Therapeutic communication is purposeful, client-centered verbal and nonverbal interaction that helps the client express feelings, understand problems, and find solutions. It is the main tool of psychiatric nursing and one of the most frequently tested areas.

Principles:

• Focus on the client's feelings and concerns, not on the nurse
• Accept feelings first; explore second; teach or problem-solve later
• Stay in the here and now
• Keep the tone calm, nonjudgmental, and respectful
• Nonverbal behavior carries much of the message; it must match the words (congruence)

Nonverbal attending (SOLER): Sit squarely facing the client, Open posture, Lean slightly forward, Eye contact (culturally appropriate), Relaxed. Respect personal space — more distance for anxious, paranoid, or agitated clients.

Assess factors that affect communication:

• Level of anxiety (severe anxiety and panic block learning — use short, simple sentences)
• Thought disorder, hallucinations, or delusions
• Cognitive impairment, hearing or vision loss
• Language, literacy, and culture (use a trained medical interpreter, not family members)
• Nonverbal cues: facial expression, posture, tone, crying, silence

Adjusting communication to the client

Therapeutic techniques

Nontherapeutic responses

• The whole team uses a consistent communication approach, especially with clients who split staff or test limits
• Verbal de-escalation is the first response to agitation; medication and restraint are last resorts
• Professional interpreters are required for clients with limited proficiency in the language of care

Listed in priority order.

1. Suicidal statements ("I'm useless; life has no meaning") — acknowledge the feeling and ask directly about suicide: "Are you thinking of killing yourself?" Asking does not plant the idea. Then assess plan and means (Topic 13)
2. Agitated or angry client — calm, low voice; short sentences; keep a safe distance and an exit; acknowledge the anger ("You're very angry"); offer choices; set clear limits on behavior
3. Hallucinations and delusions — do not argue or agree. Respond to the feeling behind the belief first ("That must be frightening"), then present reality briefly and redirect to concrete activities. Ask about command content
4. Delirium or disorientation at night ("I have to go home, my children are waiting") — address the fear and provide safety first: "You seem worried. I'm here with you," guide back to bed, then reorient gently. Do not argue or threaten
5. Mania (rapid, grandiose speech) — do not argue or join in; use brief, calm, concrete questions that invite realistic thinking ("What steps would you need to take first?"); reduce stimulation
6. Withdrawn, depressed, or silent client — use therapeutic silence and offer self: sit quietly, "I'll stay with you for a while." Avoid pressuring ("If you don't talk, I can't help you")
7. Worthless or hopeless statements — avoid reassurance; accept and explore: "You're feeling worthless. What has happened that makes you feel this way?"
8. Trauma survivors (PTSD) — let the client set the pace; maintain a supportive relationship; do not force or probe for trauma details
9. Eating disorders — acknowledge fear of weight gain, then explore distorted beliefs about food and body without power struggles or threats
10. Idealization and splitting ("You're the only nurse who understands me; the others hate me") — do not accept the special status or criticize colleagues; reflect and explore the pattern ("Do you feel this way in other relationships?"); keep the team consistent
11. Crying — offer tissues and presence; allow silence

Manage your own reactions: strong emotions in the nurse (sadness, anger) triggered by a client may be countertransference — seek supervision.

• Teach assertive communication using "I" statements ("I feel… when… I need…")
• Role-play difficult conversations before discharge
• Teach families to speak calmly, simply, and without criticism — high expressed emotion (criticism, hostility, over-involvement) in families is linked to relapse in schizophrenia and mood disorders
• Use teach-back to confirm understanding of medication instructions

• Best first response: acknowledge/reflect the feeling, then explore with an open-ended question
• "Why" questions, false reassurance, advice, and changing the subject are nontherapeutic
• Clarifying = making a vague message clear; not interpreting hidden meaning
• Silence is therapeutic with depressed or withdrawn clients; sit with them
• Delusions: do not argue or agree — address the feeling, present reality, redirect
• Suicidal statements: ask directly about suicide
• Mania: calm, brief, concrete, reality-based questions; low stimulation
• Delirium: safety and reassurance first, then gentle reorientation
• Splitting/idealization: stay professional, do not take sides, keep team consistent
• Countertransference = nurse's emotional reaction rooted in own experience
• Use professional interpreters, not family