Continuing Education Activity

Therapeutic communication is an invaluable approach to interactions with patients that is applicable across multiple disciplines. This activity reviews therapeutic communication, including its history, definition, applications, and explains the interprofessional team's role in improving the care of patients through the use of therapeutic communication.

Objectives:

• Describe the techniques used in therapeutic communication.
• Outline the common pitfalls in patient-provider communication.
• Identify the anticipated barriers to effective patient-provider communication.
• Review interprofessional strategies that can advance therapeutic communication to improve patient outcomes.

Introduction

Therapeutic communication as a concept emerged early in medicine and has since shown significant benefits borne out in research. Two of the earliest reported cases of therapeutic communication, which primarily involved the idea of the therapeutic relationship and the benefits of such a relationship, were documented during the moral treatment era of asylums.[1]  Both of the patients were admitted in 1791 and 1800, and both responded to moral treatment, despite having severe symptomatology.

In the late 1800s, Florence Nightingale had previously commented on the importance of the “communication that develops between the nurse and the patient” in the late 1800s.[2][3] She was quoted as saying, “Always sit within the patient’s view, so that when you speak to him, he has not painfully to turn his head round to look at you. Everybody involuntarily looks at the person when speaking. So, also by continuing to stand, you make him continuously raise his eyes to see you….”

In the 1950s, Harry Stack Sullivan and Jurgen Ruesch, prominent figures in interpersonal theory and communication, respectively, both published the importance of communication in providing therapeutic benefit, specifically in mental illness.[4][5]  Other significant contributors to the concept of therapeutic communication and related topics include Carl Rogers, Hildegard Peplau, and Tudor.[6][7] 

Of note, Hildegard Peplau published her original paper in 1952 and later published subsequent reviews and revisions in 1991 and 1997, which provided a foundation for the concept of therapeutic communication.[6] This theory, named “Theory of Interpersonal Relations,” was founded on integrating knowledge of Sullivan’s interpersonal theory, as well as psychoanalysis, psychotherapy, and nurse therapy.[8] Peplau's theory described multiple “phases” of the interaction and considered the relationship as a primary mediator for the healing process. The importance of the relationship to healing is accepted in common factors of psychotherapy research as a factor with empirical support.[9] Other theorists include Travelbee, Rogers, and King, who have all contributed to the field of therapeutic communication.[10]

“Therapeutic communication” ultimately emerged as a term in PubMed-indexed literature as early back as 1964 to 1965, in the setting of psychotherapy, psychiatry, sociology, medicine, rehabilitation, and nursing literature.[11][12][13][14] Since then, the concept of therapeutic communication has expanded to apply to many other fields, particularly in healthcare. Other terms in the literature that overlap with therapeutic communication include patient-centered communication and therapeutic relationships.

Function

Since the emergence of therapeutic communication as a concept in literature, it has been studied in various contexts. However, the definition of therapeutic communication has varied depending on the author and the context.  C. M. Rossiter, Jr. brought this to attention in 1975, outlining several issues to consider with the definition of therapeutic communication.[15] 

Later, a now generally accepted definition of therapeutic communication was proposed by Gwen van Servellen in 1997.  In her text, therapeutic communication was defined as an exchange between the patient and provider using verbal and non-verbal methods. The ultimate goal of this communication style was considered to help the patient overcome some form of emotional or psychological distress.[16]

Issues of Concern

Personalize the Communication

Medical diagnoses are commonly accepted as providing a classification of understanding etiologies, epidemiology, and pathophysiology of signs and symptoms that frequently cluster. In turn, these diagnoses provide a way of categorizing and providing treatment, prognosis, support, and education to patients with the same diagnosis.[17] Diagnoses also crucially provide a classification for insurance coverage and payment, competency certification of providers, disability determinations, malpractice claims, and other related functions.[18][19][20] In these ways, the process of diagnosing represents a crucial process of finding and understanding similarities between individual patients through their symptomatic presentation.

Simultaneously, identifying and appreciating individual differences between patients is often considered important, as these differences account for many healthcare outcomes.[21][22] Commonly cited examples of such differences include social determinants of health and personality characteristics. In these ways, effective communication with individual patients can depend on a number of factors.[23] The following techniques of therapeutic communication must therefore be understood as general guidelines to patient-provider interactions. Providers can use these general guidelines as a foundational approach from which an individualized approach to communication can be used for specific patients.

Specific Techniques

Specific therapeutic communication techniques have been discussed as early on as 1969 by Goldin and Russell and have been reiterated and expanded upon since then.[2][8][24][25]

These techniques are summarized in the following table:

*Note that eye contact and sitting near the patient for some individuals, including those with psychotic disorders and paranoia, could be destabilizing and should be used with caution. In cases where provider safety is uncertain, consider sitting at a safe distance without making the patient feel isolated.

Common Pitfalls

Additionally, there are several commonly used approaches with negative therapeutic value. These are summarized in the following table.

Clinical Significance

Therapeutic communication has been widely studied and has been shown to have multiple benefits.

Most recently, therapeutic communication has been primarily adopted to structure communication in physician, nursing, mental health, and social work interactions.[26] The process of communicating therapeutically has been shown to have benefits in many domains. These include increasing accuracy of diagnosis, identifying the patient’s emotion and determining the best therapeutic measure, collaborative decision making with patients, and improving identification of the patient’s perceptions and apprehensions around diagnosis and treatment options. Communication abilities of the provider have been reported as at least as important as technical competence, if not more so, in assessments by patients. Treatment adherence directly correlates with the quality of the communication, and adherence can subsequently influence outcomes.[27][28] Also, patient-centered encounters have been shown to improve patient and provider satisfaction and reduce the risk of malpractice complaints and provider burnout.[29]

Unfortunately, some studies have shown deficiencies in the training and implementation of empathetic or therapeutic communication.[26][27][29] Barriers to communication identified in the literature include patient’s anxiety, underrecognition of cultural differences between patient and provider, colloquial language differences between patient and provider, providers being overworked, shortages in time or staffing, fear of abuse or litigation, and unrealistic expectations from the patient.[29] 

As might be apparent, some of these identified barriers can be addressed at a systems level, and others at the level of patient-provider communication. One frequently expressed concern regarding therapeutic communication is that providers may not have enough time to address emotional concerns. This issue regarding lack of time has not been supported in the literature. Studies in physicians have demonstrated only a marginal change in the consultation time when an empathic response is given, and improved communication skills did not show an association with a longer duration of the consultation.[30] One observational study showed on average; empathic responses increased the duration of the consultation by only 21 seconds.[31]

Other predictors of successful therapeutic communication include differences in language, education difference between patient and provider, patient’s education level, and perceived patient view scores.[32] Recognition of these differences and tailoring the communication style to the individual are therefore important considerations.

Other Issues

Communication can be complicated by other factors, including agitation/aggression, psychosis, delirium, and intubation.  For these cases, utilizing therapeutic communication techniques and tailoring the individual patient's interaction can be particularly important.

In agitation, verbal de-escalation techniques are generally accepted as good clinical practice; however, it is an understudied field, especially in the setting of psychosis-induced aggression or agitation.[33] Non-psychosis-induced aggression has also been reviewed but has a limited evidence base as well.[34] Techniques for verbal de-escalation overlap greatly with the above listed therapeutic communication techniques, emphasizing balancing provider safety with patient comfort. These additional techniques include maintaining a moderate distance without appearing guarded, using calm and open body language and tone of voice, standing at a right angle to the client with an awareness of the exits, allowing the client to exit easily.[35]

Other complex communication issues include challenges that occur in critically ill patients, including delirium, intubation, and intellectual and developmental disabilities as well as autism.[36][37]  The communication strategy referred to as Augmentative and Alternative Communication (AAC) is a set of communication approaches to assist communication in these settings.[38][39]

Finally, psychosis presents a challenging communication barrier, especially concerning hallucinations and delusions.  Development of a shared understanding in the setting of psychotic experiences becomes particularly challenging, both from the standpoint of the patient communicating their concerns to the provider and the provider reflecting an understanding of these concerns.[40] From the provider’s standpoint, a conflict can emerge whether to respond in a manner that “colludes” with the psychotic experiences or to challenge them. Communication analysis has been used previously to analyze these encounters and has demonstrated a frequent pattern in which the patient tries to negotiate the meaning of the psychotic stimuli.[41] 

One way to develop a shared understanding with patients with psychosis is to understand the meaning of the psychotic experiences to the patient, rather than focusing on the nature and content of the experiences themselves.[41] This might include active listening for the patient’s feelings about their beliefs and experiences and validating distress around these experiences. A specific approach in literature termed Communication Skills Training (CST) has been cited as potentially beneficial, though further research is necessary.[42]

Enhancing Healthcare Team Outcomes

As noted above, therapeutic communication has shown multiple clinical benefits in the literature. Indeed, therapeutic communication has demonstrated improved patient satisfaction, among other noted benefits. Patient satisfaction as a concept is a complex and subjective concept, but it has contributed to improved medical outcomes. The mechanism by which therapeutic communication improves patient satisfaction is thought to occur by fulfilling the patient’s expectations and values for the encounter. In turn, this fosters maintenance of the patient-provider relationship.[29] Additionally, another study demonstrated that effective communication styles during history taking and management plan discussion were associated with improved physical health outcomes, functional level, and blood pressure and glucose levels.[43] [Level 2] Further study is needed to strengthen these findings.

Each healthcare team member plays a vital role in therapeutic communication with the patient. Each team member gathers information from and subsequently communicates information to the patient in various contexts. This can be illustrated through a sample inpatient medical-surgical admission, where it is estimated that patients may see nearly 18 different healthcare providers through the course of the admission.[44] Each provider that sees the patient often has specialist information to obtain, including general and specialty medical, general or specialty surgical, psychiatry, psychology, nursing, patient education, clergy, social workers and case managers, and pharmacists.

The American Nurses Association released guidelines in 2014 regarding psychiatric-mental health nursing and the importance of therapeutic communication as a standard of practice.[45] Nurses play a vital role in delivering therapeutic communication to the patient. For example, they may often interact more frequently and for longer durations with patients on medical-surgical floors. [Level 5] The Registered Nurses Association of Ontario has also published best-practice guidelines supporting the use and implementation of therapeutic communication.[46] Besides, the ACGME has also established guidelines for patient-centered communication training in graduate medical programs.[47] [Level 3] NICE has also published guidelines supporting the use and implementation of therapeutic communication for improved patient experience in the NHS.[48]

Pharmacists also play an important role in therapeutic communication with patients and providers.[49] Multiple studies have shown the importance of effective pharmacist-patient communication in improving adherence and outcomes.[49] [Level 3]

Effective interprofessional communication is also considered critical in improving patient safety and improving outcomes. IPEC, in collaboration with the American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Education Association, Association of American Medical Colleges, and the Association of Schools of Public Health, developed expert consensus guidelines on interprofessional collaborative practice.[50] Many of the above techniques, including openness, active listening, respectful language, and self-awareness, are considered critical to effective communication and collaboration. [Level 5]

Nursing, Allied Health, and Interprofessional Team Interventions

Given that team-based interventions primarily drive healthcare, all healthcare team members must be aware of and utilize therapeutic communication techniques. As such, the specific information gathered by each team member may also differ, and thus the collective information can allow for a more holistic treatment approach if all team members are involved and communicating. Tools like SBAR and STICC can provide efficient methods of interprofessional communication, and opportunities within the healthcare organization or system are important for supporting such communication.[51] 

Interprofessional communication within teams has also shown benefits in attaining efficient and safe outcomes.[52] Non-communication between two treating professionals has also been shown to significantly lower the patient’s treatment satisfaction.[53] Approaches to teaching interprofessional communication include Crew Resource Management, TRI-O guide, and TeamSTEPPS.[52][54] 

In addition, frequent and effective interprofessional communication is important to enhance treatment and prevent splitting behaviors in patients, where some providers may be considered "good" and others "bad." This is done by providing clear and consistent treatment recommendations that are from a “unified front,” as well as a consistent message of compassionate treatment from all team members. Therapeutic communication can facilitate this through the use of consistent empathetic approaches provided by each healthcare team member.

Nursing, Allied Health, and Interprofessional Team Monitoring

Through therapeutic communication, the healthcare team can provide holistic monitoring of the patient’s adherence, treatment response, adverse effects, and patient satisfaction, and identification of barriers to treatment. The biopsychosocial model of care provides a guide to approaching patients, and therapeutic communication techniques integrate well in identifying biopsychosocial contributors to health and illness in the patient.[55] 

Interprofessional approaches to monitoring for and identifying these contributors to health and illness can also provide a powerful tool for approaching patient care. Monitoring the patient’s emotional states from an interprofessional standpoint can also prove beneficial. In particular, monitoring these emotional states can allow for early identification of reactions a patient may be having towards a treatment or provider. In this way, one provider may provide liaison between these potential disruptions to care, address them early and directly with the patient, and simultaneously alert other team members to help patients work through these issues. Fostering therapeutic communication amongst interdisciplinary teams contributes to improving patient experience and enhancing health care outcomes.