Non-directive communication theories in nursing practice

Non-Directive Communication

Theories of Communication

These theories derive from behavioral and cognitive, humanistic and psychodynamic philosophies (Wagner 2011). The choice depends on the nurse's psychological orientation and approach towards mental health. These are the cognitive-behavioral, client or person-centered, psychodynamic, and humanist theories. The cognitive-behavioral theory or CBT, a creation of psychologist Aaron T. Beck, aims at identifying the person's problem areas and solving them by changing his thought and behavior patterns. The patient records his or her thoughts between sessions as his or her homework. The client or person-centered theory evolved from the concept of Carl Rogers, a prominent psychoanalyst in the mid 1900s. It is also known as the Rogerian theory of communication. It helps establish better relationships. It is based on three major factors, namely genuineness, acceptance, and understanding. The theory requires the nurse or therapist to remain aware of his or her personal feelings and is, therefore, interpersonal and analytical. It often results in much transference and counter-transference. It is comparatively more personalized than the CBT model. The psychodynamic theory is the contribution of Carl G. Jung. It emphasizes on the patient's early childhood, dreams and unconscious wishes. As such, communication relies on dream analysis, free associations, word association and unconscious repressions. The nurse or therapist comments only when interpreting in order to help the patient view something in a different way. He or she seldom comments, engages in small talk or shows empathy. And the humanistic theory views the patient in the context of his or her uniqueness and the uniqueness of his or her problems. Thus, these cannot be neatly categorized. This theory uses existential psychology principles and focuses on major life changes, like birth, death and loss. The nurse or therapist teaches and guides more than analyzes (Wagner).

The Place of Interpersonal Communication in Nursing

Verbal and non-verbal interactions are an essential part of communication and therapy. These are in the form of the nurse's choice of words, volume of voice, speed of speech, tone, facial expression, attitude and emotion (Roath 2011). These affect the way a patient interprets the nurse's message. The basic skills required of nurses in interpersonal communication include listening, questioning, encouraging or reinforcing, providing information, responding and comforting or reassuring. The four basic elements of communication are the sender, the receiver, the message and the channel. A message is interpreted according to the nature of these elements and their interaction. Both the sender of a message and its receiver necessarily infuse their personal backgrounds into the sending, receiving and interpreting of the message (Roath).

Factors, Effectiveness and Barriers

A nurse's needs, values, personality and desire are necessarily incorporated into the communication mechanism (Roath 2011). These psychological and social aspects are perceived along with the message she transmits to the patient. The patient, in turn, interprets the message with the color of his own personality, values, needs and desire as well. The nurse should struggle to see the situation from the patient's side in order to succeed in interpersonal communication and therapy. Merely passing or expressing a message or information is not enough. A nurse's message must be clear, simple, short and direct. Many times, she needs to provide examples, demonstrate and repeat in various ways. The patient needs to exactly and clearly what she is communicating. He should perceive the basics of the message as to what, why, when, how, who and where. As a listener, the nurse should not only passively receive the message. She should concentrate, pay attention to the patient's words, tone, volume, silence, emotion and attitude. She should not interrupt or judge. She should repeat or interpret the message when needed in order to insure that she understands it correctly. She should encourage the patient by nodding or through verbal cues (Roath).

Physical or psychological barriers can destroy or prevent the clear transmission of a message or information (Roath 2011). These are termed "noise," and refer to everything that distorts the communication. The nurse should be able to read and appreciate facial expressions, eye movements, hand gestures, body postures and uncontrolled responses, such as pulse and breathing rates. She should avoid swift and unpleasant expressions. She should carefully consider what she says before she says it. These are some barriers to effective communication. One more barrier is the ethics of breaking bad news. The nurse should be well aware of the hospital or institutions' written policy and guidelines on ethical and moral issues. She should know how to impart such news in different situations. She should always remember that the patient and his or her family are human and sensitive. She should break bad news personally and not through telephone (Roath).

The Theory's Central Conditions

Rogers established 6 central conditions (Zimring 1999). First, the therapist or nurse should be congruent or integrated in the therapeutic relationship. She should be aware of the way she experiences the relationship and his attitude towards the patient. It also requires her willingness to communicate about this experience if it becomes an obstacle to the two other central conditions. Another is her unconditional positive regard towards the patient. She must experience a warm acceptance of every aspect of the patient's experience as if she is part of him. When this happens, he experiences unconditional positive regard. And the last central condition is her empathic understanding of his internal basis and her endeavor to communicate this to the patient. Roger believed that these conditions, when met, are sufficient in therapy. The nurse or therapist does not need to understand the patient's personality or problems or guide him in solving his problem. If she is genuine, unconditionally accepting and empathetically understanding, therapy can occur (Zimring).

Rogers centered on motivating rather than dictating to a patient (Zimring 1999). In the patient, as well as the student, an innate capacity for health and growth already exists. When this self-actualizing process in the patient is freed, he will naturally initiate his own recovery. The recovery will be more thorough and lasting than when brought about by traditional therapy. The process can be freed through the therapist or nurse's attitudes. These attitudes unconditionally respect and appreciate the patient's ability. They are her empathic response to him. But so far, programs, which experimented on Rogers' theory have shown that therapists find difficulty in changing their attitudes. They are unable to share their power and responsibility with the patient. They fail to trust the intrinsic motivation of the patient to direct his own recovery. But the programs also highlighted that a patient's chances of recovery improved when the therapist's attitudes are changed and attuned to the patient's intrinsic ability (Zimring).

The Rogerian Model

This is a theory of communication introduced by psychologist Carl Rogers (Lee 2011). It is founded on trust and emphasizes common goals. This theory proposes that an argument or situation should begin with a brief and objective definition of the problem. Rogers believes that communication will be more effective if trust exists. The nurse or therapist should make a neutral analysis of the patient's position so in order to show understanding of his views. She should also establish and present a neutral analysis of her own position. She should then analyze the goals and values they have in common. Their problem situation should construct a proposed solution that recognizes the interests of both sides, rather than one of them dominating and winning the problem situation (Lee).

Motivational Interview

This is a client-centered, directive method meant to encourage the patient's intrinsic motivation to change by discovering and handling imbalances (Lussier 2007). It is also perceived as a patient-focused approach, as Rogers intended, wherein the patient's perspective, interests, values and concerns are central. It is directive as opposed to Rogers' nondirective approach. As a method of communication, it is designed to enhance the natural change of a patient's motivation. It encourages the therapist or nurse to seek out solutions that promote a desired change. Or it is an approach that inclines the therapist or nurse to look for and resolve the patient's imbalances or problems as the key to the targeted change (Lussier).

Psychologists Miller and Rollnick, the developers of this approach, were more interested in change than the resistance to it (Lussier 2007). They gave more weight to the willingness of the patient to change rather than on their fears or what they would like to avoid. They would want to induce and encourage the patient's predisposition to change. This approach is based on certain premises. Miller and Rollnick believed that change occurs naturally. Change is influenced by the interaction between people. Expressing empathy is a means of effecting change. Confidence best produces change on both sides that the patient will change his views and attitudes. Many of those patients who say they are motivated to change actually change. But while change occurs naturally, the two psychologists caution that ambivalence or stress accompanies it. The nurse or therapist should focus on reducing ambivalence to help the patient choose change. Miller and Rollnick identified four main strategies to do so. It must be first assumed that the patient is ready, willing and able to change (Lussier).

The motivational approach may be applied during the medical consultation with the purpose of inclining the patient to change (Lussier 2007). The first strategy is for the therapist to offer his or her viewpoint or expertise on the patient's problem and its treatment. The therapist or nurse should clarify that the viewpoint is not a personal opinion but the position of the medical profession on the condition or problem. It is a statement backed by scientific evidence. It defines the problem and states the recommended treatment. The second strategy consists of providing guidance in identifying the solution she or he believes is most appropriate for the patient. It should be in the form of a concerned suggestion but an authoritative one, at the same time. The third strategy concerns the suggested treatment. The therapist explores what the patient is capable of doing as regards treatment. She elicits his opinion and if he can follow the required regimen. She must initiate the discussion at this point so that she can come up with the most suitable solution. She should determine if the goals of the suggested treatment are achievable to the patient and why, if they are not achievable. This is the point where the therapist should endeavor to reduce the patient's ambivalence. She does this by focusing on the aspects, which she perceives as conducive to change in the patient's personal circumstances, lifestyle or habits and the incorporation of the new behavior. The patient is led to weigh between the benefits and the disadvantages of the treatment. The fourth strategy is applicable when the patient decides not to change. The therapist should analyze the patient's reasons. She should investigate his or her level of confidence in effecting the change. Inquire about alternatives or other options in addressing the problem. Then common objectives must be re-defined until new ones can be identified (Lussier).

Tackling the situation depends on any number of factors. One is the presence or absence of symptoms in the patiet (Lussier 2007). The proposed treatment is meant to solve a major or immediate problem. The objective is long-term prevention. A more critical situation may require the adoption of a new behavior and eliciting the patient's viewpoint and commitment to the treatment requirements. The criticalness of the situation may, in fact, be a motivational factor for a change in behavior in the patient. If the objective is preventive treatment, the situation is not an emergency and the predicted illness or condition becomes hypothetical. The last case gives the physician more time to think about the matter for future consultations. The most important thing is that the therapist should continue insisting on the need to develop or change into a new behavior. This should be the intention despite repeated failures. It is not harassment to insist if it is done out of professionalism. Rather, repetition can boost the patient's ongoing change efforts (Lussier).

Help in increasing patient motivation contributes to treatment maintenance and follow ups (Luissier 2007). Changing into a new behavior is not as easily done as said. There can be false starts. But nothing takes the place of continued effort. The therapist in particular should support the patient's own effort to change and then persist in encouraging him to change. Ambivalence is likely to return. The therapist should, therefore, exert persistent and honest efforts to support the new behavior until it become habitual to the patient (Lussier).

Person-Centered Therapy for Mental Health

This has the shade of the existential school of therapy (Bozarth 2011). As suggested by Carl Rogers, the patient is in control of his behavior, emotions and destiny. It is appropriate for counselors who choose the non-directive approach and for the patient who values finding and doing things his way. The use of this therapy for the mentally ill patient consists of five steps. The first is to research on the therapeutic method to be used. In this case, It evolved in response to the Freudian method, which focused more on the counselor's role than the patient's in the therapeutic process. The second is to realize that Rogers did not actually emphasize the role of the therapist or his expertise. Rogers emphasized the different stages involved in the therapy. These are congruence, unconditional positive regard, and empathy. The therapist should use three methods in the therapeutic process. Their use will free the patient to express himself. The third is to use this theory in mental health cases, such as personality disorders, schizophrenia, alcohol disorders, anxiety and other cognitive disruptions and distortions. The theory is, however, of limited results when verbal communication skills are poorly developed (Bozarth).

The fourth step is to stress the importance of personal growth and self-discovery in the patient (Bozarth 2011). The therapist should guard against too much interaction during the psychological discovery process. She should expect results to include making decisions, learning from mistakes, discovering emotional triggers, increasing positive relationships, and reducing guilt and defensiveness. And the fifth step is to treat the patient with complete respect and appreciation. The nurse or therapist should often check on inconsistencies and unclear information with the patient to make sure she understands what he is saying. She should not do anything with him or over-guiding. The patient must be given maximum opportunity analyze his own mental condition and emotional states. Empathy is the ability to understand and relate to the patient's problem or situation and see things from his point-of-view. There is unconditional positive regard when the nurse or therapist accepts the patient for what he is. She does this without investigating or censoring his reactions. This attitude is extremely important to this type of therapy. On the other hand, congruence is the therapist or nurse's ability to relate with the patient with genuineness and openness. She is able to do this without refocusing the session on her own problems (Bozarth).

Carl Rogers applied his theory in education by setting parallel conditions, which he established for therapy (Zimring 1999). He argued that learning could occur only if the student works on real problems and the teacher is genuine and open (Zimring).