Communicating with Clients Experiencing Psychiatric Illness
Christine L. Williams DNSc, APRN, BC
OBJECTIVES
To discuss the importance of communication as a therapeutic strategy for clients with severe psychiatric illnesses
To compare and contrast communication approaches to clients experiencing varying symptoms of severe psychiatric illness
To analyze barriers to therapeutic communication with clients who experience psychiatric symptoms
“Listen with compassion and an open heart, without interrupting: listening to another’s story is a healing gift of self” (p. 201).1
▪ INTRODUCTION
Nurses may care for clients with mental illness in a variety of locations, including hospital-based psychiatric units, offices, and community and urgent care settings. These clients experience the same medical illnesses, accidents, surgical procedures, and need for primary care as other clients. Individuals may exhibit symptoms of psychiatric illness during childbirth or in settings where their children receive care. Therefore, all nurses should be prepared to interact with people who have symptoms of mental illness.
There are multiple causes of psychiatric illness, including genetic influences, intrauterine and birth trauma, as well as environmental factors. Nurses use a variety of strategies to work with this population, including therapeutic milieu, group therapy, one-to-one relationships, and somatic therapies. This chapter focuses on verbal and nonverbal therapeutic techniques the nurse can use when interacting with clients who have psychiatric illnesses regardless of setting.
When clients are suffering from mental illness, successful communication can be challenging. Nurses must adapt their approach to the symptoms that clients display. Because the psychiatric client seems so different or so difficult to reach, nurses frequently experience anxiety when they begin working with this population. Caregivers’ (both family and professional) emotional reactions to clients with schizophrenia have been studied extensively.2 Caregiver hostility and absence of rapport have been significantly related to negative client outcomes such as relapse and rehospitalization. Nurses’ unrealistic expectations of clients and lack of understanding of symptoms contribute to their negative attitudes and lack of caring.
Positive relationships do make a difference. In their review of recent research, Hewitt and Coffey3 found that the quality of the relationship between patients with schizophrenia and their care provider had a significant impact on clinical outcomes. Compliance with taking medications, remaining in a therapeutic relationship, and better symptom outcomes were all associated with client-rated positive relationships. People with a serious psychiatric illness like schizophrenia want someone to talk to; someone with whom they feel comfortable and who will listen to them when they are upset.3
In his writings about the challenges of understanding the client with schizophrenia, Harry Stack Sullivan4
reminded readers that clients with psychiatric illnesses are more similar to us than we realize. He also wrote about the pain of clients’ loneliness and isolation, claiming that loneliness is the only emotion that is more painful than anxiety.4 All clients need relationships, and relationships have the potential to bolster self-worth and increase self-esteem.5 When nurses focus on what they have in common with their clients, such as the need for love and acceptance, the need for emotional security, and the need for positive relationships with others, they are more likely to be supportive and positive in their approach.
reminded readers that clients with psychiatric illnesses are more similar to us than we realize. He also wrote about the pain of clients’ loneliness and isolation, claiming that loneliness is the only emotion that is more painful than anxiety.4 All clients need relationships, and relationships have the potential to bolster self-worth and increase self-esteem.5 When nurses focus on what they have in common with their clients, such as the need for love and acceptance, the need for emotional security, and the need for positive relationships with others, they are more likely to be supportive and positive in their approach.
Peplau wrote that the goal of communication is to develop a common understanding between people to develop a relationship.6 In Peplau’s view, the relationship between nurse and client was intended to be corrective. For example, when nurses help clients to clarify unclear messages, they help to correct their confused thoughts. Today, nurses focus on creating behavior change in clients.5 Facilitating health-promoting behaviors in clients with mental illness begins with successful communication and relationship building.
Because many psychiatric illnesses share the same symptoms, this chapter is organized around psychiatric symptoms and the communication strategies appropriate for clients experiencing those symptoms. These strategies are intended to guide nurses to respond in helpful ways to clients who seem very different and are often difficult to understand.
Antipsychotic drugs that alter the biochemistry of the brain can decrease or even eliminate symptoms. Treating psychiatric symptoms with psychoactive drugs is an important component of a comprehensive approach to clients with severe psychiatric illness. Not all clients treated with antipsychotics or other psychiatric drugs will be relieved of their symptoms; therefore, other therapeutic strategies will remain an important component of their long-term care. Clients who form trusting relationships with nurses over time are more likely to take their medications consistently.3
▪ CHARACTERISTICS OF MENTAL DISORDERS
According to the 2000 Diagnostic and Statistical Manual of Mental Disorders,7 being psychotic can be defined as experiencing delusions and hallucinations when the person does not understand that these are symptoms and therefore not real. Clients with psychoses and other serious psychiatric conditions are the focus of this chapter. One of the most common manifestations of psychosis, schizophrenia, has an impressive list of symptoms to become acquainted with before communication is likely to be successful. Lego wrote that schizophrenia presented the greatest challenge to the nurse’s ability to communicate.8 The symptoms associated with schizophrenia are also common in many other mental disorders, although some symptoms will be more dominant in one disorder than others. For example, an individual with Alzheimer’s disease may experience similar symptoms to the person with schizophrenia (hallucinations, delusions, and mood symptoms). In Alzheimer’s disease, paranoid delusions and visual hallucinations may be dominant, whereas in schizophrenia, auditory hallucinations and grandiose delusions are more common. In the following discussion, symptoms will be categorized as negative, positive, cognitive, and mood related.
Creating a feeling of interpersonal safety for the client is the first step in a therapeutic interaction. Many clients with psychiatric illnesses withdraw from others or are difficult to engage in a relationship. The nurse can begin by acting in ways that are nonthreatening. Sitting quietly at a distance of 10 to 12 feet communicates availability. Being available and observant without being obvious creates a presence that is nondemanding. In this atmosphere of acceptance, the client is more likely to approach you and to initiate an interaction.
Symptoms can become habitual for people experiencing severe psychiatric illness, and nurses must demonstrate patience as clients struggle to give up familiar ways of relating.9 A gentle, supportive approach is most useful for bringing about change. An important principle is repetition. Any one strategy must be used over and over to have beneficial effects. Nurses sometimes wonder if their efforts will have any effect on client communication. Some worry about saying anything in case a poorly worded response might cause harm to the client. No one response is likely to have lasting impact. Consistency and persistence are necessary to gradually bringing about positive change.10
▪ RELATING TO CLIENTS WITH POSITIVE SYMPTOMS
Positive symptoms are positive because they are assessment findings that would be absent if the client were healthy. The positive symptoms of psychiatric illness include abnormal findings such as hallucinations and delusions.
Hallucinations
Hallucinations are perceptions that are not based in reality.7 Hallucinations can be understood as having some meaning beyond the literal description of the hallucinations themselves.9 As nurses become more familiar with their clients, they may begin to understand more about the psychological issues their clients struggle with by understanding the specific meaning of a hallucination for a specific client.
According to Peplau,11 hallucinations develop gradually in psychiatric illness, beginning when individuals call to mind thoughts of a comforting image during threatening experiences. When the stressful experience ends, individuals forget the comforting image or voice until the next stressful experience arises and the comforting image or voice is needed again. Gradually, this process becomes habitual and extends to situations in which the individual does not deliberately conjure up the comforting image or voice, but it comes to mind unexpectedly. The individual seems to be losing control. Something that brought relief during times of stress becomes a stressor in itself. As experiences of the image or voice increase and become uncontrollable, individuals distort the experience. Now the image or voice seems to be originating from outside the self. Further distortions continue, and the comforting image becomes very frightening.
From a neurobiological perspective, brain activity during hallucinations differs from normal. Transferring neural messages between different parts of the brain is thought to be impaired in schizophrenia. For the person who is hallucinating, thoughts that are expressed in words may seem to come from a source outside the person when in fact they are self-generated.12 In light of this fragmentation in the transfer of information, it is understandable that the client who is hallucinating will insist that the “voices” are not his or her own thoughts. Arguing with the client about the source of the voices doesn’t help the client to recognize reality and will only foster distrust. Accepting the client’s experience as being real for them promotes a trusting nurse-client relationship. As a therapeutic relationship develops, the client can learn more about hallucinations as a symptom of illness.
For people who develop hallucinations during physical illness (e.g., while withdrawing from alcohol or other substances), the hallucinations may be fleeting and much less organized than hallucinatory experiences of clients with schizophrenia. Such hallucinations tend to be visual and are associated with delirium (see Chapter 10 for a discussion of therapeutic communication with clients experiencing delirium). Hallucinations are common during dementia, such as in the later stages of Alzheimer’s disease. The verbal strategies that follow are appropriate for clients with hallucinations arising during delirium and dementia, as well as during psychiatric illness.
To begin helping clients recognize their own thoughts, nurses must avoid reinforcing hallucinations as something that originates outside of the person. When talking with your clients about their hallucinations, try stating, “Tell me about the voice you say you hear” rather than, “What is the voice saying?” This subtle difference implies that although the client’s experience is real to him or her, the nurse does not share that experience. It is important to acknowledge clients’ experiences, although you do not experience the same thing. For example, you could say, “You are telling me you hear a voice, but I do not hear it.” With this statement, you convey acceptance of a client’s experiences and contrast those experiences with your own. The goal is to encourage clients to question the reality of the symptom. When the experience is recognized as a symptom rather than external reality, client anxiety decreases.
Delusions
Delusions are abnormal, false beliefs that may be fleeting but are often stable over time.7 Although clients’ delusions are often quite bizarre, clients maintain them with conviction (e.g., “Every red car is following me.”). Clients cannot be persuaded to give up false beliefs with rational explanations. Arguing or presenting evidence to the contrary serves no useful purpose and will be harmful to the therapeutic relationship. Because delusions may serve as psychological defenses,13 directly challenging delusions may increase clients’ anxiety and, thus, increases their need to maintain the delusion. The delusion can be used to help the nurse recognize a client’s unmet emotional needs. For example, clients who, in reality, feel worthless may insist they are celebrities or important religious figures (grandiosity). The delusion may be an exaggeration of what clients really feel. For example, clients who feel threatened and unsafe speak of delusions of being watched, stalked, chased, or even poisoned (paranoid delusions).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
