technique Used
Analysis & Eval of Verbal/Nonverbal Communication & Eval of Therapeutic Effectiveness of Interaction
Me: “Why do you think that?”
I said this in a sad tone of voice, encouraging the client that I would like to know the reason why she expressed this.
CW: “I….. don’t know…”
The client was staring at the floor, seemed a little depressed.
Silence & Listening
“Provides time for the nurse and client to gather thoughts and to reflect. It also permits the client to be heard, conveys the interest in what the client is saying” (Frisch and Frisch, 2006, p. 93)
I felt that the client was about to get into something at this point, and I was trying my best to listen to what she wanted to say.
Student Nurse Verbal/Nonverbal
Client Verbal/Nonverbal
Communication Technique Used
Analysis & Eval of Verbal/Nonverbal Communication & Eval of Therapeutic Effectiveness of Interaction
Me: “How about your medication? Do you think that it is making you feel better too? Please explain.”
I sat forward this time and used a number of hand gestures to encourage her to speak. I did start to sit comfortably in the chair while asking the question, but I leaned forward again.
CW: “No, not at all! It makes me sleep a lot, and I’m not able to watch my favorite shows on TV!”
The client said this forcefully, while tapping her feet on the ground continuously. Her cheerful mood changed. Now she is a bit angry.
Clarification
“Puts the client’s ideas into simple statements and makes the client’s ideas explicit” (Frisch & Frisch, 2006, p. 93)
I felt that the verbal and nonverbal communication used here was instrumental in getting the client to express herself. I was still in a working phase with the client.
Student Nurse Verbal/Nonverbal
Client Verbal/Nonverbal
Communication Technique Used
Analysis & Eval of Verbal/Nonverbal Communication & Eval of Therapeutic Effectiveness of Interaction
Me: “Well, it must be hard for you to feel the way you do now. Does this make you feel bad at all?”
Eye contact was maintained with the client, although with sad eyes and manner and tone of speaking.
CW: “Just sometimes, it makes me tired thinking about it.”
The client then turned away and walked over to the door to go out.
Reflection
“Presents themes that have emerged through a series of interactions” (Frisch & Frisch, 2006, p. 93)
This was the point when the conversation between me and the client stopped. I felt that I was not able to get out of the working phase at all, and terminate the conversation appropriately.
Summary
My communication with the client in general was excellent. I can say that I have used strategies that allowed both of us to become comfortable with one another, thus, helping the atmosphere and our relationship to become established and stable. We talked inside a secluded room, where only the two of us can communicate and where other individuals and clients are not present. In addition to this, other sources of distractions, such as the television were not present in the room, thus, allowing the both of us, particularly the client to focus on our conversation. The gestures of the client indicated that she became very comfortable with me while we were talking. In this sense, I was able to use of the techniques indicated in the book, which helped me in effectively communicating with the client and keeping her in focus of the conversation instead of me. However, I also believe that my communication with the client can still be improved. I believe that I can lessen the questions so that our conversation can fit the time required to do the session. Another aspect to improve is trying to organize the questions to a more coherent flow in order to obtain more substantial answers from the client. Lastly, more techniques in communication can be used to make the conversation more lively and exciting. Overall, I feel that I have learned a lot from the experience, even though I know that some aspects of the session can still be improved. This experience will surely help me in my future clients.
References
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC.
Frisch, M.B. (2006). Quality of Life Therapy. Hoboken, New Jersey: John Wiley & Sons.
Credit:ivythesis.typepad.com
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