One. Review the list of 14 Nontherapeutic Phrases/Actions/Gestures on page 60 (continued on 62) of your textbook. Pick one of interest to you.Two. Briefly describe it as listed in the text.Three. Provide your own real world or hypothetical example of it as offered in the text on #6.) Belittling Responses. Then Utilize Exhibit 3â€“4 on Page 61 for inspiration/ideas and highlight WHY you choose it.Four. Finally select one recommended Therapeutic Communication that you would offer instead from the list on page 59 (and Exhibit 3â€“3 on p. 60)â€¦ i.e. Using silence Offering acceptance etc. PAGE 60-65 Perhaps the most important understanding of dysfunctional communication patterns is found in the historical work of certain theorists studies of family dynamics (Satir 1967; Watzlawick Weakland & Fisch 1974; Watzlawick Beavin & Jackson 1967). Satir (1967) for example explicitly defined the characteristics of a dysfunctional communicator. According to Satir dysfunctional communicators overgeneralize; assume that others share their feelings thoughts and perceptions; assume that their perceptions or evaluations are complete; and assume that what they perceive or evaluate will not change. These individuals assume there are only two possible alternatives (they tend to dichotomize or think in terms of black or white): that what they attribute to things or people are actually a part of those things or people and that they can get inside the skin of the other person (not only to act as a spokesperson for that person but also that others can do the same with them). Individuals who exhibit functional communication as opposed to dysfunctional are more likely to use qualification and clarification. These individuals tend to clearly state their case are ready to clarify or qualify their remarks and ask for feedback. They are also receptive to feedback when they receive it. Providers who establish effective communication with patients will not only exhibit functional communication they will also be model communicators. They exemplify clear communication and also teach patients how to achieve it. To do this they must spell out the rules for communicating accurately emphasizing checking out the meanings of messages and correcting invalid assumptions. Providers need to be very clear in their own messages showing a willingness to repeat restate and carefully explain how they reached conclusions. It is hoped that through both the providers modeling and their capacity to interrupt dysfunctional communication that the patient will be encouraged to move toward more effective communication styles. Therapeutic communications with patients require many knowledge and skill sets. Among these are the abilities to engage the patient in therapeutic interviewing to assist the patient to communicate more effectively and to avoid the traps of dysfunctional communication. THERAPEUTIC INTERVIEWING SKILLS Much has been written about the principles of therapeutic interviewing. In this text techniques of therapeutic communication and therapeutic interviewing (referred to as critical competencies) are described in detail one at a time in Part II. The purpose of this discussion of therapeutic interviewing is to lay some general groundwork for the most salient principles. Therapeutic interviewing has certain objectives. Generally therapeutic interviewing is established to accomplish one or more of these aims: âˆ‘ â— Elicit full descriptions from patients about their healthcare condition and concerns. âˆ‘ â— Create an interpersonally safe place for patients to talk about themselves and be able toexplore their problems in detail. âˆ‘ â— Reduce any acute emotional distress associated with the patients immediate condition. âˆ‘ â— Offer support and reassurance. âˆ‘ â— Establish an expanded list of patients primary and secondary healthcare problems. âˆ‘ â— Engage the patient in a problem-solving process that demonstrates the collaborativeaspects of the providerâ€“patient relationship. âˆ‘ â— Prepare the patient for self-management of his or her health and illness. Therapeutic Communications The specific types of questions and responses that the provider can use are many. With regard to even one therapeutic response that response can be used again can be modified or can be discontinued. For example the provider can use a question can re-ask the same question can refer back to it later or can even use an inappropriately worded question to open up the patients expression on an important related topic (see Exhibit 3â€“3). Therapeutic response modes includebut are âˆ‘ âˆ‘ âˆ‘ âˆ‘ âˆ‘ âˆ‘ âˆ‘ âˆ‘ âˆ‘ âˆ‘ not limited to: â— Using silence.â— Offering acceptance.â— Acknowledging and giving recognition (e.g. verbalizing the unspoken but implied message).â— Offering broad openings.â— Making and offering observations and summarizing.â— Reflecting ones own perception of the patients thoughts feelings and reactions. â— Focusing the patient and at other times prompting exploration.â— Translating thoughts into feelings and feelings into thoughts.â— Encouraging evaluation or appraisal.â— Validating the patients perceptions and/or beliefs. There are many responses that achieve the overall aim of the therapeutic encounter. In chapters to follow specific therapeutic response modes are discussed in detail. Nontherapeutic Communications Just as there are various recommended responses in therapeutic encounters there are also those that need to be avoided. Exhibit 3â€“4 is provided so that you can test yourself in this area. Nontherapeutic phrases and gestures are to be avoided because they tend to limit patients verbal expressions they cause negative reactions or they threaten patients. These include the following 14 items: Exhibit 3â€“3 Therapeutic Response Modes âˆ‘ â— Using silence. âˆ‘ â— Offering acceptance. âˆ‘ â— Acknowledging and giving recognition. âˆ‘ â— Offering broad openings. âˆ‘ â— Making and offering observations. âˆ‘ â— Reflecting on anothers thoughts feelings and reactions. âˆ‘ â— Focusing discourse promoting exploration. âˆ‘ â— Translating thoughts into feelings. âˆ‘ â— Encouraging mutual evaluation or appraisal. âˆ‘ â— Validating the clients perceptions and/or beliefs. âˆ‘ 1. Moralizingâ€”inferring that patients are wrong or not okay. This tends to inhibit expression. âˆ‘ 2. False reassuranceâ€”stating that the patient will be better when he will not. False reassurance can cut off the patients exploration of his concerns. âˆ‘ 3. Closed-ended questionsâ€”asking questions that can be answered in one to three words. âˆ‘ 4. Summarizingâ€”summarizing may help the patient but also shut the patient down if it isoffered too early. âˆ‘ 5. Stereotypic responsesâ€”using phrases like â€œthats badâ€ (meaning â€œgoodâ€) to expressunderstanding or attempt to impress patients. The use of stereotypic responses mayappear phony and backfire on the provider. âˆ‘ 6. Belittling responsesâ€”making replies to patients that diminish the significance of theirexperience is belittling. Saying to a depressed patient for example as she reveals the desire to die â€œOh those are common feelings of people in your positionâ€ tends to devalue the individuals experience. âˆ‘ 7. Interrupting responsesâ€”introducing an unrelated topic breaks the flow of the patients conversation before he or she can complete thoughts or ideas. âˆ‘ 8. Denial of problemsâ€”treating patients concerns in a cavalier manner. âˆ‘ 9. Giving approval or disapprovalâ€”communicating approval or disapproval explicitly orsubtly limits patients feelings of freedom to say things. âˆ‘ 10. Disagreeingâ€”responding like this puts the provider in opposition to the patient. It canmake patients defensive about their own ideas and feelings. Exhibit 3â€“4 Personal Inventory for Nontherapeutic Interviewing Skills On a scale of: 1 (all the time) to 8 (none of the time) how frequently do you do the following when interviewing patients? o I. Switch off problem-centered data by talking about: ÃŸ â— Unrelated focusÃŸ â— Incidental material o II. Maintain superficial discussion by: ÃŸ â— Avoiding elaborationÃŸ â— Switching to unrelated superficial focus; denying significance of the patients stated problemsÃŸ â— Asking closed-ended questions o III. Intervene personally by: ÃŸ â— Giving opinion to life situation of patient without exploring ÃŸ â— Giving unsolicited personal comment or opinionÃŸ â— Giving personal information or socializing responsesÃŸ â— Expressing approval or disapproval ÃŸ â— Moralizing belittling or challengingÃŸ â— Seeking agreement from the patient/disagreeing with the patient o IV. Close off exploration by: ÃŸ â— Prematurely giving an interpretation ÃŸ â— Prematurely advising solutionsÃŸ â— Prematurely giving reassuranceÃŸ â— Prematurely closing topicÃŸ â— Using judgmental stereotypical responses ÃŸ â— Interruptive responses ÃŸ â— Excessive probing o V. Introduce or follow illogical content by: ÃŸ â— Changing key words without validating changeÃŸ â— Following vague content or referent as if understoodÃŸ â— Introducing vague content or referentÃŸ â— Questioning on different topics or levels without awaiting reply ÃŸ â— Speaking to question or statement of patient in conflicting ways ÃŸ â— Ignoring question of patient Frequency of use: Pattern I. Pattern II. Pattern III. Pattern IV. Pattern V ________________________ ________________________ ________________________ ________________________ ________________________ Use of the tool: (1) Identify each provider response; (2) Mark NP = nonproblematic or P = problematic; (3) Total P responses using tool. âˆ‘ 11. Advisingâ€”advice-giving is not always helpful. Although a great deal of what providers do is to offer patients advice it can have the effect of making the patient feel incapable of being self-directed. âˆ‘ 12. Probingâ€”probing too much may make patients feel like objects. âˆ‘ 13. Challengingâ€”challenging is a clear and present danger to the patients expression.This tends to make patients feel that they have to prove what they say; they generallybecome defensive. âˆ‘ 14. Socializing responsesâ€”engaging in chitchat or revealing personal data isnontherapeutic. It generally calls for equal time for the provider to self-disclose. This decreases the patients time to self-disclose.These responses are usually nontherapeutic but not always. There are appropriate ways and times to use advice probe and even confront patients. However for beginning providers it is helpful to know that most of the responses are problematic can lead them astray and result in negative outcomes.The Context of Therapeutic EncountersThe context of the therapeutic interview is extremely important; this context influences the quality of the patients communicative capabilities and the interviewing environment.Patients as is suggested many places in this text may exhibit dysfunctional communication. Their dysfunctional communication could be a result of a transient state (e.g. stress) or it may be longstanding resulting from defects. Frequently exhibited disturbances in perception processing and expression are: âˆ‘ â— Verbalizing too much or too little. âˆ‘ â— Verbalizing inappropriately to the context of the events. âˆ‘ â— Using incomplete sentences or thoughts. âˆ‘ â— Behaving as if they have communicated clearly when they have not. âˆ‘ â— Misperceiving environmental stimuli. âˆ‘ â— Exaggerating certain meanings of a message ignoring other aspects or attributingdifferent connotations to an event than what is intended. âˆ‘ â— Overgeneralizing or undergeneralizing and failing to access stored information.Because patients experience difficulties in communicating part of the role of the provider is to correct for these deficits. This context of therapeutic interview is extremely important; it includes the social and environmental context for the providers communication with the patient.The purpose of therapeutic interviewing is to build or maintain a patientâ€“provider relationship and to assess the patient through the patients disclosure of thoughts feelings behaviors and experiences. Because interviews require patients to communicate something personal and even threatening the interviewer must establish rapport and trust with the patient. This includes creating a safe place for the patient to disclose. A place that is protected from intrusions and interruptions is important for two reasons. First a protected environment is likely to make patients feel comfortable. Second in order to collect data adequatelyâ€”this includes the multiple levels of patient communication (verbal nonverbal and meta-messages)â€”the provider must have a â€œnoise-freeâ€ environment.The data from an interview reflects the context of the interview. It is important to understand how patients communicate based on the context of the interview. We know for example that patients react differently to different interviewers. Who you are and what you are like may influence what the patient does or does not tell you. Patients also react to the particular situations in which they are asked questions. They may be rather close-mouthed if the atmosphere is threatening or there is little privacy. Patients also react to their most immediate life circumstances crisis and symptom status. Finally patients react to the providers approachâ€”the specific way in which the provider formulates questions. All successful interviewers take these elements into account.Ones style of interviewing and choice of questions should be influenced by the perceptual ethnic-cultural and educational characteristics of the patient. The adage â€œBegin where the patient isâ€ is a good one. Basically we can never push patients further than they can go nor expect them to adapt to our stylistic peculiarities. It is inappropriate to use complex medical jargon with patients who are incapable of understanding the meaning of even the simplest medical phrase. It is also inappropriate to require patients to endure lengthy interviews of two hours if their anxiety levels or attention spans cannot meet the challenge. Sometimes knowing and using the jargon or language of the specific ethnic or cultural group is likely to increase patients desires to communicate problems.Regardless of the circumstances providers must always demonstrate respect and concern for patients. Showing interest concern and understanding indicate that the provider regards the patient as worthy. The affective tone that the provider uses with the patient is extremely important and can make or break the interview no matter how sophisticated the provider is in using techniques. AVOIDING THE TRAPS OF DYSFUNCTIONAL COMMUNICATION Avoiding the traps of dysfunctional communication is certainly possible but this requires knowledge skill and practice. We need to be able to communicate effectively and therapeutically with our patients. This seems so straightforward that it is frequently ignored. However the techniques of effective communications are being taught everywhere and people once trained in effective communication must go back for booster shots. That we can always improve our communications is a maxim the business and consulting industry knows well. Billions of dollars are poured into (and are made) helping people communicate with each other. Training in Interpersonal Communications Training in interpersonal communications is helpful to health providers because it improves their ability to communicate as well as their ability to help others. The purpose of good interpersonal communication is to help others learn about themselves and make decisions based on this knowledge. Another purpose of good communication is so people can learn about themselves by sharing with others and by monitoring their own words and actions. One of the biggest entanglements that a provider can experience is the trap of defensive communication. Defensive communication in the provider is generally indicative of a perceived threat and its corresponding feelings of anxiety fear and guilt. The consequence of defensive communication is generally that messages will be misunderstood and that communication will reach a standstill. This event in a patientâ€“provider encounter is to be avoided at all costs because a disruption in communication is tantamount to a disruption in care.Defensive communication tends to be obvious. It has specific elements. The following is a list of behaviors that are generally indicative of a defensive posture: âˆ‘ â— Labeling. âˆ‘ â— Interrupting. âˆ‘ â— Judging. âˆ‘ â— Using tunnel vision. âˆ‘ â— Advice giving. âˆ‘ â— Preparing rebuttals.While there are many other indicators of defensive communication these are among the most common. People who are communicating defensively usually use more than one of these responses. So it is not only the specific response that is important it is the cluster of responses that is used and the impact of this cluster on others. Consider for example someone who is reacting very emotionally. They may label or blame interpret others behaviors judge others and develop rebuttals. When this defensive posture is executed with high intensity it can be likened to a â€œmachine gun.â€ This machine-gun approach has one resultâ€”everybody gets out of the way. No one wants to get caught in the cross-fire so observers are also likely to exit the
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