Evolving from Therapeutic to Holistic Communication
Lucia Thornton
Carla Mariano
Nurse Healer OBJECTIVES
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Theoretical
Identify foundational theories and concepts in the development of therapeutic communication.
Describe contemporary nursing theories and concepts foundational in the development of holistic communication.
Identify and describe the concepts that distinguish holistic communication.
Clinical
Integrate foundational holistic communication processes into clinical practice.
Integrate and utilize intention, centering, grounding, caring, healing, transcendent presence, and intuition in establishing a caring-healing field of communication.
Personal
Engage in reflective practices to increase self-awareness and personal growth.
Integrate and utilize intention, centering, presence, caring, and intuition in creating and maintaining a healing field of communication in daily life.
DEFINITIONS
Energy field: The fundamental unit of the living and nonliving. Field is a unifying concept. Energy signifies the dynamic nature of the field; a field is in continuous motion and is infinite.1
Holistic communication: A caring-healing process that calls forth the full use of self in interacting with another. It incorporates the constructs and processes of therapeutic communication within a framework that acknowledges the infinite, spiritual, and energetic nature of Being, the centrality of being heart centered, and the importance of intention, self-knowledge, transcendent presence, and intuition in our interactions.2
Person: An energy field that is infinite and spiritual in essence and is in continual mutual process with the environment. Each person manifests unique physical, mental, emotional, and social or relational patterns that are interrelated, inseparable, and continually evolving.3
Therapeutic communication: A goal-directed form of communication used to achieve goals that promote client health and wellbeing.p15 Empathy, unconditional regard, genuineness, respect, concern, caring, and
compassion are conveyed through active listening, active observing, focusing, restating, reflecting, and interpreting.2p533
compassion are conveyed through active listening, active observing, focusing, restating, reflecting, and interpreting.2p533
▪ THEORY AND RESEARCH
Pioneers in Therapeutic Communication
Therapeutic communication is a field of study that has been influenced by theorists, researchers, and clinicians from a multitude of professions including nursing, psychology, sociology, and physics. These early pioneers created a rich foundation of ideas and constructs, many of which were holistic in nature. It is important to understand these perspectives to gain a greater understanding of how this work has evolved and its usefulness in holistic practice. Some of the significant contributions of nurse theorist Hildegard Peplau and those of Martin Buber, Carl Jung, Harry Stack Sullivan, and Carl Rogers are presented.
Peplau: A Visionary in Relationship-Based Caring
Peplau, the “mother of psychiatric nursing,” was the first to emphasize the nurse-client relationship as being the foundation of nursing practice.
The concept of partnership between nurse and client originated in Peplau’s interpersonal model. The idea that the nurse helps guide the patient and the patient takes an active role in the treatment plan was indeed revolutionary in 1952 and was in opposition to mainstream thinking, which promoted a role in which the client was dependent on the nurse.
The essence of Peplau’s work revolved around the concept of the shared experience. She shifted the focus of nursing practice from one that was based on medical intervention to an interpersonal model in which the nurse became the therapeutic agent. Peplau identified nursing roles during the course of the nurse-client relationship. The roles include Stranger, providing acceptance and trust; Resource, answering questions and giving information; Teacher, giving instruction and analyzing the learner experience; Counselor, helping the client derive meaning from the current experience; Surrogate, advocating for the client and clarifying dependence, independence, and interdependence; and Leader, assisting the client to assume maximum responsibility for meeting goals that are mutually established.4p89
Peplau’s concepts provided a bridge between the old paradigm in which the client was dependent on the healthcare system to one in which the client was an active participant in treatment and care. Her ideas paved the way for communication that involved the whole person.
Cogent Concepts from Other Disciplines
In the field of therapeutic communication, many rich ideas and constructs originated with psychotherapists. Concepts and ideas from Buber, Sullivan, Rogers, and Jung are similar to concepts that are foundational to holistic communication.
Martin Buber introduced the idea that the therapeutic process involves mutual discovery and emphasized the importance of mutual respect in the client-therapist interaction. He coined the term I-Thou relationship, which reflects a reverence in the client-therapist relationship. In this orientation, the therapist consciously creates a transcendent space in the relationship, fostering shared authenticity and compassion.
Harry Stack Sullivan was a contemporary of Peplau and influenced the development of her interpersonal model. Sullivan introduced the idea of the therapeutic relationship and described it as being a human connection that heals. Carl Rogers saw the therapist as an agent of healing. Rogers’s hallmark characteristics that he identified as being essential to the client-centered relationship were unconditional regard, empathy, and genuineness. Carl Jung examined the complexity of gender roles and our universal heritage as human beings. He described the first half of life as a search for self and the second half of life as a search for soul.4pp9-13
All of these therapists, and many others not mentioned, have contributed ideas that have significantly influenced the effectiveness of the therapeutic communication process. The concepts of partnership, healing, reverence, unconditional regard, empathy, genuineness, spirituality, and many more first found their place in therapeutic communication before being embraced by holistic nursing.
▪ NURSING THEORY RELATED TO HOLISTIC COMMUNICATION
The nursing theorists whose theories and concepts have facilitated the evolution of therapeutic communication toward holistic
communication are Martha Rogers, Margaret Newman, and Jean Watson. Concepts related to holistic communication are explicated and briefly discussed. For an overview of these theories, see Chapter 5.
communication are Martha Rogers, Margaret Newman, and Jean Watson. Concepts related to holistic communication are explicated and briefly discussed. For an overview of these theories, see Chapter 5.
Martha Rogers
Rogers uses the term unitary human being in place of person and defines who we are as “an irreducible, indivisible, pan-dimensional energy field identified by pattern and manifesting characteristics that are specific to the whole and which cannot be predicted from knowledge of the parts.”1p7 Rogers further defines energy field as “the fundamental unit of the living and the nonliving. Field is a unifying concept. Energy signifies the dynamic nature of the field; a field is in continuous motion and is infinite.”1p7
The nature of therapeutic communication changes when Rogers’s definitions are applied. How does one communicate with an energy field that is infinite in nature? Also, if we accept Rogers’s definitions, then communication shifts from being a linear or circular process to a pan-dimensional energetic process. Accepting Rogers’s definition also shifts our thinking to view communication as a field phenomenon. And finally, Rogers’s definition invites us to entertain the idea that our interactions can extend beyond the realm of this physical universe, beyond the space-time continuum and into dimensions that are infinite.
Rogers’s Principle of Integrality also has implications for the nature of holistic communication. Rogers defines integrality as a “continuous mutual human field and environmental field process.”1p8 Rogers describes person and environment as “open systems” and states that “man and environment are continuously exchanging matter and energy with one another.”5 This implies that all that we are—our thoughts, behaviors, emotions, that which is conscious, and that which is unconscious—interacts and affects everything and everyone in our environment. Likewise, everyone and everything that exists in our environment are continuously exchanging matter and energy with us. Integrating this concept into our lives challenges us to transform our lives and our way of being. If we are to act in a way that is therapeutic, in a way that promotes healing, we ourselves must be whole and healed. This concept reinforces the importance of self-awareness and self-knowledge.
Margaret Newman
The task of nursing intervention, according to Newman, “is not to try to change another person’s patterns but to recognize it as information that depicts the whole and relate to it as it unfolds.”6 The nurse must first be able to recognize her own patterns before entering into this process with a patient. Again, self-knowledge is paramount for the nurse to be effective in a caring, healing relationship.
The responsibility of the nurse is not to make people well or to prevent their getting sick, but to assist people in recognizing the power that is within them to move to higher levels of consciousness. The nurse’s awareness of being rather than doing is the primary mechanism for helping. Newman quotes Thomas Moore to emphasize the importance of staying fully present to all that life offers, without trying to fix or intervene: “By doing less, more is accomplished … what is needed is not taking sides when there is a conflict at a deep level. It may be necessary to stretch the heart wide enough to embrace contradiction and paradox.”7
Newman illuminates the concepts of pattern recognition, being fully present, and the importance of self-awareness and transformation in the holistic communication process.
Jean Watson
Watson defines person as “an embodied spirit; a transpersonal, transcendent, evolving consciousness; unity of mind-body-spirit; person-nature-universe as oneness, connected.”8 Watson is the first nursing theorist to address the concept of soul, as in the following passage:
My conception of life and personhood is tied to notions that one’s soul possesses a body that is not confined by objective space and time. … Notions of personhood, then, transcend the here and now, and one has the capacity to coexist with past, present, future, all at once. As a result of this view, there is a great deal of regard, respect, and awe given to the concept of a human soul (spirit, or higher sense of self) that is
greater than the physical, mental, and emotional existence of a person at any given point in time.9p45
greater than the physical, mental, and emotional existence of a person at any given point in time.9p45
How does one address the soul in the process of therapeutic communication? Watson’s answer to this is the transpersonal caring relationship. Engaging with another at the transpersonal level is not a technique that can be learned. Rather, it is the ability of the person to access the higher self and move from that place of higher consciousness in interactions with another. This process calls for the “full use of the self.”9p69 Watson’s description of the art of transpersonal caring also serves as a description of the caring-healing process of holistic communication.
The nurse is able to form a union with the other person on a level that transcends the physical, and that preserves the subjectivity and physicality of persons without reducing them to the moral of objects. … The union of feelings can potentiate self-healing and discovery in his or her own existence. That is the great attractive force of the art of transpersonal caring in nursing.9p68
Another concept that Watson expanded on and that has significance in the application of holistic communication is that of the phenomenal field.
The phenomenal field incorporates consciousness along with perceptions of self and others; feelings, thoughts, bodily sensations, spiritual beliefs, desires, goals, expectations, environmental considerations, meanings, and the symbolic nature of one’s perceptions—all of this based upon one’s life history and the presenting moment as well as the imaged future.9pp55-56
From Watson’s perspective, “an event or actual caring occasion” occurs when two persons come together with their unique life histories and their phenomenal fields.9p58 When people come together they share a phenomenal field, which becomes part of the life history of both and alters the dynamics of the present and the future. From this perspective, holistic communication can be viewed as a field experience.
This is consistent with Rogers’s Principle of Integrality in relation to the open and infinite nature of energy fields, where person and environment are in continuous mutual interaction. Watson, through her descriptions of her model, shows how Rogers’s Principle of Integrality can be applied.
A field perspective adds a richer and more holistic approach to therapeutic communication, wherein the gestalt of one person interacts with another. It challenges us to develop ways of being and ways of interacting that embrace the whole.
▪ THERAPEUTIC COMMUNICATION SKILLS: A PREREQUISITE FOR HOLISTIC COMMUNICATION
Traditional models of therapeutic communication do the following: define and prescribe various stages or phases, delineate various roles for the nurse or therapist, identify verbal and nonverbal communication skills, and identify therapist characteristics that are essential to creating a therapeutic milieu.
It is important for nurses to be familiar with the various stages of relationship formation and to develop and refine communication skills. It is also important for nurses to understand and integrate the qualities and attributes that are important in creating a therapeutic exchange. Empathy, unconditional regard, genuineness, respect, concern, caring, and compassion are vital and essential attributes for therapeutic communication. Developing and refining communication skills, including active listening, active observing, focusing, restating, reflecting, and interpreting, are also important in facilitating the therapeutic process. The aforementioned knowledge, skills, techniques, and attributes are foundational to the therapeutic communication process and are prerequisites to engaging in the caring, healing exchange that characterizes holistic communication. Acquiring these skills takes time and is enhanced by experience. Mastering these skills is a lifelong process that is facilitated by reflective practices, guidance, sage mentoring, and a commitment to self-knowledge and awareness.
The next step is to identify how a holistic approach to therapeutic communication would manifest itself. It is important to consider the distinguishing characteristics of holistic communication and how can we integrate these to create a caring, healing environment.
▪ DISTINGUISHING CHARACTERISTICS OF A HOLISTIC ORIENTATION TO COMMUNICATION
Preaccess and Assessment Phase
The holistic communication process acknowledges the importance of being centered and creating an intention before engaging in a caring-healing interaction with another. These two processes, being centered and creating intention, constitute the preaccess phase involved in holistic interactions. This phase lays the foundation for caring, healing communication and occurs before any person-to-person interaction takes place. As the nurse stays present to the moment, to self, and to the person, a healing environment is maintained. Consciously creating a healing environment, no matter where one is working, nurtures both the client and the self at a deep level.2p537
It is useful to note the distinction between accessing and assessment. The word accessing is preferred because it has the connotation of being open to receiving information in a nonjudgmental way. The term assessment implies appraising, evaluating, and judging. An essential characteristic of holistic communication is the mutuality inherent in the experience—this means that both the nurse and client participate equally in the process. Utilizing language that supports the concept of partnership reinforces a commitment to mutuality.
Acknowledgment of the Infinite and Sacred Nature of Being
Holistic nursing acknowledges that people are infinite, sacred, and spiritual beings. Florence Nightingale spoke of human beings as a “reflection of the Divine with physical, metaphysical, and intellectual attributes.” Jean Watson teaches that we are “sacred beings,” and Martha Rogers speaks of unitary human beings as “energy fields that are infinite in nature.” The Model of Whole-Person Caring™ combines these concepts to define person as “an energy field that is open, infinite, and spiritual in essence and in continual mutual process with the environment. Each person manifests unique physical, mental, emotional, and social or relational patterns that are interrelated, inseparable, and continually evolving.”10 Thus, from the perspective of holistic nursing theorists and models, people are infinite and sacred in nature. This orientation makes a difference in how we approach each other. It shifts how we speak, how we listen, how we relate, and how we interact. When we perceive human beings as sacred, our words, actions, and behaviors are significantly affected.
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